Category:
Ankle; Trauma
Introduction/Purpose:
In the light of recent randomized control trials, both suture-button and syndesmotic screw fixation are considered standard-of-care for syndesmotic ...fixation, but no gold standard currently exists. An alternative technique that has been described to stabilize the syndesmosis is with use of suture-tape (InternalBrace, Arthrex) to augment a torn AITFL. This method has been the subject of several biomechanical studies that show it better restores anatomic relationships and can provide a preinjury level of syndesmotic stability. Additionally, it is thought to allow for protected healing of native ligaments, which may be of benefit to patients in the long-term. With this study we sought to explore the long-term outcomes of anatomic augmentation of the AITFL with the InternalBrace for the treatment of syndesmotic injury.
Methods:
We identified 31 patients who had suffered an acute or subacute syndesmotic injury and were treated with the InternalBrace technique (with or without adjunctive syndesmotic fixation) over a 12-month period from 2019-2020 by a single surgeon. The primary outcome variable was the Olerud-Molander Ankle Score (OMAS) at long-term follow up (12-36 months). Other outcomes collected were FAOS scores, range of motion data, and complications. Additionally, radiographs at five timepoints were reviewed to determine maintenance of syndesmotic reduction.
Results:
At final follow-up, 15 patients completed the primary outcome with a mean OMAS of 78 (SD, 18). All 31 patients were determined to have a successful syndesmotic reduction at the time of the index procedure. No patients were noted to have a radiographic loss of reduction with a tibiofibular clear space > 6mm at time of final radiographic follow up (mean follow-up 439 days). For those patients with ROM data collected at final follow up, 12/15 patients were limited in dorsiflexion (average deficit 6 degrees), and 7/15 in plantarflexion (average deficit 14 degrees). In total, 10/31 patients developed symptoms of anterolateral impingement, for which six underwent secondary arthroscopic debridement.
Conclusion:
We report the first mid-to-long term clinical results of a newer alternative method of syndesmotic stabilization. Functional results are comparable to current standards-of-care. AITFL augmentation provides consistent anatomic reduction of the syndesmosis with enough biomechanical strength to resist rotation and diastasis. However, in some patients the development of irregular thickening/scarring of the AITFL contributed to symptoms of anterolateral impingement and stiffness. To avoid this complication, alterations in technique, such as a more proximal application of the suture-tape or avoidance of overtightening, are possible and emphasize the importance of future research.
Category:
Trauma
Introduction/Purpose:
Despite the increasing awareness and literature addressing fractures of the posterior malleolus (PM), no biomechanical nor clinical studies have been able to ...establish consensus surgical indications or treatment methods for these common orthopedic injuries. A posterolateral or posteromedial approach allows fixation to be placed in a compressive mode as opposed to the more traditional anterior to poster placed screws which relies upon static screw placement. We designed a technique that utilizes a suture button device for fixation. This technique allows for compression across the fracture site while avoiding cumbersome patient positioning and extensive posterior dissection.
Methods:
Our technique utilizes a standard lateral approach to the fibula which is fixed routinely. Finger dissection is then carried out between the posterior fibula and perennial tendons to grant access to the PM which typically reduces via ligamentotaxis. A PCL drill guide is then placed on the substance of the PM and a cannulated drill is advanced through the distal tibia from anterior to posterior after careful dissection through a small incision on the anterior tibia. A suture lasso then brings the suture button through the drill tunnel and it is compressed over a knotless endobutton which rests on the anterior tibia. The medial malleolus is then addressed routinely. Following placement of all hardware an external rotation stress test is performed to assess syndesmotic stability. After IRB approval the clinical and radiographic data of patients who underwent this technique was retrospectively reviewed.
Results:
Seven patients underwent treatment of a PM fracture using our technique. All cases achieved an anatomic reduction of the PM based on available imaging. One patient was found to have a loss of reduction of her medial malleolus at the first post- operative visit and underwent revision surgery with a good result.
Final follow up averaged 9.5 months. Four of the seven patients underwent additional surgical procedures. Final ROM was available for 5 patients. Of the five, 4 achieved dorsiflexion greater than 5 degrees and had an arc of motion greater than 35 degrees. The final patient had a final ROM arc of 10-30 degrees of plantar flexion despite progressive dorsiflexion casting and lysis of adhesions. AOFAS score of available patients averaged 81.5.
Conclusion:
Our technique of using a suture button as fixation for PM fractures has several advantages. First, patient position improves surgical ease. Second, this approach avoids extensive posterior dissection and bulky hardware which we believe may lead to posterior scar formation and resultant ankle stiffness. Finally, the posterior button allows for compression of the PM which may contribute to the improved results seen with a posterior approach. We were able to achieve a radiographically anatomic reduction, satisfactory ROM and good outcome scores. We believe that our technique is a viable option in those injuries that benefit from surgical treatment of the PM component.
One hundred fifty patients were enrolled in a multicenter, randomized, placebo-controlled, prospective, doubleblind study to assess the clinical safety and effectiveness of extracorporeal shock wave ...therapy (ESWT) using the Dornier Epos Ultra for the treatment of plantar fasciitis. The Active Group was treated with electromagnetically generated shocks using ultrasound guidance during a single therapy session. The Control Group received a sham treatment under similar clinical conditions. The groups were demographically similar with respect to age, height, and weight. The average duration of symptoms was nearly 2 years in both groups. All patients were evaluated by the visual analog scale for pain, American Orthopaedic Foot and Ankle Society scores, Roles and Maudsley Score, SF-12 health status questionnaire, and physical examination. The Active Group reported 56% success at 3 months and 94% success at 12 months posttreatment. The Control Group reported 47% success at 3 months posttreatment. Twelve-month data were not collected for the Control Group as they were unblinded at 3 months and offered treatment. ESWT represents a safe treatment option for chronic proximal plantar fasciitis.
In a controlled, prospective, double-blind study, the incidence of accurate injection of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendon compartments was defined and ...correlated with clinical relief of de Quervain's tendinitis. X-ray dye was included with steroid and lidocaine injections for 19 patients; dye location was immediately checked by 1 radiologist blinded to the clinical results. Dye was confirmed to be within the first dorsal compartment in 16 of 19 cases. There was relief of symptoms in 11 of 19 patients. Four of 5 patients with dye in both the APL and EPB tendon compartments, experienced relief of symptoms, while all 3 with dye in neither compartment experienced no relief. This suggests that accurate injection of steroids is required for relief of de Quervain's tendinitis. The EPB compartment was often missed (13/19 cases), possibly because it was separated or of small size and deep location. This may be a factor in failed injections, just as surgery can fail if a separate EPB compartment is not released.
A retrospective review was made of all patients operated on by the two senior authors from January 1985 to January 1993 for problems with Kirschner wire breakage following forefoot surgery. ...Thirty-three broken K-wires in 27 patients were encountered. All of these were 0.045-inch K-wires that had been placed across the metatarsophalangeal (MTP) joint of the lesser toes. In no case was there breakage of a K-wire that was larger than 0.045 inches or that did not cross the MTP joint. The medical records and radiographs of 565 consecutive patients having fixation with 0.045-inch K-wires that crossed the MTP joints of the lesser toes were then reviewed. A total of 1002 K-wires were used with an overall failure rate of 3.2% (4.8% of the patients). All of these K-wires failed just proximal to the point of entry into the metatarsal head. No intra-articular retained fragments were noted. Twenty-five of the retained fragments were completely within the metatarsal head and shaft, and eight of these fragments pierced the cortex of the metatarsal proximally. Twenty-three patients with retained fragments were examined in follow-up and in no case could the retained fragment be palpated or directly related to postoperative symptoms. Of the three patients who complained of persistent pain, two had mild pain with persistent MTP synovitis and one had severe pain due to lateral deviation of the toe after surgery.
The Foot in Running Baxter, DE; Zingas, C
Journal of the American Academy of Orthopaedic Surgeons,
05/1995, Letnik:
3, Številka:
3
Journal Article
Recenzirano
Baylor College of Medicine, Houston.
Injuries to the foot and ankle are often encountered in runners, be they highlevel competitors or recreational joggers. Many of these injuries are due to overuse ...syndromes and training errors; others are related to the running surface or the athlete's footwear. Only with a rational approach to diagnosis can the primary underlying cause be identified so that appropriate treatment can be prescribed. Conservative measures, which include rest, cross-training, orthotic changes, and altering training methods, are often curative. Surgery is usually indicated only after conservative measures have been exhausted. Careful preoperative planning is needed to minimize dissection, thereby optimizing the chance of a return to the preinjury activity level. Preoperative counseling of the patient is also important, so that expectations about the outcome and the rehabilitation requirements are realistic.
PDF
