Daniel K. Lee

Electrical stimulation versus ultrasound guidance for popliteal-sciatic perineural catheter insertion: a randomized controlled trial.

Background: Sciatic perineural catheters via a popliteal fossa approach and subsequent local anesthetic infusion provide potent analgesia and other benefits after foot and ankle surgery. Electrical stimulation (ES) and, more recently, ultrasound (US)-guided placement techniques have been described. However, because these techniques have not been compared in a randomized fashion, the optimal method remains undetermined. Therefore, we tested the hypotheses that popliteal-sciatic perineural catheters placed via US guidance require less time for placement and produce equivalent results, as compared with catheters placed using ES. Methods: Preoperatively, subjects receiving a popliteal-sciatic perineural catheter for foot and/or ankle surgery were randomly assigned to either the ES with a stimulating catheter or US-guided technique with a nonstimulating catheter. The primary end point was catheter insertion duration (in minutes) starting when the US transducer (US group) or catheter-placement needle (ES group) first touched the patient and ending when the catheter-placement needle was removed after catheter insertion. Results: All US-guided catheters were placed per protocol (n = 20), whereas only 80% of stimulation-guided catheters could be placed per protocol (n = 20, P = 0.106). All catheters placed per protocol in both groups resulted in a successful surgical block. Perineural catheters placed by US took a median (10th-90th percentile) of 5.0 min (3.9-11.1 min) compared with 10.0 min (2.0-15.0 min) for stimulation (P = 0.034). Subjects in the US group experienced less pain during catheter placement, scoring discomfort a median of 0 (0.0-2.1) compared with 2.0 (0.0-5.0) for the stimulation group (P = 0.005) on a numeric rating scale of 0 to 10. Conclusions: Placement of popliteal-sciatic perineural catheters takes less time and produces less procedure-related discomfort when using US guidance compared with ES.

Ankle Arthroplasty Alternatives with Allograft and External Fixation: Preliminary Clinical Outcome

UNLABELLED Tibiotalar joint reconstruction for the treatment of osteoarthritic and post-traumatic arthritic joint remains controversial and unsatisfactory. While the current literature recommends joint arthrodesis as a gold standard, current developments in allograft technology may aid in the repair of articular damage; avoid any metallic implant wear, failure, and revision; and preserve normal musculoskeletal biomechanics. The purpose of this retrospective study was to report the early clinical outcomes of ankle arthroplasty with allograft and with the application of a monolateral external fixation in the treatment of ankle arthritis. Eighteen patients (18 ankles, n = 18) with end-stage ankle arthritis, underwent surgical intervention. The mean preoperative AOFAS score was 32.0 +/- 1.1 (30-33) while the postop was 87.33 +/- 7.6 (81-97) (P = .000). There were no complications associated with the allograft material. There were also no complications with the external fixator. The early clinical outcome results provided an optimistic view of this procedure as another alternative treatment for the arthritic ankle, with subjective patient improvement and satisfaction, as well as a statistically significant and functionally increased range of motion and joint space and objective improvements. Allograft implantation with external fixation for the arthritic tibiotalar joint provided encouraging preliminary results and patient satisfaction mirroring current outcomes from shoulder and animal studies. LEVEL OF CLINICAL EVIDENCE 4.

Case Presentation: Xenograft Resistance to Protease Degradation in a Vasculitic Ulcer:

Vasculitic ulcers are related to numerous underlying etiologies including autoimmune disease, rheumatoid arthritis and other inflammatory conditions.The resulting ulcerations are associated with high levels of pain, inflammation and tissue necrosis. Current therapies, including surgical intervention, are limited by the underlying inflammatory process and complications secondary to the wound etiology. conservative care has been relatively unsuccessful in promoting wound closure.This case presentations reviews the successful results of using a xenograft in the treatment of an inflammatory ulcer associated with cryoglobulinemia and vasculitis. Product integrity was maintained postoperatively, compared to an allograft, thereby allowing the wound treatment site to progress to closure.The type of cross linkage of acellular grafts may have a direct effect on product stability and treatment outcomes.

Foot and Ankle Surgery: Considerations for the Geriatric Patient

The growing number of lower-extremity abnormalities that are seen in inpatient and outpatient settings has paralleled the increased number of elderly in the population. Foot and ankle deformities, disorders, and arthritis, which are not manifested until late in life, have become more common as more individuals attain longer lifespans. Although conservative therapies are a priority when addressing the geriatric population, surgical options may be overlooked secondary to a misunderstanding of their ability to overcome perioperative management. Advanced minimally invasive surgical procedures for the foot and ankle have decreased the complications associated with foot surgery, making surgical intervention a viable option for many of the elderly. The newer procedures do not, however, minimize strict perioperative management, including pharmacological and nutritional assessment, and cardiopulmonary precautions. Outpatient surgical intervention may effectively address many ongoing problems associated with pain, decreased ambulation, and decreased quality of life. Current techniques in joint reconstruction in the forefoot and midfoot allow weight bearing from the day of surgery. Most hindfoot and ankle surgeries now permit minimal bone resection and incision through arthroscopy, resulting in improved muscle and tendon repair and early weight bearing. The changes in surgical approaches for the geriatric foot have permitted more effective and rapid intervention in problems affecting ambulation and quality of life in our aged population.

Hallux, Sesamoid, and First Metatarsal Injuries

Hallux, sesamoid, and first metatarsal injuries are common foot injuries and have implications in the biomechanical functionality of the first ray and foot. They are essential for propulsion in normal gait. As part of the first ray, it is an important contributor to normal locomotion. Any structure disruption or injury can create angular changes or arthritis, which can have biomechanical implications, including pain, disability, compensation, swelling, and reduced range of motion.

Limb Salvage Surgery and Wound Treatment in the Establishment of Globally Standardized Diabetes, Amputation, and Limb Salvage Centers to Address Lower Extremity Morbidity and Mortality in Thailand

Diabetes and its consequences, particularly diabetic foot ulcerations and amputations, are increasing exponentially on a global level. Universal interest exists in the establishment of educational programs, clinics, and patient materials. However, the availability and skills needed to develop, implement, and consistently manage diabetes and related problems are lacking. This article reviews problems related to care of the diabetic foot, with a focus on Thailand as a model. Recommendations are made to assist with the development and implementation of limb salvage centers for the treatment of the at-risk diabetic foot. The guidelines presented may be applied to any countries where diabetic foot care is in the initial stages of development.