Christopher P. Chiodo

Intramedullary rod fixation compared with blade-plate-and-screw fixation for tibiotalocalcaneal arthrodesis: a biomechanical investigation.

BACKGROUND Achieving stable fixation when performing tibiotalocalcaneal arthrodesis can be challenging, especially in osteopenic bone. The purpose of the current investigation was to compare the stiffness and fatigue endurance of blade-plate-and-screw fixation with intramedullary rod fixation in a cadaveric model. METHODS In ten matched pairs of fresh-frozen cadaveric legs, a tibiotalocalcaneal arthrodesis was performed with use of a blade-plate and a 6.5-mm sagittal screw in one leg and with use of an intramedullary rod in the contralateral leg. After an initial load-deformation curve was obtained, each specimen was loaded to 270 N through 250,000 cycles at a rate of 3 Hz. RESULTS Blade-plate-and-screw fixation resulted in significantly higher mean initial and final stiffness and decreased plastic deformation than did intramedullary rod fixation. In addition, there was an inverse correlation between bone-mineral density and the difference in plastic deformation noted between the specimens of each pair. CONCLUSIONS Blade-plate fixation is biomechanically superior to intramedullary fixation for tibiotalocalcaneal arthrodesis.

Clinical Results with the Ludloff Osteotomy for Correction of Adult Hallux Valgus

Background: Biomechanically, the Ludloff osteotomy fixed with lag screw compression has been shown to be more rigid than proximal crescentic and other proximal first metatarsal osteotomies for correction of symptomatic hallux valgus with a moderate to severe increase in the first intermetatarsal angle. The Ludloff osteotomy may, therefore, have a lower incidence of dorsal malunion and transfer metatarsalgia than other proximal first metatarsal osteotomies, such as the crescentic or chevron. Methods: We reviewed the results of 82 consecutive cases of moderate to severe hallux valgus deformities corrected with the Ludloff oblique metaphyseal-diaphyseal osteotomy of the first metatarsal combined with a distal soft-tissue procedure and medial eminence resection. Results: Follow-up was possible in 70 cases (85%) at an average of 30 months (range, 18 to 42 months). Preoperatively, the mean hallux valgus and first intermetatarsal angles were 31 degrees and 16 degrees, respectively. Postoperatively, these values improved to an average of 11 degrees and 7 degrees. In the sagittal plane, the first metatarsal was plantarflexed by an average of 1 mm, and there were no symptomatic transfer lesions of the second metatarsal. The mean AOFAS hindfoot score improved from 54 to 91 points. Complications included prominent hardware requiring removal (5), hallux varus (4), delayed union (3), superficial infection (3), and neuralgia (3). Conclusions: The use of the Ludloff oblique first metatarsal osteotomy resulted in excellent correction of the first intermetatarsal angle in patients with moderate to severe hallux valgus. With the plane of the osteotomy and rigidity of fixation, immediate ambulation was possible with minimal risk of dorsiflexion malunion of the first metatarsal.

DEVELOPMENTS AND ADVANCES IN THE DIAGNOSIS AND TREATMENT OF INJURIES TO THE TARSOMETATARSAL JOINT

Continued research and clinical advances have allowed clinicians to diagnose injuries of the tarsometatarsal joint earlier and with greater precision than in previous eras and have promoted refinements of the surgical procedures used in their treatment. For patients with such injuries, these advances should result in improved function and a substantial decrease in morbidity.

Injuries Observed in Minimalist Runners

Background: Minimalist runners have been shown to have a different gait pattern with lower impact forces than habitually shod runners. Running in minimalist footwear has been promoted as a means of reducing or eliminating running injuries by returning to a more natural gait. Methods Ten experienced runners, age 21 to 57 (mean, 43) years, were identified with injuries within 1 year of transition from traditional to minimalist running footwear. Patients were interviewed to determine their running history, injury history, transition to minimalist footwear, and their new injury including its treatment and recovery. Results Ten patients who ran with traditional footwear ran an average of 25.9 (range, 6 to 45) miles/week for an average of 18.9 (range, 1 to 40) years presented with injuries 2.8 (range 1 to 10) months after switching to minimalist footwear. Their injuries included eight metatarsal stress fractures, a calcaneal stress fracture, and a plantar fascia rupture. All patients had a successful recovery and returned to their previous level of running. Conclusion Injuries including stress fractures and plantar fascia rupture have been observed in minimalist runners. Level of Evidence: IV, Retrospective Case Series

Diagnosis and treatment of acute Achilles tendon rupture.

This clinical practice guideline is based on a series of systematic reviews of published studies in the available literature on the diagnosis and treatment of acute Achilles tendon rupture. None of the 16 recommendations made by the work group was graded as strong; most are graded inconclusive; four are graded weak; two are graded as moderate strength; and two are consensus statements. The two moderate-strength recommendations include the suggestions for early postoperative protective weight bearing and for the use of protective devices that allow for postoperative mobilization.

Current concepts review: acute ruptures of the achilles tendon.

The Achilles tendon is the largest and most powerful tendon in the body. Formed by the distal portions of the gastrocnemius and soleus muscles, its fibers internally rotate by 90 degrees to allow the tendon to further store and release energy through elongation and elastic recoil. Acute ruptures of the Achilles tendon are relatively common injuries, with an estimated incidence of 18 per 100,000 people.52 Over the past two decades, treatment of this injury has evolved substantially. Historically, high complication rates associated with operative repair led numerous authors to advocate nonoperative management.13,51,70 However, nonoperative management was associated with a high incidence of tendon re-rupture.37,75 The high incidence of rerupture and improved surgical results led to renewed support for operative repair, especially in younger, more active patients. At the same time, advances in nonoperative management have been made, especially with regard to functional bracing.62,82,92 Considerable debate remains regarding the optimal treatment of acute Achilles tendon ruptures, and management strategy must still be decided on an individual basis.

A Technique for Isolated Arthrodesis for Inflammatory Arthritis of the Talonavicular Joint

There are few reports in the literature documenting the efficacy of isolated arthrodesis for inflammatory arthritis of the talonavicular joint. Accordingly, we reviewed a single surgeons experience with this procedure in twenty consecutive cases from this patient population. A technique using indirect joint distraction and the combined use of screw and staple fixation was employed. Solid arthrodesis was noted radiographically in 19 of 20 feet (95%) at an average of 11 weeks. Complications included one non-union, one deep venous thrombosis, and one superficial wound infection. Objective results were graded as excellent in 16 cases, good in 3 cases, and poor in one case. Subjectively, 18 patients were satisfied and one patient dissatisfied with the results of the procedure. It is concluded that isolated arthrodesis is an effective procedure for the treatment of inflammatory arthritis of the talonavicular joint, offering significant pain relief and improved function. Additionally, the use of indirect joint distraction and fixation with screws and staples is a reliable technique associated with an excellent fusion rate.

Effects of morbid obesity and diabetes mellitus on risk of coronary artery bypass grafting

Abstract Obesity has been identified as an independent risk factor for cardiovascular disease 1–4 and the occurrence of complications of coronary artery bypass grafting (CABG). 5,6 A study was designed to determine if the risks associated with morbid obesity should alter the indications for CABG, the operative strategy or the postoperative care.

Histological Differences in Iliac and Tibial Bone Graft

Background: Cancellous bone graft is frequently used during orthopedic procedures. While the iliac crest has traditionally been the most common donor site, the proximal tibia is an alternative donor site, especially for foot and ankle procedures. This study tested the null hypothesis that the histologic composition of iliac and tibial bone grafts is similar. Materials and Methods: Specimens from the iliac crest (n = 10) and tibia (n = 10) in excess of that needed for patients undergoing foot or ankle fusion were examined histologically. Iliac samples were taken from the anterior iliac crest. Tibial samples were harvested from the region of Gerdys tubercle. Specimens were graded based on the percent of bone surfaces that opposed active hematopoietic marrow, with Grade I at 0%, through Grade VI at 81% to 100%. Differences between iliac and tibial grafts were evaluated with Fishers Exact Test. Results: Iliac crest and tibial bone grafts both showed trabecular fragments with abundant osteocytes. All iliac grafts contained active hematopoietic marrow. In contrast, the medullary space of tibial grafts contained fat and little hematopoietic marrow. Nine iliac grafts were graded V or VI; whereas the ten tibial bone grafts were all graded I or II (p = 0.0001). The difference in the numbers of samples in each group ranked as grade VI was also statistically significant (p = 0.005). Conclusion: Iliac bone grafts contained active hematopoietic marrow, whereas quiescent medullary fat predominated in tibial grafts. Clinical Relevance: These findings raise questions about the cellular contributions of different sources of bone graft to bone healing.

Consistent and reproducible slice selection in rodent brain using a novel stereotaxic device for MRI

Typically small animal radiological images are obtained after placing the animal in the center of the imaging device using beds or platforms, and then adjusting the position after obtaining a scout image. Such a process does not permit the reproducible visualization of the same anatomical plane with repeated examinations. We have developed a device that allows stereotaxic placement of an animal in precisely the same position for repeated examinations. The instrument incorporates a full range of physiological monitoring and life support systems including temperature control, anesthesia delivery and respiratory monitoring. Using magnetic resonance imaging (MRI), the accuracy and reliability of this device is demonstrated in a rat traumatic brain injury (TBI) model.