Samrendu K. Singh

Open Ankle Arthrodesis With a Fibular-Sparing Technique

Background: Many ankle arthrodesis techniques excise the fibula or require a fibular osteotomy. Advantages of fibular preservation include increased surface area for bony union, preservation of the peroneal groove, prevention of valgus drift in cases of delayed union, and facilitation of future ankle arthroplasty. The goal of this study was to evaluate fusion rate and clinical outcomes of a novel open fibular-sparing ankle arthrodesis technique. Methods: A total of 50 consecutive ankle arthrodeses using this technique were included in this study. These consisted of 46 patients with an average age of 52 (range, 30 to 71) years. Outcomes assessed postoperatively included radiographs, complications, patient satisfaction, and functional scoring. Results: At an average of 28 (range, 19 to 56) months postoperatively, 38 patients (42 ankles) were available for review. Of the 42 cases, 39 (93%) achieved union at an average of 12 weeks postoperatively. Of patients, 86% reported being “completely satisfied” with the outcome. Average AOFAS Ankle-Hindfoot Scale was 84 ± 12 and average Foot Function Index pain subscale was 1 ± 0.9. Two ankles (5%) were fused in excessive varus; no patient required revision surgery for malalignment. Conclusion: This method of open ankle arthrodesis preserved the fibula and had a high fusion rate with good patient outcome scores. Level of Evidence: Level IV, retrospective case series.

Cerclage wire fixation of navicular body fractures -- a treatment based on mechanism of injury.

Fractures of the tarsal navicular bones are commonly missed injuries, and when diagnosed they pose considerable difficulty with regard to reduction and stabilization of fracture fragments.1 Recovery often is poor, leading to significant pain and disability. Several theories have been proposed, regarding the mechanism of injury and how this can be used to classify fractures.3,4,5 We propose an alternative method of fixation based on our understanding of mechanism of injury. Institutional review board approval and informed consent were obtained for this study.

Severe scar problems following use of a locking barbed skin closure system in the foot.

BACKGROUND Barbed sutures provide a novel technique for knotless wound closure. They have mainly been used in plastic and general surgery. There are no reports about its use in the foot. METHODS We present a case series of 11 feet in 8 patients whose wounds were closed with barbed sutures. Ten had primary hallux valgus correction and one had a revision correction. RESULTS No problems were noted at 2-weeks follow-up. Four of the 11 cases required open suture excision due to an adverse reaction. Five were followed to delayed wound healing. Histology results from one scar showed a localised histiocytic reaction and superficial dermal abscess formation. CONCLUSIONS We feel the thin subcutaneous tissue of the foot, the amount of motion and pressure from the shoe causes the barbs to repeatedly irritate the soft tissue. Based on our short case series we cannot recommend the use of a barbed skin closure system in the foot.

A case report of three peripheral schwannomas attached to the Achilles paratenon

BACKGROUND Schwannomas are uncommon slow growing tumours arising from the nerve sheath or Schwann cell. OBJECTIVE To report a case of multiple schwannomas arising form the achilles paratenon. METHODS A 38 year old man presented lumps on the dorsum of his leg. He was clinically evaluated, subjected to imaging studies and surgery. RESULTS 3 separate lumps where removed measuring 10, 12, and 12mm. They here confirmed to be schwannomas on hitochemical staining. CONCLUSION A schwannoma must be considered in the differential of lumps in the lower leg. This is the first report of schwanommas associated with the paratenon. Removal of such masses is warranted to prevent local erosion.

Post-operative stress fractures complicating surgery for painful forefoot conditions

A stress fracture is caused by repetitive or unusual loading of a bone leading to mechanical failure. Fatigue type stress fractures occur in normal bone exposed to abnormally high repetitive loads, whereas insufficiency type stress fractures occur in abnormal bone exposed to normal loads. We describe three cases of insufficiency stress fractures that have complicated surgery for painful forefoot conditions. The diagnosis and management of these cases are discussed. Stress fractures should be included in the differential diagnosis of any patient who continues or develops pain after surgery to the forefoot.

Hindfoot Plantarflexion: A Radiographic Aid to the Diagnosis of Achilles Tendon Rupture

Although tendo Achilles (TA) rupture is a clinical diagnosis, radiographs are sometimes taken to exclude bony injury. In equivocal clinical examination findings, an ultrasound examination is often performed. We investigated whether any radiographic signs of TA rupture existed that could help diagnose TA rupture in equivocal cases. We examined the case notes of 25 consecutive patients who had undergone repair for complete TA rupture. Their lateral radiographs were reviewed and the following angles were measured: calcaneal pitch, lateral talocalcaneal, and tibiocalcaneal. These were compared with a control group of patients who had undergone radiographic examination for ankle injuries resulting in a diagnosis of ankle sprain. The results were compared using an unpaired Students t test. The mean tibiocalcaneal angle of the patients with complete TA rupture was 87.0 compared with 69.4 for the control group (p < .05). No significant difference was found with the other angles measured. The tibiocalcaneal angle can be a useful adjunct to the clinical examination in the diagnosis of TA rupture. It might also have a role in the evaluation of serial cast application after TA repair.

A Double Plate Technique for the Management of Difficult Fibula Fractures

Excessive displacement or talar shift after an ankle fracture is an indication for open reduction and internal fixation to restore the original length and orientation of the fibula. Surgical fixation is more difficult in cases requiring revision fixation, in cases of nonunion and in cases where the fracture occurs in osteopenic bone. In such circumstances the original AO technique may not confer adequate stability to permit fracture healing. We describe a new technique in which the initial anatomic reduction is first held with a posterior antiglide plate that allows the distal screws to be longer and bi-cortical without risking joint penetration. A second semi-tubular plate on the lateral border of the fibula offers more opportunities for screw placement and enhances torsional stability. In this paper we describe this surgical technique in detail together with case examples of where it can be used.

The Ludloff Osteotomy for Correction of Moderate to Severe Hallux Valgus

Biomechanical studies have shown that the Ludloff osteotomy fixed with lag screw compression is more rigid than the proximal crescentic and other 1st metatarsal osteotomies for the correction of symptomatic moderate to severe hallux valgus deformities. These studies, in conjunction with recently published clinical results, have renewed surgical interest in this osteotomy. In this article, we describe a reliable and reproducible method of performing the Ludloff osteotomy and identify several pearls and pitfalls based on our experience with this procedure. Additionally, recent clinical results are reviewed.

Correlation and comparison of syndesmosis dimension on CT and MRI

INTRODUCTION Various methods using CT scan have been described to diagnose distal tibiofibular syndesmotic injuries. However, CT scan does not take into account the amount of cartilage within the distal tibiofibular joint and could therefore lead to false positive results. We present the first study correlating the findings of the distal tibiofibular syndesmosis on CT and MRI scans. METHODS CT and MRI scan of consecutive patients over a period of 18 months, and of a time lapsed less than 12 months between the two imaging modalities, were reviewed. Measurements of the distal tibiofibular syndesmosis were taken according to a previously published study at the level of the distal tibial physeal scar. RESULTS Twenty-six ankles from 25 patients were included in this study for analysis. Significant difference between CT and MRI assessments in the overall distal tibiofibular dimensions and in the posterior distal tibiofibular distance for those ankles with evidence of osteoarthritis was found. Interclass correlation coefficients suggest that such methodology was reproducible and reliable. CONCLUSION When the widening found on a CT scan is minor or the diagnosis is equivocal, a contralateral comparative CT or an ipsilateral MRI scan is recommended to prevent misdiagnosis. LEVEL OF EVIDENCE Level IV.

Clinical tip: an anterior drawer simplifies development of a posterior flap in below knee amputation.

Below-knee amputation often is performed using a Burgess-type long posterior flap.1,2,5 This takes advantage of the well-perfused calf tissues3 and moves the suture line away from the end of the stump. Our modification of the standard method facilitates swift and atraumatic development of the posterior flap. The described anterior drawer modification to the Burgess technique offers several advantages over conventional practice. It is quicker than sharp dissection of the muscle attachments from the posterior aspect of the tibia. Development of the plane containing the posterior tibial and peroneal vessels and posterior tibial nerve is smooth and immediate and, therefore, facilitates neurovascular ligation and division. The tension on the soleus and gastrocnemius optimizes exposure of these muscles allowing for clearer identification of the line of dissection. We have used this technique in 11 patients over 6 years. In 10 of these cases the operation proceeded successfully with rapid development of a clean plane. In one patient with an old malunited tibial fracture, there was significant deep muscle adherence, and use of the amputation knife was required. However no complications resulted from the failed anterior drawer. The technique has been successfully used in patients with peripheral vascular disease, but greater care needs to be taken when applying traction because the arteries are less elastic.