Anthropomorphic Characterization of Ankle Joint.

Even though total ankle replacement has emerged as an alternative treatment to arthrodesis, the long-term clinical results are unsatisfactory. Proper design of the ankle device is required to achieve successful arthroplasty results. Therefore, a quantitative knowledge of the ankle joint is necessary. In this pilot study, imaging data of 22 subjects (with both females and males and across three age groups) was used to measure the morphological parameters of the ankle joint. A total of 40 measurements were collected by creating sections in the sagittal and coronal planes for the tibia and talus. Statistical analyses were performed to compare genders, age groups, and image acquisition techniques used to generate 3D models. About 13 measurements derived for parameters (TiAL, SRTi, TaAL, SRTa, TiW, TaW, and TTL) that are very critical for the implant design showed significant differences (p-value < 0.05) between males and females. Young adults showed a significant difference (p-value < 0.05) compared to adults for 15 measurements related to critical tibial and talus parameters (TiAL, TiW, TML, TaAL, SRTa, TaW, and TTL), but no significant differences were observed between young adults and older adults, and between adults and older adults for most of the parameters. A positive correlation (r > 0.70) was observed between tibial and talar width values and between the sagittal radius values. When compared with morphological parameters obtained in this study, the sizes of current total ankle replacement devices can only fit a very limited group of people in this study. This pilot study contributes to the comprehensive understanding of the effects of gender and age group on ankle joint morphology and the relationship between tibial and talus parameters that can be used to plan and design ankle devices.

Implementation of a Multidisciplinary Preoperative Protocol for Geriatric Hip Fractures Improves Time to Surgery at a Level III Trauma Center.

Introduction: Hip fractures are common among the elderly, and delays in time to surgery (TTS) and length of stay (LOS) are known to increase mortality risk in these patients. Preoperative multidisciplinary protocols for hip fracture management are effective at larger trauma hospitals. The purpose of this study is to evaluate the effect of a similar multidisciplinary preoperative protocol for geriatric hip fracture patients at our Level III trauma center. Materials and Methods: In this single-center retrospective study, patients aged 65 and older who were admitted from March 2016 to December 2018 (pre-protocol group, Cohort #1, n = 247) and from August 2021 to September 2022 (post-protocol group, Cohort #2, n = 169) were included. Demographic information, TTS, and LOS were obtained and compared using Student's t-test and Chi-square testing. Results: There was a significant decrease in TTS in Cohort #2 compared to Cohort #1 (P < .001). There was a significant increase in LOS in Cohort #2 compared to Cohort #1 (P < .05), but when comparing a subset of Cohort #2 (Subgroup 2B, patients admitted from May to September 2022 when the effects of COVID-19 were likely dissipated) to Cohort #1, there was no significant difference in LOS (P = .13). For patients admitted to skilled nursing facilities (SNF), LOS in Cohort #2 was significantly longer than in Cohort #1 (P = .001). Discussion: In general, Level III hospitals have fewer perioperative resources compared to larger Level I hospitals. Despite this fact, this multidisciplinary preoperative protocol effectively reduced TTS which improves mortality risk in elderly patients. LOS is a multifactorial variable, and we believe the COVID-19 pandemic was a significant confounder that reduced available SNF beds in our area which prolonged the average LOS in Cohort #2. Conclusion: A multidisciplinary preoperative protocol for geriatric hip fracture management can improve efficiency of getting patients to surgery at Level III trauma centers.

Biomechanical Comparison of Tape Versus Suture in Simulated Achilles Tendon Midsubstance Rupture.

As sutures have progressed in strength, increasing evidence supports the suture tendon interface as the site where most tendon repairs fail. We hypothesized that suture tape would have a higher load to failure versus polyblend suture due to its larger surface area. Eleven matched pairs of cadaveric Achilles tendons were sutured with 2 mm wide braided ultrahigh molecular weight polyethylene tape (Tape) or 2 mm wide braided ultrahigh molecular weight polyethylene suture (Suture) using a Krackow repair method. All Achilles repair constructs were cyclically loaded, after which they were loaded to failure. Change in suture footprint height, clinical and ultimate load to failure, and location of failure was recorded. Clinical loads to failure for Tape and Suture were 290.4 ± 74.8 and 231.7 ± 70.4 Newtons, respectively (p= .01). Ultimate loads to failure for Tape and Suture were 352.9 ± 108.1 and 289.8 ± 53.7 Newtons, respectively (p = .11). Cyclic testing resulted in significant changes in footprint height for both Tape and Suture, but the 2 sutures did not differ in terms of the magnitude of change in footprint height (p = .52). The suture tendon interface was the most common site of failure for both Tape and Suture. Our results suggest that Tape may provide added repair strength in vivo for Achilles midsubstance rupture.

Improvement and Retention of Arthroscopic Skills in Novice Subjects Using Fundamentals of Arthroscopic Surgery Training (FAST) Module.

INTRODUCTION: Analysis of the Fundamentals of Arthroscopy Surgery Training (FAST) workstation regarding increased proficiency and retention of basic arthroscopy skills in novice subjects. METHODS: First-year medical students from a single allopathic medical school performed weekly standardized FAST workstation modules for a consecutive 6 weeks. Primary outcomes evaluated were time to task completion and error rate on specific modules. Scores were analyzed using a one-way repeated measures analysis of variance design for overall trends in time and errors over the 6-week study. Psychomotor retention was analyzed after a 12-week and 24-week interlude. RESULTS: Across the initial 6-week study, the average time to complete all modules at the workstation decreased significantly (P < 0.001) with a mean reduction in the total workstation time of 21.9 minutes (s = 8.12 minutes). Weekly comparisons showed the most significant improvement from week 1 to week 2 for the total workstation time (P < 0.001). Results after a 12-week and 24-week interval of inactivity demonstrated no significant difference in the mean workstation time or errors when compared with the original 6-week study. DISCUSSION: The FAST workstation significantly improved the task performance of novice participants over a 6-week period with no significant deterioration in task performance after 12 and 24 weeks of inactivity.

Effect of Opioid Limiting Legislation on Postoperative Opioid Utilization in Patients Treated for Ankle Fractures.

BACKGROUND: The state of Ohio implemented legislation in August of 2017 limiting the quantity of opioids a provider could prescribe. The purpose of this study was to identify if implementation of legislation affected opioid and nonopioid utilization in patients operatively treated for ankle fractures in the initial 90-day postoperative period after controlling for injury severity and preoperative narcotic usage. METHODS: A retrospective review of 144 patients treated for isolated ankle fractures in a pre-law group (January 2017-July 2017; n = 73) and post-law group (January 2018-July 2018; n = 71) was completed using electronic medical records and a legal prescriber database. Total number of opioid prescriptions, pills, milligrams of morphine equivalents (MMEs), and nonopioid prescriptions were recorded. Multiple regression analysis was run to identify predictors of opioid prescribing after controlling for law group, demographic, preoperative narcotic use, and injury severity characteristics. RESULTS: Mean MME prescribed per patient significantly decreased from 817.2 MME pre-law to 380.9 post-law (P < .01). Mean number of opioid pills prescribed per patient decreased from 99.1 in the pre-law group and 55.3 in the post law group (P < .001), respectively. Multiple linear regression analysis to predict the mean number of opioid pills prescribed was statistically significant (R 2 = 0.33; P < .001), with law group adding significantly to the prediction (P < .001). The multiple linear regression analysis to predict MME per patient was found to be statistically significant (R 2 = 0.31; P < .001), with the law group contributing significantly (P < .001). CONCLUSION: The Ohio prescriber law successfully contributed to the decreased number of opioid pills and MME prescribed in the initial 90-day postoperative period after controlling for injury severity and preoperative narcotic usage. Policies on opioid prescriptions may serve as an important public health tool in the fight against the opioid epidemic. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

The Popularity of Outcome Measures Used in the Foot and Ankle Literature.

Background. Outcome measures are frequently employed in clinical studies to determine the efficacy of orthopaedic surgical procedures. However, substantial variability exists among the outcome instruments utilized in foot and ankle (F&A) literature. The purpose of this study is to determine the number of outcome measures reported in F&A literature recently published in major orthopaedic journals and the association between study characteristics and the use of particular outcome measurement categories. Methods. All manuscripts published in 6 major orthopaedic journals between 2013-2017 reporting at least one clinical outcome measure were collected. For each manuscript, the journal, title, authors, country/region of origin, level of evidence, topic, and anatomic location were recorded. Outcome measures were characterized as generic, F&A specific, and disease specific. Poisson regression with robust error variance was used to test for association between study characteristics and outcome measure categories. Results. A total of 541 F&A articles were included with fifty-two different outcome measures reported. The most popular tool was the American Orthopaedic Foot and Ankle Score (AOFAS) (56.9%). Generic outcome measures were used in 331 (61.1%) studies, while 440 (81.3%) studies used F&A specific measures and 64 (11.8%) used disease-specific measures. The use of generic and disease-specific outcome measures was associated with a higher level of evidence (p < 0.001). Conclusion. AA substantial variety of outcome measures are employed among recent published studies, with many studies utilizing non-validated measures. Reporting a combination of validated and focused outcome measures is necessary to improve the quality and generalizability of published studies in foot and ankle literature. Levels of Evidence: Level II: Systematic review.

Patterns in Opioid Prescription for Patients Operatively Treated for Ankle Fractures Following Implementation of 2017 Ohio Opioid Prescriber Law.

BACKGROUND: The purpose of this study was to report patterns of opioid prescription for patients treated operatively for ankle fractures after implementation of the 2017 Ohio Opioid Prescriber Law in comparison to the previous year. METHODS: A total of 144 patients operatively treated for isolated ankle fractures during two 6-month periods, January 2017 to July 2017 (pre-law) and January 2018 to July 2018 (post-law), were retrospectively identified. Preoperative and postoperative patient narcotic use was reviewed using a legal prescriber database. Total number of prescriptions, quantity of pills, and morphine milligram equivalents (MMEs) per patient prescribed during the 90-day postoperative period were compared between those treated before and those treated after implementation of the Ohio prescriber law. RESULTS: The average number of opioid prescriptions prescribed per patient in the 90-day postoperative period was 2.3 in the pre-law group and 2.1 in the post-law group (P = .625). The average MMEs prescribed per patient dropped from 942.4 MME pre-law to 700.5 MME post-law (P = .295). Differences in the average number of pills per prescription pre- and post-law (49.7 vs 36.2) and average MME per prescription (382.1 mg vs 275.2 mg) were statistically significant (P < .001 and P = .016, respectively). CONCLUSION: Following the implementation of the 2017 Ohio Opioid Prescriber Law, there was a downward trend in the number of pills per prescription and MMEs per prescription in patients operatively treated for isolated ankle fractures. The presence of a downward trend in the quantity of opioids prescribed in this patient cohort suggests the effectiveness of the state law. LEVEL OF EVIDENCE: Level III, comparative study.

Update on Misrepresentation of Research Publications Among Orthopaedic Surgery Residency Applicants.

BACKGROUND: Our 2 previous studies (1999, 2007) examining misrepresentation of research publications among orthopaedic residency applicants revealed rates of misrepresentation of 18.0% and 20.6%, respectively. As the residency selection process has become more competitive, the number of applicants who list publications has increased. The purpose of this study was to determine current rates of research misrepresentation by orthopaedic surgery applicants. METHODS: We reviewed the publication listings and research section of the Common Application Form from the Electronic Residency Application Service (ERAS) for all applicants applying to 1 orthopaedic residency program. The PubMed-MEDLINE database was principally used to search for citations. The PubMed Identifier (PMID) number was used; if no PMID number was listed, a combination of authors or the title of the work was used. If the citations were not found through PubMed, a previously developed algorithm was followed to determine misrepresentation. Misrepresentation was defined as (1) nonauthorship of a published article in which authorship was claimed, (2) claimed authorship of a nonexistent article, or (3) self-promotion to a higher authorship status within a published article. RESULTS: Five hundred and seventy-three applicants applied to our institution for residency in 2016 to 2017: 250 (43.6%) of 573 applicants did not list a publication, whereas 323 (56.4%) of 573 applicants listed ≥1 publication. We found 13 cases of misrepresentation among a total of 1,100 citations (1.18% in 2017 versus 18.0% in 1999 and 20.6% in 2007, p < 0.001). Ten cases of misrepresentation were self-promotion to a higher authorship status. There were 2 cases of claimed authorship of an article that could not be found. Only 1 applicant misrepresented more than once. CONCLUSIONS: Based on our findings, orthopaedic surgery residency applicants are accurately representing their publication information. The incorporation of the PMID number on the ERAS application has streamlined the process for finding publications, and has possibly encouraged veracity on residency applications. Faculty involved in the resident selection process should be aware of the significant decline in the rate of misrepresentation by medical students applying for orthopaedic surgery residency versus the rate in our prior studies.

Plantar Fascia Release Through a Single Lateral Incision in the Operative Management of a Cavovarus Foot: A Cadaver Model Analysis of the Operative Technique.

Plantar fascia release and calcaneal slide osteotomy are often components of the surgical management for cavovarus deformities of the foot. In this setting, plantar fascia release has traditionally been performed through an incision over the medial calcaneal tuberosity, and the calcaneal osteotomy through a lateral incision. Two separate incisions can potentially increase the operative time and morbidity. The purpose of the present study was threefold: to describe the operative technique, use cadaveric dissection to analyze whether a full release of the plantar fascia was possible through the lateral incision, and examine the proximity of the medial neurovascular structures to both the plantar fascia release and calcaneal slide osteotomy when performed together. In our cadaveric dissections, we found that full release of the plantar fascia is possible through the lateral incision with no obvious damage to the medial neurovascular structures. We also found that the calcaneal branch of the tibial nerve reliably crossed the osteotomy in all specimens. We have concluded that both the plantar fascia release and the calcaneal osteotomy can be safely performed through a lateral incision, if care is taken when completing the calcaneal osteotomy to ensure that the medial neurovascular structures remain uninjured.

Biomechanical Head-to-Head Comparison of 2 Sutures and the Giftbox Versus Bunnell Techniques for Midsubstance Achilles Tendon Ruptures.

BACKGROUND: Acute midsubstance Achilles tendon ruptures are a common orthopaedic problem for which the optimal repair technique and suture type remain controversial. Head-to-head comparisons of current fixation constructs are needed to establish which stitch/suture combination is most biomechanically favorable. HYPOTHESIS: Of the tested fixation constructs, Giftbox repairs with Fiberwire will exhibit superior stiffness and strength during biomechanical testing. STUDY DESIGN: Controlled laboratory study. METHODS: Two biomechanical trials were performed, isolating stitch technique and suture type, respectively. In trial 1, 12 transected fresh-frozen cadaveric Achilles tendon pairs were randomized to receive either the Giftbox-modified Krackow or the Bunnell stitch with No. 2 Fiberwire suture. Each repair underwent cyclic loading, oscillating between 10 and 100 N at 2 Hz for 1000 cycles, with repair gapping measured at 500 and 1000 cycles. Load-to-failure testing was then performed, and clinical and catastrophic failure values were recorded. In trial 2, 10 additional paired cadaveric Achilles tendons were randomized to receive a Giftbox repair with either No. 2 Fiberwire or No. 2 Ultrabraid. Testing and data collections protocols in trial 2 replicated those used in trial 1. RESULTS: In trial 1, the Bunnell group had 2 failures during cyclic loading while the Giftbox had no failures. The mean tendon gapping after cyclic loading was significantly lower in the Giftbox repairs (0.13 vs 2.29 mm, P = .02). Giftbox repairs were significantly stiffer than Bunnell (47.5 vs 38.7 N/mm, P = .019) and showed more tendon elongation (5.9 ± 0.8 vs 4.5 ± 1.0 mm, P = .012) after 1000 cycles. Mean clinical load to failure was significantly higher for Giftbox repairs (373 vs 285 N, P = .02), while no significant difference in catastrophic load to failure was observed (mean, 379 vs 336 N; P = .61). In trial 2, there were no failures during cyclic loading. The Giftbox + Fiberwire repairs recorded higher clinical load-to-failure values compared with Giftbox + Ultrabraid (mean, 361 vs 239 N; P = .005). No other biomechanical differences were observed in trial 2. CONCLUSION: Simulated early rehabilitation biomechanical testing showed that Giftbox-modified Krackow Achilles repair technique with Fiberwire suture was stronger and more resistant to gap formation at the repair site than combinations that incorporated the Bunnell stitch or Ultrabraid suture. CLINICAL RELEVANCE: A more in-depth understanding of the biomechanical properties of the Giftbox repair will help inform surgical decision making because stronger repairs are less likely to fail during accelerated postoperative rehabilitation.

Factors Predicting Length of Hospital Stay and Extended Care Facility Admission After Hindfoot Arthrodesis Procedures.

Delayed identification of patients requiring admission to extended care facilities (ECFs) can lead to greater healthcare costs through an increased length of hospital stay (LOHS). Previous studies of hip and knee arthroplasty identified factors associated with a likely discharge to an ECF. These issues have not been extensively studied for major hindfoot procedures. We conducted a retrospective review of 198 cases treated during a 3-year period to identify the risk factors for an extended LOHS and ECF admission after ankle arthrodesis, triple arthrodesis, pantalar arthrodesis, and subtalar arthrodesis. The primary outcomes were LOHS and ECF admission. The independent predictors included age, sex, body mass index, housing status, American Society of Anesthesiologists class, diabetes and/or diabetic neuropathy, health insurance, fixation type, and perioperative infection. Stepwise multiple regression analysis was used to determine which variables were related to a longer LOHS. Nonparametric discriminant function analysis was used to identify the preoperative factors that best predicted ECF admission. A longer LOHS was significantly related to postoperative ECF admission, Centers for Medicare and Medicaid Services (CMS) insurance, diabetic neuropathy, external fixation, and infection. ECF admission was required for 34 of 198 patients (17.2%). Discriminant analysis found that older age, living alone, external fixation, and CMS insurance predicted a greater probability of ECF admission. The function accurately classified 94% of ECF admissions and 80% of non-ECF admission patients. ECF admission and CMS insurance extended the LOHS, likely owing to the administrative process of arranging an ECF discharge. If externally validated, the function we have derived could provide preoperative identification of likely ECF discharge candidates and reduce costs by shortening the LOHS.

Suture-Only Repair Versus Suture Anchor-Augmented Repair for Achilles Tendon Ruptures With a Short Distal Stump: A Biomechanical Comparison.

BACKGROUND: Chronic noninsertional Achilles tendinosis can result in an acute Achilles tendon rupture with a short distal stump. In such tendon ruptures, there is a limited amount of adequate tissue that can hold suture, thus presenting a challenge for surgeons who elect to treat the rupture operatively. HYPOTHESIS: Adding suture anchors to the repair construct may result in biomechanically stronger repairs compared with a suture-only technique. STUDY DESIGN: Controlled laboratory study. METHODS: Nine paired Achilles-calcaneus complexes were harvested from cadavers. An artificial Achilles rupture was created 2 cm proximal to the insertion on the calcaneus. One specimen from each cadaver was assigned to a suture-only or a suture anchor-augmented repair. The contralateral specimen of the same cadaver received the opposing repair. Cyclic testing was then performed at 10 to 100 N for 2000 cycles, and load-to-failure testing was performed at 0.2 mm/s. This was followed by analysis of repair displacement, gapping at repair site, peak load to failure, and failure mode. RESULTS: The suture anchor-augmented repair exhibited a 116% lower displacement compared with the suture-only repair (mean ± SD, 1.54 ± 1.13 vs 3.33 ± 1.47 mm, respectively; P < .03). The suture anchor-augmented repair also exhibited a 45% greater load to failure compared with the suture-only repair (303.50 ± 102.81 vs 209.09 ± 48.12 N, respectively; P < .04). CONCLUSION: Suture anchor-augmented repairs performed on acute Achilles tendon ruptures with a short distal stump are biomechanically stronger than suture-only repairs. CLINICAL RELEVANCE: Our results support the use of suture anchor-augmented repairs for a biomechanically stronger construct in Achilles tendon ruptures with a short distal stump. Biomechanically stronger repairs may lead to less tendon repair gapping and failure, increasing the ability to start early active rehabilitation protocols and thus improving patient outcomes.

Hospital-Based Acute Care After Total Hip and Knee Arthroplasty: Implications for Quality Measurement.

BACKGROUND: Although hospital readmissions are being adopted as a quality measure after total hip or knee arthroplasty, they may fail accurately capture the patient's postdischarge experience. METHODS: We studied 272,853 discharges from 517 hospitals to determine hospital emergency department (ED) visit and readmission rates. RESULTS: The hospital-level, 30-day, risk-standardized ED visit (median = 5.6% [2.4%-13.7%]) and hospital readmission (5.0% [2.6%-9.2%]) rates were similar and varied widely. A hospital's risk-standardized ED visit rate did not correlate with its readmission rate (r = -0.03, P = .50). If ED visits were included in a broader "readmission" measure, 246 (47.6%) hospitals would change perceived performance groups. CONCLUSION: Including ED visits in a broader, hospital-based, acute care measure may be warranted to better describe postdischarge health care utilization.

Association Between Diabetes, Obesity, and Short-Term Outcomes Among Patients Surgically Treated for Ankle Fracture.

BACKGROUND: Although obesity is widely accepted as a risk factor for surgical complications following orthopaedic surgery, the literature is unclear with regard to the effect of obesity on outcomes of ankle fracture surgery, particularly in the setting of competing risks from diabetes. We hypothesized that obesity would be independently associated with more frequent complications, longer hospital length of stay, and higher costs of care among patients with and without diabetes. METHODS: With use of data from 2001 to 2010 from the Nationwide Inpatient Sample, we identified all adult patients who underwent surgical treatment for a primary diagnosis of an isolated ankle fracture or dislocation. We then divided patients into four groups according to the presence or absence of diabetes or obesity: Group A included patients with neither diagnosis; Group B, obesity alone; Group C, diabetes alone; and Group D, both diagnoses. Multivariable regression models were constructed to determine the association between diagnostic group and in-hospital complications, hospital length of stay, and imputed costs of care, while controlling for other conditions. RESULTS: The final sample included 148,483 patients (78.4% in Group A, 5.0% in Group B, 13.6% in Group C, and 3.0% in Group D). The median age was 53.0 years, and most patients (62.2%) were female and had a closed bimalleolar or trimalleolar fracture (62.2%). In the unadjusted analysis, the frequency of in-hospital complications (2.6%, 4.2%, 5.3%, and 6.5% in Groups A, B, C, and D, respectively; p < 0.001), length of stay (3.0, 3.6, 4.4, and 4.8 days, respectively; p < 0.001), and costs of care ($9686, $10,555, $11,616, and $12,804, respectively, in 2010 U.S. dollars; p < 0.001) increased across groups. Patients with obesity alone (Group B) (adjusted odds ratio [OR] = 1.4; 95% confidence interval [CI] = 1.3 to 1.6), diabetes alone (Group C) (OR = 1.1; 95% CI = 1.0 to 1.2), and both diagnoses (Group D) (OR = 1.4; 95% CI = 1.2 to 1.5) had more frequent in-hospital complications than those with neither diagnosis. CONCLUSIONS: We found that patients with concurrent diagnoses of diabetes and obesity had higher health-care utilization and costs than those with neither diagnosis or with obesity alone or diabetes alone. The delay in the diagnosis of diabetes may somewhat obscure the true effect.

Wear characteristics of WSU total ankle replacement devices under shear and torsion loads.

BACKGROUND: There are several factors that contribute to the failure of total ankle replacement (TAR). Aseptic loosening is one of the primary mechanisms of failure in TAR. Since a cross-linked ultrahigh molecular weight polyethylene (UHMWPE) is used as liner material, there is a need to quantify and develop methods to estimate the wear rates of the liners. High contact stresses develop during the gait generates wear debris resulting in osteolysis and early loosening of the prostheses. METHODS: In this paper wear characteristics of Wright State University (WSU) TARs were determined by applying shear and torsion loads. Viscoelastic properties were used to model the liner component. Finite element analysis was conducted to determine the wear rate by deriving Von Mises and contact stresses generated in the liner and wear rate equation was used to predict the wear rate. RESULTS: Titanium alloy has shown less resistance towards shear forces when compared with other metal alloys. Under torsion, rotation angle plays a significant role in affecting the peak stress values. The maximum average contact stress was 14.46 MPa under torsion load which contributes to a wear rate of 0.67 (mm(3)/year) for one of the mobile bearing models. The maximum average contact stress and wear rate obtained from the analytical study were 10.55 MPa and 0.33 (mm(3)/year), respectively for mobile bearing models. When compared with mobile bearing model, fixed bearing model has shown higher stresses at different degrees of rotation. CONCLUSION: Both shear and torsion loads cause significantly lower contact stresses and wear when compared to the axial load. Further studies are necessary to accurately determine the wear behavior of fixed bearing TAR models.

Proximal phalanx and flexor digitorum longus tendon biomechanics in flexor to extensor tendon transfer.

BACKGROUND: The flexor to extensor transfer of the flexor digitorum longus (FDL) tendon has been a relatively common operative procedure for the treatment of a flexible hammer toe deformity and chronic metatarsophalangeal (MTP) joint dislocation. A possible complication of using the tunnel technique rather than the tendon splitting technique is iatrogenic fracture through the drilled tunnel site. The purpose of this investigation was to study the FDL tendon and proximal phalanx dimensions in the area of the transfer procedure in order to improve preoperative planning and minimize postoperative complications. Additionally, this study investigated the force necessary to create a fracture in a predrilled proximal phalanx and attempted to elucidate a relationship between that force and the percentage of bone remaining after the drilling process. METHODS: The proximal phalanx and FDL tendon of the second, third, and fourth toes from both the right and the left foot of 14 fresh frozen cadavers were dissected, and the digit was amputated at the MTP joint. A total of 84 toes (42 right, 42 left) were obtained from 14 cadavers. The diameter of the FDL tendon was measured, and the circumference and volume were calculated. Fourteen proximal phalanges of either the right or the left foot were then drilled with a 3.5-mm drill, as is often done in a tendon transfer procedure. The 14 nondrilled bones from the contralateral foot were used as matched controls. Radiographs were then taken of the proximal phalanges, and the dimensions of the drill tunnel and remaining bone were calculated. These measurements were used to calculate the volume of the bone, the volume of the drill tunnel, and the percentage of bone remaining after the drilling process. The bones were then tested for load-to-failure using a biomechanical loading apparatus. RESULTS: The average bone and tendon diameter measurements showed a gradual decrease in size from the second to the fourth digits. The bone removed by drilling the tunnel accounted for approximately 20% to 30% of the total volume of bone. Half of the bones fractured with forces between 100 and 200 N, and the majority of bones with a diameter of less than 6 mm fractured with a force of less than 100 N. CONCLUSIONS: The average proximal phalanx and FDL tendon size both showed an overall decrease from the second to the fourth digit, albeit not symmetrically. The proximal phalanx diameter appeared to be the most important factor in determining the strength of the structure. CLINICAL RELEVANCE: Iatrogenic fracture may occur in proximal phalanges with a diameter of bone less than 6 mm, as there may not be adequate bone strength remaining to withstand postoperative forces.

Knotted versus knotless suture bridge repair of the achilles tendon insertion: a biomechanical study.

BACKGROUND: Surgical treatment of insertional Achilles tendinopathy often involves detachment and debridement of the Achilles tendon insertion. A recent study has shown that knotted suture bridge fixation of the Achilles to the calcaneus is biomechanically superior to single-row fixation, but there is an absence of literature on the use of different suture bridge constructs to repair the Achilles tendon. HYPOTHESIS: There will be no significant difference in the load to failure, mode of failure, tendon strain, tendon stiffness, repair site gapping, or footprint size when comparing knotted suture bridge repair to knotless suture bridge repair of the Achilles tendon after detachment for insertional Achilles tendinopathy. STUDY DESIGN: Controlled laboratory study. METHODS: A single specimen from each pair of 10 cadaveric Achilles tendons was randomized to 1 of 2 Achilles insertion repair groups: knotted (n = 10) or knotless (n = 10) suture bridge repair. Repaired footprint size was measured, and then cyclic testing from 10 to 100 N for 2000 cycles was performed. This was followed by measurement of tendon strain, repair site displacement, load to failure, and tendon stiffness. RESULTS: The knotted suture bridge repair had a significantly higher load to failure compared with the knotless suture bridge (mean ± SD, 317.8 ± 93.6 N vs 196.1 ± 12.1 N, respectively; P = .001). All constructs failed at the tendon-suture interface. Tendon strain after cyclic testing was significantly greater in the knotless (1.20 ± 1.05) compared with the knotted (0.39 ± 0.4) suture repair groups (P = .011). There was no significant difference in footprint size between the knotted (230.3 ± 63.3 mm(2)) and knotless (248.5 ± 48.8 mm(2)) groups (P = .40). There was also no significant difference in stiffness (knotted = 76.4 ± 8.0 N/mm; knotless = 69.6 ± 10.9 N/mm; P = .17) and repair site displacement after cyclic testing (knotted = 2.8 ± 1.2 mm; knotless = 3.6 ± 1.1 mm; P = .17). CONCLUSION: During suture bridge repair of the Achilles tendon after detachment, knots at the proximal suture anchors significantly improve the biomechanical strength of the repair. CLINICAL RELEVANCE: This study demonstrated that the knotless suture bridge repair had a significantly lower load to failure than the knotted suture bridge. Surgeons should be aware of these biomechanical differences, as they influence the postoperative rehabilitation protocol and may lead to higher surgical complication rates.

Excess body weight loss is associated with nonpathological gait patterns in women 4 to 5 years after bariatric surgery.

BACKGROUND: This study examined relationships between excess body weight (EBW) loss and current gait and functional status in women 5 years after Roux-en-Y gastric bypass surgery. METHODS: Gait data were analyzed in nine female bariatric patients for relationships with longitudinal changes in weight, body composition, and physical function assessed by the Short Musculoskeletal Functional Assessment (SMFA) questionnaire and the timed "get-up-and-go" (TGUG) test. Gait characteristics in the bariatric sample were also compared to an age- and BMI-matched nonsurgical reference sample from the Fels Longitudinal Study. RESULTS: Bariatric patients lost an average of 36.4 kg (61.1%) of EBW between preoperative and 5-year follow-up visits (P < 0.01); SMFA function index scores and TGUG times also decreased (both P < 0.01). Degree of EBW loss was correlated with less time spent in initial double support and more time in single support (both P = 0.02), and for all gait variables, the bariatric sample fell within the 95% confidence intervals of gait/EBW relationships in the reference sample. CONCLUSIONS: Gait and function 5 years after bariatric surgery were characteristic of current weight, not preoperative obesity, suggesting that substantial, sustained recovery of physical function is possible with rapid surgical weight loss.

Staged subtalar fusion for severe calcaneus fractures with bone loss.

BACKGROUND: With high energy fractures to the calcaneus there is the potential for significant bone loss. The loss of bone can make it difficult to fully regain calcaneal alignment. In addition these fractures are often associated with significant soft tissue injury. These two factors make it difficult to address this injury in a single stage, and can have significant complications. To address these issues our initial goal in treatment has been restoration of calcaneal alignment and stabilization of the surrounding soft tissue, followed by delayed/staged subtalar arthrodesis. METHODS: Patients with calcaneus fractures treated by a single surgeon from 2002 to 2012 were reviewed. Injuries which were found to have medial extrusion of the posterior facet and bone loss, and subsequently underwent a staged protocol involving early provisional fixation and late subtalar fusion were included. RESULTS: We treated 6 calcaneus fractures with bone loss. All patients were treated with staged subtalar fusion after initial irrigation and debridement and provisional fixation. No soft-tissue complications were noted after the fusion procedure in any of the six cases. Fusion occurred in all six patients at an average of 20.6 weeks (range, 13-23 weeks). All patients were able to ambulate and wear a regular shoe by one year following the initial injury. CONCLUSION: It is important in the high energy calcaneus fracture to assess for both soft tissue integrity and bone loss. A thorough debridement of both the soft tissues and any devitalized bone should be performed as well as provisional fixation which attempts to restore near normal calcaneal anatomy. Definitive fusion should not be performed until the soft tissues have fully recovered.