Sinus tarsi approach in high-risk patients with displaced intra-articular calcaneus fractures: A case series.

Purpose: Though research exists regarding calcaneal fractures, the treatment approach for displaced intra-articular calcaneal fractures (DIACF) remains controversial. The most common approach, the extensile lateral approach (ELA), for the treatment of DIACFs has high rates of wound complications reported. In contrast, the sinus tarsi approach (STA) is becoming more popular due to its minimally invasive technique. The objective of this retrospective study is to investigate the incidence of wound complications in high-risk patients with DIACF following operative fixation via the STA. Methods: Following IRB approval, a retrospective chart review was performed between 2007 and 2013 to assess high-risk patients for the presence of wound complications, including deep infections and delayed wound healing, following the use of STA for the management of DIACF's (n = 36). Demographics, risk factors, and secondary outcomes such as time to surgery were recorded. Results: Of the 36 high-risk patients included in our study, seven had post-operative complications following operative fixation via the STA. Specifically, four patients had delayed wound healing, and three developed deep infections. Time to surgery had the greatest negative effect on postoperative complications and was influenced by age, sex, and the presence of a concomitant injury. Conclusion: In conclusion, this study demonstrates that the STA is a viable option for high-risk patients with displaced intra-articular fractures. Additionally, time to surgery should be minimized, when possible, to reduce risks of post-operative complications, including infections and delayed wound healing.

Subtalar Fusion for Correction of Forefoot Abduction in Stage II Adult-Acquired Flatfoot Deformity.

BACKGROUND: Correction of talonavicular uncoverage (TNU) in adult-acquired flatfoot deformities (AAFD) can be a challenge. Lateral column lengthening (LCL) traditionally is utilized to address this. The primary study objective is examining stage II AAFD patients and determining if correction can be achieved with subtalar fusion (STF) comparable to LCL. METHODS: Following institutional review board approval, retrospective chart review performed identifying patients meeting criteria for stage IIB AAFD who underwent either STF with concomitant flatfoot procedures (but not LCL) to correct TNU, or who underwent LCL as part of their flatfoot reconstruction. Patients indicated for STF had one or more of the following: higher body mass index (BMI), were older, had greater deformity, lateral impingement pain, intraoperative spring ligament hyperlaxity. Patients without 1-year follow-up or compete records were excluded. All other patients were included. A total of 27 isolated STFs identified, along with 143 who underwent LCL. Pre-/postoperative radiographic parameters obtained as well as PROMIS (Patient-Reported Outcomes Measurement Information System) and FAOS (Foot and Ankle Outcome Score) scores. Radiographic and patient reported outcomes both preoperatively and at 1-year follow-up evaluated for both groups. RESULTS: STF patients were older (P < .05), with higher BMIs (P < .004). STF had significantly worse TNU (P < .001) than LCL patients, and average change in STF TNU was larger than LCL change postoperatively (P = .006), after adjusting for age, BMI, gender. PROMIS STF improvement reached statistical significance in Physical Function (P 0.011), for FAOS Pain (P 0.025) and Function (P = 0.04). CONCLUSIONS: STF can be used in appropriately indicated patients to correct flatfoot deformity without compromising radiographic or clinical, correcting not only hindfoot valgus, but also talonavicular uncoverage (TNU) and corresponding medial arch collapse. LEVELS OF EVIDENCE: Level III: Retrospective chart review comparison study (case control).

Evaluating Tourniquet Efficacy Comparing Exsanguination Techniques for the Upper Extremity.

Tourniquets have been used in the medical setting for centuries and have become the gold standard when preparing patients for surgery, particularly in orthopaedic surgery. Upper extremity tourniquet use improves intraoperative visibility and identification of anatomy. It also decreases blood loss intraoperatively and improves the safety of orthopaedic procedures. Despite the widespread use of tourniquets and differing methods of limb exsanguination, little research has been done quantifying its efficacy. The purpose of this study was to compare gravity exsanguination to Esmarch exsanguination of the upper extremity prior to tourniquet inflation in a large patient sample. A plethysmographic method based on water displacement served as a surrogate for the blood volume exsanguinated. Control measurements of water displacement were obtained from both upper extremities without tourniquet inflation. Water displacement was then measured with both gravity and Esmarch exsanguination techniques. Gender, handedness, height, weight, body mass index, and age were recorded for volunteers and used as covariates. Change in mean water displacement from control (un-exsanguinated) arm and gravity alone measurement was 37.2 ml. Change in mean water displacement between control arm and mean Esmarch measurement was 56.3 ml. Exsanguination using Esmarch compared to gravity alone resulted in a 51.2% increase in blood removal. Only age had a significant interaction effect for the Esmarch method. Analysis revealed that age accounted for 21.4% of all variance in blood exsanguinated using the Esmarch method when compared to the control group. The Esmarch technique was more efficacious for all demographics measured, but most efficacious in subjects who were older than 40 years. This data reaffirms that gravity exsanguination is more efficacious than no tourniquet use at all, and that the Esmarch technique is more efficacious than gravity. To our knowledge, this study is the most robust of its kind to critically and objectively compare upper extremity exsanguination methods and overall tourniquet use by age and supports the common practice of Esmarch exsanguination in orthopaedic extremity surgery.