RESUMO
OBJECTIVE: The purpose of this study was to assess the practices related to obtaining postoperative pelvic CT scans following acetabular ORIF and revision surgery rates. DESIGN: A 20-question survey published on the Orthopaedic Trauma Association (OTA) website assessed each surgeon's preference and rationale for or against the routine use of postoperative CT scans for acetabular fractures. PARTICIPANTS: Fellowship-trained orthopaedic traumatologists. MAIN OUTCOME MEASUREMENTS: We examined the percentage of surgeons ordering routine postoperative CT scans, surgeon demographics, and revision surgery rates based on these routine CT scan results. RESULTS: Responses were received from 57 surgeons. Practices varied regarding postoperative CT scans, with 16 surgeons (28%, Group A) routinely ordering them and 41 surgeons (72%, Group B) not ordering them on all patients. No significant difference in surgeon demographics were found between the groups. Majority of Group A report a revision surgery rate of <1% based on the results of the postoperative CT. Group A report routine postoperative scans were obtained to assess reduction, hardware placement, identify intra-articular fragments, and for educational purposes. Group B did not obtain routine postoperative CTs due to the following: unlikely to change postoperative treatment, adequate reduction and instrumentation placement assessed intraoperatively and by postoperative radiographs, and increased radiation exposure and cost to patients. Group B did report obtaining postop CT scans on select patients, with inadequate intraoperative imaging and postoperative neurological changes being the most common indications. CONCLUSION: The routine use of postoperative CTs following open reduction internal fixation of acetabular fractures is a controversial topic. While we recognize the role for postoperative CT scans in select patients, our study questions the clinical utility of these scans in all patients and in conclusion do not recommend this protocol.
RESUMO
Insertional Achilles tendinopathy causes posterior heel pain at the insertion of the Achilles tendon, often in combination with a calcaneal exostosis, or Haglund deformity. Insertional Achilles tendinopathy often presents with a posterior osseous prominence and leads to calcification of the Achilles tendon1. Nonoperative treatment of these conditions includes activity modification, nonsteroidal anti-inflammatory agents, heel lifts, shoe modification, physical therapy focused on eccentric strengthening exercises, iontophoresis, and shock wave therapy. Nonoperative treatment will fail in approximately 50% of these cases, and such patients become candidates for surgical intervention2,3. Multiple surgical approaches have been described, including the medial J-shaped, lateral, Cincinnati transverse, double incision, and central-splitting approaches4. Currently, there is no consensus regarding the ideal approach. Recent literature has suggested that the central-splitting approach allows for adequate exposure of both the most commonly diseased area of the tendon and the calcaneal exostosis, with excellent postoperative pain and functional results5-13. DESCRIPTION: Place the patient in the prone position with the feet at the edge of the operating table. Make a full-thickness, 5 to 7-cm longitudinal incision centered over the Achilles tendon and the posterior aspect of the calcaneus. Make a central incision through the Achilles tendon. Sharply mobilize the medial and lateral slips and excise the diseased portion of the Achilles tendon. Expose the calcaneal exostosis and perform the calcaneal exostectomy with a microsagittal saw. Repair the remaining healthy-appearing Achilles tendon to the calcaneus with 2 suture anchors. An additional suture anchor or, alternatively, the double-row technique for the Achilles tendon repair may be used. Repair the central split in the Achilles tendon with absorbable suture. Close the soft tissue and skin in layers. ALTERNATIVES: Alternative approaches include the medial, lateral, or Cincinnati transverse incisions. The central-splitting approach is favored because of the excellent exposure of both the diseased tendon and the calcaneal exostosis. Additional augmentations to this procedure include a flexor hallucis longus transfer and a gastrocnemius recession. RATIONALE: This technique provides adequate exposure to the diseased Achilles tendon, calcific deposits, and calcaneal exostosis. Recent studies have demonstrated it to be a safe and effective technique with high patient-satisfaction scores5-13.
