Removal of Hardware After Syndesmotic Screw Fixation: A Systematic Literature Review.

BACKGROUND: While trans-syndesmotic fixation with metal screws is considered the gold standard in treating syndesmotic injuries, controversy exists regarding the need and timing of postoperative screw removal. Formal recommendations have not been well established in the literature and clinical practice is highly variable in this regard. The purpose of this systematic review is to critically examine the most recent literature regarding syndesmotic screw removal in order to provide surgeons an evidence-based approach to management of these injuries. METHODS: The Cochrane Library and PubMed Medline databases were explored using search terms for syndesmosis and screw removal between October 1, 2010 and June 1, 2016. RESULTS: A total of 9 studies (1 randomized controlled trial and 8 retrospective cohort studies) were found that described the outcomes of either retained or removed syndesmotic screws. Overall, there was no difference in functional, clinical or radiographic outcomes in patients who had their syndesmotic screw removed. There was a higher likelihood of recurrent syndesmotic diastasis when screws were removed between 6 and 8 weeks. There was a higher rate of postoperative infections when syndesmotic screws were removed without administering preoperative antibiotics. CONCLUSION: Removal of syndesmotic screws is advisable mainly in cases of patient complaints related to the other implanted perimalleolar hardware or malreduction of the syndesmosis after at least 8 weeks postoperatively. Broken or loose screws should not be removed routinely unless causing symptoms. Antibiotic prophylaxis is recommended on removal. Radiographs should be routinely obtained immediately prior to removal and formal discussions should be had with patients prior to surgery to discuss management options if a broken screw is unexpectedly encountered intraoperatively. Radiographs and/or computed tomography imaging should be obtained after syndesmotic screw removal when indicated for known syndesmotic malreduction. LEVELS OF EVIDENCE: Level IV: Systematic review.

Salto Talaris Total Ankle Arthroplasty: Clinical Results at a Mean of 5.2 Years in 78 Patients Treated by a Single Surgeon.

BACKGROUND: In recent years, the number of total ankle arthroplasty procedures performed has increased dramatically. We sought to report the clinical results of the largest cohort of patients treated with a modern fixed-bearing total ankle arthroplasty by a single surgeon. METHODS: We retrospectively reviewed the charts of 78 consecutive patients (81 ankles) who underwent total ankle arthroplasty with a minimum clinical follow-up of 2 years. Sixty-three patients completed standardized questionnaires including the Foot and Ankle Disability Index (FADI), the Short Musculoskeletal Function Assessment (SMFA), the Short Form (SF)-36v2, and a visual analog scale (VAS) for pain. In addition, each patient underwent serial range-of-motion examination and radiographic implant evaluation at each follow-up appointment. RESULTS: Implant survival was 97.5% at a mean follow-up time of 5.2 years. There was 1 revision of a tibial component and 1 revision of a talar component. Thirty-six patients underwent a concurrent procedure at the time of the index surgery, with the most common being removal of previous hardware. Seventeen patients underwent additional procedures following the index surgery, with the most common being gutter debridement. Total range of motion averaged 35.5° preoperatively and 39.9° postoperatively (p = 0.02). Fifty-seven ankles (70%) had >2 years of radiographic follow-up, and 25 ankles (31%) displayed evidence of lucency around a metallic component at the final radiographic follow-up. Outcome scores at a mean of 5.2 years revealed promising results for the cohort, with a mean VAS pain score of 17.7 and a mean FADI score of 79.1. CONCLUSIONS: Modern fixed-bearing total ankle arthroplasty had excellent implant survival, improved plantar flexion and total range of motion, and had good-to-excellent functional outcome at a mean follow-up of 5.2 years. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Complete Avulsion of the Proximal Hamstring Insertion: Functional Outcomes After Nonsurgical Treatment.

BACKGROUND: Complete proximal hamstring avulsions are an uncommon injury. The purpose of this study was to determine the functional and subjective outcomes following nonsurgical management of complete proximal hamstring avulsions. METHODS: We retrospectively identified nineteen patients (mean age, fifty-nine years; range, forty-four to seventy-three years) at one institution who presented with complete avulsions of the proximal hamstring insertion, confirmed on magnetic resonance imaging, and had nonsurgical treatment. Results on the Lower Extremity Functional Scale (LEFS) and Short Form-12 version 2 (SF-12v2) questionnaires as well as functional and isometric testing (with a handheld dynamometer) were collected. Seventeen patients completed the questionnaires. Ten patients underwent functional testing. The average follow-up period was thirty-one months (range, eight to 156 months). RESULTS: The mean score on the LEFS was 70.2 of a maximum of 80 points. The mean SF-12v2 physical and mental component summary scores were 52.5 and 54.1, respectively. Hamstring strength at 45° and 90° of flexion was an average of 62% (p = 0.09) and 66% (p = 0.07), respectively, of that of the uninvolved limb. The single-leg hop test revealed an average decline of 2.2% (p = 0.93) compared with the uninvolved limb. Twelve of the seventeen patients were able to return to their previous sporting activities. CONCLUSIONS: Nonsurgical management after a complete proximal hamstring avulsion yields noticeable subjective and strength deficits. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Symptomatic neural loop causing hemidigital anesthesia: case report.

Digital neural loops were identified over a century ago and are common findings in cadaveric studies of palmar and digital anatomy. Symptomatic digital neural loops are rare. We report a case of hemidigital anesthesia resulting from a proper digital nerve neural loop penetrated by its common digital artery in the palm. After neurolysis of the median nerve and the common and proper digital nerves to the third webspace, we transected the common digital artery, transposed it out of the neural loop, and repaired it. The patient's sensory symptoms fully resolved over 6 weeks. The differential diagnosis, diagnostic workup, and surgical treatment are reviewed.