Giovanni Carcuro

Continuous popliteal block for postoperative analgesia in total ankle arthroplasty.

Background: Total ankle arthroplasty is associated with severe postoperative pain. Development of analgesic techniques such as a block with continuous infusion at the popliteal level has been shown to result in good pain control, a decrease in the use of rescue analgesia and a low rate of complications. We reviewed our experience with this method of analgesia in patients who underwent total ankle arthroplasty. Methods: A prospective study of 30 patients undergoing total ankle arthroplasty was carried out. Twenty-two of these received and maintained a block at the popliteal level with a continuous infusion of bupivacaine, while the remaining eight received no such block. Results: The visual analog scale evaluation (VAS) showed a significant improvement in pain control in the group with the popliteal block after 6, 12, 18, and 24 hours postsurgery, with pain levels peaking and being most different between 6 and 12 hours postsurgery for the two groups. The group with the popliteal block also exhibited a significantly lower consumption of morphine and a greater degree of patient satisfaction. Conclusion: The block with continuous infusion at the popliteal fossa was a safe technique for total ankle arthroplasty postoperative analgesia, which provided good pain control, a lower requirement of opiates and a higher level of patient satisfaction. Level of Evidence: II; Prospective Comparative Study

Are locking plates better than non-locking plates for treating distal tibial fractures?

BACKGROUND Locking and non-locking plates has been used for distal tibia fracture osteosynthesis. Sufficient evidence to favor one implant over the other is lacking in the current literature. Our aim is to compare them in terms of fracture healing, alignment, functional outcome, complications. METHODS Sixty-eight patients operated on using a percutaneous plate were retrospectively reviewed. They were divided into two groups: in group 1 (28 patients) a 4.5mm narrow conventional dynamic compression plate (DCP) was used. In group 2 (40 patients) a titanium locked compression plate (LCP) was used. RESULTS Mean time to union was 16.2 and 15.4 weeks for group 1 and 2, respectively (p=0.618). 11 patients (39.3%) in group 1 and 4 patients (10%) in group 2 showed malalignment (p=0.016). AOFAS scores at follow up were 89 and 88 in groups 1 and 2, respectively. Implant removal was necessary in 9 cases (32.1%) and 4 cases (10%) in group 1 and group 2, respectively (p=0.042). Three patients (10.7%) in group 1 and three patients (7.5%) in group 2 had an infection. CONCLUSIONS Both plating systems have similar results in terms of time to union, infection, and AOFAS scores. The LCP seems superior with respect to alignment and the need for implant removal.

Technique tip: EDL-to-EHL double loop transfer for extensor hallucis longus reconstruction

BACKGROUND Extensor hallucis longus (EHL) tendon injuries often occur in the setting of lacerations to the dorsum of the foot. End-to-end repair is advocated in acute lacerations, or in chronic cases when the tendon edges are suitable for tension free repair. Reconstruction with allograft or autograft is advocated for cases not amenable to a primary direct repair. This is often seen in cases with tendon retraction and more commonly in the chronic setting. In many countries the use of allograft is very limited or unavailable making reconstruction with autograft and tendon transfers the primary choice of treatment. Tendon diameter mismatch and diminished resistance are common issues in other previously described tendon transfers. METHODS We present the results of a new technique for reconstruction of non-reparable EHL lacerations in three patients using a dynamic double loop transfer of the extensor digitorum longus (EDL) of the second toe that addresses these issues. RESULTS At one-year follow up, all patients recovered active/passive hallux extension with good functional (AOFAS Score) and satisfaction results. No reruptures or other complications were reported in this group of patients. No second toe deformities or dysfunction were reported. CONCLUSIONS Second EDL-to-EHL Double Loop Transfer for Extensor Hallucis Longus reconstruction is a safe, reproducible and low-cost technique to address EHL ruptures when primary repair is not possible. LEVEL OF EVIDENCE IV (Case Series).

Cement Casting to Optimize Reconstruction of Chronic Osteochondral Lesions of the Talus

Few surgical techniques have been described for reconstruction in massive osteochondral lesions of the talus, and there is limited evidence of techniques for accurately reproducing native talar anatomy with bone auto/allograft techniques. In this article, we present a novel technique, which is highly reproducible, using bone cement to restore the congruence and anatomy of the ankle joint. Levels of Evidence: Level V: Technical tip