Ankle impingement after extra-articular open fracture of the leg: Full arthroscopic treatment in the supine position.

OBJECTIVE: Extra-articular open fractures of the leg often result from high energy trauma. After healing, a painful ankle impingement may occur. In the event of anterior and posterior impingements, arthroscopic treatment may require two surgical positions. We propose an operative strategy to treat anterior and posterior ankle impingement after extra-articular open fracture of the leg. Our hypothesis is that this strategy is simple, effective and with a low risk of complication. MATERIAL AND METHOD: Anterior ankle impingements were treated by anterior arthroscopy in supine position; anterior and posterior impingements were treated by anterior and posterior arthroscopy in supine position; anterior and posterior impingements associated with retraction of gastrocnemius muscles were treated with anterior arthroscopy in supine position followed by posterior arthroscopy in prone position, and an open tendon lengthening of the calcaneal tendon in the same position. The anterior and posterior arthroscopic release was tested in the cadaver laboratory. Then, the surgical strategy was applied to our patients in our clinical practice. After, we analysed retrospectively the results of the strategy in the first patients treated for a painful ankle impingement after extra-articular open fracture of the leg. The data retrieved were the importance of pain (VAS), the presence of clinical instability, ankle mobility, gastrocnemius retraction and the AOFAS functional score and the post-operative complications. Then, these data were compared before the surgery and at last follow-up. RESULTS: From the cadaver laboratory, anterior and posterior arthroscopic release was possible in all cases without changing position. From our clinical practice, we included 5 patients (3 women and 2 men, mean age 43 years) suffering from an ankle impingement after extra-articular open fracture of the leg (2 patients with isolated anterior impingement, 1 patient with anterior and posterior impingement, and 2 patients with anterior and posterior impingement plus a gastrocnemius retraction). All post-operative parameters (pain, range of motion and AOFAS score) at mean follow-up of 53 months were improved. No post-operative complication was reported. CONCLUSION: We propose a surgical strategy adapted to the different clinical presentations of ankle impingement after extra-articular open fracture of the leg.

Ureteric Stent Use - Part of the Solution and Part of the Problem.

BACKGROUND: The aim of the study is to comprehensively report on a single tertiary referral center experience with the use of ureteric stents, assess complication burden and determine risk factors to further inform institutional practice. MATERIALS AND METHODS: The retrospectively analyzed cohorts includes 529 patients treated over a 12 months period. Data regarding details of the index pathology, stent characteristics and complications were collected retrospectively. RESULTS: Most stents (58.9%) were used in the context of stone surgery. Stent encrustation occurred in 14.5% of patients and sepsis in 4.3%. There was a statistically significant difference between the complications of the stents removed after 90 days and the rest of the cohort. Infectious complications were more frequent in diabetic patients and in patients with chronic renal impairment. At our institution, we managed to avoid forgotten stents and catastrophic complications. CONCLUSION: Stent complications are the complex outcome of interplay between the foreign body and the collecting system environment, influenced by the nature and timing of surgery. Longer stent dwelling times are associated with increased complications rates, especially in patients with significant comorbidities.

Training of microsurgical skills on nonliving models.

Although direct exposure to procedures in the operating theater environment, together with practice on laboratory animals, is still seen as the gold standard of teaching in microsurgery, practice on nonliving simulators is currently being validated as an important educational tool. We reviewed the widely used nonliving training models, together with currently accepted innovations, which are parts of curricula of training courses in microsurgery. Using the experience accumulated in training programs at the Centre for Simulation and Training in Surgery, we identified which particular skills can be reliably targeted by each nonliving tissue exercise. We were able to find five groups of nonliving training models: basic manipulation, knot-tying principles, completing the anastomosis, the real tissue experience, and training in virtual reality. The more abstract models might seem quite far from the real life experience, but they each closely address specific skills. It thus becomes convenient for the instructor to train these skills separately. This generates series of consistently favorable results once the skills are integrated into a more complex procedure. Focused exercises, once assembled in continuity, reconstruct the real life scenario. The training program can comprise a series of increasingly difficult exercises, which mirror the real life situations. Performance on nonliving models in each progressively more challenging exercise can be assessed via direct observation, assisted by clear and objective criteria. Finally, focused training will help both the transition to human surgery and replication of the favorable results to large series of subjects.