Prevalence of Deep Vein Thrombosis in Low-Risk Patients After Elective Foot and Ankle Surgery.

BACKGROUND:: The evidence regarding the prevalence of deep vein thrombosis (DVT) after foot and ankle surgery in elective patients that need to be 6 weeks non-weight bearing postoperatively is incomplete and has limitations. METHODS:: The prevalence of DVT in 114 procedures involving the hindfoot and midfoot was determined using ultrasonographic surveillance at 2 and 6 weeks after surgery. RESULTS:: The prevalence of DVT was observed to be 25.4%. The majority (68.9%) of DVTs were diagnosed at the ultrasonographic scan performed 2 weeks postoperatively. The remainder (31.1%) of DVTs were diagnosed at the 6-week postoperative ultrasonographic scan. At least 75% of the patients who had early and late DVT had no clinical symptoms or signs of DVT. The prevalence of DVT in clinically detectable patients was 6%. The average age of patients with early DVT was 62.2 years, significantly higher compared to those who had no DVT. The mean tourniquet time for patients with early DVT was 68.1 minutes, significantly higher compared to those without DVT. All DVTs detected were distal to the popliteal vein. CONCLUSIONS:: The prevalence of clinically silent DVT was significantly higher than was previously thought. We believe this increased rate is directly attributable to the use of ultrasonographic surveillance postsurgery both at 2 and 6 weeks. The risk of DVT continued after the 2-week visit, and 30% of the DVTs were detected at the ultrasonographic scan at 6 weeks. LEVEL OF EVIDENCE:: Level II, prospective cohort.

Computed tomography measurements of the lesser metatarsal heads: Anatomic considerations for surgeons performing distal metatarsal osteotomies.

BACKGROUND: The purpose of the current study was to provide a standardized, anatomical description of the lesser metatarsals to assist surgeons when planning distal metatarsal surgery and fixation. METHODS: Eighty CT scans were included for assessment, based on a priori power analysis. Patient age was a mean 52.7±16.6 years (24-83). Metatarsals two through five were assessed in all patients. Three independent observers completed measurements for all metatarsals. Three measurements were made on all metatarsals, including a vertical height and metatarsal head and neck measurements. Statistical analysis was performed (alpha value 0.05). Inter-observer reliability was assessed for all measurements and intra-class correlation (ICC) reported. RESULTS: A sequential decrease in metatarsal measurements was noted from the second to the fifth metatarsal. A mean vertical height measurement of 16.1±1.4mm (range, 13.4-19.4) was recorded for the second metatarsal, decreasing 13.0±1.1mm (range, 10.3-16.1) for fifth. There were no significant differences in metatarsal measurements based on gender in our study. Similar patient and metatarsal variability was seen head and neck measurements. Intraclass correlation coefficients (ICC) for metatarsal measurements were greater than 0.9 [95% CI; 0.936-0.991] correlation, denoting an 'excellent' interobserver reliability. CONCLUSION: This study provides a baseline anatomical description of the distal metatarsals. These findings, including the variation found between patients and between metatarsal two through five, are relevant to surgeons planning and performing distal metatarsal osteotomies.

Clinical and radiologic outcomes of the second-generation Trabecular Metal™ glenoid for total shoulder replacements after 2-6 years follow-up.

BACKGROUND: A porous tantalum glenoid component for total shoulder replacements was introduced in 2003 to promote biologic ingrowth. However, reports of component failure prompted design modifications. The purpose of this study is to present the largest series to date, of TSR with the second-generation Trabecular Metal™ glenoid component. METHOD: A radiologic and clinical evaluation of the second-generation TM glenoid was conducted in consecutive cases of 76 shoulders (66 patients) with a mean follow-up of 43.2 months (range 24-72 months). Pre-operative VAS score, patient self-assessed ASES score, active shoulder range of motion, and radiologic assessment were recorded. Patients were recalled for latest follow-up clinical and radiologic evaluation. RESULTS: On latest follow-up, the mean VAS scores (pre-op: 6.4-latest: 0.9) and ASES scores (pre-op: 36.9-latest: 88.5) improved. Active range of motion improved in all planes. There was no report of glenoid component migration, loosening, or humeral stem subsidence. The incidence of non-progressive radiolucency in the glenoid was 6.6 % (Franklin 1: 3 cases, Franklin 2: 2 cases). Post-operative complications involved dislocation (n = 2) which were reduced in ED, post-operative stiffness (n = 1), transient axillary nerve neuropraxia (n = 1), and supraspinatus tear which underwent arthroscopic repair at 16 months post-op. There were no revision surgeries for implant loosening nor glenoid component fracture at the peg-base plate junction. CONCLUSIONS: The modifications established in the second-generation TM glenoid resulted to improve early to mid-term survivorship and clinical outcomes in TSR, with promise of long-term implant stability through bony ingrowth. LEVEL OF EVIDENCE: Level IV, case series, treatment study.

Evaluation of lower limb axial alignment using digital radiography stitched films in pre-operative planning for total knee replacement.

BACKGROUND: For patients with knee osteoarthritis, even slight anatomical variations in the femur or the tibia could affect total limb alignment during total knee replacement (TKR). Our hypothesis implies that the femoral valgus correction angle (VCA) in patients indicated for TKR, is variable and higher than the reported norm of 6° utilized in most intramedullary instrumentation systems, and that tibial bowing may result to a disparity of the tibial mechanical axis to the anatomical axis. METHODS: Our study is a retrospective review of 216 pre-operative arthritic knees, which investigated the lower limb axial alignment using digitally-stitched films. Patients excluded from the study are those with history of previous tibial or femoral osteotomy, secondary gonarthrosis, rheumatoid arthritis, previous femoral or tibial fracture, patients for bilateral TKR, or history of hip surgery. RESULTS: The mean age was 68-years old (range 39-86 years). The mean VCA was 7° (4.7-9.3) for men and 6.6° (4.9-9) for women. However, 71 patients (33%) had more than 7° VCA. Subsequently, 46 patients (21%) had tibial bowing producing an angle >1.5° between its mechanical and anatomic axis. CONCLUSIONS: The 6° standard when used as a guide may result in suboptimal prosthesis positioning during conventional TKR surgery. Therefore our findings suggest that the femoral valgus correction angle has a broad range, and using standard femoral intramedullary guides should not be overlooked.

Technique Tip: The Use of McGlamry Elevator to Assist Suture Passing in the Dorsal Technique of Plantar Plate Repair With Weil Osteotomy for Lesser Metatarsophalangeal Joint Instability.

UNLABELLED: The combination of a dorsal approach to the plantar plate with a Weil's metatarsal osteotomy has been shown to provide an adequate exposure for plantar plate repair. However, soft tissues in a restricted area of the metatarsophalangeal joint could present as a technical difficulty during suture retrieval during repair of the plantar plate. The purpose of this article is to describe the use of the McGlamry elevator for assistance in the retrieval of sutures through the proximal phalanx. LEVEL OF EVIDENCE: Level V: Expert opinion.

Clinical outcomes of patients with isolated femoral shaft fractures treated with S.I.G.N interlock nails versus Cannulated Interlock Intramedullary nails.

OBJECTIVE: The S.I.G.N (Surgical Implant Generation Network Inc.) solid intramedullary nail is originally designed for tibial shaft fractures and is currently being used for femoral shaft fractures as an extended use. The nail is used in developing nations such as the Philippines, as an alternative for those who could not afford the commercially available nails. The main objective of the study is to determine whether there is a difference in clinical outcomes of patients with isolated femoral shaft fractures in Philippine General Hospital, treated with S.I.G.N intramedullary nails versus Cannulated intramedullary nails, from year 2007 to 2012. POPULATION: A total of 175 patients fulfilled the inclusion criteria based from reviews of censuses, in-patient and OPD charts of the trauma section of the Department of Orthopedics, Philippine General Hospital. The Surgical Implant Generation Network (S.I.G.N) Fracture Care On-line Database was also screened for patients to be included in the study. A total of 68 patients were able to follow-up, with 48 patients in the S.I.G.N group and 20 patients for the Cannulated group. MAIN OUTCOME MEASURES: The dependent variables of the study are radiographic and clinical union, knee range of motion, weight bearing status, and complications. RESULTS: The subjects were divided into patients operated with S.I.G.N nails and with Cannulated Interlock Intramedullary nails. For the S.I.G.N group, the mean age is 32.1 years and mean follow-up is 40.75 weeks post-op. The Cannulated group has a mean age of 27.9 years and mean follow-up of 35.85 weeks post-op. Radiographic union rate for the S.I.G.N group is 68.8% while for the Cannulated group is 80%. Clinical union and full weight bearing status of patients are 100% in both groups. There is no significant difference with the number of patients with full range of motion in both groups: (S.I.G.N: 85%; Cannulated: 90%). Complication rates are also non-significant (S.I.G.N: 12.5%; Cannulated: 5%). CONCLUSIONS: There is no significant difference between patients with isolated femoral shaft fractures treated with S.I.G.N. Interlock Intramedullary nail versus Cannulated Interlock Intramedullary nail in terms of Clinical and radiographic union, weight bearing, knee range of motion and complication rate.