Stenotic intercondylar notch type is correlated with anterior cruciate ligament injury in female patients using magnetic resonance imaging.

PURPOSE AND HYPOTHESIS: The principal purpose of this paper was to identify whether femoral notch morphology was different in females without anterior cruciate ligament (ACL) injury from those with ACL injury. Magnetic resonance imaging (MRI) was used to assess the femoral notch type, notch width index and 'α angle' in female patients and measure these differences. METHODS: This is a retrospective case control study of 119 female patients, 58 with ACL injury and 61 patients without ACL injury who underwent knee MRI between March 2014 and April 2016. The morphometric measurements were taken by two independent observers. The femoral notch width index was calculated as the ratio between the central notch width and transcondylar or intercondylar width; values >0.27 were considered normal. The femoral notch shape was classified as Type A, Type U or Type W, with Type A describing a stenotic notch, Type U a notch with a wider contour and Type W a wider Type U with two apices apparent. The angle between the longitudinal femoral axis and the Blumensaat line was identified as the 'α angle'. The statistical analysis was performed with t tests, simple and multivariable logistic regression analysis to evaluate the strength of these specific femoral notch morphometric values as predictive factors to ACL rupture. RESULTS: Stenotic femoral notch Type A was identified as a high risk factor to ACL injury (odds ratio [OR] = 2.8; p = 0.03). There was no significant difference between the two groups for the notch width index (OR = 0.7; p = n.s.) and the 'α angle' (OR 1.02; p = n.s.). Significant association between NWI and stenotic notch was found (p < 0.01). CONCLUSIONS: This study showed that Type A stenotic femoral notch can be considered as a valuable predictive factor for ACL injury. Notch width index and 'α angle' are weak indicators in ACL injury prognosis. Ligament impingement may be inferred as an important mechanism in female ACL rupture. Injury prevention strategies, such as prehabilitation programmes, could be introduced in the benefit of young females with stenotic notch. LEVEL OF EVIDENCE: III.

Foreign body granulomatous reaction associated with polyethelene 'Fiberwire(®)' suture material used in Achilles tendon repair.

Repair of acute Achilles tendon rupture is a common procedure. There are many accepted surgical techniques; suture selection is largely due to surgeon preference. We present a case report of a granulomatous reaction to suture material following Achilles tendon repair. 'Fiberwire(®)' is an increasingly popular suture material for the repair of tendons and ligamentous structures; the polyethelene braided structure with silicone and polyester coating provides high tensile strengths and good handling characteristics. Eight months following uneventful Achilles tendon repair surgery in an otherwise fit and well patient, pain, swelling and loss of function was noted. She required revision surgery with debridement and reconstruction of the tendo Achillis with flexor hallucis longus tendon transfer. Histology revealed a granulomatous reaction with giant cell response surrounding sections of the suture. Both the silicone coating of Fiberwire(®) and polyethylene core have the potential to cause a severe granulomatous reaction. We would advise caution in the use of this suture for tendo Achillis repair, and use the readily available alternatives.

Pneumatic tourniquet use in foot and ankle surgery--is padding necessary?

BACKGROUND: The majority of foot and ankle surgery is carried out in a bloodless field achieved by the use of a pneumatic tourniquet. The risks of tourniquet use may be divided into those resulting from direct mechanical pressure from the cuff and those secondary to prolonged limb ischaemia. Current peri-operative guidelines advise the use of padding beneath the cuff, in particular to reduce skin complication. OBJECTIVES: To assess the complication rate of tourniquet use when the cuff is applied directly to the skin. METHOD: Patients undergoing foot and ankle surgery under tourniquet control without use of padding were assessed pre and post operatively for soft tissue complication, neurological deficit and post-tourniquet syndrome. RESULTS: We recorded findings for 97 patients, 47 thigh and 50 ankle tourniquets. We found a complication rate of 0%. There were no cases of skin blistering, abrasion, bruising, laceration or burn. CONCLUSIONS: These findings are contrary to published RCTs supporting the use of padding. Our study demonstrates the safe use of pneumatic tourniquets without padding in foot and ankle surgery.

Treatment of ankle instability with an associated cavus deformity.

This article reviews the role of cavus in foot and ankle injury and summarizes the current surgical and nonsurgical treatments. Recognition of foot position is crucial in the management of ankle instability associated with cavovarus. Correcting foot alignment with orthoses or surgery improves the mechanics of the ankle, reducing the risk of instability and potentially delaying the onset of posttraumatic ankle arthritis. Progressive steps in the correction alignment are described, with technical tips and strategies for dealing with chronic instability.

Anatomic direct repair of chronic distal biceps brachii tendon rupture without interposition graft.

BACKGROUND: Rupture of the biceps brachii insertion is relatively uncommon and may present late. Chronic ruptures pose a management dilemma, with higher reported complication rates when surgery is delayed, whilst conservatively treated injuries may do badly in active patients. MATERIALS AND METHODS: Six consecutive male patients with delayed presentation of biceps rupture were treated operatively using a limited standard anterior approach, a secondary proximal "retrieval" incision, and EndoButton fixation. This modification of the well-described EndoButton technique for distal biceps reconstruction allows passage of the shortened tendon in maximal elbow flexion and a rehabilitation program without immobilization. The mean interval to repair was 79 days (range, 35-116 days). The mean age at presentation was 47.5 years. The injury mechanisms were unexpected loads on a flexed supinated forearm. RESULTS: Patients were assessed at a mean of 20.2 months. Range of motion was restored to 94% in flexion and 95% in prosupination compared with the uninjured limb. Supination endurance was reduced by 9 repetitions/min compared with the contralateral side (mean, 83.4 repetitions/min). Mayo Elbow Performance Scores were universally 100 and the mean Disabilities of Arm, Shoulder and Hand score was 4. Patient satisfaction was high, with visual analog scores of 92 to 100. No major complications occurred, and all repairs were intact at the final follow-up. CONCLUSIONS: Our outcomes are comparable to acute repair, with restoration of range of motion and function and few complications.