Robert Z. Tashjian

Flexor Hallucis Longus Transfer for Repair of Chronic Achilles Tendinopathy

Background: The flexor hallucis longus (FHL) tendon has been used to augment the repairs for chronic Achilles tendinopathy. Two common methods of FHL harvesting include a single incision (posterior) technique and a double incision (posterior and medial utility) technique. This cadaver study was designed to measure and compare the lengths of FHL tendon obtainable for reconstruction with each technique. Methods: Fourteen fresh-frozen cadaver lower limbs were utilized for FHL harvest. The tendon was first exposed through the single posterior-medial incision approach adjacent to the Achilles. A second medial utility midfoot incision was then made and the FHL was marked at the level of Henrys knot with a suture, to approximate the level of potential harvest via a two-incision technique. The FHL was then harvested and delivered into the posterior wound. Single incision technique graft length was then measured from the tip of the calcaneal tuber to the level of transection. The remaining in situ tendon was then also measured between its level of transection and the more distal suture placed at Henrys knot. These two lengths were then combined to determine the total potential tendon graft length obtainable using a double incision technique. Results: The average length of the FHL tendon harvested through the single posterior incision technique measured 5.16 cm (range, 3.4–6.9 cm, SD = 1.29). The average total tendon graft length available using the double incision technique measured 8.09 cm (range, 5.1–11.1 cm, SD = 1.63). The difference between the lengths obtained from these two techniques was significant (p < .001). Conclusions: These results demonstrate approximate FHL graft lengths obtainable by using either a single or double incision harvest technique and show that a significantly longer graft can be obtained using a double incision technique. Further data need to be obtained, however, to support whether the extra surgery and graft length obtained from a double incision technique are of any benefit in improving the ultimate functional outcome of these repairs.

Endoscopic gastrocnemius recession: evaluation in a cadaver model.

The purpose of this study was to describe a new method of gastrocnemius recession using an endoscopic approach and to determine the accuracy of incision placement during gastrocnemius recession. Fifteen fresh-frozen cadaveric limbs underwent an endoscopic gastrocnemius recession utilizing a two-portal technique. All limbs were anatomically dissected after the procedure and each was examined for injury to the sural nerve. The ability to visualize the sural nerve intraoperatively, improvement in ankle dorsiflexion, time requirement for the procedure, incision size, and appropriateness of placement to facilitate recession were recorded for each specimen. An average of 83% of the gastrocnemius aponeurosis was transected in all 15 cadavers. After modifications of the technique, the final eight cadavers were noted to have had the entire (100%) gastrocnemius aponeurosis transected. Sural nerve injury occurred in one specimen (7%) in which the aponeurosis and the sural nerve were not well visualized. The sural nerve was definitively visualized during the procedure in 5 of 15 specimens (33%). No Achilles tendon injury was noted in any specimen. There was a mean improvement in ankle dorsiflexion of 20° (range, 10°–30°) during full knee extension. The average length of time to perform the procedure was 20 minutes (range, 10–35 minutes). The average medial and lateral incision lengths used in the two-portal technique were 18 mm (range, 14–22 mm) and 17 mm (range, 12–19 mm), respectively, and the average distance from the midpoint of the medial incision to the level of the gastrocnemius-soleus junction was 26 mm (range, 5–60 mm). These results indicate that a complete gastrocnemius aponeurosis transection may be obtained utilizing a modified endoscopic gastrocnemius recession, but visualization of the sural nerve is poor with possible risk of iatrogenic nerve injury.

Effect of medical comorbidity on self-assessed pain, function, and general health status after rotator cuff repair.

BACKGROUND In a previous study, we found that medical comorbidities have a negative effect on preoperative pain, function, and general health status in patients with a chronic rotator cuff tear. In this study, we evaluated the relationship between medical comorbidities and the postoperative outcome of rotator cuff repair. METHODS One hundred and twenty-five patients were evaluated on the basis of a history (including medical comorbidities) and use of outcome tools preoperatively and at one year after rotator cuff repair. Outcome was evaluated with the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire, the Simple Shoulder Test (SST), visual analog scales (pain, function, and quality of life), and the Short Form-36 (SF-36). RESULTS The mean number of medical comorbidities was 1.91 (range, zero to six). At one year after rotator cuff repair, there were no significant correlations between comorbidities and pain, shoulder function, or quality of life as determined with the SST, DASH, and visual analog scales (p > 0.05). A greater number of comorbidities was associated with a worse postoperative general health status (SF-36 role emotional [p = 0.045], SF-36 bodily pain [p = 0.032], SF-36 general health [p = 0.001], and SF-36 vitality [p = 0.033]). Nevertheless, a greater number of comorbidities was associated with greater improvement, compared with the preoperative status, in the pain score on the visual analog scale (p = 0.009), function as assessed with the visual analog scale (p = 0.022) and the DASH (p = 0.044), and quality of life as assessed with the visual analog scale (p = 0.041). CONCLUSIONS Patients with more medical comorbidities have a worse general health status after rotator cuff repair. Interestingly, it also appears that these patients have greater improvement in overall shoulder pain, function, and quality-of-life scores compared with preoperative scores. Therefore, despite a negative effect of comorbidities on outcomes, patients with more comorbidities have greater improvement after the repair, to the point where postoperative shoulder function and pain are not significantly influenced by medical comorbidities. Consequently, a higher number of medical comorbidities should not be considered a negative factor in determining whether a patient should undergo rotator cuff repair.

Anatomic study of the gastrocnemius-soleus junction and its relationship to the sural nerve.

Background: Gastrocnemius recession is performed for equinus contracture of the ankle and as an adjunct treatment for various foot pathologies. Successful release relies on many factors, including a thorough knowledge of the anatomy of the gastrocnemius-soleus junction and its relationship to the sural nerve which may be vulnerable to iatrogenic injury. Neither the average width of the tendon at the gastrocnemius-soleus junction, the anatomy of the sural nerve with respect to the gastrocnemius-soleus junction, nor appropriate landmarks for accurate incision placement at this level to avoid undesirable vertical extension, however, have yet to be acceptably defined. Methods: Fourteen fresh-frozen cadavers were dissected and the width of the tendon at the gastrocnemius-soleus junction, the distance of the sural nerve from the lateral border of the tendon at this level, the length of the fibula, and the distance from the distal tip of the fibula to the gastrocnemius-soleus junction were measured. Results: The average width of the gastrocnemius-soleus complex at the junction was 58 mm (range, 44–69 mm), the average distance of the sural nerve from the lateral border of the gastrocnemius-soleus complex at the level of the gastrocnemius-soleus junction was 12 mm (range, 7–17 mm), the average percentage of this distance as compared to the entire width of gastrocnemius-soleus junction was 20% (range, 13%-27%), and the ratio of the distance of the gastrocnemius-soleus junction from the distal tip of the fibula divided by the length of the fibula was 0.5 (range, 0.5–0.6). Conclusion: These results provide some guidelines as to the approximate size of the gastrocnemius–soleus complex at the site of gastrocnemius recession along with the location of the sural nerve at the musculotendinous junction. Also, the results indicate that the fibula can serve as a reproducible anatomic landmark to enable localization of the gastrocnemius–soleus junction at the time of gastrocnemius recession.

Subatmospheric pressure-induced compartment syndrome of the entire upper extremity: A case report

We describe the case of a patient in whom a compartment syndrome developed in the upper extremity as the result of prolonged application of considerable negative pressure, a phenomenon that we have termed subatmospheric pressure-induced compartment syndrome (SAPICS). To our knowledge, this is the first reported case of a compartment syndrome that involved all compartments of the upper extremity. Our patient was informed that data concerning this case would be submitted for publication. The entire right (dominant) upper extremity of a healthy twenty-seven-year-old man became entrapped in the 20-cm-diameter intake snorkel of an industrial vacuum machine (Fig. 1) while he was cleaning debris from a demolition site. The patient was working alone at the time of the injury and estimated that his arm was in the snorkel for approximately five minutes. After the vacuum had been turned off, there was immediate pain and paresthesias throughout the limb. Fig. 1 Industrial vacuum machine with intake snorkel. The patient initially was brought to an outlying institution and then was expeditiously transferred to the trauma unit at our institution 2.5 hours after the injury. Measurement of the vital signs revealed a temperature of 99.2°F (37.2°C), a heart rate of 83 bpm, a respiratory rate of 22 breaths/min, a blood pressure of 140/86 mm Hg, and an arterial oxygen saturation of 98%. The patient remained hemodynamically stable throughout the entire treatment. Physical examination revealed that the right upper extremity was visibly swollen and that there was a sharply demarcated continuous line along the pectoral and lateral deltoid regions where the suction snorkel had become sealed against the skin (Figs. 2-A and 2-B). Inferior to this line was a uniform field of petechiae. The compartments of the upper arm, forearm, and hand were all tense. There was no active motion of the extremity, and there was excruciating …

Primary malignant non-Hodgkin lymphoma of the talus: a case report.

Primary non-Hodgkin lymphoma of bone (PLB) is rare, accounting for only 3% to 7% of all malignant bone tumors.5 Delays or errors in diagnosis are common because it usually is not associated with systemic symptoms suggestive of a malignancy.1 The present case is noteworthy because it demonstrates how such lesions can be met with diagnostic confusion in consideration of more common musculoskeletal conditions.

Ruptured septic popliteal cyst associated with psoriatic arthritis

Popliteal cyst (Baker’s cyst) was first described by Adams in 1840, popularized by Baker in 1877, and was theorized as an enlarged gastrocnemiussemimembranosus bursa that communicated with the knee and trapped synovial fluid.1 Numerous bursa are located in the popliteal space between the knee ligaments, hamstring tendons, gastrocnemius muscle, and collateral ligaments. The two proposed etiologies of Baker’s cyst include an abnormal herniation of synovial fluid through the posterior knee capsule into the popliteal space or fluid escape from the knee through a normal communication with a bursa located in the popliteal space. This bursa has been reported as the gastrocnemius bursa (located behind the medial head of the gastrocnemius) or semimembranosus bursa (between the semimembranosus and medial head of the gastrocnemius).2 A valvular mechanism allows fluid to pass into the cyst but not escape.3 Intra-articular pathology (meniscal disease, degenerative joint disease, rheumatoid arthritis, patellofemoral arthrosis, or any chronic synovitis) is commonly associated with Baker’s cyst.3,4 Popliteal cyst dissection has been infrequently reported throughout the literature, mostly in cases of rheumatoid arthritis, juvenile rheumatoid arthritis, gonococcal arthritis, and Reiter’s syndrome. Clinically, they mimic deep venous thrombophlebitis.5,6 Popliteal cyst infections also have been reported; however, they are a rare complication of septic arthritis. This article presents a patient with psoriatic arthritis who underwent dissection of a ruptured septic popliteal cyst.

Calcaneus osteomyelitis from community-acquired MRSA

Since the identification of methicillin-resistant Staphylococcus aureus (MRSA) as a hospital-acquired pathogen in the late 1960s,3 it has become commonplace in most US healthcare facilities.5 Only recently has there been recognition of the increasing MRSA prevalence in populations without obvious medical risk factors or exposure to hospital or institutional environments.2,9,11,13,22 Community-acquired MRSA (CA-MRSA), also called community-associated MRSA, typically results in skin and subcutaneous infections and rarely involve bone.9 We present a case of CA-MRSA causing hematogenous calcaneal osteomyelitis in a healthy adolescent.

11&#946;-Hydroxysteroid Dehydrogenase Type 1 Expression in Periprosthetic Osteolysis

Periprosthetic membranes contain fibroblasts, macrophages and cytokines including interleukin 1Beta (IL-1Beta) and tumor necrosis factor alpha (TNF-alpha). Glucocorticoids may play an inhibitory role in osteolysis through the upregulation of 11Beta-hydroxysteroid dehydrogenase type 1 (11Beta-HSD1) in membrane fibroblasts by IL-1Beta and TNF-alpha. This study evaluated 15 periprosthetic membranes for the presence of 11Beta-HSD1 using immunochemistry. Also, fibroblast cell cultures were exposed to IL-1Beta and TNF-alpha, and 11Beta-HSD1 gene expression was evaluated. In all membranes, 11Beta-HSD1was present, and fibroblast 11Beta-HSD1 was upregulated significantly after the addition of IL-1Beta and TNF-alpha. These findings suggest increased 11Beta-HSD1 expression in fibroblasts may be a mechanism for increasing local cortisol levels in membranes, which could potentiate the osteolytic process through inhibition of osteoblastic function.