Andrea Veljkovic

Complication rates of open surgical versus percutaneous tracheostomy in critically ill patients.

In the setting of critical care, the most common indications for tracheostomy include: prolonged intubation, to facilitate weaning from mechanical ventilation, and for pulmonary toileting. In this setting, tracheostomy can be performed either via open surgical or percutaneous technique. Advantages for percutaneous dilatational tracheostomy (PDT) include: simplicity, smaller incision, less tissue trauma, lower incidence of wound infection, lower incidence of peristomal bleeding, decreased morbidity from patient transfer, and cost‐effectiveness. Despite many studies comparing surgical tracheostomy (ST) versus PDT, there remains no consensus on which of these techniques minimizes complications in critically ill patients.

Lateral talar station: a clinically reproducible measure of sagittal talar position.

Background: The sagittal relationship of the talus to the tibial shaft can prove invaluable to the orthopedist in understanding and effectively treating ankle pathologies such as ligamentous laxity and ankle arthritis. Any useful radiographic analysis tool to assess the lateral position of the talus must be employable reliably in the clinical setting. Previously published measurements to assess the lateral translational relationship of the talus relative to the tibial axis may not be available in the clinical setting or may be subject to significant inaccuracies. We have defined a sagittal talar position measurement (lateral talar station; LTS), which we postulated could be used reproducibly on clinical radiographs by the orthopedist to define the position of the talus as it relates to the anatomic tibial axis. In addition, we defined the normal range of the LTS measurement. Methods: A retrospective cohort of patients (121 ankles, 104 patients) who presented to our clinic with foot pain between 2005 and 2011 was evaluated for inclusion in the study. Exclusion criteria included patients with ankle trauma, instability, prior ankle surgery, or radiographic evidence of ankle osteoarthrosis. The final cohort consisted of 82 ankles. The LTS was measured digitally for each subject on weight-bearing lateral ankle radiographs by 3 observers. The mean LTS and standard deviation was determined for the entire cohort. In addition, as a means of validating our methodology, we performed an assessment of interobserver and intraobserver reliability in terms of the LTS measurements. Results: The LTS measurements for the entire cohort fit a Gaussian distribution with a mean of 1.17 mm (SD = 0.9893 mm). Interobserver intraclass coefficients for 2 observers (medical student and radiologist) and intraobserver intraclass coefficients for 1 reader (orthopaedic surgeon) indicated excellent reliability, being above 0.9. Conclusion: The LTS was a reliable measure that could be used on weight-bearing lateral ankle radiographs to define sagittal position of the talus in a clinical setting. The normal distribution for the LTS was described in our study population. Level of Evidence: Level IV, case series.

A Coding System for Reoperations Following Total Ankle Replacement and Ankle Arthrodesis.

Background: Repeated surgery can be a measure of failure of the primary surgery. Future reoperations might be avoided if the cause is recognized and procedures or devices modified accordingly. Reoperations result in costs to both patient and the health care system. This paper proposes a new classification system for reoperations in end-stage ankle arthritis, and analyzes reoperation rates for ankle joint replacement and arthrodesis surgeries from a multicenter database. Methods: A total of 213 ankle arthrodeses and 474 total ankle replacements were prospectively followed from 2002 to 2010. Reoperations were identified as part of the prospective cohort study. Operating reports were reviewed, and each reoperation was coded. To verify inter- and intraobserver reliability of this new coding system, 6 surgeons experienced in foot and ankle surgery were asked to assign a specific code to 62 blinded reoperations, on 2 separate occasions. Reliability was determined using intraclass correlation coefficients (ICCs) and proportions of agreement. Results: Of a total of 687 procedures, 74.8% (514/687) required no reoperation (Code 1). By surgery type, 14.1% (30/213) of ankle arthrodesis procedures and 30.2% (143/474) of ankle replacement procedures required reoperation. The rate for reoperations surrounding the ankle joint (ie, Codes 2 and 3) was 9.9% (21/213) for ankle arthrodesis versus 5.9% for ankle replacement (28/474). Reoperation rates within the ankle joint (ie, Codes 4 to 10) were 4.7% (10/213) for ankle arthrodesis and 26.1% (124/474) for ankle replacement. Overall, 0.9% (2/213) of arthrodesis procedures required reoperation outside the initial operative site (Code 3), versus 4.6% (22/474) for total ankle replacement. The rate of reoperation due to deep infection (Code 7) was 0.9% (2/213) for arthrodesis versus 2.3% (11/474) for ankle replacement. Interobserver reliability testing produced a mean ICC of 0.89 on the first read. The mean ICC for intraobserver reliability was 0.92. For interobserver, there was 87.9% agreement (804/915) on the first read, and 87.5% agreement (801/915) on the second. For the intra observer readings, 88.5% (324/366) were in agreement. Conclusions: The new coding system presented here was reliable and may provide a more standardized, clinically useful framework for assessing reoperation rates and resource utilization than prior complication- and diagnosis-based classification systems, such as modifications of the Clavien Dindo System. Analyzing reoperations at the primary site may enable a better understanding of reasons for failure, and may therefore improve the outcomes of surgery in the future. Level of Evidence: Level III, retrospective comparative cohort study based on prospectively collected data.

Supramalleolar Osteotomies for Posttraumatic Malalignment of the Distal Tibia

Supramalleolar osteotomies of the tibia (SMOT) for posttraumatic distal tibial malalignment has shown to reduce pain, improve function and radiographic signs of osteoarthritis, and delay ankle arthrodesis or total joint replacement. The procedure also protects the articular cartilage from further degenerative processes by shifting and redistributing loads in the ankle joint. It is technically demanding and requires extensive preoperative planning. The type of osteotomy (opening vs closing wedge) does not influence the final outcome. However, based on the limited evidence, a grade I treatment recommendation has been given for supramalleolar osteotomies of the tibia to treat mild to moderate ankle arthritis in the presence of distal tibial malalignment.

Current Update in Total Ankle Arthroplasty : Salvage of the Failed Total Ankle Arthroplasty with Anterior Translation of the Talus

Ankle replacement results may be compromised by malposition of the components. An anterior displacement can be measured on a lateral standing radiograph. The ankle may appear anteriorly translated because the ankle is overstuffed, the heel cord is tight, or the posterior capsule is tight. In ankle instability with degenerative arthritis, the talus may be anteriorly translated, internally rotated, and in varus. In an ankle replacement, this deformity may persist and will require correction. On occasion, the talus is inserted too anterior; revision to a flat cut talar component and posterior translation of the talar component will result in correction.

An Anatomic Study of the Percutaneous Endoscopically Assisted Calcaneal Osteotomy Technique to Correct Hindfoot Malalignment

Background: Open calcaneal osteotomy using traditional methods is associated with complications such as sural nerve injury and potential wound healing problems. We hypothesized that by using novel minimally invasive techniques, these potential risks could be mitigated. This anatomic cadaveric study serves to assess the safety of percutaneous endoscopically assisted calcaneal osteotomy (PECO) compared to a traditional open osteotomy technique. Methods: Anatomic safety of PECO was assessed using 8 fresh-frozen cadaver below-knee specimens. Lateral calcaneal nerve (LCN) damage was primarily noted and then secondly compared to a potential open surgical incision approach. Results: Only 1 of 11 LCN branches (n = 8 limbs) was transected using PECO, compared to up to 8 of 10 LCN branches (n = 6 limbs) that potentially would have been injured during open surgery. Conclusions: Percutaneous endoscopically assisted calcaneal osteotomy is a minimally invasive technique that had fewer nerve injuries in this cadaveric model than traditional open surgery. Clinical Relevance: Percutaneous endoscopically assisted calcaneal osteotomy due to its less invasive nature may result in fewer neurovascular injuries relative to an open procedure.

Sagittal Distal Tibial Articular Angle and the Relationship to Talar Subluxation in Total Ankle Arthroplasty.

Background: Longevity of total ankle replacement (TAR) depends heavily on anatomic alignment. The lateral talar station (LTS) classifies the sagittal position of the talus relative to the tibia. We hypothesized that correcting the sagittal distal tibial articular angle (sDTAA) during TAR would anatomically realign the tibiotalar joint and potentially reduce the risk of prosthesis subluxation. Methods: The LTS (millimeters) and sDTAA (degrees) were measured twice by 2 blinded observers using weight-bearing lateral ankle radiographs obtained before (n = 96) and after (n = 94) TAR, with excellent interobserver and intraobserver reliability (correlation coefficient >0.9). Results: Preoperative LTS was as follows: anterior (60.4%), posterior (27.1%), and neutral (12.5%). A strong preoperative correlation was found between LTS and sDTAA (r = 0.81; P < .0001). In ankles that were initially anterior and became less anterior postoperatively (n = 41), LTS decreased from an average 8.1 mm to 6.5 mm and the LTS changed 1.1 mm per degree of sDTAA change. In ankles that were initially posterior (n = 25), LTS increased from an average of −5.1 mm to −2.8 mm and the LTS changed 0.6 mm per degree of sDTAA change. The correlation between LTS and sDTAA was reduced postoperatively (r = 0.62; P < .0001). Conclusions: Our results suggest that rather than following generic recommendations, the surgeon should customize the sagittal distal tibial cut to the individual patient based on the preoperative LTS in order to achieve neutral TAR alignment. Level of Evidence: Level III, retrospective comparative series.

Successful fifth metatarsal bulk autograft reconstruction of thermal necrosis post intramedullary fixation

Reamed intramedullary (IM) screw fixation for proximal fifth metatarsal fractures is technically challenging with potentially devastating complications if basic principles are not followed. A case of an iatrogenic fourth-degree burn after elective reamed IM screw fixation of a proximal fifth metatarsal fracture in a high-level athlete is reported. The case was complicated by postoperative osteomyelitis with third-degree soft-tissue defect. This was successfully treated with staged autologous bone graft reconstruction, tendon reconstruction, and local bi-pedicle flap coverage. The patient returned to competitive-level sports, avoiding the need for fifth ray amputation. Critical points of the IM screw technique and definitive reconstruction are discussed. Bulk autograft reconstruction is a safe and effective alternative to ray amputation in segmental defects of the fifth metatarsal. Level of evidence V.

Boots Are Not Made for Driving: A Cautionary Case Report About the Dangers of Driving in a CAM Walker Boot and Literature Review

This case report is the first documented case of a serious motor vehicle accident caused by a patient driving in a controlled ankle motion (CAM) walker boot. The real-life nature and severity of injury in this case supplements the existing experimental studies on the dangers of driving while immobilized in a CAM boot and is likely to resonate strongly with both patients and surgeons. With CAM boots used so commonly after lower limb surgery, this case not only has the potential to change practice as an educational tool for patients but also raises important medicolegal implications for orthopaedic surgeons. Levels of Evidence: Level V

Low-Energy Lisfranc Injuries in an Athletic Population

Tarsometatarsal (TMT) joint complex injuries can be caused by either direct or indirect injuries. The Lisfranc joint represents approximately 0.2% of all fractures. Up to 20% of these injuries are misdiagnosed or missed on initial radiographic assessment; therefore, a high index of suspicion is needed to accurately diagnose TMT joint injuries and avoid the late sequelae of substantial midfoot arthrosis, pain, decreased function, and loss of quality of life. This review discusses the anatomy, diagnosis, and management of athletic Lisfranc injuries, including a description of the preferred minimally invasive surgical techniques used by the senior author of this article.