Comparison of standard screw fixation versus suture button fixation in Lisfranc ligament injuries.

BACKGROUND: The standard operative treatment for Lisfranc injuries is to openly reduce them and use screw fixation. Due to the current trend of applying a more physiologic fixation and decreasing the need for screw removal, a recent interest has developed in suture-button fixation. The purpose of this study was to compare the suture button technique for Lisfranc fracture fixation to the traditional interfragmentary screw fixation. MATERIALS AND METHODS: Eight fresh-frozen matched paired cadavers with an average age of 50 (range, 37 to 55) years were tested. For each specimen, the distance between marked points on the base of the first metatarsal and second metatarsal was measured. The distance was then re-measured when a 600 Newton load was applied to the specimen with an intact ligament, a sectioned Lisfranc ligament, and after the fixation method. RESULTS: Fixed loaded measurement displacements were significantly (p < 0.00) smaller with screw fixation compared to their respective intact loaded measurements. Fixed loaded measurement displacements were significantly (p = 0.001) smaller than the fixed unloaded measurements in the screw group when compared to the suture button group. CONCLUSION: In the current cadaveric model, standard interfragmentary screw fixation with a 4.0 cannulated screw had less displacement than the Arthrex Mini Tightrope in isolated Lisfranc ligament injuries. Therefore, we conclude that until more comparative studies are performed with more accurate measuring devices, open reduction and screw fixation of these injuries should continue to be the accepted treatment.

Safety of ankle trans-syndesmotic fixation.

BACKGROUND: Ankle syndesmosis fixation is often employed with the utilization of many variable methods and implants. Complications secondary to trans-syndesmotic fixation have been described, yet the proximity of a single trans-syndesmotic screw to the perforating branch of the peroneal artery (PBPA) has not. MATERIALS AND METHODS: Sixteen cadaveric legs received a single trans-syndesmotic screw using standard AO technique. The PBPA was identified and the following distances were measured using photographic images and morphometric software: the tip of lateral malleolus to the PBPA, the tibial plafond to the PBPA, tip of lateral malleolus to the screw, and the PBPA to the screw. Average distances were calculated and statistically compared. RESULTS: The location of the trans-syndesmotic screw inserted 2 cm proximal to the tibial plafond was on average less than 1.3 cm distal to the PBPA. In six out of the 16 specimens, the screw was less than 1 cm from the PBPA. In one specimen, the screw came within 0.22 cm of the PBPA. CONCLUSION/CLINICAL RELEVANCE: The placement of trans-syndesmotic fixation places the PBPA at risk. In order to avoid injury to the PBPA with trans-syndesmotic fixation, fixation should be avoided 2.3 to 4.1 cm proximal to the tibial plafond or 4.5 to 6.2 cm proximal to the tip of the lateral malleolus in females and 2.8 to 5.9 cm proximal to the tibial plafond or 5.1 to 7.2 cm proximal to the tip of the lateral malleolus in males.

The complicated Jones fracture, including revision and malalignment.

Using radiographs culled over a 33-month period, the treatment, complications, revision, and rehabilitation of complicated Jones fractures and stress fractures involving the proximal diaphysis are examined. Although the non-operative approach remains viable, the exigencies and desires of the athletic and leg-based working population require sooner-rather-than-later return to play or work. Fortunately, these needs can be matched by the available and functioning orthopedic practice of intramedullary screw fixation. This practice is coupled with prevention, reliable orthopedic techniques, the orthopedist's surgical skills, and devices necessary for successful surgery. Recent attention directed toward handling complications promise better, quicker, and more reliable recovery for the patient.

Comparison of a continuous temperature-controlled cryotherapy device to a simple icing regimen following outpatient knee arthroscopy.

This prospective, randomized study compared postoperative pain control with use of a continuous temperature-controlled cryotherapy system versus a traditional ice therapy regimen following outpatient knee arthroscopy. Patients with unilateral knee pathology scheduled for outpatient arthroscopic surgery were included. Patients with major ligament reconstructions were excluded. A specific cold therapy regimen was begun postoperatively and continued for 2 weeks as adjunctive management of postoperative pain. Preoperative and postoperative pain intensity, pain type, functionality, and sleep quality were assessed. Patients were randomly assigned to either an ice or a continuous cryotherapy group. Follow-up questionnaires were completed on 5 postoperative days. Data were analyzed using a chi-square test with a level of significance at P < 0.05. Fifty-three patients completed the study. Pain intensity was similar between groups throughout the course of the study. Among patients who reported experiencing night pain, 36% of those in the continuous cryotherapy group were able to sleep soundly with minimal awakening through postoperative day 2 versus 5.9% among the ice therapy group (P = 0.04). No significant differences existed between groups regarding functional ability, and no differences were noted on other follow-up days. These findings support use of continuous temperature-controlled cold therapy devices for nighttime pain control and improved quality of life in the early period following routine knee arthroscopy.

Endoscopic bony and soft-tissue decompression of the retrocalcaneal space for the treatment of Haglund deformity and retrocalcaneal bursitis.

BACKGROUND: The traditional operative management of Haglund deformity and retrocalcaneal bursitis consists of an open excision of the inflamed bursa, resection of the posterosuperior calcaneal tuberosity, and debridement of the Achilles tendinopathy. In an effort to reduce morbidity and recovery time, an endoscopic technique was used for the management of this condition. METHODS: Thirty consecutive patients (32 heels) who had retrocalcaneal bursitis unrelieved by nonoperative measures were treated with the endoscopic technique. Two portals were created, one laterally and one medially, over the posterosuperior portion of the calcaneus to gain access to the retrocalcaneal space. The inflamed bursal tissue was removed, and the prominent bone was resected. Patients were evaluated preoperatively and postoperatively with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. RESULTS: The mean followup was 35 months. Twenty-eight patients (30 heels) were available for followup. The AOFAS scores averaged 62 preoperatively and 97 postoperatively. There were 26 excellent results, three good results and one poor result. One major and one minor complication occurred: an Achilles tendon rupture three weeks after surgery and residual pain and swelling that required reoperation through an open procedure. There were no wound complications or postoperative infections. CONCLUSIONS: The endoscopic technique can be done outpatient and has a low morbidity and high patient satisfaction. The time to return to normal activity level is short. Sufficient exposure of the Achilles tendon and removal of the calcaneal prominence and retrocalcaneal bursa can be done effectively using an endoscopic technique.

The hallucal sesamoid complex.

The hallucal sesamoids are vitally important to normal weight bearing and foot mechanics. The sesamoid complex of the hallux normally transmits up to 50% of body weight and during push-off can transmit loads >300%. These high stresses may lead to both acute and chronic pathologies of the hallucal sesamoids. Sesamoidal problems may occur in the weekend warrior or the elite-level athlete. Thus, patients with sesamoid pathology may present to a general orthopaedic surgeon, sports medicine physician, foot and ankle specialist, or podiatrist. Physical examination, radiographs, and other specialized studies assist with the classification of sesamoid pathology. Initial treatment almost always involves an accommodative orthosis, but surgical intervention may be necessary in recalcitrant cases. Surgical options for managing problems of the hallucal sesamoid complex include curettage, bone grafting, shaving, internal fixation, and partial or complete excision.

Repeat patellar tendon rupture in a child.

In summary, we present the first published case of a patellar tendon midsubstance rupture in an otherwise healthy 9-year-old with repeat rupture at age 10.