Indications and Surgical Treatment of Acute and Chronic Tibiofibular Syndesmotic Injuries with and Without Associated Fractures.

Syndesmosis injury may occur in a wide variety of clinical scenarios. Accurate diagnosis and anatomic reconstruction are necessary for optimizing clinical outcomes. The management considerations of syndesmotic injuries with associated proximal fibula fractures are reviewed. Methods to improve the accuracy of syndesmotic reduction are outlined. The management of fractures of the posterior malleolus, Chaput tubercle, and Wagstaffe tubercle is discussed with an emphasis on their contributions to syndesmotic stability. The evolving role of flexible fixation for syndesmosis injuries is discussed. Causes and strategies for dealing with loss of reduction and malreduced syndesmotic injuries are presented.

Treatment of Peripheral Talus Fractures.

Peripheral talus fractures include injuries to the lateral process, posteromedial talar body, and talar head. These injuries are rare and are often missed. Nonunion with conservative treatment is high and excision can lead to joint instability, rapid arthrosis, and earlier need for arthrodesis. Open reduction internal fixation of most peripheral talus fractures is critical to achieving a good outcome. Open reduction leads to more rapid union and ability to mobilize the ankle and subtalar joints, quicker revascularization of the talus, and lower rates of arthrosis. Surgical treatment can lead to substantial functional improvement and a slowing of the degenerative process.

Late Treatment of Syndesmotic Injuries.

Normal syndesmosis anatomy and alignment are essential to ankle function. Although injuries to the syndesmosis are common with ankle injuries, accurate diagnosis and reduction continue to be a challenge. Late reconstruction for syndesmosis is reviewed. A surgical technique for late reconstruction is outlined in detail.

Prognostic value of computed tomography classification systems for intra-articular calcaneus fractures.

BACKGROUND: There are several published computed tomography (CT) classification systems for calcaneus fractures, each validated by a different standard. The goal of this study was to measure which system would best predict clinical outcomes as measured by a widely used and validated musculoskeletal health status questionnaire. METHODS: Forty-nine patients with isolated intra-articular joint depression calcaneus fractures more than 2 years after treatment were identified. All had preoperative CT studies and were treated with open reduction and plate fixation using a lateral extensile approach. Four different blinded reviewers classified injuries according to the CT classification systems of Crosby and Fitzgibbons, Eastwood, and Sanders. Functional outcomes evaluated with a Musculoskeletal Functional Assessment (MFA). The mean follow-up was 4.3 years. RESULTS: The mean MFA score was 15.7 (SD = 11.6), which is not significantly different from published values for midfoot injuries, hindfoot injuries, or both, 1 year after injury (mean = 22.1, SD = 18.4). The classification systems of Crosby and Fitzgibbons, Eastwood, and Sanders, the number of fragments of the posterior facet, and payer status were not significantly associated with outcome as determined by the MFA. The Sanders classification trended toward significance. Anterior process comminution and surgeon's overall impression of severity were significantly associated with functional outcome. CONCLUSIONS: The amount of anterior process comminution was an important determinant of functional outcome with increasing anterior process comminution significantly associated with worsened functional outcome (P = .04). In addition, the surgeon's overall impression of severity of injury was predictive of functional outcome (P = .02), as determined by MFA. LEVEL OF EVIDENCE: Level III, comparative series.

A comparison of forearm supination and elbow flexion strength in patients with long head of the biceps tenotomy or tenodesis.

PURPOSE: The purpose of this study was to compare the forearm supination and elbow flexion strength of the upper extremity in patients who have had an arthroscopic long head of the biceps tendon (LHBT) release with patients who have had an LHBT tenodesis. METHODS: Cybex isokinetic strength testing (Cybex Division of Lumex, Ronkonkoma, NY) was performed on 17 patients who underwent arthroscopic LHBT tenotomy, 19 patients who underwent arthroscopic LHBT tenodesis, and 31 age-, gender-, and body mass index-matched control subjects. Subjects were considered fully recovered from shoulder surgery, were released for unrestricted activities, and were at least 6 months after surgery before testing. Subjects were tested for forearm supination and elbow flexion strength of both arms by use of a Cybex II NORM isokinetic dynamometer at 60°/s and 120°/s. Testing was performed on injured and uninjured arms as well as dominant and nondominant arms in control subjects. Both forearm supination and elbow flexion strength values were recorded. RESULTS: Comparison between the involved and uninvolved upper extremities within each group by use of a paired t test showed a 7% increase in elbow flexion strength when the dominant and nondominant arms were compared at 60°/s. Neither the tenotomy nor tenodesis groups exhibited elbow flexion strength differences at 120°/s (all P ≥ .147). Comparison between groups by use of 2 × 3 analysis of variance (speed × group) showed no statistical difference in either forearm supination or elbow flexion strength when we compared the tenotomy, tenodesis, and control groups. CONCLUSIONS: In asymptomatic patients who have had biceps tenotomy or tenodesis, no statistically significant forearm supination or elbow flexion strength differences existed in the involved extremity between the 2 study groups. LEVEL OF EVIDENCE: Level III, case-control study.

Syndesmosis fixation: a comparison of three and four cortices of screw fixation without hardware removal.

BACKGROUND: Great variability exists in methods of stabilization for syndesmotic disruptions of the ankle. We hypothesized that syndesmotic screw fixation with 3.5-mm fully threaded cortical screws through either three or four cortices would have similar strength and rate of mechanical failure and that retention of screws after fracture healing would not result in adverse clinical symptoms. METHODS: In a prospective, surgeon-randomized study at a Level-one trauma center, 127 patients with syndesmotic disruptions were treated surgically. Seven patients were lost to followup, leaving 120 for review. Syndesmotic disruptions were stabilized with 3.5-mm fully threaded cortical screws placed through three or four cortices. Screws were removed only if symptomatic. Outcome criteria were screw failure, loss of reduction, and need for hardware removal. RESULTS: Fifty-nine patients received fixation through three cortices and 61 patients received fixation through four cortices. Mean follow-up was 150 days. In the group with stabilization through three cortices, hardware failure occurred in five patients (8%) and three had a loss of reduction. In the group with stabilization through four cortices, hardware failure occurred in four patients (7%); all were asymptomatic and did not require screw removal. There was no loss of reduction in that group. Comparing the two groups using binary logistic analysis, there was no difference in loss of reduction (p = 0.871), screw breakage (p = 0.689), or need for hardware removal (p = 0.731). CONCLUSION: The data suggest that either three or four cortices of fixation can be used when stabilizing syndesmotic injuries of the ankle. There was a trend towards higher loss of reduction in the group with tricortical fixation when weightbearing restrictions were not followed. Retention of the syndesmotic screws, even with mechanical failure, does not pose a clinical problem. Weightbearing can be allowed at 6 to 10 weeks without routine removal of screws.

Bilateral peroneal nerve palsy following emergent stabilization of a pelvic ring injury.

External noninvasive compressive devices are becoming popular for emergent stabilization of pelvic ring disruptions. The ease of application utilizing available materials such as sheets, the noninvasive nature of such measures, and perceived absence of complications has made this a popular stabilization modality. The authors report a case of bilateral peroneal nerve palsy related to the use of external compressive wraps in a patient with pelvic ring injury.