Open ankle fractures in the elderly: predisposing factors and the associated mortality.

The purpose of this study was to investigate the independent effect of open ankle fractures on postoperative mortality and to identify factors leading to open ankle fractures in the elderly population. This is a retrospective case-control study of 1,045 patients aged 65 years and older, with ankle fractures undergoing surgical fixation between 2010 and 2020 at three medical centers (Levels 1-2). A logistic regression analysis was used to identify risk factors for open fractures. Propensity score matching and survival analysis were used to measure the hazard of mortality attributable to open versus closed ankle fractures. There were 128 (12.2%) patients with open ankle fractures. Patients with open ankle fractures were more likely to be older, to be active smokers (OR = 1.7, p = 0.049), and tended to have a higher number of medical comorbidities including hypertension (OR = 2, p = 0.006) and chronic kidney disease (OR = 2.9, p = 0.005). Open ankle fractures were, independently of comorbid conditions and age, associated with higher risk of mortality (HR = 1.7, p = 0.03).

Use of a Lightweight Portable Fluoroscopy Device for Obtaining Weightbearing Ankle Images.

Portable fluoroscopy devices provide point-of-care imaging in emergency and out-patient clinics. In this prospective study, we compared weightbearing images of syndesmosis obtained using a novel lightweight portable battery-powered fluoroscopy device with those obtained with a conventional radiography device. Eleven healthy participants underwent bilateral 3-view weightbearing imaging of both ankles using a radiography (X-ray group) device and a portable fluoroscopy system (LPF group). Anteroposterior, mortise, and lateral views were compared between the 2 techniques. Radiographic measurements were done by 2 observers. These measurements included talar tilt, tibiofibular clear space, tibiofibular overlap, plafond malleolar angle, medial distal tibial angle, medial clear space, lateral distal tibial angle, anterior and posterior tibiofibular distance were measured using the appropriate view. Data were compared between the 2 techniques; the interobserver agreement was calculated within each group. P < .05 was considered statistically significant. Comparing the 2 imaging modalities, there was no significant difference between the measurements in LPF and X-ray groups except plafond malleolar angle. The overall interobserver agreement was excellent between the 2 observers. There was no significant difference between the measures by the 2 observers and between the bilateral ankles. Fluoroscopy was associated with about 50% extra radiation exposure, although the absolute amount of radiation was not clinically significant. These results support the use of weightbearing images using portable fluoroscopy device as an alternative for the conventional radiography systems.

Factors influencing treatment recommendations for base of 5th metatarsal fractures in orthopaedic residency programs.

BACKGROUND: Management of proximal 5th metatarsal fractures remains a controversial topic in orthopaedic surgery. Both operative and non-operative approaches have been described in the clinical setting. This confusion has led to non-standardized treatment recommendations for proximal 5th metatarsal fractures. This study was designed to analyze concordance rate of treatment recommendations between orthopaedic trainees and orthopaedic foot and ankle experts. METHODS: An online survey containing 14 cases of proximal 5th metatarsal fractures were distributed to 92 orthopaedic residents in two ACGME-accredited programs. Relevant weight-bearing radiographs, patient's age and gender were provided, and two questions regarding treatment recommendations were surveyed. Resident's recommended treatment was then matched against ultimate treatment by orthopaedic foot and ankle experts. ANOVA and T-test are used for associations between the rate of concordant treatment with PGY and trainee foot and ankle experience. Fleiss' kappa was used to assess the inter-observer agreement. RESULTS: Seventy-two residents returned the survey. The overall concordance rate was 43.98% with no correlation between agreement rate and PGY-years. No difference in agreement rate was observed between residents who had completed their foot and ankle rotation versus those who had not. There was a slight inter-observer agreement in recommending treatment among all residents (κ=0.117, 95% CI: 0.071-0.184). CONCLUSIONS: Our data demonstrated no significant concordance between resident level in training regarding proximal 5th metatarsal fracture treatment decisions, nor between residents and subspecialty-trained foot and ankle surgeons. Increased rotations with foot and ankle fellowship-trained surgeons throughout residency may be desirable to improve the quality of residency training. LEVEL OF EVIDENCE: III.

Complete Cuboid Dislocation With Associated Lisfranc Injury: A Case Report and Review of the Literature.

Cuboid dislocations are rare midfoot injuries that usually occur in the setting of high-energy trauma. Diagnosis can be challenging and optimal treatment remains unknown. This case report and review aims to summarize the recent literature on this topic.

Inter- and intra-observer agreement of femoroacetabular impingement (FAI) parameters comparing plain radiographs and advanced, 3D computed tomographic (CT)-generated hip models in a surgical patient cohort.

PURPOSE: The purpose of our study was to investigate whether advanced, 3D computed tomographic (CT)-generated hip models improves inter-and intra-observer agreement when compared to plain radiographs in identifying femoroacetabular impingement (FAI) morphology. METHODS: Eight consecutive patients who underwent surgery for FAI pathology were selected for this study. Preoperative CT scan image data were used to create high resolution, 3D hip reconstruction models. Four observers (two attending hip surgeons and radiologists) performed a blinded review of preselected radiographs and 3D CT hip models. Alpha and lateral center-edge angle measurements, location of cam lesion and the presence of a "crossover sign" were assessed. Inter- and intra-observer agreement was determined by calculating the intra-class correlation coefficients (ICC) or kappa coefficients to evaluate agreement for categorical variables. RESULTS: The parameter that demonstrated the highest and poorest inter-observer agreement was the presence of a "crossover sign" using 3D CT-generated high resolution hip models (ICC = 0.76, p = 0.00) and anteroposterior pelvis radiography, respectively (ICC = 0.20, p = 0.02). Alpha angle values were significantly higher using plain radiographs when compared to 3D hip reconstruction models (61.1° ± 10.4° versus 55.4° ± 14.4°, p = 0.003). Furthermore, when compared to radiographs, 3D hip reconstruction models demonstrated significantly higher intra-observer agreement (ICC = 0.856 versus 0.405, p = 0.005) when determining the presence of a "crossover sign". CONCLUSIONS: Our findings were suggestive that for most commonly used FAI morphology parameters, CT-generated hip models demonstrated little benefit over plain radiographs in improving inter-observer agreement among providers. LEVEL OF EVIDENCE: III.

Use of Bio-integrative Screws for Fixation of Lisfranc Instability; Pros and Cons from Surgeons' Point of View in a Cadaver Study.

Objectives: Majority of Lisfranc fracture-dislocations require anatomic reduction and rigid internal fixation to prevent debilitating sequelae. Current methods include solid screws and flexible fixations which have been in use for many years. Biointegrative screw is a newer option that has not yet been thoroughly investigated for its effectiveness for Lisfranc injuries. Methods: The ligaments of the Lisfranc complex were resected in eight lower-leg cadaveric specimens. This was done by eight foot and ankle surgeons individually. Distraction forces were applied from opposite sides at the joint to replicate weight bearing conditions. Three methods of fixation - flexible fixation, metal, and biointegrative screws- were evaluated. The diastasis and area at the level of the ligament were measured at four conditions (replicated injury and each type of fixation) in neutral and distraction conditions using fluoroscopy images. The Wilcoxon test and Kruskal Wallis test were used for comparison. P value <0.05 was considered statistically significant. Results: The diastasis value for the transected ligament scenario (2.47 ± 0.51 mm) was greater than those after all three fixation methods without distraction (2.02 ± 0.5 for flexible fixation, 1.72 ± 0.63 mm for metal screw fixation and 1.67 ± 0.77 mm for biointegrative screw fixation). The transected ligament diastasis was also greater than that for metal screw (1.61 ± 1.31mm) and biointegrative screws (1.69 ± 0.64 mm) with distraction (p<0.001). The area at the level of the ligament showed higher values for transected ligament (32.7 ± 13.08 mm2) than the three fixatives (30.75 ± 7.42 mm2 for flexible fixation, 30.75 ± 17.13 mm2 for metal screw fixation and 29.53 ± 9.15 mm2 for biointegrative screw fixation; p<0.05). Conclusion: Metal screws, flexible fixation and biointegrative screws showed comparable effectiveness intra-op, in the correction of diastasis created as a consequence of Lisfranc injury.

Compressive Strength of Midfoot Fusion Nail vs Midfoot Fusion Bolt and Role of Subtalar Fusion in Midfoot Charcot Fixation Model.

BACKGROUND: Operative management of midfoot Charcot arthropathy often involves an extended midfoot arthrodesis with intramedullary bolts for fixation, a method called "beaming." Recently intramedullary nails have been introduced for the same indication, presumably providing stronger fixation. This study compares midfoot fusion nails to bolts with regard to stiffness and compressive ability. Additionally, we assessed how the addition of a subtalar fusion affects the construct. METHODS: Medial column fusions were performed on 10 matched cadaver foot specimens with either a midfoot fusion nail or bolt. Specimens underwent cyclical compression loading, and displacement was measured. Separately, compressive forces produced were compared between the 2 fixation constructs using a synthetic bone block model. Lastly, another 10 matched specimens with midfoot fusion nails were evaluated with or without subtalar fusions. RESULTS: No differences in stiffness were found in comparing matched specimens between nail vs bolt or comparing nail only without subtalar fusion (STF) vs nail with STF. The compressive force produced by the nail specimens was significantly and substantially greater than the bolted specimens (751.7 vs 139.0 N, P = .01). The accumulated height drop at the midfoot after cycling was 0.5 mm more in the nail group than in the bolt group (1.72 vs 1.22 mm, P = .008). The nail with STF group had greater initial height drop at the midfoot than the nail-only group (0.68 vs 0.34 mm, P = .035) with similar initial height drop at the ankle. However, there were no differences in strength among the matched pairs of midfoot nail-only vs midfoot nail with STF as measured by displacement after fatigue or maximum force at load to failure. CONCLUSION: The overall cadaveric comparisons between matched pairs of nails vs bolts, and nail-only vs nail with STF, did not provide noteworthy differences between the groups with regard to strength or stiffness. However, the compressive force of the midfoot fusion nail was far superior to the bolt in a synthetic bone model. These data provide valuable insight comparing implants used in Charcot midfoot arthrodesis.

Republication of "Stress Fractures of the Foot and Ankle in Athletes".

Stress fractures of the foot and ankle are common injuries in athletes. Management differs considerably based on fracture location and predisposing factors. Repetitive loading of the foot and ankle in athletes should result in physiologic bone remodeling in accordance with Wolff's law. However, when there is not sufficient time for complete healing to occur before additional loads are incurred, this process can instead lead to stress fracture. Assessment of the athlete's training regimen and overall bone health is paramount to both the discovery and treatment of these injuries, although diagnosis is often delayed in the setting of normal-appearing initial radiographs. While most stress fractures of the foot or ankle can usually be treated nonoperatively with a period of activity modification, fractures in certain locations are considered "high risk" due to poor intrinsic healing and may warrant more proactive operative management.

The Lateral Fibular Stress Test: High Variability of Force Applied by Orthopaedic Surgeons in a Biomechanical Model.

Background: The lateral fibular stress test (LFST), also known as the hook or Cotton test, is commonly performed to assess syndesmotic instability intraoperatively. Several studies have used 100 N as the force applied when performing the LFST to detect syndesmotic instability, though no evidence-based requisite force has been described for the test. We hypothesize that surgeons do not apply force uniformly or consistently when performing the LFST and that substantial variation exists. Fundamentally, this could lead to inconsistent diagnosis of syndesmotic instability as surgeons may not be applying the force in a consistent manner. Methods: A biomechanical ankle model consisting of an industrial force gauge attached through a SawBones model was fashioned. Orthopaedic attending surgeons and trainees were asked to perform a series of LFSTs and to simulate the force they typically apply intraoperatively. Basic demographic data were collected on each participant. Results: Thirty-three surgeons participated in the study, including 18 trainees. The median (IQR) force applied during the LFST was 96.42 (71.42-126.33), 87.49 (69.19-117.40), 99.99 (79.91-137.49), for the pooled group, attendings, and trainees respectively. More than half (54.5%) of all trials were less than 100 N (57.8% of surgeons, 51.8% trainees). Intraobserver correlation was excellent within the overall cohort (0.92, P < .001), trainees (0.90, P < .001), and attendings (0.94, P < .001), respectively. Interobserver reliability was fair among the overall cohort (κ =0.28, P = .49), and poor between the attendings (κ = 0.11, P = .69) and the trainees (κ = 0.05, P = .82), respectively. Conclusion: Our study demonstrates that the amount of force applied by typical surgeons when performing the LFST test is highly variable. Variable force application when performing the LFST may lead to inconsistent detection of syndesmotic instability, which may portend a poorer outcome. Clinical Relevance: In this study, we demonstrate the wide variability in the amount of force used during a lateral fibular stress test. High variability of force application when performing the LFST may lead to inconsistent diagnosis of syndesmotic instability, which may portend a poorer outcome. Our findings suggest the need for further investigation into the technical aspects of syndesmotic testing that will permit more reproducible and valid interrogation of the syndesmosis.

Quality of MIS vs Open Joint Preparations of the Foot and Ankle.

BACKGROUND: Minimally invasive surgery (MIS) is growing in the field of foot and ankle, and the MIS burr is an emerging tool. Although commonly used to perform osteotomies, the burr can also be used for arthrodesis joint preparation that traditionally would be performed through open incisions. To date, there is no study comparing the quality of joint preparation between using a fluoroscopy-guided MIS technique compared to traditional open techniques. The goal of this cadaveric study is to compare the percentage of joint surfaces prepared between MIS and open techniques for the most common joints that are fused in foot and ankle surgery. METHODS: Open joint preparation was performed under direct visualization with open incisions. MIS joint preparation was performed percutaneously using fluoroscopic guidance alone, without arthroscopy. After joint preparation, cadaveric samples were disarticulated, and joint surfaces were analyzed for percentage of cartilaginous surface removed. The percentage of joint surface prepared was compared between the open and MIS techniques. RESULTS: Ten cadaveric samples were used for the MIS technique and 5 samples for the open technique. Percentage of joint surface prepared was similar for all joint surfaces. CONCLUSION: The MIS technique in the hands of experienced surgeons was found to provide overall similar percentages of surface area prepared compared to traditional open techniques. CLINICAL RELEVANCE: MIS joint preparation may be useful for specific patient populations. This study suggests that MIS joint preparation is a reasonable, and possibly advantageous, alternative to open preparation in arthrodesis surgery when performed by experienced MIS surgeons.

Utility of WBCT to Diagnose Syndesmotic Instability in Patients With Weber B Lateral Malleolar Fractures.

BACKGROUND: Diagnosing syndesmotic instability accompanying Weber B ankle fractures can be challenging. This study aimed to evaluate the ability of weight-bearing computed tomography (WBCT) to diagnose syndesmotic instability using one-dimensional, two-dimensional, and three-dimensional measurements among patients with unilateral Weber B lateral malleolar fractures with symmetric medial clear space (MCS) on initial radiographs and yet demonstrated operatively confirmed syndesmotic instability. METHODS: The treatment group included 23 patients with unilateral surgically confirmed syndesmotic instability accompanying Weber B ankle fractures who underwent preoperative bilateral foot and ankle WBCT. The control group included 18 unilateral Weber B ankle fracture patients without syndesmotic instability who underwent bilateral WBCT. Measurements on WBCT images included the following: (1) syndesmotic area, (2) anterior, middle, and posterior distal tibiofibular distance, (3) fibular rotation, (4) distance from fibular tip to plafond, (5) fibular fracture displacement, and (6) MCS distance. In addition, the following volumetric measurements were calculated: (1) syndesmotic joint volume from the tibial plafond extending to 3 and 5 cm proximally, (2) MCS volume, and (3) lateral clear space volume. Area under the receiver operating characteristic curve analysis and Delong test were used, and optimal cutoff values to distinguish between stable and unstable syndesmosis were determined using Youden J statistic. RESULTS: Among patients with unilateral syndesmotic instability and Weber B ankle fractures, all WBCT measurements were significantly greater than uninjured side, except MCS distance, syndesmotic area, and anterior and posterior tibiofibular distances (P values <0.001 to 0.004). Moreover, syndesmosis volume spanning from the tibial plafond to 5 cm proximally had the largest area under the curve of 0.96 (sensitivity = 90%; specificity = 95%), followed by syndesmosis volume up to 3 cm proximally (area under the curve = 0.91; sensitivity = 90%; specificity = 90%). Except for MCS volume and distal fibular tip to tibial plafond distance, the control group showed no side-to-side difference in any parameter. CONCLUSION: Syndesmotic joint volume measurements seem to be best suited to diagnose syndesmotic instability among patients with Weber B ankle fractures, compared with other two-dimensional and three-dimensional WBCT measurements. LEVEL OF EVIDENCE: Level III, comparative diagnostic study.

A Prospective Randomized Controlled Trial Comparing Physical Therapy With Independent Home Stretching for Plantar Fasciitis.

BACKGROUND: Although formal physical therapy (PT) is effective in treating plantar fasciitis (PF), it is unclear how this compares with home-based plantar fascia stretching (HS). METHODS: Fifty-seven patients with PF were enrolled in a prospective randomized trial comparing PT with HS. Visual analog scale (VAS), Foot and Ankle Ability Measure (FAAM), and Short Form (36) Health Survey (SF-36) scores were analyzed at 6 weeks, 3 months, 6 months, and 1 year. RESULTS: At 6 months, VAS improved in both HS (35% decrease; P < 0.001) and PT (26% decrease; P = 0.002) relative to baseline. FAAM Activities of Daily Living scores improved 13.0% (P = 0.005) in HS and 21.3% (P < 0.001) in PT at 6 months relative to baseline. The SF-36 Physical Component Summary Scores demonstrated improvement at all time points in both groups. There were no notable intergroup differences in VAS, FAAM, or SF-36 at any time point. DICUSSION: The clinical outcomes of a home stretching protocol and PT did not markedly differ for the treatment of PF. LEVEL OF EVIDENCE: Therapeutic Level I.

Novel values in the radiographic diagnosis of ligamentous Lisfranc injuries.

BACKGROUND: Ligamentous Lisfranc instability is commonly missed on unilateral radiographs. However, measurement protocols for bilateral weightbearing radiographs have not been standardized. The primary aim of this study was to investigate the optimal cut-off values for diagnosing Lisfranc instability by evaluating the side-to-side differences of preoperative bilateral weightbearing radiographs among patients with surgically-confirmed ligamentous Lisfranc instability. A secondary aim was to investigate whether the midfoot measurements for detecting Lisfranc injury could also be used in patients with a pre-existing bilateral Hallux Valgus (HV) deformity by evaluating whether the Lisfranc measurements could be affected by a foot deformity as HV. PATIENTS AND METHODS: Patients who underwent surgical repair of ligamentous Lisfranc instability, as well as a separate cohort with bilateral hallux valgus deformity, were included in this multicenter retrospective cohort study. A standardized radiographic measurement protocol was used to assess the midfoot and a receiver operator correlation (ROC) analysis was used to identify the optimal cut-off value for measurements. Interclass Correlation (ICC) scores were calculated to assess the interrater reliability of the Lisfranc area measurement. RESULTS: Forty-seven patients were included in the Lisfranc group with a mean age of 33 (± 15) years and 25 patients were included in the HV group with a mean age of 51 (± 15) years. For the Lisfranc group, measurements that demonstrated a significant side-to-side difference included; increased C1M2 diastasis of 2.4 mm (± 1.4, P<0.001), increased C1M2 surface area of 24 mm2 (± 15, P<0.001), C2M2 malignment by 1.7 mm (± 1.2, P<0.001), second tarsometatarsal joint dorsal step-off sign by 0.8 mm (± 0.7, P<0.001), and arch height by 2.5 mm (± 6.4, P<0.048), all greater on the injured side. In the HV group, side-to-side measurements were not significantly different. There was no significant difference comparing the M1M2 measurement in the HV group with the injured (P = 0.16) or uninjured (P = 0.08) foot in the Lisfranc group. The optimal cut-off points were between the injured and uninjured foot in the Lisfranc group were 2.1 mm for C1M2 diastasis, 0.7 mm for the C2M2 alignment, and 30 mm2 for the C1M2 surface area. The ICC-score for the second C1M2 area measurement was 0.88. CONCLUSION: Bilateral foot weightbearing radiographs can effectively diagnose ligamentous Lisfranc instability using a standardized measurement protocol. Malalignment of the medial aspect of the second metatarsal base ≥0.3 mm relatively to the intermediate cuneiform offers a high sensitivity, and distance ≥2.1 mm between the second metatarsal base and the medial cuneiform has a high specificity. Intermetatarsal distance between the first and second metatarsal base has a low sensitivity and specificity and should not be used in solitary for diagnosis. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Factors Related to Neuropathic Pain following Lower Extremity Amputation.

BACKGROUND: Lower extremity amputations are common, and postoperative neuropathic pain (phantom limb pain or symptomatic neuroma) is frequently reported. The use of active treatment of the nerve end has been shown to reduce pain but requires additional resources and should therefore be performed primarily in high-risk patients. The aim of this study was to identify the factors associated with the development of neuropathic pain following above-the-knee amputation, knee disarticulation, or below-the-knee amputation. METHODS: Retrospectively, 1565 patients with an average follow-up of 4.3 years who underwent a primary above-the-knee amputation, knee disarticulation, or below-the-knee amputation were identified. Amputation levels for above-the-knee amputations and knee disarticulations were combined as proximal amputation level, with below-the-knee amputations being performed in 61 percent of patients. The primary outcome was neuropathic pain (i.e., phantom limb pain or symptomatic neuroma) based on medical chart review. Multivariable logistic regression was performed to identify independent factors associated with neuropathic pain. RESULTS: Postoperative neuropathic pain was present in 584 patients (37 percent), with phantom limb pain occurring in 34 percent of patients and symptomatic neuromas occurring in 3.8 percent of patients. Proximal amputation level, normal creatinine levels, and a history of psychiatric disease were associated with neuropathic pain. Diabetes, hypothyroidism, and older age were associated with lower odds of developing neuropathic pain. CONCLUSIONS: Neuropathic pain following lower extremity amputation is common. Factors influencing nerve regeneration, either increasing (proximal amputations and younger age) or decreasing (diabetes, hypothyroidism, and chronic kidney disease) it, play a role in the development of postamputation neuropathic pain. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Surgical Management of Musculotendinous Balance in the Progressive Collapsing Foot Deformity: The Role of Peroneal and Gastrocnemius Contracture.

Surgical treatment of progressive collapsing foot deformity (PCFD) relies on understanding the dynamic and deforming musculotendinous structures that contribute to hindfoot valgus, forefoot abduction, forefoot varus, and collapse or hypermobility of the medial column. Equinus commonly is seen in PCFD and consideration should be given to isolated gastrocnemius or Achilles lengthening. Although transfer of the flexor digitorum longus tendon is performed in PCFD attributed to dysfunction and pathology of the posterior tibialis tendon (PTT), retention of PTT is an area for further research. The peroneus brevis, which contributes to hindfoot imbalance in chronic cases, is a possible component of tendon rebalancing.

The Syndesmosis, Part II: Surgical Treatment Strategies.

Syndesmotic injuries in the setting of ankle fracture are critically important to diagnosis and treat to restore an anatomic tibiotalar relationship. Physical examination and clinical suspicion remain critically important for diagnosis. Ultrasound examination and weight-bearing computed tomography scans are evolving to help diagnosis more subtle injuries. Although flexible syndesmotic fixation may decrease malreduction rates, the benefits over rigid fixation is the subject of ongoing study. Anatomic reduction remains critical regardless of fixation choice. Routine removal of rigid syndesmotic hardware does not seem to offer substantial clinical improvement in pain or range of motion; however, broken hardware may cause irritation.

Implant Removal Matrix for the upper Extremity Orthopedic Surgeon.

Orthopedic implant removal is a commonly performed procedure. While implant removal can be associated with improved symptoms, risks of the surgery are notable. Stripped screws, broken and retained hardware, and morbidity associated with soft tissue compromise during difficult removal are all common. Familiarity with the instruments is critical to procedure success. The purpose of this study is to assist removal of unfamiliar screws in upper extremity surgery by offering a reference for screw and driver compatibility across manufacturers. Inclusion of device manufacturers was determined by market share. Screw size, drive configuration, and screw removal system compatibility data was collected and recorded. Screw, guide-wire, and screwdriver compatibility was assessed and compared to two commonly utilized universal implant-removal sets. Eight upper extremity implant vendors were included. The data was compiled in table format according to manufacturer and sub-categorized to facilitate screw identification according to radiographically identifiable characteristics. The diversity of orthopaedic implants in upper extremity surgery requires careful preoperative planning to identify the appropriate equipment for implant removal. The goal of this work is to provide a centralized reference of commonly implanted screws, guide-wires, and drivers for the upper extremity to facilitate removal.

Consideration of medial anatomical structures at risk when placing quadricortical syndesmotic fixation: A cadaveric study.

BACKGROUND: Surgical fixation of syndesmotic instability using quadricortical fixation, whether screws or suture-button devices, places structures on the medial side of the tibia at iatrogenic risk. This study aims to radiographically map the anatomic course of structures on the medial aspect of the distal tibia to be able to at-risk zones (ARZs) for syndesmotic fixation. METHODS: Eighteen fresh-frozen cadaveric ankle specimens were dissected. The saphenous neurovascular bundle (SNVB) and the posterior tibial tendon (PTT) were identified and marked with copper wiring. Standardized and calibrated lateral radiographs of the distal tibia and fibula were analyzed using a grid system consisting of 3 columnar zones from anterior to posterior and five 1-cm rows to chart the anatomic course of the SNVB and the PTT. RESULTS: The SNVB was located in the more anterior zones (1, 2, or anterior to Zone 1) in 97.3% of specimens. The SNVB traversed from posterior to anterior as it descended proximal to distal. The PTT was found in Zone 3 (most posterior zone) for all specimens. The PTT was noted to pass behind (radiographically overlap) the tibia in 83.3% (15 of 18) of specimens between 1 and 3 cm above the tibiotalar joint. CONCLUSIONS: Placement of quadricortical syndesmotic fixation places structures on the medial ankle at risk. The SNVB is at considerable risk along the anterior course of the distal tibial while the PTT is only at risk in zone 3 at the distal extent of the tibia.

A Limited Fixation, Olecranon Sparing Approach, for Management of Geriatric Intra-Articular Distal Humerus Fractures.

PURPOSE: We propose that geriatric comminuted intra-articular distal humerus fractures can be effectively treated with a limited fixation approach aimed at achieving varus/valgus stability with columnar fixation, but allowing intra-articular comminution to heal by secondary congruency against an intact olecranon, thus avoiding an olecranon osteotomy. METHODS: Fifty-six elderly patients with AO 13-C type fractures, who underwent surgical fixation with ≥12-months of follow-up were retrospectively reviewed. Thirty patients were treated with intra-articular open reduction internal fixation (ORIF) with an olecranon osteotomy and 26 patients were treated with our limited fixation (L-ORIF) approach. Outcomes were range of motion (ROM), complications, additional surgery, and patient-reported outcome measures (PROMIS). RESULTS: At final follow-up, the average elbow ROM was 97° (40°-155°) in the ORIF group and 86.5° (20°-145°) in the L-ORIF group. There was a trend toward more complications and additional surgery in the ORIF group. PROMIS scores for pain were 53.1 and 52.14, and PROMIS functional scores were 41.7 and 41.4 in the ORIF and L-ORIF group respectively. No differences in outcomes were statistically significant. CONCLUSION: A limited fixation technique based on achieving varus/valgus stability with columnar fixation, demonstrated equivalent outcomes in elderly patients with intra-articular distal humerus fractures when compared to intra-articular ORIF with an olecranon osteotomy.

Getting the Starting Point Right: Prevention of Skiving and Fibular Cortical Breach During Suture Button Placement for Syndesmotic Ankle Injuries.

The use of suture button (SB) devices in the treatment of syndesmotic ankle injuries is increasing. These constructs have demonstrated better syndesmotic reduction, improved clinical outcomes, and lower rates of hardware removal compared with screw fixation. However, placing a SB device without a fibular plate can be technically challenging. In this technique tip, we use an illustrative case to demonstrate a technique tip that minimizes the risk of anterior or posterior cortical breach of the fibula and helps facilitate more accurate placement of a SB device.Levels of Evidence: Level V: Expert opinion.