Indications for retrograde intramedullary screw fixation of the distal fibula: a retrospective cohort series.

Introduction: Ankle fractures are a common orthopaedic injury that often require surgical fixation. Because the comorbid population in the United States continues to survive longer, it has become routine to treat comorbid patients with unstable ankle fractures. The literature has identified comorbidities known to increase the risk of ankle fracture complications to include age 55 years or older, body mass index >29.9, polytrauma, open fractures, diabetes mellitus, smoking, peripheral neuropathy, and alcohol use. Methods: We retrospectively reviewed 37 patients who received retrograde intramedullary screw fixation of the distal fibula, all of whom had preexisting conditions known to increase the rate of postoperative complications. Results: Thirty-seven patients were included in this study, of whom 36 (97.3%) went on to union. Six of 37 patients (16.2%) had complications although only one (2.7%) was due to inadequate fixation. The average time to weight-bearing as tolerated was 57.2 days (15-115 days). Two patients (5.4%) had symptomatic instrumentation requiring removal after union. Two patients (5.4%) had delayed union of the distal fibula, which responded to the use of a bone stimulator. One patient (2.7%) developed a nonunion which led to chronic subluxation of the ankle joint. One patient (2.7%) had a minor medial ankle wound complication that was treated with oral antibiotics and local wound care. Conclusions: Retrograde intramedullary screw fixation of the distal fibula is a viable alternative to plate and screw fixation in patients with unstable ankle fractures who have known risk factors for increased complications. However, not all distal fibula fractures are amenable to this fixation method. Level of Evidence: Level III retrospective cohort study.

The Effects of Distal Pole Scaphoid Resection on Wrist Biomechanics.

Background: Distal pole scaphoid resection (DPSR) is an effective way to manage chronic scaphoid non-union with limited degenerative arthritis. Studies have reported positive results in terms of pain relief, wrist range of motion and grip strength, and patient satisfaction. However, the biomechanical consequences of DPSR remain unclear. This study evaluates the effects of DPSR on carpal mechanics by assessing changes in radiographic parameters with varying quantities of scaphoid removal. Methods: Six fresh frozen cadaveric upper extremities were used. Resections of 25%, 50%, and 75% of the length of each scaphoid were performed under fluoroscopic image guidance. For the intact scaphoid and each resection level, the following radiographic parameters were assessed: radiolunate and capitolunate angles; carpal height and first metacarpal subsidence ratios, and ulnar carpal translation. Measurements were then repeated for grip and pinch as well as radial and ulnar wrist deviation positions. Radial styloid to trapezium distance in wrist radial deviation was also measured to assess for impingement. Results: There was a statistically significant increase in the mean radiolunate angle with increasing scaphoid resection quantities. No statistically significant correlations were found between radial styloid clearance and increasing scaphoid resection percentages. Changes in the remaining variables did not reach statistical significance. Conclusion: Increasing levels of scaphoid resection is associated with progressive signs of carpal malalignment best depicted by increasing radiolunate angles. Diminishing radial styloid clearance was clinically evident as more scaphoid was resected. For this, prophylactic radial styloidectomy may be considered to avoid bony impingement.

The Hip Arthroscopy Post-less Procedure Impingement (HAPPI) Technique: Achieving Distraction With Standard Hip Tables at Zero Additional Cost.

Hip arthroscopy is becoming a more common treatment for femoroacetabular impingement, labral tears, and a variety of other hip pathologies. Unlike arthroscopy of the shoulder and knee, hip arthroscopy requires a significant amount of traction to gain access into the joint. Historically, traction has been achieved with the use of a perineal post. The use of a perineal post in hip arthroscopy can cause several avoidable complications such as neuropraxias (i.e., the pudendal nerve), vaginal or scrotal injuries, and perineal skin injuries. Several articles have been proposed using post-less techniques to obtain hip traction, but many of these techniques are expensive and require the purchase of new equipment. The purpose of this Technical Note is to describe a post-less technique for hip arthroscopy, the HAPPI technique (hip arthroscopy post-less procedure impingement), which is more affordable and does not require the addition of any special equipment. In addition, we will review some pearls and pitfalls, as well as advantages and disadvantages of the proposed technique.

Medial Femoral Condyle Periosteal Free Flap for the Treatment of Talus Avascular Necrosis.

BACKGROUND: In patients with avascular necrosis (AVN) of the talus in the precollapse stage unresponsive to conservative measures, joint preservation should be considered. Good results have previously been reported for vascularized bone grafting. The medial femoral condyle (MFC) free flap has recently been introduced, which consists of corticoperiosteal bone. We present a novel surgical technique using a periosteal-only MFC (pMFC) free flap in the treatment of talus AVN. METHODS: We retrospectively reviewed all pMFC free flaps performed from 2016 to 2018 in the precollapse stage of talus AVN. Surgical management included an ankle arthroscopy, talus core decompression, and ipsilateral pMFC free flap to the talus. Foot and Ankle Ability Measure (FAAM)-Activities of Daily Living (ADL) and visual analog scale (VAS) pain scores were evaluated, and pre- and postoperative imaging studies were assessed by a musculoskeletal-trained radiologist for all patients. Six pMFC free flaps in 5 patients were included in this case series. AVN etiology included idiopathic, posttraumatic, and sepsis-related treatment. All patients were female with an average age of 44.2 (range, 37-67) years. Average postoperative follow-up was 16.9 (range, 6-28) months. RESULTS: Pre- to postoperative FAAM-ADL, ADL single assessment numeric evaluation, and VAS scores showed statistically significant improvement (P < .039). No reoperations or flap complications were observed. There was 1 minor complication, which included postoperative paresthesias at the pMFC harvest site. Postoperative x-rays showed no subsequent collapse, and magnetic resonance imaging (MRI) illustrated progressive improvement of bone marrow edema, decreased surrounding areas of AVN, and decreased joint effusion when compared to preoperative MRI. CONCLUSION: The pMFC free flap is a novel modification of a previously described technique, which appears to have similar results compared to the traditional MFC free flap. It was safe and effective in the short term with excellent clinical and radiographic outcomes. LEVEL OF EVIDENCE: Level IV, case series.

Comparison of Pulse Oximetry and Handheld Doppler for Assessing Digital Perfusion.

PURPOSE: The utility of pulse oximetry for evaluating the perfusion of an injured digit is not well established. The goal of our study was to compare the use of a handheld Doppler to the use of pulse oximetry to determine perfusion in the digits of healthy volunteers. METHODS: Fifteen healthy volunteers participated in our study. All digits of both hands were assessed, for a total of 150 digits. Baseline measurements were performed for both the Doppler and pulse oximeter. Then, a pulse oximeter was placed on each digit for 1 minute and the recordings taken at the end of the minute. A Penrose drain was used to occlude each digit. Once perfusion was absent, the pulse oximeter was placed onto the digit. Pulse oximeter readings were recorded for 1 minute and then averaged over that time. For the first five patients, a hinge type sensor was used and for the second group of 10 patients, a rubber sleeve type sensor was used. RESULTS: The mean baseline pulse oximeter reading averaged an oxygen saturation of 98.9% (range: 96% to 100%). For the hinge type pulse oximeter sensor, no readout was obtained for the unperfused digits, thus making the results binary. Using the rubber sleeve type pulse oximeter sensor, the mean unperfused readings dropped to an oxygen saturation of 85.0% (range: 71% to 98%). The difference between baseline and the rubber sleeve sensor was significant. The mean drop in pulse oximetry oxygen saturation reading between baseline and occluded digits was 15%. CONCLUSION: Our study supports the use of pulse oximetry in the assessment of fingertip perfusion, specifically for confirming that a digit is well perfused. Depending on the model of pulse oximeter used, results may be binary (signal or no signal) or show a decrease in reading compared to a perfused digit. Although pulse oximetry cannot be utilized as a sole diagnostic study for vascular injury, it can be a useful adjuvant. Statement of Significance: The evaluation of an injured finger includes the assessment of vascular status. Handheld Doppler in conjunction with physical exam can be used to diagnose vascular injury, but this is often unavailable or unfamiliar to the medical staff initially evaluating the patient. This study analyzes the use of pulse oximetry in the evaluation of poorly perfused digits. Pulse oximeters are simple, inexpensive, readily available, and familiar to all medical personnel.

Single-Bundle vs Double-Bundle (Anatomical) Reconstruction of the Thumb Ulnar Collateral Ligament: Biomechanical Study.

Background: The goal of this study is to compare the biomechanical properties of anatomic (double-bundle) versus single-bundle reconstruction of the thumb metacarpophalangeal (MCP) joint ulnar collateral ligament (UCL) in a cadaveric model. Methods: Twelve fresh frozen cadaver hands were randomly assigned to single- or double-bundle reconstruction groups using a palmaris longus autograft and tenodesis screws. Two blinded examiners performed mechanical testing and measurements using fluoroscopic imaging. We evaluated MCP joint congruence and angle in the coronal plane at 0°, 30°, and 60° of flexion with valgus loads of 1.36 and 2.72 kg. Maximum MCP flexion and extension with a 0.45 kg load was also measured. Results: There was no significant difference between single- versus double-bundle reconstruction in ulnar congruence or MCP angle. With varying amounts of flexion, there was no significant difference in MCP valgus angle between the 2 techniques, suggesting comparable joint congruity and coronal MCP angle along the arc of thumb MCP motion. Conclusions: Single- and double-bundle UCL reconstructions of the thumb MCP joint have comparable biomechanical properties in regard to joint congruity under valgus load.