Spherical ceramic interpositional arthroplasty for basal fourth and fifth metatarsal arthritis.

BACKGROUND: Arthrosis of the fourth and fifth tarsometatarsal joints is difficult to treat. Arthrodesis is both difficult to achieve as well as disabling. Tendon interpositional arthroplasty has been performed with some success. A new technique using ceramic ball interpositional arthroplasty was evaluated. METHODS: Between 2001 and 2003, 13 patients in whom nonoperative treatment had failed had resection arthroplasty of the base of the fourth or fifth metatarsals with ceramic ball interposition (Orthosphere, Wright Medical Technology, Arlington, Tennessee). Patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale, a visual analogue scale, a satisfaction index, physical examination, and radiographs. RESULTS: At an average 34-months followup, 11 of the 13 patients were available for evaluation. The five men and six women had an average age of 48 years. Seven patients reported a traumatic etiology. Average postoperative AOFAS score was 53 points, an 87% improvement over preoperative values. Visual analogue scale pain improved 42%. All 11 patients were satisfied and would undergo the operation again. One of the patients demonstrated subsidence of the implant into the cuboid but continued to have improvement in symptoms. To date there have been no implant dislocations. Three of the 11 patients had differential injections before surgery. CONCLUSIONS: Lateral column tarsometatarsal interpositional arthroplasty is an effective salvage operation for lateral column midfoot arthrosis and should be considered in this patient population. The use of the ceramic ball allows a technically simple procedure and rapid recovery.

Midline posterior approach to the ankle and hindfoot.

BACKGROUND: The posterior approach to the ankle and hindfoot can be used for fixation of fractures, fusions, or osteotomies and is especially useful in patients with poor soft tissue anteriorly, medially, or laterally. However, a high rate of wound complications has been reported with standard posterolateral and posteromedial approaches. Because of local wound problems with the standard approaches, we have used a midline posterior approach and a longitudinal midline splitting of the Achilles tendon. This approach provides excellent exposure while minimizing wound healing complications. This approach provides dissection between angiosomes, which should optimize preservation of the blood supply to the skin flaps. METHODS: We retrospectively evaluated wound healing in 33 consecutive patients who had surgery using the modified midline posterior approach. The mean age of the patients was 48 (range 16 to 83) years. The mean followup was 24 (range 12 to 73) months. Surgical procedures included ankle and pantalar arthrodeses (primary and revision), talectomies with tibiocalcaneal arthrodesis, repairs of fracture nonunions, reconstruction of a chronic Achilles rupture, and hardware removal with multiple debridements of chronic osteomyelitis. RESULTS: There were no instances of skin flap necrosis. One patient with diabetic neuropathic arthropathy developed a small superficial wound eschar that healed with dressing changes alone. Four patients developed deep infections; two of these had a history of deep infection and the other two had significant comorbidities. CONCLUSIONS: The modified midline posterior approach to the distal tibia, ankle, and hindfoot has a low primary wound complication rate without sacrificing exposure. This approach can be used for any procedure requiring posterior access to the distal tibia, ankle joint, or subtalar joint.

Massive perineal wound slough after treatment of complex pelvic and acetabular fractures using a traction table.

An operating table with the capacity for skeletal traction against a pudendal post is a helpful and commonly used piece of equipment for certain pelvic and acetabular fracture patterns. Perineal soft tissue trauma and urogenital injuries are associated with some pelvic and acetabular fractures. The perineal region is vulnerable to compromise after such injuries. There is little documentation available in the literature that addresses intraoperative complications of the perineum after the use of a traction table for pelvic fractures. We present here a case in which prolonged traction against a pudendal post during operative fixation of complex pelvic and acetabular fractures resulted in massive perineal wound slough. This case should heighten surgeons' awareness of the vulnerability of the perineum to injury with the use of a traction table and should prompt measures to prevent complications.