ABSTRACT
BACKGROUND: Various fixation methods have been described for Akin osteotomy, based on using metal implants or transosseous sutures. The aim of this study was to evaluate radiological outcomes and complications of closing wedge Akin osteotomy based on a crossed suture configuration of the joint capsule rather than using implants. The null hypothesis is that a crossed suture has comparable radiological results to other techniques, with no additional complications. METHODS: It's a retrospective study. Patients who underwent Akin osteotomy fixed either with implant or joint capsule suture between 2015 and 2018 were included. Distal articular set angle corrections in pre- and postoperative anteroposterior foot x-rays were calculated by 2 observers. Complications, such as pain, infection, non-union and need of surgery revision, was compared at 1 year follow-up. RESULTS: 89 patients, 30 in the implant group and 59 in the suture group. Mean distal articular set angle corrections were 6.43 (SD 5.54) and 7.36 (SD 5.48) degrees in the implant and suture groups, respectively, without statistically significant differences (p 0.454). Complications were 2 local pain and 1 wound infection cases in the suture and implant groups, respectively (p 0.138, p 0.197). CONCLUSION: Akin osteotomy with suture fixation yields comparable radiological results to metal implant fixation methods without increasing the associated complications.
Subject(s)
Hallux Valgus , Humans , Hallux Valgus/surgery , Retrospective Studies , Osteotomy/methods , Suture Techniques , Pain/surgery , Treatment OutcomeABSTRACT
Proximal medial gastrocnemius release (PMGR) is a technique that is performed to relieve tension in the Achilles-calcaneus-plantar system when a biomechanical overload is present1-3. One of the main indications for this technique is recalcitrant plantar fasciitis. This procedure may also be useful in second-rocker metatarsalgia or midportion Achilles tendinitis4. It is considered to be an easy and safe method for achieving good results5-7. Description: PMGR is performed with the patient in the prone position. A thigh tourniquet is not utilized. We prefer to use spinal anesthesia, but local anesthesia could be applied along with sedation. A posteromedial incision is made on or just below the posterior knee crease. The crural fascia is divided, and the proximal insertion of the medial gastrocnemius is identified. Performing the "hook maneuver" with a curved dissector is helpful at this step. Only the white fibers are sectioned in order to allow for a lengthening of the muscular fibers that is completed with forceful ankle dorsiflexion. After proper hemostasis has been achieved, the subcutaneous layer and skin are closed, leaving the fascia open. Alternatives: Nonoperative treatment should be the first option, including analgesics, insoles, heel cups, calf-stretching, injections, and extracorporeal shock wave therapy8. Some authors have also suggested that application of a walking cast for 3 to 6 weeks should be attempted9,10. Once all of these treatment options have failed, operative treatment is appropriate. Historically, open plantar fasciotomy was offered to patients with recalcitrant plantar fasciitis, and this treatment continues to be a surgical option. Other procedure, like the Strayer, Vulpius, or Baumann techniques, involve the calf system and are called "gastrocnemius recession." However, these techniques act in the more distal aspect of the calf system compared with PMGR. Rationale: PMGR offers patients with recalcitrant plantar fasciitis rapid recovery and good results. This procedure obviates the complications associated with plantar fasciotomy, in which the medial aspect of the proximal plantar fascia is divided to relieve the overload. A plantar fasciotomy (either open or endoscopic11) risks lateral column overload12 or a painful flatfoot if >50% of the fascia is divided. A long recovery period following plantar fasciotomy has also been described7. On the other hand, other procedures have been utilized to lengthen the Achilles-calcaneus-plantar system to an even greater extent. Techniques like the Silfverskiöld (i.e., medial and lateral proximal gastrocnemius release) or Strayer (i.e., division of the distal aspect of the gastrocnemius fascia) technique present a higher rate of complications (up to 38%), specifically nerve injuries13,14. We consider these procedures (classified as gastrocnemius recession procedures) more properly indicated for patients with neurological diseases or with an equinus contracture. The medial gastrocnemius is the more powerful of the 2 bellies. Releasing the medial head alone offers a robust decrease in tension and is safer than approaching the lateral head of the gastrocnemius15. At the same time, this technique provides a quick recovery for the patient. PMGR can also help those patients with other clinical signs related to gastrocnemius tightness, such as calf cramps and pain or repeated muscle injuries. Moreover, it can be effective in patients with second-rocker metatarsalgia or midportion Achilles tendinitis1,16. Expected Outcomes: PMGR has a reported rate of satisfaction of >80%. Most patients undergoing this procedure experience substantial pain relief within the first 2 to 3 months6,17. PMGR is an outpatient procedure with a short operative time and a rapid return to recreational and labor activities. The complication rate is low, and the most common complications are calf hematomas and delayed wound healing. The present article demonstrates a reduction in pain and good functional results. An improvement in the perception of health-related quality of life, especially in the physical and pain domains of the Short Form-36 questionnaire, was also observed. Important Tips: The prone position allows for direct access to the proximal medial head of the gastrocnemius. Preferably, perform PMGR without a tourniquet in order to assure proper hemostasis. Keep the ankle joint free at the end of operating table because ankle dorsiflexion is a helpful maneuver at some stages in this procedure. Digital (index finger) dissection should be performed among the medial head of the gastrocnemius, the hamstrings, and the posterior aspect of the proximal tibia. The hook maneuver, performed with use of a blunt dissector, is helpful to identify all of the white fibers. Only white fibers should be divided. The surgeon must also make sure to cut the more anterior part of the aponeurosis that is hidden by red fibers. After cutting the white fibers, forceful ankle dorsiflexion is required to obtain full lengthening of the muscle. Proper hemostasis should be achieved to prevent formation of a calf hematoma. Advise the patient to do calf-stretches as soon as pain permits in order to prevent a contracting muscle scar. Acronyms & Abbreviations: PMGR = proximal medial gastrocnemius releaseESWT = extracorporeal shock wave therapySD = standard deviation.
ABSTRACT
Introducción: la depresión al nacer constituye una causa frecuente de ingreso de neonatos en cuidados intensivos.Objetivo: identificar los factores influyentes en la depresión neonatal.Métodos: se realizó un estudio descriptivo longitudinal retrospectivo en el Policlínico Hospital Alberto Fernández Valdés durante los años 2003 al 2012, en el municipio Santa Cruz del Norte, provincia Mayabeque. El universo fue de 124 recién nacidos con Apgar, al minuto de nacer, menor de 7 y la muestra de 92 casos escogidos al azar. Los datos se recolectaron mediante un formulario para el análisis de las variables de estudio y se empleó la distribución de frecuencias, media aritmética, desviación estándar y porcentaje como medidas de resumen. Resultados: la depresión al nacer fue más frecuente en hijos de madres mayores de 35 años 43,48 por ciento, blancas 42,39 por ciento y con antecedentes de hipertensión arterial y tabaquismo en el 25 por ciento y 18,48 por ciento respectivamente; la circular del cordón 45,65 por ciento, la preeclampsia 25 por ciento y la rotura prematura de las membranas 14,13 por ciento fueron las afecciones del embarazo que más se presentaron; el nacimiento a término fue el más representado 57,61 por ciento y la cesárea la vía del parto más frecuente 44,57 por ciento; la mayoría de los recién nacidos deprimidos fueron masculinos 57,61 por ciento y con peso normal al nacer 46,74 por ciento.Conclusiones: existen múltiples factores que pudieran influir en la depresión al nacer, mucho de los cuales son susceptibles de ser modificados o controlados desde la atención primaria de salud (AU)
Introduction: depression at birth is a common cause of admission to neonatal intensive care.Objective: to identify the factors influencing neonatal depression.Methods: a descriptive, longitudinal, retrospective study was conducted at Alberto Fernández Valdés Teaching Hospital during the years 2003 to 2012, in the municipality of Santa Cruz del Norte. The universe was 124 newborns with Apgar at 1 minute less than 7 and a sample of 92 randomly selected cases. Data were collected using a form for the analysis of the study variables and it frequency distribution, arithmetic mean, standard deviation and percentage summary measures were used.Results: depression at birth was more frequent in children of mothers over 35 years 43,48 per cent, white 42,39 per cent and antecedents of arterial hypertension and tobaccoism in 25 per cent and 18,48 per cent respectively; cord loops 45,65 per cent, preeclampsia 25 per cent and premature rupture of membranes 14,13 per cent were the pregnancy conditions of pregnancy most frequently presented; full term birth was the most represented 57,61 per cent and C-section the most frequent delivery via 44,57 per cent; most depressed newborns were male 57,61 per cent and with normal weight at birth 46,74.Conclusions: there are multiple factors that might influence on depression at birth, many of which are susceptible of being altered or controlled from the primary health care (AU)
