Ezequiel Palmanovich

Plasma rich in growth factors (PRGF) as a treatment for high ankle sprain in elite athletes: a randomized control trial.

PurposeSyndesmotic sprains are uncommon injuries that require prolonged recovery. The influence of ultrasound-guided injections of platelet-rich plasma (PRP) into the injured antero-inferior tibio-fibular ligaments (AITFL) in athletes on return to play (RTP) and dynamic stability was studied.MethodsSixteen elite athletes with AITFL tears were randomized to a treatment group receiving injections of PRP or to a control group. All patients followed an identical rehabilitation protocol and RTP criteria. Patients were prospectively evaluated for clinical ability to return to full activity and residual pain. Dynamic ultrasound examinations were performed at initial examination and at 6xa0weeks post-injury to demonstrate re-stabilization of the syndesmosis joint and correlation with subjective outcome.ResultsAll patients presented with a tear to the AITFL with dynamic syndesmosis instability in dorsiflexion–external rotation, and larger neutral tibia–fibula distance on ultrasound. Early diagnosis and treatment lead to shorter RTP, with 40.8 (±8.9) and 59.6 (±12.0)xa0days for the PRP and control groups, respectively (pxa0=xa00.006). Significantly less residual pain upon return to activity was found in the PRP group; five patients (62.5xa0%) in the control group returned to play with minor discomfort versus one patient in the treatment group (12.5xa0%). One patient in the control group had continuous pain and disability and subsequently underwent syndesmosis reconstruction.ConclusionsAthletes suffering from high ankle sprains benefit from ultrasound-guided PRP injections with a shorter RTP, re-stabilization of the syndesmosis joint and less long-term residual pain.Level of evidenceII.

Tear of peroneus longus in long distance runners due to enlarged peroneal tubercle

BackgroundTear of the Peroneus longus in association with a prominent peroneal tubercle is rare.Case presentationRecently we treated two long distance runners who developed lateral ankle pain. Maximum tenderness was located over the lateral surface of the heel in the area of the peroneal tendons. Imaging disclosed a tear of the peroneus longus at the area of the peroneal tubercle.ConclusionFollowing resection of the peroneal tubercle and repair of the peroneus longus, both patients regained full activity with no pain. This report describes the clinical presentation and surgical management of this rare injury.

The effect of minimally displaced posterior malleolar fractures on decision making in minimally displaced lateral malleolus fractures.

PurposeDespite the high incidence of cases of minimally displaced lateral or posterior malleolus ankle fractures, treatment guidelines are still an issue of controversy. The purpose of this study was to delineate treatment preferences among orthopaedic surgeons in these fractures with and without concomitant posterior malleolus fractures. We hypothesized that concomitant minimally displaced fractures of the posterior malleolus can shift treatment preference towards operative intervention.MethodsA questionnaire-based study was conducted among orthopaedic surgeons attending the 2012 European Federation of National Associations of Orthopaedics and Traumatology Conference (EFORT) in Berlin, Germany. Treatment preferences were reported for minimally displaced lateral malleolus fractures seen on radiographs and were then compared with treatment preferences when computed tomography (CT) was added revealing a concomitant minimally displaced posterolateral fracture of the posterior malleolus.ResultsThe cohort comprised 177 surgeons from all six continents. When radiographs showing a minimally displaced lateral malleolus fracture were presented, nonoperative management was indicated by 35xa0% (62) of participants, whereas 65xa0% (115) preferred operative intervention. After CT views were added showing an accompanying minimally displaced posterolateral posterior malleolus fracture, 79xa0% (140) suggested operative intervention and only 21xa0% (37) advocated nonoperative management (pu2009=u20090.03).ConclusionsMost surgeons prefer open reduction with internal fixation for minimally displaced lateral malleolar fractures. The presence of concomitant posterior malleolus fractures in these cases shifts treatment preference further towards open reduction with internal fixation. Because the posterior malleolus fragment might not be well delineated on standard ankle radiographs, a high index of suspicion is warranted, and the use of CT should be considered in these cases.

Use of a Spinal Cage for Creating Stable Constructs in Ankle and Subtalar Fusion

In complicated foot surgery with reconstruction of the hindfoot, a gap will sometimes be present between the bones that must be filled and stabilized. Bone grafting with structural bone graft is 1 alternative; however, it can collapse and must be stabilized with screws or a nail. A locking intramedullary nail can be used but could lead to nonunion owing to distraction. Newer nails include a compression device but that can result in shortening. We developed a technique that includes distraction of the fusion area with a spinal cage and then compression of the construct by inserting a compression screw through the cage. We present our experience with this technique.We reviewed the data from 7 patients who had undergone surgery using this technique. The technique included distraction of the fusion area and insertion of a titanium cylindrical spinal cage filled with autologous cancellous bone graft. A cannulated compression screw was then inserted through the cage, creating compression of the fusion area against the cage and achieving stabilization of the fusion area. Postoperatively, a non-weightbearing cast was applied for 3 months, followed by a full weightbearing cast until radiographic fusion was apparent. Complete radiographic union was observed in all 7 patients within 6 to 12 months postoperatively. At the latest follow-up visit, the mean American Orthopaedic Foot and Ankle Society scale score was 54 ± 16 (range 30 to 71) points. The use of a cylindrical titanium cage with a local bone graft and stabilization by distraction and compression provided a stable construct, avoided shortening, and led to good fusion. In addition, donor site complications and unpredictable strength loss and lysis of bone allograft were avoided.

The incidence of life threatening iatrogenic vessel injury following closed or open reduction and internal fixation of intertrochanteric femoral factures

Aim of the studyBleeding due to a vascular injury is a possible life-threatening complication of intertrochanteric femoral fracture internal fixation. Our goals were to find the current incidence of these events, and to describe the reasons, the presentation, and the treatment options.MethodWe conducted a retrospective record review of 1,469 patients who were operated upon at our institution due to AO31A femoral fractures from 2011 through 2015 and were treated with closed reduction and internal fixation.ResultsThree patients were diagnosed with iatrogenic vascular bleeding, which constitute an incidence of 0.2%. The vascular injuries were detected as deep femoral artery bleeding adjacent to the distal locking screws. The patients were treated with ultrasound guided thrombin injection, endovascular coil embolization or with no endovascular intervention.DiscussionVascular injuries are caused mainly by perforating a vessel while drilling the distal locking screw holes. A high level of suspicion and immediate imaging work-up are mandatory.ConclusionsA vascular injury due to internal fixation of a proximal AO31A femoral fracture is a rare complication.

Femoroacetabular impingement syndrome is associated with alterations in hindfoot mechanics: A three-dimensional gait analysis study

BACKGROUNDnGait analysis studies in patients with femoroacetabular impingement syndrome focused until today on alterations in pelvic and hip mechanics, but distal articulations in this syndrome were not explored. Viewing the inter-relationships between foot and hip mechanics and the importance of the subtalar joint in load attenuation at heel strike and during forward propulsion thereafter, alterations in hindfoot mechanics in this syndrome may have clinical significance.nnnMETHODSnThree-dimensional gait kinematics were explored with emphasis on hindfoot mechanics in a group of 15 men with cam-type femoroacetabular impingement and compared to 15 healthy men.nnnFINDINGSnSubjects with femoroacetabular impingement had decreased pelvic internal rotation (effect size=0.70) and hip abduction (effect size=0.86) at heel strike, and increased sagittal pelvic range of motion during the stance (effect size=0.81), compared to controls. At the hindfoot level, subjects with femoroacetabular impingement had inverted position at heel strike compared to neutral position in controls (effect size=0.89), and reduced maximum hindfoot eversion during the stance (effect size=0.72). Range of motion from heel strike to maximum eversion was not different between the groups (effect size=0.21).nnnINTERPRETATIONnYoung adult men with cam-type femoroacetabular impingement syndrome present excessively inverted hindfoot at the moment of heel strike and reduction in maximum eversion during the stance phase. Viewing the deleterious effects of hindfoot malalignment on load attenuation during the stance, custom-designed insoles may be a consideration in this population and this should be investigated further.

Cerebrovascular accidents associated with hip fractures: morbidity and mortality—5-year survival

BackgroundHip fractures are associated with increased cerebrovascular accidents (CVAs) in the first postoperative year. Long-term follow-up for CVA and mortality after hip fracture is lacking. The purpose of this study was to identify risk factors for CVA and follow mortality in hip fractures in a cohort with greater than 2xa0years follow-up.MethodsWe compared past medical history of patients with hip fractures to long-term survival and the occurrence of CVA. Past medical history, surgical intervention, CVA occurrence, and death were queried from the electronic medical recorder system. Level of significance was set at pxa0<u20090.05 with 95% confidence interval.ResultsTwo thousand one hundred ninety-five patients met inclusion criteria. Mean follow-up was 5xa0years. One hundred ten (5.01%) patients were diagnosed with post-fracture CVA. Forty-one patients had CVA in the first year and 55 patients had CVA between 1 to 5xa0years after surgery. Among the potential risk factors, hypertension (HTN), atrial fibrillation (AF), and diabetes mellitus (DM) had the highest odds ratio for CVA (ORu2009=u20091.885, p valueu2009=u20090.005; ORu2009=u20091.79, p valueu2009=u20090.012; ORu2009=u20091.66, p valueu2009=u20090.012). The median survival time in patients with CVA was 51.12u2009±u20093.76xa0months compared to 59.60u2009±u20090.93xa0months in patients without CVA (pu2009=u20090.033).ConclusionsHTN, AF, and DM are significant risk factors for the occurrence of CVA after hip fracture. The majority of CVAs occur between the first and fifth year postoperatively, and CVA is a negative prognostic factor for postoperative survival.

The effect of eliminating leg length difference on plantar foot pressure distribution in patients wearing forefoot offloading shoe

BACKGROUND AND PURPOSEnElevated heel construction offloads the forefoot after surgery. However, side-to-side height difference alters limb kinetics, whereas leg-length equalizing-sole at non-operated side may have beneficial effects on foot loading. The purpose of this study was to characterize leg-length equalizing sole effect on bilateral plantar pressures when using heel-lift forefoot-offloading shoe.nnnMATERIALS AND METHODSnTwenty men were tested walking. Plantar peak pressures (PP) and pressure-time integrals (PTI) in the forefoot-offloading shoe and in contralateral running shoe were compared between two conditions: one with- and the other without leg-length equalizing sole elevation at the running shoe.nnnRESULTSnAdding leg-length equalizing sole to the running shoe resulted in the following changes in the forefoot-offloading shoe: increased lateral midfoot PP (8.7%, p=0.03), increased lateral midfoot (11.3%, p=0.05) and lateral metatarsals PTI (10.3%, p=0.04), and decreased medial and lateral heel PTI (>5%, p=0.02). These changes were non-significant when applying a Bonferroni correction. Changes in the running shoe were: increased medial midfoot (20.5%, p=0.03) and decreased 2nd and lateral metatarsals PP (23%, p<0.01). PTI increased in medial and lateral heel (>25%, p<0.01), medial midfoot (63.2%, p<0.01) and lateral midfoot (9.2%, p=0.04) and decreased in 2nd and lateral metatarsals (>24.5%, p<0.01).nnnCONCLUSIONnLeg-length equalizing sole at contralateral running shoe in subjects wearing forefoot-offloading shoe results in lateral load shift alongside heel pressure attenuation within the forefoot-offloading shoe, which is beneficial during first month after medial forefoot surgery. Reciprocal medial load-shift in the elevated running shoe itself should yet be considered when bilateral medial forefoot pathology is present.

Arthroscopic Excision of Osteoid Osteoma of the Talus

Osteoid osteoma is a benign tumor that can cause significant pain and disability. Excision of the tumor can be accomplished with open surgery or, as advocated in recent years, with computed tomography (CT)-guided radiofrequency ablation. In this article, a unique arthroscopic approach to excise an osteoid osteoma of the talus is presented. This was possible by relying on a clear intra-articular prominent osteophyte, which was used as a landmark to indicate tumor location in accordance with preoperative CT views. This technique enabled excision of the tumor with concomitant arthroscopic decompression of the osteophyte, which contributed to symptoms of anterior ankle impingement.

Measurement of transverse forces between the first and second metatarsals: a cadaveric study

BackgroundThis study was designed to measure transverse forces between the 1st and 2nd metatarsals after reducing the intermetatarsal angle (IMA) in normal and hallux valgus (HV) feet, during non weight-bearing and weight-bearing phases of gait.MethodsFour cadaver feet, three normal and one with hallux valgus, were used. A new suture button device (CyclaPlex™) composed of screw-type buttons connected with a wire was implanted at the mid-shaft of the 1st and 2nd metatarsals of all the feet. IMA was reduced using a tensioning device to pull the wire which was secured laterally at the 1st metatarsal. The 1st metatarsal was pulled laterally towards the 2nd metatarsal until an IMA of about 6° was achieved. The amount of force applied at this point was registered on the force indicator. Each foot attached to the tensioning device was placed in a special construct loaded with weights equal to the original body weight of the donor and positioned at 15° tilt (simulating propulsion phase of the gait cycle). The intermetatarsal force under load indicated on the tensioning device was recorded.ResultsThe average recorded transverse intermetatarsal force was 28.5xa0N (SD 4.2xa0N) during non weight-bearing phase; the mean increase in the measured force at weight-bearing and 15° tilt was 6xa0N (SD 2.6xa0N).ConclusionsWe measured the transverse forces between the 1st and 2nd metatarsals with the use of a suture button device (CyclaPlex™). The data obtained from the measurements will provide a better understanding of foot biomechanics and may therefore also facilitate the development of new devices designed to decrease IMA in HV surgery.