Prospective Results of the Modified Glide Path Technique for Improved Syndesmotic Reduction During Ankle Fracture Fixation.

BACKGROUND: Malreduction after syndesmotic stabilization occurs in as many as 52% of cases and has been shown to detrimentally affect clinical outcomes. We propose that the modified Glide Path technique reduces the occurrence of syndesmotic malreduction. METHODS: This study is a prospective series comparing 16 patients reduced with the modified Glide Path technique with a retrospectively reviewed series of 25 patients reduced with a traditional technique using fluoroscopy and a clamp. The modified Glide Path technique consists of manual reduction of the fibula and placement of a Kirschner wire through the fibula and tibia along the transmalleolar axis. The syndesmosis can then be reduced along the glide path created by the Kirschner wire to prevent posterior or anterior malreduction. Computed tomographic scans of the repaired and contralateral ankles were obtained postoperatively to assess reduction. RESULTS: We found a statistically significant decrease of syndesmotic malreductions using the modified Glide Path technique when compared with technique that did not use a glide path. In our study, 2 of 16 patients (12.5%) had syndesmotic malreductions using the modified Glide Path technique, compared with 11 of 25 patients (44%) with syndesmotic malreductions in the historical cohort. CONCLUSION: The modified Glide Path technique is a simple method for ankle syndesmotic reduction. The technique has lower rates of malreduction compared with historical methods and may be useful for most operative syndesmotic injuries. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Arthroscopic Versus Open Anterior Shoulder Stabilization: A Prospective Randomized Clinical Trial With 15-Year Follow-up With an Assessment of the Glenoid Being "On-Track" and "Off-Track" as a Predictor of Failure.

BACKGROUND: Recent studies have demonstrated equivalent short-term results when comparing arthroscopic versus open anterior shoulder stabilization. However, none have evaluated the long-term clinical outcomes of patients after arthroscopic or open anterior shoulder stabilization, with inclusion of an assessment of preoperative glenoid tracking. PURPOSE: To compare long-term clinical outcomes of patients with recurrent anterior shoulder instability randomized to open and arthroscopic stabilization groups. Additionally, preoperative magnetic resonance imaging (MRI) studies were used to assess whether the shoulders were "on-track" or "off-track" to ascertain a prediction of increased failure risk. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A consecutive series of 64 patients with recurrent anterior shoulder instability were randomized to receive either arthroscopic or open stabilization by a single surgeon. Follow-up assessments were performed at minimum 15-year follow-up using established postoperative evaluations. Clinical failure was defined as any recurrent dislocation postoperatively or subjective instability. Preoperative MRI scans were obtained to calculate the glenoid track and designate shoulders as on-track or off-track. These results were then correlated with the patients' clinical results at their latest follow-up. RESULTS: Of 64 patients, 60 (28 arthroscopic and 32 open) were contacted or examined for follow-up (range, 15-17 years). The mean age at the time of surgery was 25 years (range, 19-42 years), while the mean age at the time of this assessment was 40 years (range, 34-57 years). The rates of arthroscopic and open long-term failure were 14.3% (4/28) and 12.5% (4/32), respectively. There were no differences in subjective shoulder outcome scores between the treatment groups. Of the 56 shoulders, with available MRI studies, 8 (14.3%) were determined to be off-track. Of these 8 shoulders, there were 2 surgical failures (25.0%; 1 treated arthroscopically, 1 treated open). In the on-track group, 6 of 48 had failed surgery (12.5%; 3 open, 3 arthroscopic [P = .280]). CONCLUSION: Long-term clinical outcomes were comparable at 15 years postoperatively between the arthroscopic and open stabilization groups. The presence of an off-track lesion may be associated with a higher rate of recurrent instability in both cohorts at long-term follow-up; however, this study was underpowered to verify this situation.

Digital Tomography for Detection of Acute Occult Scaphoid Fractures.

Diagnosis of occult scaphoid fractures remains a challenge. Traditional management consisting of 2 weeks of immobilization and repeat radiographs results in unnecessary immobilization of many patients without fracture. Magnetic resonance imaging (MRI) is sensitive but expensive. Digital tomography (DT) is an imaging technique that provides fine-cut visualization with minimal radiation exposure and may be used when there is high clinical suspicion despite negative findings on initial radiographs. The authors compared the ability of DT vs MRI to detect acute occult scaphoid fractures. This was an institutional review board-approved, prospective series. Adults for which clinical suspicion for acute scaphoid fracture (presenting within 96 hours of trauma) and negative findings on initial radiographs existed were included. Both a wrist tomogram and MRI were obtained. Wrists were immobilized and reevaluated at 10 to 14 days with repeat radiographs as a control. Studies were interpreted by a radiologist in a blinded fashion. Forty consecutive extremities in 39 patients met the inclusion criteria. Six (15%) of the 40 scaphoids were determined to be fractured on repeat radiographs. Digital tomogram yielded positive findings in 4 of these. Magnetic resonance imaging yielded positive findings in 8 (20%) of the 40 extremities. Sensitivities were 67% and 100% for digital tomogram and MRI, respectively (P=.0001). The positive predictive value was 100% for DT and MRI. The authors found that DT detects more occult scaphoid fractures than initial standard radiographs but is less sensitive than MRI. This is the first study to compare DT with MRI. Digital tomography can be used to augment radiographs and may increase diagnostic efficiency, minimize unnecessary immobilization, and reduce health care costs. [Orthopedics. 2017; 40(6):e1092-e1095.].

The Effect of Syndesmosis Screw Removal on the Reduction of the Distal Tibiofibular Joint: A Prospective Radiographic Study.

BACKGROUND: Injury to the tibiofibular syndesmosis is frequent with rotational ankle injuries. Multiple studies have shown a high rate of syndesmotic malreduction with the placement of syndesmotic screws. There are no studies evaluating the reduction or malreduction of the syndesmosis after syndesmotic screw removal. The purpose of this study was to prospectively evaluate syndesmotic reduction with CT scans and to determine the effect of screw removal on the malreduced syndesmosis. METHODS: This was an IRB-approved prospective radiographic study. Patients over 18 years of age treated at 1 institution between August 2008 and December 2011 with intraoperative evidence of syndesmotic disruption were enrolled. Postoperative CT scans were obtained of bilateral ankles within 2 weeks of operative fixation. Syndesmotic screws were removed after 3 months, and a second CT scan was then obtained 30 days after screw removal. Using axial CT images, syndesmotic reduction was evaluated compared to the contralateral uninjured ankle. Twenty-five patients were enrolled in this prospective study. The average age was 25.7 (range, 19 to 35), with 3 females and 22 males. RESULTS: Nine patients (36%) had evidence of tibiofibular syndesmosis malreduction on their initial postoperative axial CT scans. In the postsyndesmosis screw removal CT scan, 8 of 9 or 89% of malreductions showed adequate reduction of the tibiofibular syndesmosis. There was a statistically significant reduction in syndesmotic malreductions ( t = 3.333, P < .001) between the initial rate of malreduction after screw placement of 36% (9/25) and the rate of malreduction after all screws were removed of 4% (1/25). CONCLUSIONS: Despite a high rate of initial malreduction (36%) after syndesmosis screw placement, 89% of the malreduced syndesmoses spontaneously reduced after screw removal. Syndesmotic screw removal may be advantageous to achieve final anatomic reduction of the distal tibiofibular joint, and we recommend it for the malreduced syndesmosis. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Postoperative range of motion following anterior cruciate ligament reconstruction using autograft hamstrings: a prospective, randomized clinical trial of early versus delayed reconstructions.

BACKGROUND: There is a common belief that surgical reconstruction of an acutely torn anterior cruciate ligament (ACL) should be delayed for at least 3 weeks because of the increased incidence of postoperative motion loss (arthrofibrosis) and suboptimal clinical results. HYPOTHESIS: There is no difference in postoperative range of motion or stability after ACL reconstructions performed either acutely or delayed. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients with an acute ACL tear were prospectively randomized to either early (within 21 days) or delayed (beyond 6 weeks) reconstruction using autograft hamstring tendon. Previous knee surgery on the index extremity and a multiligamentous injury were exclusionary criteria. Surgical technique and postoperative rehabilitation were identical for all patients. Postoperative assessments included range of motion and KT-1000 arthrometer measurements compared with the contralateral knee. Standardized outcome measures were used including single assessment numeric evaluation (SANE), Lysholm, and Tegner Activity Score. RESULTS: Seventy consecutive patients were enrolled, and 1 patient was dropped after a postoperative infection. Sixty-nine patients (34 acute, 35 delayed) with an average age of 27 years composed the study cohort. The mean time from injury to surgery was 9 days (range, 2-17 days) for patients in the early group and 85 days (range, 42-192) for those in the delayed group. The average follow-up from surgery was 366 days (range, 185-869). Articular cartilage and meniscal injuries were comparable between the 2 groups. There were no significant differences between the 2 treatment groups in degrees of extension or flexion lost relative to the nonoperative side, operative time, KT-1000 arthrometer differences, or subjective knee evaluations. CONCLUSION: Excellent clinical results can be achieved after ACL reconstructions performed soon after injury using autograft hamstrings. Although the authors do not advocate that all reconstructions should be performed acutely, they found that early ACL reconstructions do not result in loss of motion or suboptimal clinical results as long as a rehabilitation protocol emphasizing extension and early range of motion is employed.

Serial sonographic evaluation of Achilles tendons in patients taking fluoroquinolone antibiotics.

We performed a prospective study to determine if subclinical tendinopathy occurs in asymptomatic adults treated with fluoroquinolone antibiotics. Thirty-eight adults were enrolled. Serial ultrasounds of the Achilles tendons were performed. A board certified musculoskeletal radiologist interpreted the images in a blinded fashion. No changes were identified. Subclinical tendinopathy does not appear to exist in asymptomatic adults treated with fluoroquinolone antibiotics.