Is Palpation Sufficient for Estimation of IOP Immediately Following Cataract Surgery?

The aim of this study was to evaluate the accuracy of standard palpation techniques and Barraquer tonometry relative to Tono-Pen for measurement of postoperative intraocular pressure (IOP) immediately following routine micro-incision cataract surgery (MICS). We conducted a prospective comparative analysis of postoperative IOP immediately after MICS in a single academic outpatient surgery center. A random block of 166 eyes that underwent MICS at our institution was selected for inclusion. Exclusion criteria consisted of any complications including posterior capsule rupture. IOP was measured immediately postoperatively, first with palpation or a Barraquer tonometer, then with a Tono-Pen handheld applanation tonometer. Measurements obtained by each method were compared. The mean difference between IOP measurements obtained by palpation and Tono-Pen was 10 mmHg, 95% confidence interval (CI; 8, 12); whereas the mean difference between IOP measurements obtained by Barraquer tonometer and Tono-Pen was 2 mmHg, 95% CI (1, 3). IOP measurements acquired via palpation differed from their corresponding Tono-Pen measurements by > 5 mmHg in 48.0% of cases compared to only 5.9% of measurements acquired using a Barraquer tonometer. Spearman correlation coefficient for measurements obtained by standard palpation and Tono-Pen was r = 0.397 (p < 0.01) compared to r = 0.774 (p < 0.01) for those obtained by Barraquer tonometer and Tono-Pen. In conclusion, palpation is not an accurate method for estimating IOP immediately after cataract surgery compared to Tono-Pen. Appropriate measurement and adjustment of IOP at the end of cataract surgery may decrease complications such as cystoid macular edema. In settings where a Tono-Pen is not readily available, Barraquer tonometry may serve as a reasonable and cost-effective alternative.

Does surgical approach affect sagittal plane alignment and pilon fracture outcomes?

PURPOSE

Sagittal plane alignment beyond articular reduction and its effect on clinical outcomes has not been emphasized. Surgical approach may influence a surgeon's ability to correct the sagittal plane alignment. The purpose of our study was to evaluate how surgical approach impacts anterior distal tibial angle (ADTA) and lateral talar station (LTS). Our hypothesis was that the anterolateral (AL) approach would improve the sagittal plane parameters due to the primary plate placement.

PATIENTS AND METHODS

A retrospective review was performed on patients who underwent operative management for pilon fractures at 2 ACS Level 1 Academic Trauma Centers. Clinical data points including demographics, comorbidities, AO/OTA classification, surgical approach, and complications were recorded. Quality of reduction was measured using the ADTA, lateral distal tibia angle (LDTA), and lateral talar station (LTS) from radiographs.

RESULTS

580 pilon fractures met inclusion criteria. When compared to the AL approach, the modified anteromedial (AM) approach had decreased rates of local wound care, and unplanned reoperations. The AM approach had increased rates of superficial infection, deep infection, non-union, and amputations. There was no difference in ADTA, LDTA, or LTS between the AM and AL approach (P = 0.49, P = 0.41, P = 0.85). There was a difference in LTS with tobacco users (P = 0.02).

CONCLUSIONS

The sagittal plane alignment does not appear to be affected by the surgical approach. Therefore, the surgical approach to pilon fractures should be based on the fracture pattern and the patient's soft tissue envelope. This study shows that the AM is a relatively safe and effective approach to complex fractures and the surgeon should consider the specific fracture pattern and patient soft tissue envelope when choosing the specific approach.