Phinit Phisitkul

Complications of Locking Plate Fixation in Complex Proximal Tibia Injuries

Objectives: To report the complications and pitfalls in the treatment of complex injuries of the proximal tibia when locking plates are used. Design, Setting, and Patients: This was a retrospective case series conducted at a university Level I trauma center. Thirty-seven patients with complex proximal tibia fractures (41C1, 41C2, 41C3, 41A2, 42A2) were treated with locking plates. Intervention: All fractures were treated with locking plates (Less Invasive Stabilization System (LISS); Synthes, Paoli, PA). Main Outcome Measurements: Healing, alignment, infection, and other complications. Results: Twelve fractures (32%) healed without any complications. Eight patients (22%) developed deep infections that required operative debridements, and 5 of them had a hardware removal; 1 eventually required an above-knee amputation. Eight cases (22%) had postoperative malalignment, with hyperextension as the most common deformity. Three cases (8%) had loss of alignment into varus during healing. Other complications were 1 superficial wound dehiscence, 1 delayed soft-tissue breakdown, 4 hardware irritations, 1 peroneal nerve injury at the distal part of a 9-hole plate, 1 tibial tubercle nonunion, and 1 postoperative compartment syndrome. Conclusion: The complication rate, particularly infection, was higher than in previous reports. Other complications such as hardware prominence, malalignment, and loss of alignment were similar to those of historical controls. Some of the complications may reflect the techniques that were used and should decrease with more experience; however, some may be inherent in the treatment of high-energy fractures using locking plates.

Postoperative complications of posterior ankle and hindfoot arthroscopy.

BACKGROUND Posterior ankle and hindfoot arthroscopy, performed with use of posteromedial and posterolateral portals with the patient in the prone position, has been utilized for the treatment of various disorders. However, there is limited literature addressing the postoperative complications of this procedure. In this study, the postoperative complications in patients treated with posterior ankle and hindfoot arthroscopy were analyzed to determine the type, rate, and severity of complications. METHODS The study included 189 ankles in 186 patients (eighty-two male and 104 female; mean age, 37.1 ± 16.4 years). The minimum duration of follow-up was six months, and the mean was 17 ± 13 months. The most common preoperative intra-articular diagnoses were subtalar osteoarthritis (forty-six ankles), an osteochondral lesion of the talus (forty-two), posterior ankle impingement (thirty-four), ankle osteoarthritis (twenty), and subtalar coalition (five). The most common extra-articular diagnoses were painful os trigonum (forty-six), flexor hallucis longus tendinitis (thirty-two), and insertional Achilles tendinitis (five). RESULTS The most common intra-articular procedures were osteochondral lesion debridement (forty-four ankles), subtalar debridement (thirty-eight), subtalar fusion (thirty-three), ankle debridement (thirty), and partial talectomy (nine). The most common extra-articular procedures were os trigonum excision (forty-eight), tenolysis of the flexor hallucis longus tendon (thirty-eight), and endoscopic partial calcanectomy (five). Complications were noted following sixteen procedures (8.5%); four patients had plantar numbness, three had sural nerve dysesthesia, four had Achilles tendon tightness, two had complex regional pain syndrome, two had an infection, and one had a cyst at the posteromedial portal. One case of plantar numbness and one case of sural nerve dysesthesia failed to resolve. CONCLUSIONS Our experience demonstrated that posterior ankle and hindfoot arthroscopy can be performed with a low rate of major postoperative complications.

Forceps Reduction of the Syndesmosis in Rotational Ankle Fractures A Cadaveric Study

BACKGROUND Recent studies have shown that it is difficult to accurately reduce and assess the reduction of the syndesmosis after ankle injury. The syndesmosis is most commonly reduced with use of reduction clamps to compress across the tibia and fibula. However, intraoperative techniques to optimize forceps reductions to restore syndesmotic relationships accurately have not been systematically studied. The purpose of the present study was to evaluate the accuracy of syndesmosis reduction with different rotational vectors of clamp placement. METHODS Ten through-the-knee cadaveric specimens were used. Markers were placed on the tibia and fibula to produce consistent clamp placement and radiographic evaluation. A computed tomographic scan of the ankle was made to serve as a control, followed by a stepwise destabilization of the anterior inferior tibiofibular ligament, syndesmosis, deltoid ligament, small posterior malleolus fracture, and large posterior malleolus fracture. Following each step in the destabilization, clamps were applied to compress the syndesmosis at varying angles and computed tomography was performed to measure the alignment of the syndesmosis as compared with that on the control scan. RESULTS In all degrees of induced instability, and for all vectors of clamp placement, a small but consistent amount of overcompression of the syndesmosis was observed. The average overcompression (and standard deviation) for all samples was 0.93 ± 0.70 mm. Both obliquely oriented clamp arrangements consistently caused fibular malreductions in the sagittal plane. Placing the clamp in the neutral anatomical axis reduced the syndesmosis most accurately, with an average displacement of 0.1 ± 0.77 mm compared with control through all degrees of instability. CONCLUSIONS Clamp placement in the neutral anatomical axis reduced the syndesmosis most accurately in our cadaveric model, although slight overcompression was frequently observed. Placing the clamp obliquely malreduced the unstable syndesmosis.

Psychometric Comparison of the PROMIS Physical Function CAT With the FAAM and FFI for Measuring Patient-Reported Outcomes

Background: Selecting optimal patient-reported outcome (PRO) instruments is critical to improving the quality of health care. The purpose of this study was to compare the reliability, responsiveness, and efficiency of three PRO measures: the Foot and Ankle Ability Measure–Activity of Daily Living subscale (FAAM_ADL), the Foot Function Index 5-point verbal rating scale (FFI-5pt), and the PROMIS Physical Function computerized adaptive test (PF CAT). Methods: Data were aggregated from 10 clinical sites in the AOFAS’s National Orthopaedic Foot and Ankle Research (OFAR) Network from 311 patients who underwent elective surgery for a disorder of the foot or ankle. Patients were administered the FAAM_ADL, FFI-5pt, and PF CAT at their preoperative visit and at 6 months after surgery. Reliabilities were evaluated using a Rasch model. Responsiveness was calculated using paired samples t test and efficiency was recorded as number of seconds to complete the instrument. Results: Similar reliabilities were found for the three instruments. Item reliabilities for FAAM_ADL, FFI-5pt, and PF CAT were all .99. Pearson reliabilities for FAAM_ADL, FFI-5pt, and PF CAT were .95, .93, and .96, respectively. On average, patients completed the FAAM_ADL in 179 seconds, the FFI-5pt in 194 seconds, and the PF CAT in 44 seconds, (P < .001). The PF CAT and FAAM_ADL showed significant improvement (P = .01 and P = .001, respectively) in patients’ physical function after treatment; the FFI-5pt did not show improvement. Conclusions: Overall, the PF CAT performed best in terms of reliability, responsiveness, and efficiency in this broad sample of foot and ankle patients. It can be a potential replacement for the conventional PRO measures, but further validation is needed in conjunction with the PROMIS Pain instruments. Level of Evidence: Level I, prospective comparative outcome study.

Role of high tibial and distal femoral osteotomies in the treatment of lateral-posterolateral and medial instabilities of the knee.

Mechanical alignment has been overlooked as an important contributor to knee stability with respect to collateral ligament laxity. The detrimental effects of varus or valgus limb malalignment become more obvious when the restraining force is lost because of ligamentous injury especially on the medial or the lateral/posterolateral side. Even with repair or reconstruction of these injuries, with repetitive load, the ligament will eventually fail to restore its structure and strength, resulting in failure and secondary restraint laxity.We have found that realignment of the limb is the most important factor in restoring a functional limb. After realignment, joint laxity, if persistent, can be addressed successfully with ligamentous reconstruction. Diagnosis and treatment of limb malalignment cannot be ignored in the management of chronic ligamentous instabilities, especially those with prior failed reconstruction. Our approach to these difficult problems and the preferred techniques of osteotomies on both tibial and femoral sides are described.

Arthroscopic Resection of Talocalcaneal Coalitions

Excision of symptomatic talocalcaneal coalitions, after failure of an adequate conservative treatment, is a widely accepted surgical treatment when less than 50% of the subtalar joint is involved and in the absence of degenerative changes to the subtalar or surrounding tarsal joints. Favorable results have been reported in 80% to 100% of patients with open resection. The traditional medial incision to the subtalar joint provides excellent exposure of the middle facet but inadequate visualization of the posterior facet. Other common disadvantages of the traditional open technique include (1) risk of incisional neuroma formation, (2) risk of superficial wound infection and delayed wound healing, and (3) prolonged hospitalization for wound management and pain control. Prone ankle/subtalar arthroscopy has been reported to yield excellent results in the treatment of numerous hindfoot pathologies, with the advantage of reducing postoperative pain, hospital stay, infection rates, wound complications, and recovery time. A posterior arthroscopic technique for posterior-facet talocalcaneal coalition excision has been developed in an attempt to reduce the complications of the traditional open resection. Possible disadvantages of the arthroscopic procedure may include (1) longer learning curve, (2) increased surgical time, (3) possible tibial neurovascular bundle damage, and (4) difficulties in using interposition material.

The Effect of Suture-Button Fixation on Simulated Syndesmotic Malreduction: A Cadaveric Study

BACKGROUND The accuracy of reduction of distal tibiofibular syndesmosis disruptions has been associated with the clinical outcome. Suture-button fixation of the syndesmosis is a dynamic alternative mode of fixation. We hypothesized that with deliberate clamp-induced malreduction, suture-button fixation of the syndesmosis would allow a more anatomic post-fixation position compared with screw fixation. METHODS Forty-eight syndesmotic fixations were performed on twelve through-knee cadaveric specimens. The syndesmosis was destabilized and off-axis clamping was used to produce both anterior and posterior malreduction patterns. In twelve scenarios (six anterior and six posterior malreductions), syndesmotic screw fixation was used, followed by computed tomography. With tenacula holding the malreduction, the syndesmosis screws were exchanged for a suture-button construct and the specimens underwent a subsequent computed tomography scan. In the other twelve scenarios, the suture-button fixation was achieved first, followed by screw fixation. Standardized measurements of anterior-posterior and medial-lateral fibular displacement were performed by two observers blinded to the method of fixation. RESULTS With anterior off-axis clamping, the mean sagittal malreduction was 2.7 ± 2.0 mm with screw fixation and 1.0 ± 1.0 mm with suture-button fixation (p = 0.02). With posterior off-axis clamping, the sagittal malreduction was 7.2 ± 2.3 mm with screw fixation and 0.5 ± 1.4 mm with suture-button fixation (p < 0.01). No differences were observed between fixation types in the coronal plane (p = 0.20 for anterior malreductions and p = 0.06 for posterior malreductions). CONCLUSIONS With deliberate malreduction in a cadaver model, suture-button fixation of the syndesmosis results in less post-fixation displacement compared with screw fixation. The suture buttons ability to allow for natural correction of deliberate malreduction was greatest with posterior off-axis clamping. CLINICAL RELEVANCE Although the clinical relevance is unknown, dynamic syndesmotic fixation may mitigate clamp-induced malreduction.

Accuracy of Anterolateral Drawer Test in Lateral Ankle Instability: A Cadaveric Study

Background: In the assessment of lateral ankle instability, the anterior drawer test has been found to be inaccurate and the focus on pure anterior translation cannot properly perceive the anterolateral rotatory nature of the talar displacement. In order to address this, the anterolateral drawer test can be done with digital palpation of the talar displacement anterolaterally with a controlled angle of plantarflexion as well as application of the translational force. Materials and Methods: We evaluated the anterolateral drawer test and the original anterior drawer test in 10 fresh below-the-knee specimens using a direct anatomic measurement (DAM) loaded by a Telos stress device as a reference. Specimens were assigned into three groups: intact ligaments, ATFL-cut, and ATFL&CFL-cut. The examiners were blinded with one performing the anterolateral drawer test (E1) while the other performed the original anterior drawer test (E2). Results: Pearsons correlation coefficient indicated a statistically significant linear relationship between DAM/E1 r = 0.931, p < 0.001 but not between DAM/E2 r = 0.519, p = 0.124. Intraclass correlation coefficient show correlation between DAM/E1 and DAM/E2 to be 0.945 (p < 0.001) and 0.683 (p = 0.051). When 3 mm or more was used as the threshold to diagnose a lateral ligament rupture, sensitivity and specificity were E1(100%, 100%) and E2(75%, 50%). Conclusion: The anterolateral drawer test showed high accuracy in the determination of lateral ankle instability and in the diagnosis of a ligament rupture. Clinical Relevance: Further investigation regarding the accuracy and reliability of this test in comparison with the original anterior drawer test is warranted in a patient population with ankle instability.

Risks to the blood supply of the talus with four methods of total ankle arthroplasty: a cadaveric injection study.

BACKGROUND Despite the use of contemporary total ankle arthroplasty implant designs, clinical outcomes of total ankle arthroplasty continue to lag behind those of other joint replacement procedures. Disruption of the extraosseous talar blood supply at the time of ankle replacement may be a factor contributing to talar component subsidence-a common mechanism of early failure following ankle replacement. We evaluated the risk of injury to specific extraosseous arteries supplying the talus associated with specific total ankle arthroplasty implants. METHODS Sixteen fresh-frozen through-knee cadaveric specimens were injected with latex and barium sulfate distal to the popliteal trifurcation to visualize the arteries. Four specimens each were prepared for implantation of four contemporary total ankle arthroplasty systems: Scandinavian Total Ankle Replacement (STAR), INBONE II, Salto Talaris, and Trabecular Metal Total Ankle (TMTA). Postoperative computed tomography scans and 6% sodium hypochlorite chemical debridement were used to examine, measure, and document the proximity of the total ankle arthroplasty instrumentation to the extraosseous talar blood supply. RESULTS All four implant types subjected the extraosseous talar blood supply to the risk of injury. The INBONE subtalar drill hole directly transected the artery of the tarsal canal in three of four specimens. The lateral approach for the TMTA transected the first perforator of the peroneal artery in two of four specimens. The STAR caused medial injury to the deltoid branches in all four specimens, whereas the other three systems did not directly affect this supply (p < 0.005). The Salto Talaris and STAR implants caused injury to the artery of the tarsal canal in one of four specimens. CONCLUSIONS All four total ankle arthroplasty systems tested posed a risk of injury to the extraosseous talar blood supply, but the risks of injury to specific arteries were higher for specific implants.

The Orthopaedic Foot and Ankle Outcomes Research (OFAR) network: feasibility of a multicenter network for patient outcomes assessment in foot and ankle.

Introduction: There is an increasing need for orthopaedic practitioners to measure and collect patient-reported outcomes data. In an effort to better understand outcomes from operative treatment, the American Orthopaedic Foot & Ankle Society (AOFAS) established the Orthopaedic Foot and Ankle Outcomes Research (OFAR) Network, a national consortium of foot and ankle orthopaedic surgeons. We hypothesized that the OFAR Network could successfully collect, aggregate, and report patient-reported outcome (PRO) data using the National Institutes of Health (NIH) Patient Reported Outcomes Measurement Information System (PROMIS). Methods: Ten sites enrolled consecutive patients undergoing elective surgery for 1 of 6 foot/ankle disorders. Outcome instruments were collected preoperatively and at 6 months postoperatively using the PROMIS online system: Foot and Ankle Ability Measure (FAAM), Foot Function Index (FFI), and PROMIS physical function (PF) and pain computerized adaptive tests (CAT). During the 3-month period, 328 patients were enrolled; 249 (76%) had completed preoperative patient-reported outcomes data and procedure-specific data. Of these, 140 (56%) also completed 6-month postoperative patient- reported outcomes data. Results: Ankle arthritis and flatfoot demonstrated consistently worse preoperative scores. Five of 6 disorders showed significant improvement at 6 months on PF CAT and FAAM, 4 of 6 showed improvement on pain interference CAT, and no disorders showed improvement on FFI. Ankle arthritis and flatfoot demonstrated the greatest magnitude of change on most patient-reported outcomes scales. Conclusion: We were able to enroll large numbers of patients in a short enrollment period for this preliminary study. Data were easily aggregated and analyzed. Substantial loss of follow-up data indicates a critical area requiring further effort. The AOFAS OFAR Network is undergoing expansion with goals to ultimately facilitate large, prospective multicenter studies and optimize the quality and interpretation of available outcome instruments for the foot and ankle population. Level of Evidence: Level II, prospective comparative study.