Anterior Inferior Tibiofibular Ligament Suture Tape Augmentation for Isolated Syndesmotic Injuries.

BACKGROUND: The best operative construct and technique for treatment of isolated syndesmotic injuries is highly debated. The purpose of this study was to determine whether the addition of anterior inferior tibiofibular ligament (AITFL) suture repair or suture tape (ST) augmentation provides any biomechanical advantage to the operative repair of an isolated syndesmotic injury. METHODS: Twelve lower leg specimens underwent biomechanical testing in 6 states: (1) intact, (2) AITFL suture repair, (3) AITFL suture repair + transsyndesmotic suture button (SB), (4) AITFL suture repair + ST augmentation + SB, (5) AITFL suture repair + ST augmentation, and (6) complete syndesmotic injury. The ankle joint was subjected to 6 cycles of 5 Nm internal and external rotation torque under a constant axial load. The spatial relationship between the tibia, fibula, and talus was continuously recorded with a 5-camera motion capture system. RESULTS: AITFL suture repair and AITFL suture repair + ST augmentation showed no statistically significant change in fibula kinematics compared to the intact state. Compared to native, AITFL suture repair + SB showed increased fibular external rotation (+2.32 degrees, P < .001), and decreased tibiofibular gap (overtightening) (-0.72 mm, P = .007). AITFL suture repair + ST augmentation + SB also showed increased fibular external rotation (+1.46 degrees, P = .013). Sagittal plane motion of the fibula was not significantly different between any states. None of the repairs restored intact state talus rotation; however, the repairs that used ST augmentation reduced the talus external rotation laxity compared to the complete syndesmotic injury. CONCLUSION: AITFL suture repair and AITFL ST augmentation best restored the rotational kinematics and stability of the fibula and ankle joint in an isolated syndesmotic injury model. CLINICAL RELEVANCE: AITFL suture repair with or without ST augmentation may be a good operative addition or alternative to SB fixation for isolated syndesmotic disruptions.

Minimally Invasive Achilles Repair Techniques.

Achilles tendon rupture is an increasingly common problem with an aging population participating in high-level physical activities. Appropriate treatment has been debated for decades, but good outcomes have been reported after conservative and surgical management. The development of minimally invasive surgical techniques for Achilles repair has reduced the incidence of complications and maintained the high level of function reported after open surgery. The Achilles Midsubstance SpeedBridge repair is a newer minimally invasive technique that has demonstrated promising results and is the authors' preferred treatment of Achilles tendon rupture in athletes and active patients.

Reduction of Opioid Use After Upper-Extremity Surgery through a Predictive Pain Calculator and Comprehensive Pain Plan.

PURPOSE: For outpatient hand and upper-extremity surgeries, opioid prescriptions may exceed the actual need for adequate pain control. The purposes of this study were to (1) determine rates of opioid wasting and consumption after these procedures and (2) create and implement a patient-specific calculator for opioid requirements with a detailed multimodal analgesic plan to guide postoperative prescriptions. METHODS: Patients undergoing hand and upper-extremity surgery at a single ambulatory surgery center were recruited before (n = 305) and after (n = 221) implementation of a postoperative pain control program. On the first postoperative visit, patients were given a questionnaire regarding opioid use and pain control satisfaction. Demographic and procedural data were collected via chart review. With these data from the first cohort, we developed a patient-specific opioid calculator and pain plan that was implemented for the second cohort of patients. Bivariate analysis and multivariable regression analysis were used to determine the effect of the intervention. RESULTS: Pre-intervention data suggested that younger age; baseline opioid use; use of regional block; unemployment; procedures involving bony, tendinous, or ligamentous work (as opposed to soft tissue alone); and longer procedure time were predictive of higher opioid consumption. Pre- and post-intervention cohorts had similar age and sex distributions as well as procedure length. After the intervention, opioids prescribed decreased 63% from a mean of 32.0 ± 15.0 pills/surgery or 194.5 ± 120.2 morphine milligram equivalents (MMEs) to 11.7 ± 8.9 pills/surgery or 86.4 ± 67.2 MMEs. Opioid consumption decreased 58% from a mean of 21.7 ± 25.0 pills/surgery (137.7 ± 176.4 MMEs) to 9.3 ± 16.7 (64.4 ± 113.4 MMEs). Opioid wastage decreased 62% from 13.8 ± 13.5 pills/surgery (62.8 ± 138.0 MMEs) to 5.2 ± 10.3 (24.8 ± 89.9 MMEs). Implementation of the pain plan and calculator did not affect the odds of unsatisfactory patient-rated pain control or unplanned opioid refills. CONCLUSIONS: With implementation of a comprehensive pain plan for ambulatory upper-extremity surgery, it is possible to reduce opioid prescription, consumption, and wastage rates without compromising patient satisfaction with pain control or increasing rates of unplanned pain medication refills. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Analysis of the Effect of Tibial Stem Length on Coronal Plane Deformity of the Tibial Component in Total Ankle Arthroplasty.

BACKGROUND: Coronal plane deformity is common in patients who undergo total ankle arthroplasty. The correction of this deformity is paramount to the long-term survival of the implant. Coronal plane correction is achieved with soft tissue balancing and, in some part, is maintained through articular geometry constraint. The purpose of this study was to assess the influence of tibial component stem length on the coronal plane stability. METHODS: A consecutive case series of stemmed implants that met inclusion criteria were reviewed to determine the correction and maintenance of the correction of coronal plane deformity with special emphasis on the effect of modular tibial stem lengths of 2 and >2 segments. Twenty patients received a tibial component with 2 stem segments, and 23 patients received a tibial component with >2 stem segments. At an average patient age of 62.1 years at implantation, there was no significant difference between the 2 cohorts with respect to preoperative deformity or demographics. RESULTS: Our case series had a mean coronal deformity of 5.7 degrees, with valgus being more common than varus. At a mean final radiographic follow-up of 266.3 days after the first postoperative weightbearing radiography, coronal deformity increased by 0.4 degrees (P = .031). From the first postoperative measurement to the last postoperative measurement, there was no difference in mean coronal plane ankle deformity change between patients who received 2 stem segments and patients who received >2 stem segments (t = -1.14, df = 41, P = .259). CONCLUSION: Coronal plane deformity had a tendency to recur, albeit at a much smaller angle than preoperatively. This recurrence of deformity did not occur because of tibial component movement. Tibial stem lengths of >2 segments did not influence the maintenance of correction of coronal plane deformity or the stability of the tibial component in the coronal plane. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Lack of Acute Hand Care in the Southwest United States.

OBJECTIVES: To describe the epidemiology of acute hand injuries and hand infections and to describe the factors associated with the transfer of these patients to a level 1 trauma center. In addition, we sought to understand management before transfer. DESIGN: Retrospective review of patients with hand trauma or hand infection transferred to our level 1 trauma center from May 2009 to August 2011. We also identified hospitals with emergency departments (EDs) in our region and surveyed ED providers in these hospitals with regard to acute hand care. SETTING: A level 1 trauma center in the United States. PATIENTS: Four hundred sixty consecutive transfers for acute hand care. RESULTS: The average patient age was 38. Most were male (84%), uninsured (51%), and from another county (59%). The average distance of transfer was 51 miles, and 80% were transferred by ground ambulance. The most common reasons for transfer were amputations (24%), infections (21%), lacerations (17%), and fractures/dislocations (16%). Of the 345 hospitals with an ED surveyed, 71% never had hand surgery coverage. CONCLUSIONS: Patients transferred for acute hand care were young and male, and traveled an average 51 miles to get to our center. More than half of these patients were treated and discharged from our ED. This indicates that a majority may have been managed in a clinic setting. Most EDs in our region do not have a hand surgeon available. Most emergency physicians surveyed had received little training in management of acute hand injuries and hand infections. Further research is needed to identify methods to remove barriers to provision of care for patients with hand trauma. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.