Bilal Jamal

An Anatomical Study Comparing Two Surgical Approaches for Isolated Talonavicular Arthrodesis

Background: Two operative approaches are commonly used for isolated talonavicular arthrodesis: the medial and the dorsal approach. It is recognized that access to the lateral aspect of the talonavicular joint can be limited when using the medial approach, and it is our experience that using the dorsal approach addresses this issue. We performed an anatomical study using cadaver specimens, to compare the amount of articular surface that can be accessed by each operative approach. Methods: Medial and dorsal approaches to the talonavicular joint were performed on each of 11 cadaveric specimens (10 fresh frozen, 1 embalmed). Distraction of the joint was performed as used intraoperatively and the accessible area of articular surfaces was marked for each of the 2 approaches using a previously reported technique. Disarticulation was performed and the marked surface area was quantified using an immersion digital microscribe, allowing a 3-dimensional virtual model of the articular surfaces to be assessed. Results: The median percentage of total accessible talonavicular articular surface area for the medial and dorsal approaches was 71% and 92%, respectively (Wilcoxon signed-rank test, P < .001). Conclusion: This study provides quantifiable measurements of the articular surface accessible by the medial and dorsal approaches to the talonavicular joint. Clinical Relevance: These data support for the use of the dorsal approach for talonavicular arthrodesis, particularly in cases where access to the lateral half of the joint is necessary.

Monoaxial external fixation of the calcaneus: an anatomical study assessing the safety of monoaxial pin insertion

The use of external fixation for intra-articular calcaneal fractures is increasing in popularity. Studies have shown fine wire and monoaxial external fixation to be a viable surgical alternative to more invasive methods of open reduction and internal fixation of the calcaneus. However, there is an absence of literature that quantifies the risk of pin insertion for monoaxial fixation. This study aimed to determine the safety of inserting monoaxial pins within the calcaneus to house the Orthofix Calcaneal Mini-Fixator. Five formalin embalmed cadaveric ankle and lower leg specimens were inserted with six monoaxial pins. Careful dissection then revealed the presence of the tendons of peroneus longus and brevis, the sural nerve and the small saphenous vein in relation to these pins. Measurements from each pin to each of these structures were made as the structures transected lines drawn from each pin to two palpable bony landmarks: the inferior tip of the lateral malleolus and the posterosuperior calcaneus. In doing this, the risk posed by each pin could be evaluated. We found that two particular pins, those used to hold the articular surface of the subtalar joint in a reduced position, posed a larger risk of injury to surrounding structures than the remaining pins. These findings therefore suggest that monoaxial fixation of the calcaneus using a six pin approach is a relatively safe method of rectifying calcaneal fractures and thus may serve as a welcome alternative to other methods of calcaneal fixation.

Circular frame fixation for calcaneal fractures risks injury to the medial neurovascular structures: a cadaveric description

AIM There is a risk of iatrogenic injury to the soft tissues of the calcaneus and this study assesses the risk of injury to these structures in circular frame calcaneal fracture fixation. MATERIALS AND METHODS After olive tip wires were inserted, an L-shaped incision on the lateral and medial aspects of 5 formalin fixed cadaveric feet was performed to expose the underlying soft tissues. The calcaneus was divided into zones corresponding to high, medium and low risk using a grading system. RESULTS Structures at high risk included the posterior tibial artery, posterior tibial vein and posterior tibial nerve on the medial aspect. Soft tissue structures on the lateral side that were shown to be at lower risk of injury were the small saphenous vein and the sural nerve and the tendons of fibularis longus and fibularis brevis. CONCLUSION The lateral surface of the calcaneus provides a lower risk area for external fixation. The risk of injury to significant soft tissues using a circular frame fixation approach has been shown to be greater on the medial aspect. CLINICAL RELEVANCE This study highlights the relevant anatomical relations in circular frame fixation for calcaneal fractures to minimise damage to these structures.

Acute fractures of the pediatric foot and ankle

BackgroundInjuries around the foot and ankle are challenging. There is a paucity of literature, outside that of specialist orthopedic journals, that focuses on this subject in the pediatric population.Data sourcesIn this review, we outline pediatric foot and ankle fractures in an anatomically oriented manner from the current literature. Our aim is to aid the emergency department doctor to manage these challenging injuries more effectively in the acute setting.ResultsThese injuries require a detailed history and examination to aid the diagnosis. Often, plain radiographs are sufficient, but more complex injuries require the use of magnetic resonance imaging. Treatment is dependent on the proximity to skeletal maturity and the degree of displacement of fracture. Children have a marked ability to remodel after fractures and therefore mainstay treatment is immobilization by a cast or splint. Operative fixation, although uncommon in this population, may be necessary with adolescents, certain unstable injuries or in cases with displaced articular surface. In the setting of severe foot trauma, skin compromise and compartment syndrome of the foot must be excluded.ConclusionThe integrity of the physis, articular surface and soft tissues are all equally important in treating these injuries.

The Evolution of Total Ankle Arthroplasty

Ankle arthritis can lead to disabling pain and loss of function. While arthrodesis surgery leads to reliable pain relief, it is associated with development of degenerative joint disease in adjacent joints. The success of hip and knee arthroplasty has led to interest in developing a total ankle arthropalsty. Unfortunately, this has, historically, been associated with poor results. This is due to a failure to appreciate joint biomechanics and optimial fixation techniques. In this article, we describe the evolution in design of ankle arthoplasty. We comment upon differing generations of designs and introduce the reader to differing outcomes between these implants.