A clinical and radiographic comparison of two hardware systems used to treat jones fracture of the fifth metatarsal.

BACKGROUND: There is a broad variation in the type and size of screws used for Jones fractures. Therefore, a screw implant specifically designed for the operative treatment of a Jones fracture has been developed. The purpose of this retrospective study was to compare the clinical and radiographic results of patients treated with a screw specifically designed for this fracture to a group treated with a traditional screw. METHODS: Forty-seven patients underwent surgery (47 feet) for a Jones fracture between 1999 and 2007, performed by 4 foot and ankle fellowship-trained orthopaedic surgeons at one institution. Twenty-six patients (26 feet) were treated with the indication-specific screw (group I), while 21 patients (21 feet) were operated on with the traditional screw (group II). All patients were retrospectively reviewed for either radiographic signs of union or an adverse event. Radiographic parameters were evaluated by 2 independent observers, which included Torg's classification system (intramedullary sclerosis, cortical hypertrophy, periosteal reaction), hardware failure, with an endpoint of healing or nonunion. Of 47 patients, 40 were available for clinical follow-up, and functional outcomes with VAS pain scores at final follow-up visit were compared. Additional procedures (bone grafting), complications, and adverse events were recorded. The results were analyzed using Fisher's exact tests and independent t test with a significance level of .05. The average age of the patients was 43.8 years, with a mean clinical follow-up of 37 months (range of 6 to 105 months). RESULTS: Preoperative films were classified according to the Torg classification system and did not demonstrate any difference between group I and group II, with respect to the type of Jones fracture. There was no significant difference found between the 2 groups as related to fracture union, but there was a higher number of adverse events in group II as compared with group I (P = .03). The adverse events included 2 implant failures, 1 intraoperative fracture, and 1 symptomatic hardware, all requiring further surgical interventions. All adverse events occurred within an average of 2 months after surgery. Clinically, there were no statistically significant differences between the 2 systems in regard to limitations in activity, shoe-wear modifications, recovery time, satisfaction, and willingness to repeat the surgery. The VAS pain scales (0-100) were equivalent; average VAS pain of group II was reported as 9 (range, 0-33), as compared to the VAS pain of patients in group I averaging 11 (range, 0-47). CONCLUSIONS: In our retrospective series, comparing 2 differing instrumentation systems in treating Jones fractures, both groups were found to progress to radiographic union above 95%. Although there was a statistically greater number of adverse events in the traditional hardware system (group II), clinically both groups had similar outcomes with good results. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

BMP-14 gene therapy increases tendon tensile strength in a rat model of Achilles tendon injury.

BACKGROUND: Molecular and cellular-based enhancements of healing combined with conventional methods may yield better outcomes after the surgical management of tendon injury. We examined the histological and biomechanical effects of adenovirus-mediated transgene expression of bone morphogenetic protein-14 (BMP-14) on healing in a rat Achilles tendon laceration model. Specifically, we hypothesized that this delivery system for gene therapy would hasten the restoration of the normal histological appearance and tensile strength of a surgically repaired tendon. METHODS: The right Achilles tendon of ninety male Sprague-Dawley rats was transected, repaired, and immediately infected with adenovirus expressing either the gene for green fluorescent protein (AdGFP) or the gene for human BMP-14 and green fluorescent protein (AdBMP-14). A sham control group received no viral-mediated infection after repair. Animals from each of the three groups were killed at one, two, and three weeks after surgery. The retrieved tendons were inspected, examined under light and fluorescent microscopy, and tested to determine their tensile strength. RESULTS: Tendons transduced with BMP-14 exhibited less visible gapping, a greater number of neotenocytes at the site of healing, and 70% greater tensile strength than did either those transduced with GFP or the sham controls at two weeks after repair. Histological examination revealed no inflammatory response to the adenovirus in tendons transduced with BMP-14 or GFP. No ectopic bone or cartilage formed in the tendons transduced with BMP-14. CONCLUSIONS: Adenovirus-mediated gene therapy with BMP-14 expedites tendon-healing in this animal model. No adverse immunological response to the adenoviral vector was detected in the host tissue, and the local production of BMP-14 did not induce unwelcome bone or cartilage formation within the healing tendon. CLINICAL RELEVANCE: The results of this animal study suggest that gene therapy with BMPs may improve the capacity of injured musculoskeletal tissue to heal.

Realtime Achilles Ultrasound Thompson (RAUT) Test for the Evaluation and Diagnosis of Acute Achilles Tendon Ruptures.

BACKGROUND: Acute complete Achilles tendon ruptures are commonly missed injuries. We propose the Realtime Achilles Ultrasound Thompson (RAUT) test, a Thompson test under ultrasound visualization, to aid in the diagnosis of these injuries. We hypothesized that RAUT testing would provide improved diagnostic characteristics compared with static ultrasound. METHODS: Twenty-two consecutive patients with operatively confirmed acute Achilles tendon ruptures were prospectively evaluated with RAUT testing and static ultrasonography. RAUT video recordings and static ultrasound images from both ruptured and uninjured sides were randomized and graded by a group of novice reviewers and a group of expert attendings. From these observations, sensitivity, specificity, positive predictive value, and negative predictive value for RAUT and static ultrasound were calculated. In addition, κ interobserver coefficients were computed. Forty-seven novice reviewers and 11 foot and ankle attendings made a total of 4136 and 528 observations, respectively. RESULTS: For static ultrasound, sensitivity and specificity were 76.8% and 74.8% for the novice reviewers and 79.6% and 86.4% for the attendings, respectively. For RAUT testing, sensitivity and specificity were 87.2% and 81.1% for the novice group and 86.4% and 91.7% for the attending group, respectively. The κ coefficient was 0.62 and 0.27 for novice and attending RAUT reviewers, indicating substantial and fair agreement, respectively, but only 0.46 and 0.12 for static ultrasonography, representing moderate and slight agreement, respectively. CONCLUSION: RAUT testing was a sensitive and specific test, providing a cost-effective adjunct to the clinical examination when diagnosing acute Achilles tendon ruptures. This test can be used by surgeons with minimal training in ultrasonography. LEVEL OF EVIDENCE: Level II, diagnostic study.

Arthroscopic suture anchor repair of the lateral ligament ankle complex: a cadaveric study.

BACKGROUND: Operative treatment of mechanical ankle instability is indicated for patients with multiple sprains and continued episodes of instability. Open repair of the lateral ankle ligaments involves exposure of the attenuated ligaments and advancement back to their anatomic insertions on the fibula using bone tunnels or suture implants. HYPOTHESIS: Open and arthroscopic fixation are equal in strength to failure for anatomic Broström repair. STUDY DESIGN: Controlled laboratory study. METHODS: Seven matched pairs of human cadaveric ankle specimens were randomized into 2 groups of anatomic Broström repair: open or arthroscopic. The calcaneofibular ligament and anterior talofibular ligament were excised from their origin on the fibula. In the open repair group, 2 suture anchors were used to reattach the ligaments to their anatomic origins. In the arthroscopic repair group, identical suture anchors were used for repair via an arthroscopic technique. The ligaments were cyclically loaded 20 times and then tested to failure. Torque to failure, degrees to failure, initial stiffness, and working stiffness were measured. A matched-pair analysis was performed. Power analysis of 0.8 demonstrated that 7 pairs needed to show a difference of 30%, with a 15% standard error at a significance level of α = .05. RESULTS: There was no difference in the degrees to failure, torque to failure, or stiffness for the repaired ligament complex. Nine of 14 specimens failed at the suture anchor. CONCLUSION: There is no statistical difference in strength or stiffness of a traditional open repair as compared with an arthroscopic anatomic repair of the lateral ligaments of the ankle. CLINICAL RELEVANCE: An arthroscopic technique can be considered for lateral ligament stabilization in patients with mild to moderate mechanical instability.

Salvage of chronic instability of the syndesmosis with distal tibiofibular arthrodesis: functional and radiographic results.

BACKGROUND: Failure to treat an injury of the syndesmosis after an ankle fracture can lead to a poor functional outcome and posttraumatic arthritis. The results after reconstruction of an ankle with an incongruous mortise, chronic diastasis of the syndesmosis, and arthritis remain unknown. The purpose of the present study was to review the radiographic and clinical results of salvaging this condition through reduction and arthrodesis of the distal tibiofibular articulation. METHODS: Ten patients (mean age, fifty-four years) with chronic syndesmotic instability who underwent salvage by a single surgeon were evaluated retrospectively. Five parameters of mortise and syndesmotic alignment were measured on weight-bearing radiographs that were made preoperatively and at the time of the latest follow-up. The extent of arthritis in the ankle was graded with use of an established classification system. Clinical rating scores that were recorded preoperatively and at the time of the latest follow-up were culled from the medical records and were compared. Each patient's stated satisfaction with the operation and willingness to undergo the operation again were retrieved from the medical records. RESULTS: After a mean duration of follow-up of forty-one months (minimum, two years), the medial clear space, talocrural angle, and talar tilt had improved. No ankle demonstrated progression of arthritis on the basis of the radiographic grade. The clinical rating score improved significantly because of improvements in the pain, activity, maximum walking distance, and gait subscales. Two patients had a total of three additional procedures. Both had prominent implants removed, and one subsequently underwent an ankle arthroscopy. All patients reported satisfaction with and a willingness to undergo the procedure again. At the time of the latest follow-up, no patient had undergone an ankle arthrodesis. CONCLUSIONS: The significant improvements in the radiographic and functional measures of outcome that were observed in this small cohort suggest that chronic syndesmotic instability after ankle fracture can be salvaged with reduction and arthrodesis of the distal tibiofibular articulation. Furthermore, the reconstruction of an incongruous and arthritic ankle is an alternative to and may postpone the subsequent need for ankle arthrodesis or arthroplasty.