The modified Broström-Gould procedure--early results using a newly described surgical technique.

Ankle lateral ligament injuries are one of the most common sporting injuries, with the majority being successfully treated conservatively. However, reconstruction is required if this fails. We present the clinical results of a newly described surgical technique of triple-breasting the lateral ligament complex using suture anchors. Sixteen patients (18 ankles) were treated with this new technique. The mean duration of symptoms was 77 months. The mean follow-up was 25 months. All patients underwent an arthroscopy followed by lateral ligament reconstruction by this new technique. Additional pathology included osteoarthritis (2), ankle impingement due to anterior cheilus (2), osteochondral defects (3) and non-union of fracture of anterior process of calcaneus. Additional procedures above diagnostic arthroscopy, soft tissue debridement and modified Broström-Gould repair included debridement and microfracture (3), open excision of anterior calcaneal process (1) and arthroscopic anterior ankle cheilectomy (2). At final follow-up, all ankles were subjectively and objectively stable. Mean AOFAS score improved from 53 to 88. This was statistically significant (p<0.05). Eight patients had resumed normal pre-injury level of activities (including sports), 8 had some reduction in normal level of activity. The early results of our modification show it to be safe, successful and comparable with previously published series with all patients having objectively and subjectively stable ankles at final follow-up.

Surgical technique, fusion rates, and planovalgus foot deformity correction with naviculocuneiform fusion.

BACKGROUND: Arthrodesis of the naviculocuneiform (NC) joints is not a common procedure, as it is perceived by many to be less reliable or less predictable than arthrodesis of proximal or distal joints in the medial column. There is a subset of patients with planovalgus feet, cavovarus feet, and degenerative arthritis who also have an apex of deformity at the NC joints in whom fusion is indicated. The surgical technique, fusion rates, and deformity correction data for NC fusion in planovalgus feet are evaluated in this report. METHODS: Twenty-eight patients (33 feet) who underwent surgery between October 2008 and November 2012 were identified who had NC fusion as their only arthrodesis procedure. Medical records and radiographs were reviewed, and time to union was calculated. Twenty patients from that group underwent NC fusion for symptomatic planovalgus feet, and their preoperative and last postoperative weight-bearing radiographs were reviewed and compared for deformity correction. All patients were operated on by the senior author or a senior foot and ankle trainee during fellowship using the same surgical technique, and all patients followed a standardized postoperative rehabilitation protocol. RESULTS: Mean time to union for all 33 NC fusions was 21.7 ± 2 weeks (mean ± SEM). One patient underwent revision for nonunion, resulting in an arthrodesis rate of 97%. For NC fusions in those with planovalgus feet, an improvement in mean lateral talus-first metatarsal angle (Meary's line) from 12.3 ± 1.3 degrees to 5.2 ± 1.2 degrees (P < .05) was found. There was also a mean improvement in talonavicular coverage angle from 14.1 ± 1.8 degrees to 7.4 ± 1.3 degrees (P < .05). There were 2 superficial wound infections that were successfully treated with oral antibiotics, there were no cases of deep vein thrombosis or pulmonary embolism, and all patients came out of cast at 6 weeks into a fixed angle boot to commence weight bearing. Patients were happy with 32 of the 33 procedures and required no further treatment for their condition. CONCLUSIONS: NC fusion was a safe and predictable procedure for any of its indications, with a fusion rate similar to that of other joints in the foot albeit with a longer time to union. For patients with symptomatic and flexible planovalgus feet, NC fusion resulted in deformity correction in multiple planes and good symptomatic relief. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Ankle arthrodesis vs TTC arthrodesis: patient outcomes, satisfaction, and return to activity.

BACKGROUND: It is believed that patients with an ankle arthrodesis (AA) have better outcomes than after a tibiotalocalcaneal (TTC) arthrodesis due to preservation of subtalar motion. However, there are no studies comparing actual functional outcomes and patient satisfaction between AA and TTC arthrodesis. METHODS: We retrospectively analyzed patient satisfaction and functional outcomes of patients after an AA and TTC arthrodesis using a postal survey. A total of 173 patients who underwent TTC and 100 AA patients from 2002 to 2010 were identified with a minimum of 24 months follow-up. In all, 53 AA and 64 TTC arthrodesis patients were included in the study, with the remainder lost to follow-up. A return to activity questionnaire and SF-12 scores were used to compare functional outcomes. The mean follow-up time was 63 months. RESULTS: Both groups showed good outcomes with a low visual analogue pain score (2.7 for AA and 2.8 for TTC), high satisfaction score (90.6% for AA and 87.5% for TTC), and return to work (77.4% for AA and 73.0% for TTC). In all, 84.6% of AA and 81.0% of TTC patients would have the surgery again. There were no significant differences between the 2 groups for these parameters. However, when asked if their desired activity level was met, fewer AA patients met their desired level (58.5% for AA and 66.5% for TTC, P = .02). AA patients were also more likely to feel their level was unmet due to the foot and ankle (85.6% for AA vs 25.7% for TTC, P < .001). CONCLUSIONS: Both AA and TTC arthrodesis were associated with good functional outcomes and satisfaction. AA patients had higher postoperative activity expectations and were less likely to meet them. When they failed to meet these expectations, they were much more likely to attribute it to their operated ankle. We believe it is because of the different ways the 2 groups of patients are counseled preoperatively, which highlights the importance of managing patient expectations. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Postoperative range of motion trends following total ankle arthroplasty.

BACKGROUND: It is still unknown how ankle range of motion changes following total ankle arthroplasty. This study was undertaken to more accurately address patient expectations, guide postoperative rehabilitation, and improve our understanding of how ankle range of motion changes with time. METHODS: 119 total ankle replacements of 3 different prosthetic designs from 1 surgeon were retrospectively examined and compared. Ankle dorsiflexion and plantar flexion ranges of motion were calculated and analyzed preoperatively and postoperatively at 6 weeks, 3 months, 6 months, and 1 year. The different ankle replacement systems were analyzed individually and together to determine whether trends were replicated. RESULTS: No significant increase in ankle range of motion was found 6 months postoperatively (P = .75). Mean combined postoperative range of motion did not change significantly from 24.3 degrees at 1 year versus a preoperative mean of 22.7 degrees (P = .75). Mean dorsiflexion improved significantly at the 6-week postoperative stage by 5.5 degrees (P < .001), whereas plantar flexion only improved by 2.9 degrees (P = .06). Mean dorsiflexion improved from preoperative levels by 5.4 degrees (P = .001), whereas mean plantar flexion decreased by 3.7 degrees (P = .004). CONCLUSIONS: We found no notable improvement in ankle range of motion after 6 months following total ankle arthroplasty. We also found a disproportionately higher increase in dorsiflexion compared with plantar flexion following surgery and an overall reduction in mean plantar flexion range compared with preoperative values. Notwithstanding this discrepancy, total mean ankle range of motion 1 year postoperatively was similar to preoperative values. Reasons for the discrepancy between dorsiflexion and plantar flexion are unclear. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Osteochondral distal metatarsal allograft reconstruction: a case series and surgical technique.

BACKGROUND: Painful degenerative diseases of the metatarsophalangeal joints (MTPJs) are frequently progressive and difficult to treat. Traditional operative treatments such as debridement, distal metatarsal osteotomies, and arthroplasty present a unique set of complications, and pain and deformity may still occur. Osteochondral distal metatarsal allograft reconstruction (ODMAR) is presented as a salvage procedure, reserved for patients with significant bone loss or avascular necrosis in whom traditional interventions have failed or are inadequate to address the underlying joint deformity. METHODS: A retrospective review identified all ODMAR cases performed by the senior author over the past 10 years. Patient symptoms, satisfaction, and MTPJ range of motion were measured at each postoperative evaluation. Graft healing and subsequent degenerative changes at the MTPJ were observed at each visit with foot radiographs. The surgical techniques for both first and lesser metatarsal reconstructions are described. RESULTS: Six patients were identified with average follow-up interval of 36 months (range, 6-66). Preoperative diagnoses included infection (1), fracture (1), and avascular necrosis (4). Mean total arc of motion was 40 degrees (range, 30-50). All patients maintained viability of the allograft metatarsal head and joint space was normal or Kellgren-Lawrence grade 1 in 5 of 6 patients at final follow-up. All patients demonstrated osseous union of the metatarsal osteotomy site. No patients have undergone revision surgery to date. CONCLUSIONS: ODMAR is a safe and effective procedure for treatment of painful, degenerative conditions of the MTPJs. Further studies are required to determine the definitive indications and long-term outcomes for this procedure. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Management of chronic ruptures of the Achilles tendon.

Chronic ruptures of Achilles tendons are those that present four to six weeks after the original injury. They have become more common as acute Achilles tendon injuries have become more frequent, and they are associated with considerable functional morbidity. Most surgeons agree that chronic ruptures should be managed operatively. Diagnosis is based predominantly on history and clinical examination. Real-time, high-resolution ultrasound and magnetic resonance imaging are helpful in preoperative planning or as a diagnostic aid. Local tissue, local tendons, and allografts can be used to reconstruct the tendon, and end-to-end repair is possible if the gap is <2.5 cm. Compared with acute injuries, chronic injuries are associated with a higher rate of postoperative infection and more prolonged recovery.

Chronic rupture of tendo Achillis.

The Achilles tendon is the most commonly ruptured tendon in the human body. About 20% of complete ruptures of the Achilles tendon are diagnosed late. The management of chronic ruptures of tendo Achillis is usually different from that of acute rupture, as the tendon ends normally will have retracted. As clinical diagnosis of chronic ruptures can be problematic, imaging can be useful. Most investigators counsel operative management, and the possibility of undertaking a tendon transfer should be kept in mind. Local tendons, such as the flexor digitorum longus, the flexor hallucis longus, and the tendon of peroneus brevis, can be used, and some investigators have reported the use of a free gracilis tendon graft. Allografts and synthetic grafts are also employed. There are no comparative studies and no randomized controlled trials to guide clinicians toward an evidence-based approach to management.

Nurse-led preoperative screening and targeted optimization of pulmonary dysfunction in patients undergoing cardiac surgery.

Postoperative pulmonary dysfunction prolonging intensive care treatment after cardiac surgery most commonly occurs in patients with a background of pre-existing pulmonary dysfunction. However, many patients have occult dysfunction and present primarily after surgery. We describe and discuss the results of a respiratory optimization program utilizing a peak expiratory flow rate below 400 L/min as a screening test to identify patients in a nurse-directed preoperative clinic.

Conservative management of chronic ankle instability.

Chronic ankle instability is a significant cause of morbidity. There are well-documented and effective surgical options for managing this condition. However, conservative management can be a viable option in selected patients. Failure of conservative management can be an indication for surgery if morbidity warrants it. Surgery can be delayed without necessarily affecting outcome.

Anatomic repair for chronic lateral ankle instability.

Symptomatic ankle instability will develop in upto 20% of patients after inversion injury. Although most patients can be successfully managed with rehabilitation and bracing, some will continue to suffer recurrent ankle instability with activities of daily living, work on uneven terrain, or sports. For this group of patients, we advocate direct anatomic surgical repair with the Brostrom procedure with or without its modifications.

Tailor's bunion: a review.

The tailor's bunion is a painful bony prominence on the lateral aspect of the fifth metatarsal head that occurs in many individuals, but seldom causes symptoms. This article reviews the current literature regarding the presentation, etiology, and management of the tailor's bunion. The first line of management should be conservative, with advice on shoe wear. Orthotics may be useful if a symptomatic tailor's bunion results from excessive subtalar joint pronation. Operative management, indicated when symptoms are not controlled nonoperatively, aims to decrease foot width and the prominence of the tailor's bunion. Procedures can be grouped into resections and distal, diaphyseal, and proximal osteotomies. A distal osteotomy is recommended if medial translation of the head for one-third of the width of the metatarsal shaft produces a normal fourth-fifth intermetatarsal angle. A proximal osteotomy can be performed in the face of larger deformities. The management of recurrent tailor's bunion is still controversial. If the recurrence is due to under-correction, or if the initial procedure was not the best suited to that particular patient, then revision surgery may be helpful, after the cause of the failure has been established. Although unpopular, resection should be considered as the final salvage procedure.

Effect of endothelin antagonists on the renal haemodynamic and tubular responses to ischaemia-reperfusion injury in anaesthetised rats.

In this investigation we have evaluated whether blockade of endothelin receptors influenced the renal haemodynamic and excretory responses to a period of ischaemia and reperfusion in the anaesthetised rat. The renal artery was occluded for 30 min and renal haemodynamic and excretory function followed for 90 min of reperfusion while either saline, the non-selective endothelin 1 receptor (ET(A)/ET(B)) antagonist SB209670 or the selective ET(A) receptor antagonist UK-350,926 was infused. In the post-ischaemic period, renal cortical and medullary perfusions were reduced by 40-50 %. When SB209670 was administered (30 micro g kg(-1) min(-1) I.V.) for 30 min before, during and for 90 min after renal artery occlusion, cortical and medullary perfusions returned to baseline levels, responses different from those obtained during saline infusion (both P < 0.05). In the presence of UK-350,926 (30 micro g kg(-1) min(-1) I.V.), perfusion in the medulla returned to baseline on clamp removal whereas that in the cortex remained depressed (P < 0.05). Renal ischaemia for 30 min decreased glomerular filtration rate during reperfusion and increased urine flow and sodium excretion 5- to 15-fold. UK-350,926 (30 micro g kg(-1) min(-1) I.V.) reduced (P < 0.05) fluid excretion prior to ischaemia but during reperfusion, glomerular filtration rate returned to basal levels and there were progressive increases in fluid excretion which were smaller compared to the saline-treated group (all P < 0.05). The ischaemic challenge may cause release of endothelin, which acts on ET(B) receptors in the cortex and ET(A) receptors in the medulla to decrease perfusion. The blunted natriuresis and diuresis during blockade of ET(A) receptors may result from either a vascular or tubular action of endothelin.