Adductor canal block versus femoral nerve block combined with sciatic nerve block as an anesthetic technique for hindfoot and ankle surgery: A prospective, randomized noninferiority trial.

BACKGROUND: A femoral nerve block (FNB) in combination with a sciatic nerve block (SNB) is commonly used for anesthesia and analgesia in patients undergoing hindfoot and ankle surgery. The effects of FNB on motor function, related fall risk, and rehabilitation are controversial. An adductor canal block (ACB) potentially spares motor fibers in the femoral nerve, but the comparative effect on hindfoot and ankle surgeries between the 2 approaches is not yet well defined. We hypothesized that compared to FNB, ACB would cause less weakness in the quadriceps and produce similar pain scores during and after the operation. METHODS: Sixty patients scheduled for hindfoot and ankle surgeries (arthroscopy, Achilles tendon surgery, or medial ankle surgery) were stratified randomized for each surgery to receive an FNB (FNB group) or an ACB (ACB group) combined with an SNB. The primary outcome was the visual analog scale (VAS) pain score at each stage. Secondary outcomes included quadriceps strength, time profiles (duration of the block procedure, time to full anesthesia and time to full recovery), patients' analgesic requirements, satisfaction, and complications related to peripheral nerve blocks such as falls, neurologic symptoms, and local anesthetic systemic toxicity were evaluated. The primary outcome was tested for the noninferiority of ACB to FNB, and the other outcomes were tested for the superiority of each variable between the groups. RESULTS: A total of 31 patients received an ACB and 29 received an FNB. The VAS pain scores of the ACB group were not inferior during and after the operation compared to those of the FNB group. At 30 minutes and 2 hours after anesthesia, patients who received an ACB had significantly higher average dynamometer readings than those who received a FNB (34.2 ±â€Š20.4 and 30.4 ±â€Š23.7 vs 1.7 ±â€Š3.7 and 2.3 ±â€Š7.4, respectively), and the results were similar at 24 and 48 hours after anesthesia. There were no differences between the 2 groups with regard to time profiles and patient satisfaction. No complications were noted. CONCLUSION: ACB preserved quadriceps muscle strength better than FNB, without a significant difference in postoperative pain. Therefore, ACB may be a good alternative to FNB for reducing the potential fall risk.

Misdiagnosis of Talar Body or Neck Fractures as Ankle Sprains in Low Energy Traumas.

BACKGROUND: The talus has a very complex anatomical morphology and is mainly fractured by a major force caused by a fall or a traffic accident. Therefore, a talus fracture is not common. However, many recent reports have shown that minor injuries, such as sprains and slips during sports activities, can induce a talar fracture especially in the lateral or posterior process. Still, fractures to the main parts of the talus (neck and body) after ankle sprains have not been reported as occult fractures. METHODS: Of the total 102 cases from January 2005 to December 2012, 7 patients had confirmed cases of missed/delayed diagnosis of a talus body or neck fracture and were included in the study population. If available, medical records, X-rays, computed tomography scans, and magnetic resonance imaging of the confirmed cases were retrospectively reviewed and analyzed. RESULTS: In the 7-patient population, there were 3 talar neck fractures and 4 talar body fractures (coronal shearing type). The mechanisms of injuries were all low energy trauma episodes. The causes of the injuries included twisting of the ankle during climbing (n = 2), jumping to the ground from a 1-m high wall (n = 2), and twisting of the ankle during daily activities (n = 3). CONCLUSIONS: A talar body fracture and a talar neck fracture should be considered in the differential diagnosis of patients with acute and chronic ankle pain after a minor ankle injury.

Consequences of Avulsion Fracture of the Proximal Phalanx Caused by a Technical Failure of Hallux Valgus Surgery.

Several cases of avulsion fracture of the proximal phalanx of the big toe during the lateral capsular release procedure were observed. However, these fractures have not been reported as a complication of hallux valgus surgery. The purpose of the present study was to report the proximal phalanx base fracture as an unrecognized complication and to evaluate the clinical and radiographic consequences of this complication. We retrospectively reviewed 225 feet that had undergone hallux valgus surgery involving proximal chevron osteotomy and distal soft tissue release from May 2009 to December 2012. Of these 225 feet (198 patients), 12 (5.3%) developed proximal phalanx base fracture postoperatively. These patients were assigned to the fracture group. The remaining patients were assigned to the nonfracture group. Patients were followed to observe whether the fractures united and whether degenerative changes developed at the first metatarsophalangeal joint because of this fracture. The mean follow-up period was 36 (range 12 to 72) months. All the subjects in the fracture and nonfracture groups underwent weightbearing anteroposterior and lateral radiographs of the foot at the initial presentation and final follow-up point. The 2 groups were compared with respect to the hallux valgus angle, intermetatarsal angle, range of motion, American Orthopaedic Foot and Ankle Society score, satisfaction, and degenerative changes. No significant differences were found in age, follow-up period, hallux valgus angle, intermetatarsal angle, range of motion of the first metatarsophalangeal joint, American Orthopaedic Foot and Ankle Society score, satisfaction, and degenerative changes between the 2 groups. Ten (83.3%) of the 12 fractures healed, 2 (16.7% of the fractures, 0.89% of the operated feet) progressed to asymptomatic nonunion, and 3 (1.33%) developed first metatarsophalangeal joint degeneration. Avulsion fracture of the proximal phalanx of the big toe is an uncommon complication of hallux valgus surgery. It seems to be caused by excessive tension placed on the lateral soft tissues that attach to the base of the proximal phalanx at the time of plantarlateral soft tissue release. However, this fracture does not seem to cause significant clinical problems.

Accessory Navicular Syndrome in Athlete vs General Population.

BACKGROUND: Symptomatic accessory navicular syndrome (ANS) typically develops in young athletes. The symptoms are exacerbated during exercise or while walking, affecting the sports performance of athletes. The purpose of this study was to evaluate the radiologic findings and clinical course in athletes with accessory navicular syndrome (ANS) in comparison with a nonathletic population. METHODS: Seventy-nine patients with ANS between August 2012 and August 2013 were included. Overall, 29 were athletes and 50 were not athletes, and 19 (2 athletes and 17 nonathletes) of them improved after at least 6 months of conservative treatment. The records of 60 patients (64 consecutive feet) of ANS treated by modified Kidner operation were evaluated retrospectively. The study population included 27 athletes (31 feet) and 33 nonathletes (33 feet). Clinical features and radiologic findings were compared between them. RESULTS: Overall, 34% of the nonathletes improved after conservative treatment, but only 6.9% of athletes improved (P < .001). Mean age at surgery in the athlete group was 16.1 years (range, 12-26), and 24.3 years (range, 12-52) in the nonathlete group (P < .001). There was a history of trauma in 23 feet (74%) of the athlete group and in 13 feet (39%) of the nonathlete group (P = .006). Eighteen feet (58%) in the athlete group and 11 feet (32%) in the nonathlete group showed movement between the 2 bones (P = .047). Bone marrow edema was observed in both navicular and accessory navicular in all of the athletes (27/27, 100%). But it was only present in 80% (16/20) for nonathletes (P = .012). CONCLUSION: The radiologic findings and clinical course of athletes were different from that of the general population. Their symptoms were more refractory to conservative treatment than the nonathletes group. Therefore, early operative treatment could be considered in cases of symptomatic ANS especially for athletes. LEVEL OF EVIDENCE: Level III, retrospective comparative case series.

Comparison of alternate references for femoral rotation in female patients undergoing total knee arthroplasty.

PURPOSE: Accurate rotational alignment of the femoral component is of vital importance for successful total knee arthroplasty (TKA). Two anatomical references located on the anterior femur were recently introduced. To determine which is more reliable reference axis for the femoral component rotation in female patients receiving TKA, the trochlear anterior line was compared with the femoral anterior tangent line. MATERIALS AND METHODS: Preoperative computed tomography in 76 patients receiving TKA for varus deformity was performed, and the images were reconstructed into three-dimensional models. The trochlear anterior line was defined as the line connecting the most anterior portion of the lateral and medial femoral condyles and the femoral anterior tangent line as the line parallel to distal anterior femoral surface. The two angles between these reference axes and the surgical transepicondylar axis (TEA) in three-dimensional images (trochlear anterior line/TEA, femoral anterior tangent line/TEA) were measured. The correlation between these two angles was computed. We investigated to see whether a significant difference in variance existed. RESULTS: The trochlear anterior line was internally rotated by 6.1° ± 2.5° with respect to TEA, whereas the femoral anterior tangent line by 9.5° ± 3.8°. The trochlear anterior line was externally rotated by 3.4° ± 3.3° with respect to the femoral anterior tangent line. There was a significant correlation between the trochlear anterior line/TEA and the femoral anterior tangent line/TEA. CONCLUSIONS: The variance of the trochlear anterior line/TEA was significantly smaller than that of the femoral anterior tangent line/TEA demonstrating a more consistent distribution. When conventional reference axes such as the posterior condylar axis or the anteroposterior axis are unclear or differ, surgeons can rely on these alternative references. When trochlear anterior line and femoral anterior tangent line contradicts, the former might be more reliable for the rotational alignment of the femoral component in female patients. LEVEL OF EVIDENCE: Case series with no comparison group, Level IV.

Clinical and radiological characteristics of concomitant peripheral arterial obstructive disease in patients with lumbar spinal stenosis.

BACKGROUND: Intermittent claudication is a typical symptom of lumbar spinal stenosis (LSS) and peripheral arterial obstructive disease (PAD). Because both LSS and PAD are predominantly associated with degenerative conditions, concomitant conditions are not uncommon. However, few reports of the demographic, clinical, and radiological characteristics of concomitant LSS and PAD (LSSPAD) have been published. OBJECTIVE: To identify the demographic, clinical, and radiological risk factors for concomitant PAD in LSS. STUDY DESIGN: A retrospective matched-control study. METHODS: This study involved a retrospective cohort of 43 consecutive patients with LSSPAD and a control cohort of 45 age- and gender-matched patients diagnosed with LSS without PAD. Each patient in both groups underwent plain lumbar radiographs, magnetic resonance imaging of the lumbar spine, and ankle-brachial index (ABI) measurement. Demographic and clinical parameters were obtained. The abdominal aorta calcification score (AACS) was evaluated on the lateral lumbar radiographs. Computed tomographic angiography (CTA) of the lower limb was performed to confirm PAD. RESULTS: The mean age of the LSSPAD group was 67.7 ± 10.7 years (52 - 88 years). The prevalence of diabetes mellitus (DM) was significantly higher in the LSSPAD group than in the LSS group (P = 0.022). The mean ABI was 0.71 ± 0.22 (0.32 - 0.91) for the LSSPAD group and 0.96 ± 0.18 (0.83 - 1.10) for LSS group (P < 0.001). The prevalence of aortic calcification was significantly higher in the LSSPAD group than in the LSS group (P < 0.001). The mean AACS was 10.2 ± 3.2 (2 - 18) for the LSSPAD group and 3.4 ± 4.1 (0 - 14) for the LSS group (P < 0.001). LIMITATIONS: Retrospective design. CONCLUSION: We found that concomitant PAD in patients with LSS is associated with old age, DM, the presence of aortic calcification, and ABI < 0.9. When these risk factors exist, further work up is needed to exclude the concomitant PAD.

Increased size of a gas-filled intradural cyst causing acute foot drop: a case report.

We describe the case of a 76-year-old man presenting with a gas-filled intradural cyst that increased in size over a 10-month period and caused acute bilateral foot drop. The gas-filled intradural cyst was resected from the adherent cauda equina, and histopathological examination identified cystic tissue with degenerated fibrocartilage. Leg pain disappeared immediately following surgery, and the bilateral foot drop resolved within 8 months.