Neurologic Deficit Associated With Lateralizing Calcaneal Osteotomy for Cavovarus Foot Correction.

BACKGROUND: Lateralizing calcaneal osteotomy (LCO) is a frequently used technique to correct hindfoot varus deformity. Tibial nerve palsy following this osteotomy has been described in case reports but the incidence has not been quantified. METHODS: Eighty feet in 72 patients with cavovarus foot deformity were treated over a 6-year span by 2 surgeons at their respective institutions. Variations of the LCO were employed for correction per surgeon choice. A retrospective chart review analyzed osteotomy type, osteotomy location, amount of translation, and addition of a tarsal tunnel release in relation to the presence of any postoperative tibial nerve palsy. Tibial nerve branches affected and the time to resolution of any deficits was also noted. RESULTS: The incidence of neurologic deficit following LCO was 34%. With an average follow-up of 19 months, a majority (59%) resolved fully at an average of 3 months. There was a correlation between the development of neurologic deficit and the location of the osteotomy in the middle third as compared to the posterior third of the calcaneal tuber. We found no relationship between the osteotomy type, amount of correction, or addition of a tarsal tunnel release and the incidence of neurologic injury. CONCLUSIONS: Tibial nerve palsy was not uncommon following LCO. Despite the fact that deficits were found to be transient, physicians should be more aware of this potential problem and counsel patients accordingly. To decrease the risk of this complication, we advocate extra caution when performing the osteotomy in the middle one-third of the calcaneal tuberosity. Although intuitively the addition of a tarsal tunnel release may protect against injury, no protective effect was demonstrated in this retrospective study. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Retroperitoneal fluid collection following anterior spine surgery--differential and management.

Iatrogenic ureteral injuries are rare and must be accurately identified to minimizing the risk for additional complications. Anterior lumbar interbody fusion (ALIF) is a valuable technique utilized in spine surgery, with its own unique set of complications. For example, retroperitoneal fluid collections, following ALIF surgery are rare and may result in back pain, radicular pain, nausea, and even death. It is important to rapidly identify the nature of the fluid collection to clarify appropriate management options. The purpose of this case report is to present a differential diagnosis for a delayed presentation of an extremely large retroperitoneal fluid collection following anterior lumbar surgery, as well as to provide discussion on this rare complication. Specifically, a 51-year-old female with a history of numerous previous abdominal surgeries underwent an L3-S1 ALIF through a paramedian retroperitoneal approach. Postoperatively, she developed a large retroperitoneal fluid collection heralded by unilateral left lower extremity swelling and paresthesias. Fluid aspiration suggested a urine leak, but no specific injury was identified on retrograde pyelogram, most likely due to hardware obscuration in the area of presumed injury. A presumptive ureteral injury resulted in a ureteral stent placement, with resolution of the fluid collection and hydronephrosis. A high index of suspicion allowed for proper treatment, healing, and ultimately, a satisfactory outcome.

Sport and activity restrictions following total ankle replacement: A survey of orthopaedic foot and ankle specialists.

BACKGROUND: Despite an increasing utilization of total ankle replacement, surgeons have little guidance with regards to physical activity and sport participation recommendations following the procedure. METHODS: Orthopaedic foot and ankle specialists were surveyed as to the activity and sports restrictions they place on their patients following ankle replacement. Fifty sports and activities were included and the results were used to derive a set of consensus recommendations. Of the 1063 surgeons that were sent the survey, 173 responded, yielding a response rate of 16.3%. RESULTS: In general, surgeons were comfortable with aerobic or low impact sports and activities. Boot immobilized sports represented a grey area with the determination of whether or not to allow them based largely on the prior experience of the patient. High impact, cutting and jumping sports and activities were largely discouraged. Young age, high BMI and poor bone quality led surgeons to be more restrictive. CONCLUSIONS: These consensus recommendations serve as a useful guideline for surgeons and help patients set appropriate expectations for the procedure.

Surgical techniques of gastrocnemius lengthening.

This article summarizes the various alternatives for direct gastrocnemius lengthening and elucidates the relative strengths and tradeoffs of each as a means of providing balanced perspective in selecting the appropriate procedure for any given patient.

Forces across the middle of the intact clavicle during shoulder motion.

HYPOTHESIS: The optimal management of displaced middle third clavicle fractures is currently under investigation. Advances in fracture fixation technology have expanded the indications for operative fracture management. Data are currently unavailable regarding the normal forces and moments that occur in the middle clavicle with motion of the glenohumeral joint. This study tested our null hypothesis that active range of motion in internal rotation, external rotation, and abduction would produce a similar magnitude of force across the middle clavicle. MATERIALS AND METHODS: Clavicle forces were measured in 6 whole fresh frozen cadavers using a 6 degree-of-freedom load cell mounted to the middle third of the clavicle. The rotator cuff tendons were isolated, divided, and connected to a system of weights. The forces across the clavicle in 3 orthogonal directions were quantified during simulated active abduction, internal rotation, and external rotation. RESULTS: There were statistically greater axial compressive force and torque in the clavicle during humeral abduction compared with internal or external rotation. During external rotation, there were statistically greater tensile forces compared with abduction or internal rotation. There were no statistical differences in the superior-inferior or anterior-posterior forces with the 3 motions studied. DISCUSSION: Overall, active abduction caused the greatest increase in middle clavicle forces and torque. Abduction resulted in the most significant axial compressive force, whereas active external rotation caused the greatest tensile force across the intact middle clavicle. CONCLUSIONS: To our knowledge, these findings represent the first results describing the forces across the intact clavicle during glenohumeral motion. These data can be used to aid clinicians in treating these fractures, guide the design of future biomechanical studies, and develop rehabilitation protocols.