Reducing the Hypertensive Effects of the Prolonged Surgical Tourniquet Using a Dual-Cuff Strategy: A Prospective Randomized Controlled Trial.

We evaluated whether moving the "line of crush" from thigh to the calf before onset of tourniquet-mediated hypertension would prevent or diminish it. We also evaluated any change in pain or functional outcome. Twenty adult patients were recruited and randomly assigned to either control or intervention groups. Inclusion criteria: any willing participant >18 years old with foot and/or ankle pathology requiring an operation lasting >90 minutes. Exclusion criteria included contraindication to general anesthesia, peripheral neuropathy affecting lower limbs of any etiology, or chronic pain requiring regular opiate analgesia. The intervention group received a thigh tourniquet for 60 minutes, after which a calf tourniquet was inflated and the thigh tourniquet was deflated. The control group received only a thigh tourniquet throughout surgery. At 90 minutes, the control group had mean arterial pressure of 86.8 mmHg, compared with the intervention group at 76.3 mmHg (p ≤ .014). At end of surgery, the difference had increased further (control 98.1 mmHg, intervention 78.3 mmHg (p ≤ .001). Moving the line of crush during limb tourniquet application prevents development of the hypertensive response. For cases in which a prolonged tourniquet application is required, a dual-tourniquet technique will prevent intraoperative hypertension and may influence long-term pain and function.

Long-term follow-up of patients undergoing tibialis posterior transfer: Is acquired pes planus a complication?

In this retrospective study, a series of 10 elective patients treated with transfer of the tibialis posterior (TP) tendon for pes cavus and drop foot are described. Since TP transfer completely subtracts the role of this tendon, this cohort of patients provides an opportunity to examine the consequences of tibialis posterior (TP) deficiency. After a mean follow up period of 44.7 months, only one patient showed evidence of strain in the spring ligament but none of the patients in this series developed clinical or radiological evidence of planovalgus deformity. The authors conclude that planovalgus deformity is not an inevitable sequelae of TP Tendon transfer and that established theory underestimates the role of static soft tissue restraints such as spring ligament in hindfoot stability.

The resistance to failure of spring ligament reconstruction.

INTRODUCTION: The spring ligament (SL) is increasingly recognised as the major structure that fails in acquired adult flatfoot deformity (AAFD). This is the first study that demonstrates integrity of repair of the SL. PATIENTS AND METHODS: Six pairs of fresh frozen cadavers were setup in a standardised fashion with ankle in plantargrade (mean age 59 years, BMI 25). A 25N lateral force was applied to the medial metatarsal head using an algometer. Lateral displacement of the foot was measured with SL intact, sectioned, following FibreWire® repair, then Arthrex InternalBrace (IB) reconstruction, then with selective sectioning of each limb of the IB reconstruction. RESULTS: In 12 specimens, overall lateral translation with SL intact was 21mm±4.9. This increased to 39.2mm±10.9 (p<0.05) with SL sectioning, no significant improvement to 34.2mm±9.5 with repair (p=0.159), before significantly returning to baseline 16.55mm±5.1 (p<0.001) with the IB. Augmenting with FDL did not influence lateral translation (p=0.586). CONCLUSION: Restoration of SL integrity is fundamental to prevent flatfoot. This study shows traditional repair models fail to provide sufficient resistance to planovalgus. Using an augmented device such as the IB provides optimal resistance to lateral translation and hence planovalgus, particularly the plantar limb of the augmentation.

Arthroplasty in the Valgus Knee: Comparison and Discussion of Lateral vs Medial Parapatellar Approaches and Implant Selection.

Constrained implants are frequently used for primary total knee arthroplasty (TKA) in patients with moderate and severe genu-valgum (>10˚). This deformity presents corrective challenges for ligament release. The lateral-parapatellar approach has been advocated as an alternative to the traditional medial-parapatellar approach. Claimed advantages include better access for release of tight ligamentous structures, without requirement for release of the medial-collateral ligament. We present our comparative experience of the use of an unconstrained knee-replacement prosthesis inserted by the lateral-parapatellar approach in comparison to a constrained-knee prosthesis inserted via the medial-parapatellar approach. 49 primary total knee-replacements in 48 (6 males, 42 females) patients were performed; 32 through a lateral-parapatellar approach (group L) using an unconstrained-prosthesis and 17 through a medial-parapatellar approach more often requiring a constrained-prosthesis (group M). Mean preoperative valgus angle was 18.5 (range 11-34˚). Patient demographics (p=0.7) and valgus correctability were similar between the two groups. There was no significant difference in the mean post-operative valgus angle. This was 4.2˚ (range 1-9.5˚) using the lateral-parapatellar approach and 5.3˚ (range 0.3-10˚), p=0.12, using the medial-parapatellar approach. Transient common peroneal injury occurred in 2 patients, both group L, in the presence of valgus angles of greater than 20˚. To date no joints have been revised, or are unstable. The use of a lateral-parapatellar approach, appropriate soft tissue release, and an unconstrained PCL-preserving implant, yielded in all cases a stable, well aligned knee arthroplasty. This represents a viable alternative to the constrained-prosthesis using a medial-parapatellar approach in patients with moderate and severe genu-valgum.

Neutral heel lateral push test: The first clinical examination of spring ligament integrity.

INTRODUCTION: The spring (calcaneonavicular) ligament is an intricate multiligament complex whose primary role is to stabilise the medial longitudinal arch and head of talus. Clinical suspicion of a spring ligament injury in isolation is roused when persistent medial midfoot pain is present with associated pes planus following trauma. METHOD: We undertook a cadaveric study on 21 specimens to assess the use of a neutral heel lateral push test to examine the spring ligament in a standardised procedure, measuring lateral translation with graduated antegrade and retrograde defunctioning of surrounding structures and the spring ligament. RESULTS: In all specimens, a significant displacement occurred on incision of the spring ligament regardless of order of dissection. The degree of displacement increased by an insignificant amount as surrounding structures were incised at each incremental force applied. DISCUSSION: The neutral heel push test is the first clinical examination to be described to determine integrity of the spring ligament complex. Our study objectively demonstrates that lateral displacement in relation to the mid and hind-foot is influenced most significantly by the integrity of the spring ligament and to a lesser extent by tibialis posterior and flexor digitorum longus.

Long-term outcomes of laparoscopic intracorporeal inguinal hernia ligation in infants under 1 year of age.

BACKGROUND: The majority of current literature regarding laparoscopic inguinal hernia repair group all their pediatric patients together. This study aimed to evaluate the long-term outcomes of patients who underwent laparoscopic intracorporeal inguinal hernia ligation under the age of 1 year to ascertain if there were hidden advantages or limitations in this particular group. PATIENTS AND METHODS: Patients under the age of 1 year at time of laparoscopic intracorporeal inguinal hernia ligation by a single pediatric surgeon were identified. Data were obtained from case notes, hospital electronic records, and parental telephone consultation. RESULTS: One hundred fourteen patients under the age of 1 year underwent laparoscopic inguinal hernia repair from November 2003 to October 2010. The male:female ratio was 4:1. The mean corrected age at surgery was 15.5 (range, 3-42) weeks, and the mean weight at surgery was 5.3 (range, 1.9-9.8) kg. All patients' case notes and electronic records were accessed. Forty-two percent of parents were contactable (mean of 4 years following surgery). There was one recurrence on the asymptomatic side in a boy that presented 3 years later. Five patients required orchidopexy following laparoscopic hernia repair, although 3 cases were known to be undescended at the time of surgery. One patient had intermittent ipsilateral groin swelling that resolved spontaneously after 6 months. CONCLUSIONS: Laparoscopic intracorporeal inguinal hernia ligation in patients under the age of 1 year is safe and effective. Recurrence rates may be lower than those in patients under 1 year of age undergoing a traditional open repair. However, there may be a higher rate iatrogenic of cryptorchidism in this laparoscopic group.