Limited Open Reduction and Internal Fixation of Calcaneal Fractures.

BACKGROUND: The treatment of displaced intra-articular calcaneal fractures remains a challenge and the optimal approach is still controversial. The main reason to avoid the extended lateral approach is the high complication rate due to wound healing problems. We report on 16 years of experience with a standardized limited open reduction and internal fixation technique. METHODS: Between 2001 and 2017, we prospectively followed 240 consecutive patients operatively treated for a displaced intra-articular calcaneal fracture. Patients with open, multiple, bilateral, extra-articular, and Sanders IV fractures and those lost to follow-up were excluded. A lateral subtalar approach was used, with a cast for 8 weeks and full weightbearing allowed after 12 weeks. Follow-up examinations were scheduled until 24 months. Subjective and clinical assessment included gait abnormality, subtalar and ankle range of motion, and stability and alignment. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score was calculated. Alignment was analyzed on standard radiographs. In total, 131 patients were excluded. The remaining 109 patients were followed for a minimum of 24 months (34.4 ± 14.2 [range, 24-102] months). RESULTS: The mean AOFAS score was 87 ± 13 (range, 32-100). "Excellent" and "good" results, as well as hindfoot motion with "normal/mild" and "moderate" restrictions, were seen in 80% of patients. Early reoperations were performed for insufficient reduction (2 patients), delayed wound healing (debridement, 3 patients), and hematoma (1 patient). Late revisions were arthrodesis (3 patients), medializing calcaneal osteotomy (1 patient), and implant removal (53 patients; 49%). CONCLUSION: The presented approach has remained unmodified for 16 years and resulted in consistently good functional results. The main disadvantage was the high rate of heel screw removal. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Prospective Use of a Standardized Nonoperative Early Weightbearing Protocol for Achilles Tendon Rupture: 17 Years of Experience.

BACKGROUND: Acute traumatic rupture of the Achilles tendon can be treated operatively or nonoperatively. Throughout the literature, there is no consensus regarding the optimal treatment protocol. PURPOSE: To report on 17 years of experience with treating this injury with a standardized nonoperative treatment protocol. STUDY DESIGN: Case Series; Level of evidence, 4. METHODS: The treatment protocol was based on a combination of an equinus cast and rehabilitation boot, which promoted immediate full weightbearing and early functional rehabilitation. A total of 171 patients were consecutively treated and prospectively followed from 1996 to 2013. Assessed were subjective parameters such as pain, loss of strength, return to previous activity level, meteosensitivity, and general satisfaction with the treatment outcome. Clinical assessment included testing of plantar flexion strength and endurance, calf circumference, and tendon length. Subjective and clinical parameters were then used to calculate a modified Thermann score. The correlation between tendon lengthening and function was calculated using the Pearson correlation coefficient. RESULTS: A total of 114 patients were followed for a minimum of 12 months (mean, 27 ± 20 months; range, 12-88 months). The mean Thermann score was 82 ± 13 (range, 41-100), and subjective satisfaction was rated "very good" and "good" in 90%. An inverse correlation was found between tendon length and muscle strength (R = -0.3). There were 11 reruptures (8 with and 3 without an adequate trauma). General complications were 5 deep venous thromboses, 1 complex regional pain syndrome, and minor problems such as transient heel pain (n = 3), heel numbness (n = 1), and cast-associated skin abrasions (n = 4). CONCLUSION: Seventeen years of experience with a nonoperative treatment protocol for acute rupture of the Achilles tendon confirmed good functional outcome and patient satisfaction. Reruptures mostly occurred with new traumatic events in the vulnerable phase from 6 to 12 weeks after the initial injury. Muscle strength correlated to tendon length, making its assessment a crucial follow-up parameter. The protective equinus cast and boot can protect against excessive tendon lengthening during the healing process.

Moment arms of forearm rotators.

BACKGROUND: Rotation about a longitudinal axis of the forearm has been a matter of investigation for over 100 years. However, most studies were limited to only a few muscles and to their action in specific set positions of elbow and forearm rotation. This investigation aims at determining the moment arms of muscles that contribute to pronation and supination at three different angles of elbow flexion throughout the entire range of forearm rotation. METHODS: Muscle moment arms were derived from tendon excursions that were recorded on a full-size epoxy model of the radioulnar complex. The results were verified on a fresh cadaver specimen. FINDINGS: Moment arms of all major supinators exhibit peak values in 40-50 degrees of pronation, for all three positions of the elbow. These peak values vary with elbow position, the biceps muscle showing the highest dependency with its greatest moment arm in 90 degrees of elbow flexion. The pronators show a maximum of moment arm about the neutral position, with little dependency on elbow flexion. Brachioradialis brings the pronated, or supinated forearm into the neutral position. The bow of the radius is in function comparable to the 'throw' of a crankshaft, forming a greater lever arm between the point of insertion of the muscles and the axis of rotation of the radius. INTERPRETATION: The observations drawn from this study could be of eminent value in planning rotator muscle transplantation, in understanding functional disorders after injury, and in the physical treatment of forearm rotator muscle deficiency. Reconstruction of the physiological anatomical arrangement in the treatment of injuries is strongly recommended for restoration of function.