Anterolateral Drawer Versus Anterior Drawer Test for Ankle Instability: A Biomechanical Model.

BACKGROUND: The addition of unconstrained internal rotation to the physical examination could allow for detection of more subtle degrees of ankle instability. We hypothesized that a simulated anterolateral drawer test allowing unconstrained internal rotation of the ankle would provoke greater displacement of the lateral talus in the mortise versus the anterior drawer test. METHODS: Ten cadaveric lower extremities were tested in a custom apparatus designed to reproduce the anterior drawer test and the anterolateral drawer test, in which the ankle was allowed to internally rotate about the intact deep deltoid ligament while being subluxed anteriorly. Specimens were tested intact and with anterior tibiofibular ligament sectioned. A differential variable reluctance transducer was used to measure lateral talar displacement with anterior forces of 25 and 50 N. RESULTS: No significant differences in talar displacement or ankle rotation were noted in intact specimens between the groups. Among sectioned specimens, significantly more talar displacement (25 N [6.5 ± 1.7 mm vs 3.8 ± 2.4 mm] and 50 N [8.7 ± 0.9 mm vs 4.5 ± 2.5 mm], P < .001) and ankle rotation (25 N [13.9 ± 8.0 degrees vs 0.0 ± 0.0 degrees] and 50 N [23.7 ± 5.8 degrees vs 0.0 ± 0.0 degrees], P < .001) were found in the anterolateral drawer versus anterior drawer group. CONCLUSION: In an ankle instability model, the anterolateral drawer test provoked almost twice the lateral talus displacement found with the anterior drawer test. CLINICAL RELEVANCE: Allowing internal rotation of the ankle while testing for ankle instability may allow the examiner to detect more subtle degrees of ankle instability.

Distal femoral fracture during primary total knee arthroplasty.

PURPOSE: To review 6 cases of periprosthetic distal femoral fracture during total knee arthroplasty (TKA). METHODS: Of 778 women and 691 men who underwent primary TKAs using posterior-stabilised (n=1240), cruciate-retaining (n=165), or semiconstrained (n=64) implant, 5 women and one man with a mean age of 73.3 years and a mean body mass index of 31.6 kg/m(2) sustained an intra-operative periprosthetic distal femoral fracture and were followed up for a mean of 12.8 (range, 2-39) months. RESULTS: Respectively in patients with a posterior-stabilised, cruciate-retaining, or semi-constrained implant, the intra-operative fracture rates were 0.32%, 0%, and 3.13%. For women, the respective rates were 0.46%, 0%, and 5.10%. Intra-operative fracture was 9.69 times (p=0.03) more likely to occur in patients with a semi-constrained implant than those with a posterior-stabilised implant, and was 4.44 times (p=0.22) more likely to occur in women than in men. Half of the fractures occurred during the trial phase when the tibia was reduced onto the femur, and half during final prosthesis implantation. CONCLUSION: Distal femoral fracture during primary TKA is rare and associated with the use of a semiconstrained implant. Preserving as much bone in the distal femur is advised.

Recurrence of hallux valgus: a review.

Recurrence of hallux valgus deformity can be a common complication after corrective surgery. The cause of recurrent hallux valgus is usually multifactorial, and includes patient-related factors such as preoperative anatomic predisposition, medical comorbidities, compliance with postcorrection instructions, and surgical factors such as choice of the appropriate procedure and technical competency. For a successful outcome, this cause must be ascertained preoperatively. Although the algorithm to determine which intervention should be used is not unlike that of primary hallux valgus surgery, operative correction of hallux valgus recurrence can be challenging. This article discusses these challenges, complications, causes, and techniques.

Spinal anesthesia: should everyone receive a urinary catheter?: a randomized, prospective study of patients undergoing total hip arthroplasty.

BACKGROUND: The objective of this randomized prospective study was to determine whether a urinary catheter is necessary for all patients undergoing total hip arthroplasty under spinal anesthesia. METHODS: Consecutive patients undergoing total hip arthroplasty under spinal anesthesia were randomized to treatment with or without insertion of an indwelling urinary catheter. All patients received spinal anesthesia with 15 to 30 mg of 0.5% bupivacaine. The catheter group was subjected to a standard postoperative protocol, with removal of the indwelling catheter within forty-eight hours postoperatively. The experimental group was monitored for urinary retention and, if necessary, had straight catheterization up to two times prior to the placement of an indwelling catheter. RESULTS: Two hundred patients were included in the study. There was no significant difference between the two groups in terms of the prevalence of urinary retention, the prevalence of urinary tract infection, or the length of stay. Nine patients in the no-catheter group and three patients in the catheter group (following removal of the catheter) required straight catheterization because of urinary retention. Three patients in the catheter group and no patient in the no-catheter group had development of urinary tract infection. CONCLUSIONS: Patients undergoing total hip arthroplasty under spinal anesthesia appear to be at low risk for urinary retention. Thus, a routine indwelling catheter is not required for such patients.

Near-anatomic allograft tenodesis of chronic lateral ankle instability.

BACKGROUND: Current operative treatment options for chronic lateral ankle instability include anatomic repairs utilizing existing local tissue and nonanatomic reconstructions sacrificing the peroneus brevis tendon to mechanically stabilize the ankle. Recent studies have modified these techniques to create an anatomic reconstruction utilizing allograft tendons. The purpose of this study was to retrospectively examine the clinical outcomes of a near-anatomic ligament reconstruction utilizing an allograft tendon for recurrent or complex lateral ankle instability. METHODS: Twenty-eight patients underwent a near-anatomic allograft lateral ankle ligament reconstruction with a semitendinosis allograft for severe or recurrent lateral ankle ligamentous instability, and all of them were available for follow-up at an average 32 months. Twelve patients had previously undergone lateral ankle ligament stabilizing surgery, 4 had Ehlers Danlos syndrome with poor local tissue, 5 had greater than 30 degrees of varus angulation of talar tilt, while 12 had associated hindfoot varus requiring concomitant reconstruction. Patients were assessed pre- and postoperatively for Visual Analog Scores (VAS) for pain, Foot and Ankle Ability Measures (FAAM), patient satisfaction, radiographic correction, and complications. RESULTS: Median VAS of pain decreased from 8 before surgery to 1 after surgery (P < .001). Median FAAM score increased from 41.7 to 95.2 after surgery (P < .001). Radiographic comparison demonstrated correction of preoperative varus malalignment in all but 1 patient. No patients developed subsequent subtalar arthritis or pain. Three patients had mild persistent instability, all of which was managed nonoperatively. One of the patients with persistent instability also developed chronic regional pain syndrome following surgery. At final follow-up, 25 of 28 patients rated their satisfaction as good or excellent and 3 as fair. No patients required revision surgery. CONCLUSION: Lateral ligament reconstruction utilizing a near-anatomically placed and tensioned allograft tendon was a viable option in treating recurrent and complex lateral instability. Not sacrificing the peroneal tendons avoided loss of eversion strength. Near-anatomic placement of the allograft provided good ankle stability without sacrificing subtalar motion or predisposition to subtalar arthritis in short-term follow-up. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Conversion arthrodesis for failed first metatarsophalangeal joint hemiarthroplasty.

BACKGROUND: Arthrodesis is currently the most commonly performed surgical procedure for the treatment of arthritis of the first metatarsophalangeal (MTP) joint. Hemiarthroplasty of the first MTP joint has been shown to have inferior clinical results and higher revision rates. The objective of this study was to assess the clinical outcome of the salvage of failed hallux phalangeal hemiarthroplasty with conversion to arthrodesis. METHODS: A retrospective review of patients who underwent salvage of the first MTP joint hemiarthroplasty with conversion to arthrodesis was performed. Preoperative assessment included the visual analog pain (VAP) scale and AOFAS Hallux Metatarsophalangeal Interphalangeal scoring system (AOFAS-HMI). Postoperative outcomes were graded via AOFAS-HMI, VAP, and Foot and Ankle Ability Measure (FAAM). RESULTS: Twenty-one hemiarthroplasties were converted to arthrodesis in 21 patients, with 18 available for follow-up included in the study. There were 13 women and 5 men. Local autologous bone graft was used in 12 cases, while 6 patients required tricortical iliac crest bone graft for the treatment of extensive bone loss. At final follow-up, at a mean of 4.3 years, the average VAS pain score had diminished to 0.75 from 7.8 preoperatively out of 10, while the mean AOFAS-HMI improved from 36.2 out of 100 preoperatively to 85.3 out of 90 (modified to exclude first MTP motion). The mean FAAM ADL/sports were 97.3/91.3, respectively. All patients achieved fusion although at a longer interval than primary fusions. CONCLUSIONS: Conversion from a failed hallux phalangeal hemiarthroplasty to arthrodesis showed similar success to primary arthrodesis which was achieved in the majority of cases with the use of regional bone graft for small defects. However, the time to fusion was longer than that of primary arthrodesis, and it sometimes required structural bone graft for augmentation. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Risk factors for wound complications after ankle fracture surgery.

BACKGROUND: The overall rate of complications after ankle fracture fixation varies between 5% and 40% depending on the population investigated, and wound complications have been reported to occur in 1.4% to 18.8% of patients. Large studies have focused on complications in terms of readmission, but few studies have examined risk factors for wound-related issues in the outpatient setting in a large number of patients. A review was performed to identify risk factors for wound complications tracked in the hospital and outpatient setting. METHODS: Four hundred and seventy-eight patients underwent open reduction and internal fixation of an ankle fracture between 2003 and 2010 by a single surgeon at a single institution. Demographic characteristics, time to surgery, comorbidities, and postoperative care were tracked. Wound complications were defined as those requiring dressing care and oral antibiotics or requiring further surgical treatment. RESULTS: Of the 478 patients who were followed, six (1.25%) had wounds requiring surgical debridement. Fourteen patients (2.9%) required further dressing care or a course of oral antibiotics. There were significant associations between wound complications and a history of diabetes (p < 0.001), peripheral neuropathy (p = 0.003), wound-compromising medications (p = 0.011), open fractures (p = 0.05), and postoperative noncompliance (p = 0.027). There was a significant difference in age between patients with and without wound complications (p = 0.045). We did not identify a relationship between time to surgery and complications. CONCLUSIONS: These results highlight the difficulty of treating medically complex and noncompliant patient populations. With careful preoperative monitoring of swelling, time to surgery does not affect wound outcome. The failure of the patient to adhere to postoperative instructions should be a concern to the treating surgeon.

Outcome of modified Kidner procedure with subtalar arthroereisis for painful accessory navicular associated with planovalgus deformity.

BACKGROUND: Type II accessory naviculars are frequently associated with planovalgus deformity. Operative treatment for patients recalcitrant to nonoperative treatment involves resection, with or without takedown, and reattachment of the tibialis posterior tendon as described by Kidner. This does not address the planovalgus deformity. The authors hypothesized that adding a subtalar arthroereisis to the Kidner procedure would lead to improvement of pain and function and correction of the deformity. METHODS: Institutional Review Board-approved, prospectively collected data were reviewed for 20 patients (23 feet), who underwent a combined modified Kidner and subtalar arthroereisis for painful type II accessory navicular with planovalgus deformity recalcitrant to nonoperative treatment. The average age at the time of surgery was 18 years. Patients were evaluated preoperatively and at final follow-up clinically, radiographically, and via the visual analog pain scale (VAPS), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle hindfoot score, and a satisfaction rating. Mean follow-up was 53.9 months. RESULTS: The mean AOFAS scores improved from 53 preoperatively to 95 at final follow-up and the mean VAPS score decreased from 7.4 preoperatively to 1.7 at final follow-up. Radiographically, the average Meary's angle improved from 18.5° apex plantar preoperatively to 3° apex plantar on weight-bearing lateral radiographs, and the average talar head uncoverage percentage on weight-bearing anteroposterior radiographs improved from 24% preoperatively to 3%. Nineteen of 20 patients reported good or excellent results. Three patients required implant removal because of pain; no recurrence of planovalgus deformity occurred after implant removal. No patients developed subtalar arthritis. CONCLUSION: The modified Kidner procedure combined with a subtalar arthroereisis resulted in significant pain and functional improvement. The deformity correction obtained at surgery was maintained even if the arthroereisis plug was removed. The extra-articular plug did not lead to subtalar arthritis.

Effect of work-hour restrictions and resident turnover in orthopedic trauma.

The resident 80-hour workweek and the July phenomenon have raised concern regarding the continuity of care of orthopedic patients in teaching institutions and its effect on postoperative complications and mortality. This study examined the effect of resident work-hour restrictions and the July phenomenon on patient outcomes after hip fracture at a large academic institution. Seven hundred twenty-two patients (mean age, 76.7 years) sustaining 319 femoral neck fractures and 403 intertrochanteric fractures between 2000 and 2010 were identified. Analysis was performed before and after July 1, 2003, as well as for the month of treatment. No difference existed in the postoperative outcome measures of delay of surgery (P=.061), complications (P=.904), and mortality (P=.981) between patients treated before and after July 1, 2003. Patients treated after July 1, 2003, had a significantly higher median number of preoperative comorbidities (4 vs 3, respectively; P<.0005). Turnover months, July and August, showed no difference in the outcome measures of delay of surgery (P=.171), complications (P=.776), and mortality (P=.524) compared with other months. This study suggests that 80-hour workweek restrictions or resident turnover months have no effect on patient care with respect to in-hospital time to surgery, complications, and mortality. This success can be attributed to ancillary staff support, physician extenders, and well-designed patient care protocols.

Nonagenarian hip fracture: treatment and complications.

BACKGROUND: Hip fracture is a common yet serious injury sustained by the elderly patient and represents one of the major healthcare challenges today. The aim of this study was to better define the unique characteristics of treating nonagenarian peritrochanteric hip fractures and their subsequent complications during hospital stay. METHODS: Seven hundred twenty-two patients underwent surgery for isolated fracture around the femoral neck. These patients were divided into one of three age groups: A, <50 years; B, 51-89 years; and C, >90 years. We performed a retrospective chart review to compare these groups in terms of patient characteristics, comorbidities, postoperative complications, fracture type, type of surgery performed, and mortality rate. RESULTS: There was no difference in time to surgery between groups. Comorbidities were similar in groups B and C but were higher than group A. Nonagenarians received a significantly greater percentage of hemiarthroplasties compared with those aged 51 years to 89 years. Cardiac complications were significantly higher in group C. In patients with sustained cardiac complications, the odds ratio for mortality was 15.88. CONCLUSIONS: Our results suggest that groups B and C were not significantly different pre- or intraoperatively. Nevertheless, there is an increase in cardiac complications and mortality in nonagenarians postoperatively. Nonagenarians should undergo similar treatment in the operating room compared with less elderly patients with the caveat that older patients, especially those with cardiac disease, may be more at risk for complication. The surgeon must evaluate the elderly patient with a hip fracture on a case-by-case basis, while ignoring chronological age. LEVEL OF EVIDENCE: III, prognostic study.

Terrible triad of the shoulder in a competitive athlete.

The terrible triad injury to a shoulder consists of shoulder dislocation, rotator cuff tear, and brachial plexus palsy. We present a case of a high velocity shoulder dislocation in an athlete with concomitant massive rotator cuff tear and incomplete infraclavicular brachial plexus injury. In this injury, most neurologic symptoms resolve, prompt surgical intervention is warranted, and comprehensive physical therapy is integral to recovery.

Conversion total hip arthroplasty: a reason not to use cephalomedullary nails.

Previous studies have yet to compare outcomes of conversion to hip arthroplasty from screw and side plate vs cephalomedullary nail. Seventy-six patients at our institution underwent hip conversion after fixation failure. We performed a retrospective chart review to compare perioperative outcomes in these 2 groups. Both operative time (P = .020) and blood loss (P = .041) were significantly greater in patients converted from cephalomedullary nail. Greater length of stay in this group trended to significance (P = .101). Perioperative complications were similar. Recent practice patterns reveal a dramatic increase in the use of cephalomedullary nails despite lack of evidence suggesting their clinical superiority in certain fracture patterns. Our results suggest that conversion to total hip arthroplasty after internal fixation with cephalomedullary nail is a more complex procedure than is conversion from screw and side plate. The surgeon should consider possible later hip conversion and these results when choosing the appropriate fixation implant.

Total knee arthroplasty component templating: a predictive model.

Preoperative planning is essential to total knee arthroplasty (TKA); however, TKA templating is historically inaccurate. To improve on templating accuracy and streamline preoperative planning, we set out to predict component sizes based on patient characteristics without radiographs. A total of 123 consecutive patients undergoing unilateral TKA were identified and included in the model study. Input variables consisted of age, gender (as a binary number), height, weight, and body mass index. A linear regression model was created. The models predicted component size exactly in 74% of femurs and 85% of tibias. All model predictions were within a ±1 size of the actual components implanted. Our models were more accurate than any previous model for TKA reported.

Accuracy of digital templating in total knee arthroplasty.

Preoperative planning is an important aspect of total joint arthroplasty. Although significant attention has been given to how total hip arthroplasty templates are magnified, total knee arthroplasty (TKA) digital templating magnification methods have not been compared. In this study, 50 patients undergoing TKA by the same surgeon were digitally templated using 2 common digital magnification methods to determine if there is any difference in accuracy or precision. Radiographs were randomly chosen to include a 25-mm magnification marker (MM) at the level of the joint or no magnification marker with uniform 115% magnification (NM). There was no statistical difference between templated and actual component sizes. Preoperative templating determined the exact component size in 64% of femurs and 60% of tibias using the NM technique. Femurs were slightly oversized (mean, 0.2 femur size), whereas tibias had no such trend. In MM templating, 52% of femurs and 48% of tibias were exact. Various methods of digital templating-the new standard of preoperative templating-provide no clear advantage over one another. The benefit of templating in TKA appears to be 2-fold: the surgeon can reliably predict a range of implant sizes needed and can ascertain a reliable starting point in determining implant size and position.

Multimodal pain management after total joint arthroplasty.

Adequate postoperative pain control in patients who have undergone total joint arthroplasty allows faster rehabilitation and reduces the rate of postoperative complications. Multimodal pain management involves the introduction of adjunctive pain control methods in an attempt to control pain with less reliance on opioids and fewer side effects. Current research suggests that traditional nonsteroidal anti-inflammatory drugs (NSAIDs) and the associated cyclooxygenase type-2 (COX-2) inhibitors improve pain control in most cases. Nearly all multimodal pain management modalities have a safe side-effect profile when they are added to existing methods. The exception is the administration of DepoDur (extended-release epidural morphine) to elderly or respiratory-compromised patients because of a potential for hypoxia and cardiopulmonary events.

Dermabond efficacy in total joint arthroplasty wounds.

The goals of wound closure are a low infection rate and timely healing. Total joint arthroplasty (TJA) requires mobile recovery, and, therefore, a high-tension wound care environment. We conducted a study to compare the efficacy of high-viscosity Dermabond (Ethicon, Somerville, New Jersey) and the efficacy of surgical staples in healing high-tension, mobile surgical sites of TJA. Of 236 total knee arthroplasties and 223 total hip arthroplasties (459 surgeries total), 250 were performed with Dermabond and 209 with staples. According to χ2 analysis, case and control infection rates were equivalent. Signs of acute inflammation (redness, drainage, dehiscence) also were statistically equivalent. Absence of staples accounted for a significant decrease in tape blisters and skin abscesses. Dermabond is superior to staples in high-tension wound care.