Displaced medial malleolus fractures are considered unstable and typically require open reduction... more Displaced medial malleolus fractures are considered unstable and typically require open reduction and internal fixation for anatomic reduction and early joint range of motion. These fractures are usually fixated with either compression lag screws or tension band wiring depending on the fracture pattern, size of the distal fragment, and bone quality. When fracture fixation fails, it is typically in pullout strength. Failure of primary bone healing can result in nonunion, malunion, and need for revision surgery. The current study wished to explore a potentially stronger fixation technique in regard to pullout strength for medial malleolar fractures compared with traditional cancellous screws. This was a comparative study of the relative pullout strength of 2 fully threaded 3.5-mm bicortical screws versus 2 partially threaded 4.0-mm cancellous screws for the fixation of medial malleolar fractures. Ten fresh-frozen limbs from 5 cadavers, mean age 79 years (range of 65-97 years), were tested using the Instron 8500 Plus system. The median force recorded at 2 mm of distraction using unicortical partially threaded cancellous screws was 116.2 N (range 70.2 to 355.5N) compared with 327.6 N (range 117.5 to 804.3 N) in the fully threaded bicortical screw (P = .04). The unicortical screw fixation displayed only 64.53% of the median strength noted with the bicortical screw fixation at clinical failure. The current study demonstrated statistically significantly greater pullout strength for 3.5-mm bicortical screws when compared with 4.0-mm partially threaded cancellous screws used to fixate medial malleolar fractures in a cadaveric model.
Background: The modified Broström (MB) procedure has long been the mainstay for the treatment of ... more Background: The modified Broström (MB) procedure has long been the mainstay for the treatment of chronic lateral ankle instability (CLAI). Recently, suture tape (ST) has emerged as augmentation for this repair. The clinical benefit of such augmentation has yet to be fully established. The purpose of this study was to determine if ST augmentation provides an advantage over the traditional MB. Methods: Adult patients were identified for inclusion in the study based on indications for primary lateral ligament reconstruction for CLAI. The primary outcome measure was time to return to preinjury level of activity (RTPAL). Secondary outcome measures included complications, ability to participate in an accelerated rehabilitation protocol (ARP), patient-reported outcomes (PROs), and visual analog pain scale (VAS). A total of 119 patients with CLAI were enrolled and randomized to the MB (59 patients) or ST (60 patients) treatment arm. Results: Average RTPAL was 17.5 weeks after MB and 13.3 we...
Category: Sports; Ankle; Arthroscopy Introduction/Purpose: The modified Brostrom (MB) procedure h... more Category: Sports; Ankle; Arthroscopy Introduction/Purpose: The modified Brostrom (MB) procedure has long been the mainstay for the treatment of chronic lateral ankle instability (CLAI) despite concerns about the strength of the repair. Recently, the InternalBraceTM (IB) has emerged as augmentation for this repair. The clinical benefit of such augmentation has yet to be established. The purpose of this study is to determine whether or not IB augmentation provides an advantage over the traditional MB. The preliminary results of this study are presented. Methods: Patients were identified for inclusion in the study based on indications for primary lateral ligament reconstruction for CLAI, age over 18, and able to provide informed consent. Exclusion criteria included pregnancy, cognitive disability, concomitant bony correction, inadequate soft tissue for MB, or prior ankle surgery affecting the lateral ligament complex. Preliminary outcome measures included complication rates, ability to...
Arthrodesis of the ankle or foot is a common procedure for chronic pain and disability. Nonunion ... more Arthrodesis of the ankle or foot is a common procedure for chronic pain and disability. Nonunion remains a prevalent complication among arthrodesis procedures. Some patients present with an inherent risk of developing a nonunion. Allograft biologics have gained popularity in an effort to reduce complications such as nonunion. Various biologics bring unique properties while maintaining a singular purpose. Platelet-derived growth factor (PDGF) may be introduced into a fusion site to facilitate healthy bony consolidation. The purpose of this article is to review the benefits and modalities of PDGF and how it can improve patient outcomes in ankle and hindfoot fusions.
Acute deltoid injuries may occur with ankle fractures. They are often left to heal without repair... more Acute deltoid injuries may occur with ankle fractures. They are often left to heal without repair, possibly leading to chronic medial ankle instability. Stress radiographs identify the need for surgical repair of fractures or soft tissue damage. Gravity stress views have benefits over manually stressing the ankle. MRI can explore the extent of medial soft tissue injuries. Arthroscopy can evaluate and potentially treat deltoid injuries. Interposition of the deltoid may preclude adequate fracture reduction. Except with deltoid tear, fractures should be reduced and fixated, then the deltoid assessed. With persistent instability, primary repair may prevent long-term sequelae.
Journal of the American Podiatric Medical Association, 2014
Squamous cell carcinoma is the second most common type of skin cancer and may present in the dist... more Squamous cell carcinoma is the second most common type of skin cancer and may present in the distal extremities including the foot. We present a case in which a primary squamous cell carcinoma of the foot, which presented as a granulomatous ulcerating lesion, was diagnosed and successfully treated with a radical resection. Our case shows an atypical presentation of a very common malignancy and, it is therefore essential for health-care providers to consider malignancy in all suspicious lesions of the foot.
Femoral head allograft is an accepted alternative for significant bone loss in severe hindfoot re... more Femoral head allograft is an accepted alternative for significant bone loss in severe hindfoot reconstruction. This is primarily because the size and shape of the graft provides not only structural support but additionally prevents significant loss of limb length. We present a case using a technique from a directly lateral approach and simultaneous preparation of the tibia and calcaneus for tibiocalcaneal arthrodesis. Acetabular resurfacing reamers were used to prepare the joint for grafting as well as sculpt the graft itself for near press fit between the tibia and calcaneus. Fixation with a lateral locking plate avoids the unnecessary decompression reaming of the graft core itself, ultimately sparing the valuable poles of the graft for increased likelihood of incorporation.
The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons, Jan 16, 2014
Injury to the lateral ankle ligaments is very common among both athletes and nonathletes alike. A... more Injury to the lateral ankle ligaments is very common among both athletes and nonathletes alike. Although anterior talofibular ligament injuries and combination anterior talofibular ligament and calcaneofibular ligament injuries are considerably common, an isolated injury to the calcaneofibular ligament has rarely been reported. We present the case reports of 2 patients, both of whom had sustained an isolated calcaneofibular ligament injury. In both patients, the diagnosis was obtained from the clinical examination and magnetic resonance imaging. Also, in 1 patient, formal open surgical inspection was performed. We advocate conservative treatment initially using the same protocols used for common lateral ankle ligament injuries and, if necessary, surgical intervention to address this unique and rare pathologic entity.
Lapidus arthrodesis (first metatarsal cuneiform arthrodesis) has become an accepted procedure for... more Lapidus arthrodesis (first metatarsal cuneiform arthrodesis) has become an accepted procedure for hallux abducto valgus. Several variations of fixation have been described. Earlier weightbearing postoperatively has been one reported benefit of using locking plates for fixation. Additionally, studies have demonstrated that fixation placed on the plantar or tension side of the arthrodesis increases the biomechanical advantage. We performed a biomechanical cadaveric study of the Lapidus procedure, comparing a previously reported technique using a low profile locking plate with an intraplate compression screw versus the same locking plate with a plantar interfragmentary screw (PIFS) placed on the tension side of the arthrodesis in 10 fresh, paired, cadaver limbs. The mean ultimate load of the plate with a PIFS was 383.2 ± 211.5 N, and the mean ultimate load of the plate with an intraplate compression screw was 205.5 ± 97.2 N. The mean ultimate load of the LPS Lapidus plate with a PIFS was statistically greater (p = .027) than that with the plate intraplate compression screw. Our results indicated that changing the orientation of the compression screw to a PIFS significantly increased the stability of the Lapidus arthrodesis fixation construct. The modified construct with the PIFS might decrease the incidence of nonunion and, ultimately, allow patients to bear weight faster postoperatively.
The Austin procedure has become a common method of osteotomy for the correction of hallux abducto... more The Austin procedure has become a common method of osteotomy for the correction of hallux abductovalgus when indicated. The V-type configuration is intrinsically stable but not without complications. One complication encountered is rotation and/or displacement of the capital fragment. We present the use of an axial loading screw in conjunction with a dorsally placed compression screw. The benefit to this technique lies in the orientation of the axial loading screw, because it is directed to resist the ground reactive forces while also providing a second point of fixation in a crossing screw design. In a head-to-head biomechanical comparison, we tested single dorsal screw fixation versus double screw fixation, including both the dorsal and the axial loading screws in 10 metatarsal Sawbones(®) (Pacific Research Laboratories Inc, Vashon, WA). Five metatarsals received single dorsal screw fixation and five received the dorsal screw and the additional axial loading screw. The metatarsals were analyzed on an Instron compression device for comparison; 100% of the single screw fixation osteotomies failed with compression at an average peak load of 205 N. Four of five axial loading double screw fixation osteotomies did not fail. This finding suggests that the addition of an axial loading screw providing cross screw orientation significantly increases the stability of the Austin osteotomy, ultimately decreasing the likelihood of displacement encountered in the surgical repair of hallux abductovalgus.
Lateral ankle sprains are the most common injury in sports. Nonoperative therapy is recommended i... more Lateral ankle sprains are the most common injury in sports. Nonoperative therapy is recommended initially, including functional rehabilitation. Surgery might be an option for those patients in whom nonoperative attempts fail. Various surgical approaches have been described in published studies for treating chronic lateral ankle instability. The procedures are typically grouped into 2 main categories: anatomic and nonanatomic repair of the lateral ligament complex. The open modified Broström-Gould anatomic repair technique is widely accepted as the reference standard for lateral ankle stabilization. In the present study, we used an arthroscopic approach to treat chronic anterior talofibular ligament tears without the extensive open incisions common in the traditional modified Broström-Gould procedure. Our hypothesis was that the use of an all-inside arthroscopic Broström procedure would provide a minimally invasive technique with acceptable patient outcomes. We also wished to explore the complication rates and interval to return to weightbearing activity. A total of 40 ankles in 40 consecutive patients were included in the cohort.
Posterior heel pain caused by insertional Achilles tendinosis can necessitate surgical interventi... more Posterior heel pain caused by insertional Achilles tendinosis can necessitate surgical intervention when recalcitrant to conservative care. Surgical treatment can necessitate near complete detachment of the Achilles tendon to fully eradicate the offending pathologic features and, consequently, result in long periods of non-weightbearing. A suture bridge technique using bone anchors is available for reattachment of the Achilles tendon. This provides restoration of the Achilles footprint on the calcaneus, including not only contact, but also actual pressure between the tendon and bone. We performed a review of 43 patients who underwent surgical treatment of insertional Achilles tendinosis with reattachment of the Achilles tendon using the suture bridge technique. The mean age was 53 (range 29 to 87) years. The mean follow-up period was 24 (range 13 to 52) months. The mean postoperative American Orthopaedic Foot and Ankle Society score was 90 (range 65 to 100). The mean preoperative visual analog scale pain score was 6.8 (range 2 to 10) and the mean postoperative visual analog scale pain score was 1.3 (range 0 to 6). The mean interval to weightbearing was 10 (range 0 to 28) days. No postoperative ruptures occurred. Of the 43 patients, 42 (97.6%) successfully performed the single heel rise test at the final postoperative visit. Concomitant procedures were performed in 35 patients, including 33 (77%) requiring open gastrocnemius recession and 2 (5%) requiring flexor hallucis longus tendon transfer. A total of 42 patients (97.6%) returned to regular shoe gear, and 42 (97.6%) returned to their activities of daily living, including running for 20 athletic patients (100%). Complications included postoperative wound dehiscense requiring surgical debridement in 2 patients (5%) and soft tissue infection requiring antibiotics and surgical debridement in 1 (2%) patient. Our findings support using the Achilles tendon suture bridge for reattachment of the Achilles tendon in the surgical treatment of insertional Achilles tendinosis.
Syndesmotic diastasis can occur as an isolated injury or with concomitant fractures. A review of ... more Syndesmotic diastasis can occur as an isolated injury or with concomitant fractures. A review of 37 patients with 64 TightRopes® for syndesmotic repair was performed, with a mean follow-up of 23.6 ± 4.3 months, from 2007 to 2011. The patients' mean age was 40.67 (range 14 to 87) years. The mean initial measurements were as follows: tibiofibular clear space (TFCS) = 4.1 ± 1.1 mm, tibiofibular overlap (TFO) = 7.2 ± 2.7 mm, and medial clear space (MCS) = 2.9 ± 0.5 mm. The mean final measurements were as follows: TFCS = 4.2 ± 1.3 mm, TFO = 7.4 2.8 mm, and MCS = 3.0 0.5 mm. The calculated measurable difference from the initial to final TFCS, TFO, and MCS was significantly less than the maximum threshold for allowable widening of the syndesmosis: TFCS, p < .001; TFO, p < .002; and MCS, p < .001. Complications occurred in 10 patients; 7 (19%) experienced knot irritation and 3 (8%) developed an infection. The mean interval to weightbearing was 33.2 ± 12.7 days. The mean postoperative American Orthopaedic Foot and Ankle Society score was 97 (range 90 to 100). Of 64 suture endobuttons, 4 (6.25%) required removal. The fracture types were as follows: 3 (8%) isolated syndesmotic injuries, 9 (24%) trimalleolar fractures, 10 (27%) bimalleolar fractures, 7 (18%) Weber B fractures, 3 (8%) Weber C fractures, 1 (3%) Salter Harris type 3 fracture, and 4 (11%) Maisonneuve fractures. TightRope® fixation was advantageous because it rarely required removal, allowed for physiologic motion of the syndesmosis, and resulted in an early return to weightbearing. In addition, we have concluded that the TightRope® provides long-term stability of the ankle mortise, which was confirmed by the radiographic criteria and excellent American Orthopaedic Foot and Ankle Society scores.
Displaced medial malleolus fractures are considered unstable and typically require open reduction... more Displaced medial malleolus fractures are considered unstable and typically require open reduction and internal fixation for anatomic reduction and early joint range of motion. These fractures are usually fixated with either compression lag screws or tension band wiring depending on the fracture pattern, size of the distal fragment, and bone quality. When fracture fixation fails, it is typically in pullout strength. Failure of primary bone healing can result in nonunion, malunion, and need for revision surgery. The current study wished to explore a potentially stronger fixation technique in regard to pullout strength for medial malleolar fractures compared with traditional cancellous screws. This was a comparative study of the relative pullout strength of 2 fully threaded 3.5-mm bicortical screws versus 2 partially threaded 4.0-mm cancellous screws for the fixation of medial malleolar fractures. Ten fresh-frozen limbs from 5 cadavers, mean age 79 years (range of 65-97 years), were tested using the Instron 8500 Plus system. The median force recorded at 2 mm of distraction using unicortical partially threaded cancellous screws was 116.2 N (range 70.2 to 355.5N) compared with 327.6 N (range 117.5 to 804.3 N) in the fully threaded bicortical screw (P = .04). The unicortical screw fixation displayed only 64.53% of the median strength noted with the bicortical screw fixation at clinical failure. The current study demonstrated statistically significantly greater pullout strength for 3.5-mm bicortical screws when compared with 4.0-mm partially threaded cancellous screws used to fixate medial malleolar fractures in a cadaveric model.
Displaced medial malleolus fractures are considered unstable and typically require open reduction... more Displaced medial malleolus fractures are considered unstable and typically require open reduction and internal fixation for anatomic reduction and early joint range of motion. These fractures are usually fixated with either compression lag screws or tension band wiring depending on the fracture pattern, size of the distal fragment, and bone quality. When fracture fixation fails, it is typically in pullout strength. Failure of primary bone healing can result in nonunion, malunion, and need for revision surgery. The current study wished to explore a potentially stronger fixation technique in regard to pullout strength for medial malleolar fractures compared with traditional cancellous screws. This was a comparative study of the relative pullout strength of 2 fully threaded 3.5-mm bicortical screws versus 2 partially threaded 4.0-mm cancellous screws for the fixation of medial malleolar fractures. Ten fresh-frozen limbs from 5 cadavers, mean age 79 years (range of 65-97 years), were tested using the Instron 8500 Plus system. The median force recorded at 2 mm of distraction using unicortical partially threaded cancellous screws was 116.2 N (range 70.2 to 355.5N) compared with 327.6 N (range 117.5 to 804.3 N) in the fully threaded bicortical screw (P = .04). The unicortical screw fixation displayed only 64.53% of the median strength noted with the bicortical screw fixation at clinical failure. The current study demonstrated statistically significantly greater pullout strength for 3.5-mm bicortical screws when compared with 4.0-mm partially threaded cancellous screws used to fixate medial malleolar fractures in a cadaveric model.
Background: The modified Broström (MB) procedure has long been the mainstay for the treatment of ... more Background: The modified Broström (MB) procedure has long been the mainstay for the treatment of chronic lateral ankle instability (CLAI). Recently, suture tape (ST) has emerged as augmentation for this repair. The clinical benefit of such augmentation has yet to be fully established. The purpose of this study was to determine if ST augmentation provides an advantage over the traditional MB. Methods: Adult patients were identified for inclusion in the study based on indications for primary lateral ligament reconstruction for CLAI. The primary outcome measure was time to return to preinjury level of activity (RTPAL). Secondary outcome measures included complications, ability to participate in an accelerated rehabilitation protocol (ARP), patient-reported outcomes (PROs), and visual analog pain scale (VAS). A total of 119 patients with CLAI were enrolled and randomized to the MB (59 patients) or ST (60 patients) treatment arm. Results: Average RTPAL was 17.5 weeks after MB and 13.3 we...
Category: Sports; Ankle; Arthroscopy Introduction/Purpose: The modified Brostrom (MB) procedure h... more Category: Sports; Ankle; Arthroscopy Introduction/Purpose: The modified Brostrom (MB) procedure has long been the mainstay for the treatment of chronic lateral ankle instability (CLAI) despite concerns about the strength of the repair. Recently, the InternalBraceTM (IB) has emerged as augmentation for this repair. The clinical benefit of such augmentation has yet to be established. The purpose of this study is to determine whether or not IB augmentation provides an advantage over the traditional MB. The preliminary results of this study are presented. Methods: Patients were identified for inclusion in the study based on indications for primary lateral ligament reconstruction for CLAI, age over 18, and able to provide informed consent. Exclusion criteria included pregnancy, cognitive disability, concomitant bony correction, inadequate soft tissue for MB, or prior ankle surgery affecting the lateral ligament complex. Preliminary outcome measures included complication rates, ability to...
Arthrodesis of the ankle or foot is a common procedure for chronic pain and disability. Nonunion ... more Arthrodesis of the ankle or foot is a common procedure for chronic pain and disability. Nonunion remains a prevalent complication among arthrodesis procedures. Some patients present with an inherent risk of developing a nonunion. Allograft biologics have gained popularity in an effort to reduce complications such as nonunion. Various biologics bring unique properties while maintaining a singular purpose. Platelet-derived growth factor (PDGF) may be introduced into a fusion site to facilitate healthy bony consolidation. The purpose of this article is to review the benefits and modalities of PDGF and how it can improve patient outcomes in ankle and hindfoot fusions.
Acute deltoid injuries may occur with ankle fractures. They are often left to heal without repair... more Acute deltoid injuries may occur with ankle fractures. They are often left to heal without repair, possibly leading to chronic medial ankle instability. Stress radiographs identify the need for surgical repair of fractures or soft tissue damage. Gravity stress views have benefits over manually stressing the ankle. MRI can explore the extent of medial soft tissue injuries. Arthroscopy can evaluate and potentially treat deltoid injuries. Interposition of the deltoid may preclude adequate fracture reduction. Except with deltoid tear, fractures should be reduced and fixated, then the deltoid assessed. With persistent instability, primary repair may prevent long-term sequelae.
Journal of the American Podiatric Medical Association, 2014
Squamous cell carcinoma is the second most common type of skin cancer and may present in the dist... more Squamous cell carcinoma is the second most common type of skin cancer and may present in the distal extremities including the foot. We present a case in which a primary squamous cell carcinoma of the foot, which presented as a granulomatous ulcerating lesion, was diagnosed and successfully treated with a radical resection. Our case shows an atypical presentation of a very common malignancy and, it is therefore essential for health-care providers to consider malignancy in all suspicious lesions of the foot.
Femoral head allograft is an accepted alternative for significant bone loss in severe hindfoot re... more Femoral head allograft is an accepted alternative for significant bone loss in severe hindfoot reconstruction. This is primarily because the size and shape of the graft provides not only structural support but additionally prevents significant loss of limb length. We present a case using a technique from a directly lateral approach and simultaneous preparation of the tibia and calcaneus for tibiocalcaneal arthrodesis. Acetabular resurfacing reamers were used to prepare the joint for grafting as well as sculpt the graft itself for near press fit between the tibia and calcaneus. Fixation with a lateral locking plate avoids the unnecessary decompression reaming of the graft core itself, ultimately sparing the valuable poles of the graft for increased likelihood of incorporation.
The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons, Jan 16, 2014
Injury to the lateral ankle ligaments is very common among both athletes and nonathletes alike. A... more Injury to the lateral ankle ligaments is very common among both athletes and nonathletes alike. Although anterior talofibular ligament injuries and combination anterior talofibular ligament and calcaneofibular ligament injuries are considerably common, an isolated injury to the calcaneofibular ligament has rarely been reported. We present the case reports of 2 patients, both of whom had sustained an isolated calcaneofibular ligament injury. In both patients, the diagnosis was obtained from the clinical examination and magnetic resonance imaging. Also, in 1 patient, formal open surgical inspection was performed. We advocate conservative treatment initially using the same protocols used for common lateral ankle ligament injuries and, if necessary, surgical intervention to address this unique and rare pathologic entity.
Lapidus arthrodesis (first metatarsal cuneiform arthrodesis) has become an accepted procedure for... more Lapidus arthrodesis (first metatarsal cuneiform arthrodesis) has become an accepted procedure for hallux abducto valgus. Several variations of fixation have been described. Earlier weightbearing postoperatively has been one reported benefit of using locking plates for fixation. Additionally, studies have demonstrated that fixation placed on the plantar or tension side of the arthrodesis increases the biomechanical advantage. We performed a biomechanical cadaveric study of the Lapidus procedure, comparing a previously reported technique using a low profile locking plate with an intraplate compression screw versus the same locking plate with a plantar interfragmentary screw (PIFS) placed on the tension side of the arthrodesis in 10 fresh, paired, cadaver limbs. The mean ultimate load of the plate with a PIFS was 383.2 ± 211.5 N, and the mean ultimate load of the plate with an intraplate compression screw was 205.5 ± 97.2 N. The mean ultimate load of the LPS Lapidus plate with a PIFS was statistically greater (p = .027) than that with the plate intraplate compression screw. Our results indicated that changing the orientation of the compression screw to a PIFS significantly increased the stability of the Lapidus arthrodesis fixation construct. The modified construct with the PIFS might decrease the incidence of nonunion and, ultimately, allow patients to bear weight faster postoperatively.
The Austin procedure has become a common method of osteotomy for the correction of hallux abducto... more The Austin procedure has become a common method of osteotomy for the correction of hallux abductovalgus when indicated. The V-type configuration is intrinsically stable but not without complications. One complication encountered is rotation and/or displacement of the capital fragment. We present the use of an axial loading screw in conjunction with a dorsally placed compression screw. The benefit to this technique lies in the orientation of the axial loading screw, because it is directed to resist the ground reactive forces while also providing a second point of fixation in a crossing screw design. In a head-to-head biomechanical comparison, we tested single dorsal screw fixation versus double screw fixation, including both the dorsal and the axial loading screws in 10 metatarsal Sawbones(®) (Pacific Research Laboratories Inc, Vashon, WA). Five metatarsals received single dorsal screw fixation and five received the dorsal screw and the additional axial loading screw. The metatarsals were analyzed on an Instron compression device for comparison; 100% of the single screw fixation osteotomies failed with compression at an average peak load of 205 N. Four of five axial loading double screw fixation osteotomies did not fail. This finding suggests that the addition of an axial loading screw providing cross screw orientation significantly increases the stability of the Austin osteotomy, ultimately decreasing the likelihood of displacement encountered in the surgical repair of hallux abductovalgus.
Lateral ankle sprains are the most common injury in sports. Nonoperative therapy is recommended i... more Lateral ankle sprains are the most common injury in sports. Nonoperative therapy is recommended initially, including functional rehabilitation. Surgery might be an option for those patients in whom nonoperative attempts fail. Various surgical approaches have been described in published studies for treating chronic lateral ankle instability. The procedures are typically grouped into 2 main categories: anatomic and nonanatomic repair of the lateral ligament complex. The open modified Broström-Gould anatomic repair technique is widely accepted as the reference standard for lateral ankle stabilization. In the present study, we used an arthroscopic approach to treat chronic anterior talofibular ligament tears without the extensive open incisions common in the traditional modified Broström-Gould procedure. Our hypothesis was that the use of an all-inside arthroscopic Broström procedure would provide a minimally invasive technique with acceptable patient outcomes. We also wished to explore the complication rates and interval to return to weightbearing activity. A total of 40 ankles in 40 consecutive patients were included in the cohort.
Posterior heel pain caused by insertional Achilles tendinosis can necessitate surgical interventi... more Posterior heel pain caused by insertional Achilles tendinosis can necessitate surgical intervention when recalcitrant to conservative care. Surgical treatment can necessitate near complete detachment of the Achilles tendon to fully eradicate the offending pathologic features and, consequently, result in long periods of non-weightbearing. A suture bridge technique using bone anchors is available for reattachment of the Achilles tendon. This provides restoration of the Achilles footprint on the calcaneus, including not only contact, but also actual pressure between the tendon and bone. We performed a review of 43 patients who underwent surgical treatment of insertional Achilles tendinosis with reattachment of the Achilles tendon using the suture bridge technique. The mean age was 53 (range 29 to 87) years. The mean follow-up period was 24 (range 13 to 52) months. The mean postoperative American Orthopaedic Foot and Ankle Society score was 90 (range 65 to 100). The mean preoperative visual analog scale pain score was 6.8 (range 2 to 10) and the mean postoperative visual analog scale pain score was 1.3 (range 0 to 6). The mean interval to weightbearing was 10 (range 0 to 28) days. No postoperative ruptures occurred. Of the 43 patients, 42 (97.6%) successfully performed the single heel rise test at the final postoperative visit. Concomitant procedures were performed in 35 patients, including 33 (77%) requiring open gastrocnemius recession and 2 (5%) requiring flexor hallucis longus tendon transfer. A total of 42 patients (97.6%) returned to regular shoe gear, and 42 (97.6%) returned to their activities of daily living, including running for 20 athletic patients (100%). Complications included postoperative wound dehiscense requiring surgical debridement in 2 patients (5%) and soft tissue infection requiring antibiotics and surgical debridement in 1 (2%) patient. Our findings support using the Achilles tendon suture bridge for reattachment of the Achilles tendon in the surgical treatment of insertional Achilles tendinosis.
Syndesmotic diastasis can occur as an isolated injury or with concomitant fractures. A review of ... more Syndesmotic diastasis can occur as an isolated injury or with concomitant fractures. A review of 37 patients with 64 TightRopes® for syndesmotic repair was performed, with a mean follow-up of 23.6 ± 4.3 months, from 2007 to 2011. The patients' mean age was 40.67 (range 14 to 87) years. The mean initial measurements were as follows: tibiofibular clear space (TFCS) = 4.1 ± 1.1 mm, tibiofibular overlap (TFO) = 7.2 ± 2.7 mm, and medial clear space (MCS) = 2.9 ± 0.5 mm. The mean final measurements were as follows: TFCS = 4.2 ± 1.3 mm, TFO = 7.4 2.8 mm, and MCS = 3.0 0.5 mm. The calculated measurable difference from the initial to final TFCS, TFO, and MCS was significantly less than the maximum threshold for allowable widening of the syndesmosis: TFCS, p < .001; TFO, p < .002; and MCS, p < .001. Complications occurred in 10 patients; 7 (19%) experienced knot irritation and 3 (8%) developed an infection. The mean interval to weightbearing was 33.2 ± 12.7 days. The mean postoperative American Orthopaedic Foot and Ankle Society score was 97 (range 90 to 100). Of 64 suture endobuttons, 4 (6.25%) required removal. The fracture types were as follows: 3 (8%) isolated syndesmotic injuries, 9 (24%) trimalleolar fractures, 10 (27%) bimalleolar fractures, 7 (18%) Weber B fractures, 3 (8%) Weber C fractures, 1 (3%) Salter Harris type 3 fracture, and 4 (11%) Maisonneuve fractures. TightRope® fixation was advantageous because it rarely required removal, allowed for physiologic motion of the syndesmosis, and resulted in an early return to weightbearing. In addition, we have concluded that the TightRope® provides long-term stability of the ankle mortise, which was confirmed by the radiographic criteria and excellent American Orthopaedic Foot and Ankle Society scores.
Displaced medial malleolus fractures are considered unstable and typically require open reduction... more Displaced medial malleolus fractures are considered unstable and typically require open reduction and internal fixation for anatomic reduction and early joint range of motion. These fractures are usually fixated with either compression lag screws or tension band wiring depending on the fracture pattern, size of the distal fragment, and bone quality. When fracture fixation fails, it is typically in pullout strength. Failure of primary bone healing can result in nonunion, malunion, and need for revision surgery. The current study wished to explore a potentially stronger fixation technique in regard to pullout strength for medial malleolar fractures compared with traditional cancellous screws. This was a comparative study of the relative pullout strength of 2 fully threaded 3.5-mm bicortical screws versus 2 partially threaded 4.0-mm cancellous screws for the fixation of medial malleolar fractures. Ten fresh-frozen limbs from 5 cadavers, mean age 79 years (range of 65-97 years), were tested using the Instron 8500 Plus system. The median force recorded at 2 mm of distraction using unicortical partially threaded cancellous screws was 116.2 N (range 70.2 to 355.5N) compared with 327.6 N (range 117.5 to 804.3 N) in the fully threaded bicortical screw (P = .04). The unicortical screw fixation displayed only 64.53% of the median strength noted with the bicortical screw fixation at clinical failure. The current study demonstrated statistically significantly greater pullout strength for 3.5-mm bicortical screws when compared with 4.0-mm partially threaded cancellous screws used to fixate medial malleolar fractures in a cadaveric model.
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Papers by Ryan Rigby