Arthroscopic Quantification of Syndesmotic Instability in a Cadaveric Model.

PURPOSE: To investigate whether arthroscopy or stress radiography can identify instability resulting from single-ligament injury of the ankle syndesmosis and to determine whether either modality is capable of differentiating between various levels of ligament injury. METHODS: Syndesmotic/deltoid ligament sectioning was performed in 10 cadaver legs. Arthroscopic evaluation and fluoroscopic stress testing were completed after each sectioning. In group 1 (n = 5), sectioning began with anteroinferior tibiofibular ligament (AITFL), then interosseous membrane (IOM), posteroinferior tibiofibular ligament (PITFL), and deltoid. In group 2 (n = 5), this order was reversed. Measurements were made by determining the largest-sized probe that would fit in the anterior and posterior syndesmosis. Radiographic parameters included tibiofibular overlap/clear space and medial clear space. RESULTS: No radiographic measurement proved useful in distinguishing between intact and transected AITFL. Anterior probe (AP) size reached significance when distinguishing between intact and AITFL-transected specimens (P < .0001). AP detected significant differences comparing single with 2-, 3-, and 4-ligament (AITFL, IOM, PITFL, deltoid) disruptions (P = .05, <.0001, and <.0001, respectively). Significant differences were observed between 2- and 3/4-ligament (P = .02) transections. Posterior probe (PP) size detected significant differences between intact and single-, double-, triple-, and complete ligament transections (P values .0006, <.0001, <.0001, <.001, respectively). PP detected significant differences between single- and double-, triple-, and complete ligament transection models (P = .0075, .0010, and .0010, respectively). PP distinguished between 2- and 3/4-ligament (P = .03) transections. CONCLUSIONS: Stress radiography did not distinguish between intact and single-ligament disruption, and was unreliable in distinguishing between sequential transection models. Arthroscopy significantly predicted isolated disruption of the AITFL or deltoid ligaments. Also, probing was able to differentiate between most patterns of ligament injury, including sequential transections. CLINICAL RELEVANCE: These data can aid surgeons during arthroscopy of the ankle when attempting to correlate intraoperative syndesmotic evaluation findings with the extent of ligament injury.

Subtle anterior subtalar dislocation.

Subtalar dislocations are uncommon injuries, and anterior subtalar dislocations are extremely rare. Only 7 cases have been reported in detail in the literature, but all were associated with substantial displacement immediately apparent on radiographs. We report a case of a subtle anterior subtalar dislocation that was missed on initial plain films but was subsequently treated successfully with closed reduction.

Assessment of Malpractice Claims Associated With Acute Compartment Syndrome.

BACKGROUND: Because acute compartment syndrome is one of the few limb-threatening and life-threatening orthopaedic conditions and is difficult to diagnose, it is a frequent source of litigation. Understanding the factors that lead to plaintiff verdicts and higher indemnity payments may improve patient care by identifying common pitfalls. METHODS: The VerdictSearch legal claims database was queried for the term "compartment syndrome." After 46 cases were excluded for missing information or irrelevancy, 139 cases were reviewed. The effects of plaintiff demographics, mechanism of injury, and complications were assessed. RESULTS: Of 139 cases, 37 (27%) were settled, 69 (50%) resulted in a defendant ruling, and 33 (24%) resulted in a plaintiff ruling. Juries were more likely to rule in favor of juvenile plaintiffs than adult patients (P = 0.002) and female plaintiffs than male plaintiffs (P = 0.008), but indemnity payments were not affected by the age or sex of the plaintiff. Plaintiffs who experienced acute compartment syndrome as a complication of surgery were more likely to win their suit and receive higher awards (P < 0.05), compared with those in whom the condition developed as a result of trauma. Amputation or delay in diagnosis or treatment did not affect plaintiff verdicts or awards. CONCLUSION: Defendants were more likely to lose a lawsuit concerning the management of acute compartment syndrome if the patient was a woman or child or if acute compartment syndrome developed as a complication of a surgical procedure.

Deep Infections After Syndesmotic Fixation With a Suture Button Device.

Suture button devices such as the TightRope (Arthrex, Naples, Florida) have been increasingly used for syndesmotic fixation of ankle fractures. Despite proposed advantages, prior studies have shown equivalent outcomes, with a theoretical decreased need for removal of hardware. Complications of suture button fixation of syndesmotic instability may be underreported and include lateral suture knot inflammation with or without granuloma formation, infection, aseptic osteolysis with widening of the tibial drill tunnels, heterotopic ossification, and osteomyelitis. In this case series, the authors review the current literature and describe 3 patients with TightRope fixation for syndesmotic instability who developed deep infection. The authors believe that braided suture within suture button devices may provide an environment conducive to the propagation of infection across the syndesmotic fixation tract. Evidence of suture button migration or osteolysis of the TightRope tract should prompt an infectious workup and removal of hardware. If there is concern for infection associated with the TightRope, the authors recommend removing both metallic buttons and the entirety of the suture to prevent harboring a nidus for further infection. [Orthopedics. 2017; 40(3):e541-e545.].

Nail Dynamization for Delayed Union and Nonunion in Femur and Tibia Fractures.

Femoral and tibial shaft fractures are common injuries in the United States. Since their introduction, reamed intramedullary nails have become the treatment of choice for most of these fractures. However, delayed union and nonunion can complicate treatment in up to 10% of patients. Removal of interlocking screws, or dynamization, can promote fracture healing in cases of delayed union or nonunion. The efficacy of nail dynamization has been reported to range from 19% to 82%. This study was conducted to evaluate the efficacy of dynamization, identify the factors associated with its success or failure, and analyze the cost compared with exchange nailing. The authors retrospectively reviewed charts from 2011 to 2014 and searched billing records for Current Procedural Terminology codes 27506 and 27759, for intramedullary nailing of femoral and tibial shaft fractures, and code 20680, for removal of deep hardware. This search identified 34 patients with 35 fractures treated with dynamization for delayed union or nonunion. Dynamization was effective in creating union in 54% of patients. The factor that best correlated with the success of dynamization was the diameter of the fracture callus at the time of dynamization. Direct costs associated with dynamization were nearly $10,000 less than those associated with exchange nailing. Dynamization can be an effective first-line treatment for delayed union and nonunion of femoral and tibial shaft fractures. The union rate in the current study is similar to previously published rates, and cost data suggest that dynamization is a viable alternative to exchange nailing for some patients with delayed union or nonunion. [Orthopedics. 2016; 39(6):e1117-e1123.].

Psychological Aspects of Recovery Following Anterior Cruciate Ligament Reconstruction.

Recovery following anterior cruciate ligament reconstruction is an arduous process that requires a significant mental and physical commitment to rehabilitation. Orthopaedic research in recent years has focused on optimizing anterior cruciate ligament surgical techniques; however, despite stable anterior cruciate ligament reconstructions, many athletes still never achieve their preinjury ability or even return to sport. Psychological factors associated with patient perceptions and functional outcomes following anterior cruciate ligament reconstruction are important to acknowledge and understand. Issues related to emotional disturbance, motivation, self-esteem, locus of control, and self-efficacy can have profound effects on patients' compliance, athletic identity, and readiness to return to sport. The psychological aspects of recovery play a critical role in functional outcomes, and a better understanding of these concepts is essential to optimize the treatment of patients undergoing anterior cruciate ligament reconstruction, particularly those who plan to return to sport. Identifying at-risk patients, encouraging a multidisciplinary approach to patient care, and providing early referral to a sports psychologist may improve patient outcomes and increase return-to-play rates among athletes.

Distal femoral complications following antegrade intramedullary nail placement.

While antegrade nailing for proximal and diaphyseal femur fractures is a commonly utilized fixation method with benefits including early mobilization and high rates of fracture union, both intraoperative and postoperative complications may occur. Intraoperative errors include leg length discrepancy, anterior cortical perforation, malreduction of the fracture, and neurovascular injury, and postoperative complications include nonunion, malunion, infection, and hardware failure. This case series reviews complications affecting the distal femur after intramedullary nailing including fracture surrounding a distal femoral interlocking screw (Case #1), nonunion after dynamization with nail penetration into the knee joint (Case #2), and anterior cortical perforation (Case #3). Prevention of intraoperative and postoperative complications surrounding intramedullary nailing requires careful study of the femoral anatomy and nail design specifications (radius of curvature), consideration of the necessity of distal interlocking screws, the need for close radiographic follow-up after nail placement with X-rays of the entire length of the nail, and awareness of possible nail penetration into the knee joint after dynamization.

Use of a Pneumatic Limb Positioner for Invasive Skeletal Traction in Posterior Hindfoot Arthroscopy.

Posterior hindfoot arthroscopy is a useful tool to treat a variety of foot and ankle pathologies. Skeletal distraction of the hindfoot to increase visualization in posterior ankle arthroscopy has been described in previous studies, but the described distractor is not readily available in most operating rooms. We describe a case of posterior hindfoot distraction in the prone position using a pneumatic limb positioner and other readily available Food and Drug Administration-approved equipment to apply tension to a transcalcaneal wire. The distraction technique we describe does not require any custom equipment, can fit on most standard operating tables, and is readily available in standard operating rooms. This method achieves adequate distraction, resulting in better visualization and more space for arthroscopic instrumentation.