Georg Klammer

Posterior pilon fractures: a retrospective case series and proposed classification system.

Background: Posterior malleolus fractures occur in 7% to 44% of ankle fractures and are associated with worse clinical outcomes. Fractures that involve the posteromedial plafond extending to the medial malleolus have been described previously in small case series. Failure to identify this fracture pattern has led to poor clinical outcomes and persistent talar subluxation. The purpose of this study was to report our outcomes following fixation of this posterior pilon fracture and to describe a novel classification system to help guide operative planning and fixation. Methods: Eleven patients were identified following fixation of a posterior pilon fracture over a 4-year span; 7 returned at minimum 1-year follow-up to complete a physical examination, radiographs, and RAND-36 (health-related quality of life score developed at RAND [Research and Development Corporation] as part of the Medical Outcomes Study) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot questionnaires. Patient records were reviewed to evaluate for secondary complications or operative procedures. Results: Our mean postoperative AOFAS ankle/hindfoot score was 82. Anatomical reduction of the plafond was noted radiographically in 7 of 11 patients, with the remainder demonstrating less than 2 mm of articular incongruity. Five of 7 patients demonstrated ankle and hindfoot range of motion within 5 degrees of the uninvolved extremity. Four complications required operative intervention; 2 patients reported continued pain secondary to development of CRPS. Conclusion: The posterior pilon fracture is a challenging fracture pattern to treat, and it has unique characteristics that require careful attention to operative technique. Our results following fixation of this fracture pattern are comparable with results in the literature. In addition, a novel classification scheme is described to guide recognition and treatment of this fracture pattern. Level of Evidence: Level IV, retrospective case series.

Natural history of nonoperatively treated osteochondral lesions of the talus.

Background: We hypothesized that patients undergoing nonoperative treatment for asymptomatic or minimally symptomatic osteochondral lesions of the talus (OLTs) would not deteriorate clinically or radiologically over time. Methods: Forty-eight patients (mean age = 48 years; range, 13-78 years) with an OLT confirmed by magnetic resonance imaging (MRI) who had not undergone ankle joint surgery were retrospectively reviewed. All patients were evaluated after a minimum follow-up of 2 years (mean = 52 months; range, 27-124 months). All patients filled out an individual questionnaire and underwent a physical and radiographic assessment (radiograph and hindfoot MRI). Results: At final follow-up, 43 ankles (86%) in 41 patients were pain-free (visual analogue scale [VAS] 0, n = 12) or less painful (VAS 1-3, n = 31). Radiographically, osteoarthritis was absent in 47%, and grade 1 and 2 osteoarthritis each were found in 27% (van Dijk classification). Magnetic resonance imaging revealed no substantial progression in staging or lesion size. Pain at time of follow-up correlated with the depth of the lesion at initial MRI (P < .05) and with subchondral cyst formation and presence or change of bone marrow edema at follow-up MRI (P < .05). Conclusion: Minimally symptomatic OLTs did not appear to progress or worsen over time when treated nonoperatively. Level of Evidence: Level IV, case series.

Inferior Results of Salvage Arthrodesis After Failed Ankle Replacement Compared to Primary Arthrodesis

Background: Up to now, there has been no evidence that salvage arthrodesis would perform inferior when compared with primary ankle arthrodesis. The purpose of this study was to compare their clinical and radiographic results. Methods: A retrospective analysis was performed using 2 validated scores and assessment of radiographic union by comparing 23 patients who underwent salvage ankle arthrodesis (group SA = salvage arthrodesis) after failed total ankle replacement with 23 matched patients who received primary ankle arthrodesis (group PA = primary arthrodesis). The mean follow-up period was 38 (range 16-92) months in group SA and 56 (23-94) months in group PA. Results: Complete union was achieved in 17 patients (74%) after a mean time of 50 (13- 114) weeks in group SA and in 16 patients (70%) after a mean time of 23 (10-115) weeks in group PA. The SF-36 score averaged 48 points (7-80) in SA and 66 points (14-94; P = .006) in group PA. In group SA the mean FFI was 57% (22-82) for pain and 71% (44-98) for function. In group PA significantly better results for pain with 34% (0-88; P = .002) and function with 48% (1-92; P = .002) were found. Conclusion: Salvage arthrodesis led to impaired life quality and reduced function combined with significantly higher pain when compared with primary ankle arthrodesis. These findings can be used to counsel our patients preoperatively. Level of Evidence: Level III, retrospective case series.

The Varus Ankle and Instability

Varus ankle associated with instability can be simple or complex. Multiple underlying diseases may contribute to this complex pathologic entity. These conditions should be recognized when attempting proper decision-making. Treatment options range from conservative measures to surgical reconstruction. Whereas conservative treatment might be a possible approach for patients with simple varus ankle instability, more complex instabilities require extensive surgical reconstructions. However, adequate diagnostic workup and accurate analysis of varus ankle instability provide a base for the successful treatment outcome.

Operative Management of Common Forefoot Deformities A Representative Survey of Australian Orthopaedic Surgeons

Background. Hallux valgus and hallux rigidus are common conditions for which numerous operative interventions have been described in the literature. Various clinical and radiological measurements have been used to help grade severity and to guide treatment. Materials and methods. A survey was e-mailed to all members of the Australian Orthopaedic Association. Questions were asked regarding respondents’ demographics as well as their preferred treatment for 3 separate cases of hallux valgus and hallux rigidus of varying severity. They were specifically asked about type of deformity correction and type of fixation. The responses were collected and statistically analyzed. Results. The authors collected the answers of 454 respondents with a response rate of 36%. There was a disproportionately large percentage of respondents who were members of the Australian Orthopaedic Foot and Ankle Society. Preferred treatments were different for the 3 different cases. Older surgeons were more likely to use Chevron osteotomies, and Australian Orthopaedic Foot and Ankle Society members were more likely to use a scarf. Scarf osteotomy was preferred by more than 50% for the cases of moderate and severe hallux valgus, whereas first metatarsophalangeal joint fusion was preferred for the case with significant arthritic changes. Conclusions. There are significant associations between the surgeons’ age and expertise and their training and their preferred operative intervention. Considerable differences were found in the practice of the general orthopaedic surgeons and the foot and ankle specialists. Despite the large number of surgical options available for hallux valgus, only a small number were preferred by the majority of surgeons. Although anecdotally aware that lesser deformity is treated with distal osteotomies and more severe deformity with a proximal osteotomy, the authors are unaware of any current literature that verifies this.

Calcific tendinitis of the peroneus longus: case report.

Level of Evidence: V, Expert Opinion

Percutaneous Lateral Ankle Stabilization: An Anatomical Investigation

Background: The current study investigated the topographic anatomy of the percutaneous anatomical lateral ankle stabilization in relation to the neurovascular hindfoot structures. The study should serve as an aid for performance of this new minimally invasive technique. Materials and Methods: Eleven cadaver specimens were dissected exposing the nerves, vessels, ligaments and tendons. The portals and transosseous tunnels were performed with Kirschner wires. All distances of the Kirschner wires and the neurovascular structures were measured with reference to clearly identifiable bony landmarks. Results: On the medial side the average distance of the Kirschner wire to the medial calcaneal branch of the tibial nerve was found to be 7 mm (SD ± 4). The medial calcaneal branch was hit twice by the transosseous Kirschner wire. On the lateral side the mean distance of the fibular exit point of the Kirschner wire to the sural nerve was 13 mm (SD ± 4). The closest distance of the superficial peroneal nerve to the footprint of the ATFL averaged 11.5 mm (SD ± 3) and its anterior location in relation to the tip of the fibula was 28 mm (SD ± 8). The posterior tibial artery was found at a mean distance of 41 mm from the perforating Kirschner wire (SD ± 6). Conclusion: The current study introduced a novel percutaneous approach to treat chronic ankle instability that had minimal risk to neurovascular structures in a cadaver model. Clinical Relevance: Further clinical studies must be undertaken to identify whether this technique would also be superior when compared with open surgery.

Bilateral diffuse pigmented villonodular synovitis of the knee.

Pigmented villonodular synovitis (PVNS) is a proliferative disease of synovial tissue characterized by lipid-laden macrophages, multinucleated giant cells, and hemosiderin deposits. PVNS presents either in a localized form with minimal rates of recurrence after surgical resection or in a diffuse form with an expansive growth pattern showing formation of osseous erosions and extra-articular manifestation. In the diffuse form high recurrence rates occur as a result of the challenge of achievement of total synovectomy. Typically only one single joint, being the knee in 80% of cases, is involved with diffuse PVNS. Reports of bi- or multiarticular manifestation are at best rare. Here, a case of a 16-year-old girl with bilateral diffuse PVNS of the knee allows discussion of diagnostic and treatment considerations.

Intraoperative Imaging of the Distal Radioulnar Joint Using a Modified Skyline View

PURPOSE Nonanatomic reduction of the sigmoid notch in distal radius fractures may lead to limited motion, instability, or pain with pronation and supination. Standard radiological projections only poorly capture the sigmoid notch contours in the axial plane. The purpose of this study was to find an intraoperatively feasible radiological projection that will facilitate an axial view of the distal radioulnar joint. METHODS We modified a previously described radiographic projection termed the skyline view for evaluating the distal radius axially. We created intra-articular steps at the sigmoid notch in solid foam forearm models to identify the best of 12 projections using an image intensifier. Four observers scored each projection based on the clarity of the sigmoid notch contour and indicated the presence and location of an intra-articular stepoff. RESULTS The sigmoid notch was best visualized in the modified skyline view with the wrist in extension and 10° to 15° of dorsal forearm angulation relative to the x-ray path. All observers correctly recognized the presence and location of intra-articular steps at the sigmoid notch with this view. The same forearm angulation with the wrist in flexion did not reach equally good visibility of the sigmoid notch. Arm position (wrist flexion, forearm rotation, or forearm angulation) and intra-articular stepoff (none, palmar, or dorsal) were dependent determinates. Elimination of the variable forearm rotation had minimal effect, indicating that forearm rotation is not important for visualization of the sigmoid notch. CONCLUSIONS The modified skyline view for visualization of the distal radioulnar joint in an axial plane allows good visibility of the sigmoid notch and reliable identification of stepoffs. Further cadaver and in vivo studies are required to verify the validity of this method.

Correlation of psychomotor findings and the outcome of a physical therapy program to treat scapular dyskinesis

BACKGROUND This pilot study was performed to investigate the influence of psychomotor skills on the outcome of a specific nonoperative program (scapular dyskinesis-program) to treat scapular dyskinesis. MATERIALS AND METHODS Fifteen patients (group A) with positive and 11 patients (group B) with a negative outcome after physical therapy were included. To test the psychomotor skills of the patients the Motorische Leistungsserie (MLS) was used. The test results of the patients of group A were then compared with those of group B. RESULTS For 2 parameters, a significant correlation could be detected. However, due to the small sample size, a clear but statistically insignificant difference could be found for several other factors. CONCLUSION We, therefore, hypothesize that psychomotor skills testing is a potential method to predict the outcome of nonoperative treatment for scapular dyskinesis. Further investigations with a larger sample size are necessary to confirm this assumption.