Exposure to UV Radiation in Lifeguards on Barcelona's Beaches: An Underestimated Occupational Risk

BACKGROUND

The development of skin cancer is closely related to high exposure to UV radiation. Lifeguards are at an increased risk of excessive sun exposure.

OBJECTIVES

The main objective of this study was to measure the exposure of Barcelona's beach lifeguards to UV radiation.

METHODS

Measurements in the work chair were taken every 30min on a typical working day from 10:45 am to 19:15 pm. These measurements were carried out on four different days. These data were used to calculate the erythematous doses received during working hours, as well as those potentially received throughout the summer season. Vitamin D production was also estimated for the four days that the radiation received was measured, and the amount generated was calculated for the entire summer season.

RESULTS

Exposure to UV radiation among Barcelona lifeguards far exceeds safety limits. In some locations, the exposure to UVB radiation is more than 16 times the minimum erythematous dose for phototype II skin.

LIMITATIONS

This study assessed the radiation received during only four days. However, is a much higher number than most of the published papers.

CONCLUSION

Although the health risks of excessive exposure to UV radiation are known, Barcelona's beach lifeguards are insufficiently protected.

Exposure to UV Radiation in Lifeguards on Barcelona's Beaches: An Underestimated Occupational Risk

BACKGROUND

The development of skin cancer is closely related to high exposure to UV radiation. Lifeguards are at an increased risk of excessive sun exposure.

OBJECTIVES

The main objective of this study was to measure the exposure of Barcelona's beach lifeguards to UV radiation.

METHODS

Measurements in the work chair were taken every 30min on a typical working day from 10:45 am to 19:15 pm. These measurements were carried out on four different days. These data were used to calculate the erythematous doses received during working hours, as well as those potentially received throughout the summer season. Vitamin D production was also estimated for the four days that the radiation received was measured, and the amount generated was calculated for the entire summer season.

RESULTS

Exposure to UV radiation among Barcelona lifeguards far exceeds safety limits. In some locations, the exposure to UVB radiation is more than 16 times the minimum erythematous dose for phototype II skin.

LIMITATIONS

This study assessed the radiation received during only four days. However, is a much higher number than most of the published papers.

CONCLUSION

Although the health risks of excessive exposure to UV radiation are known, Barcelona's beach lifeguards are insufficiently protected.

Behandlung des Plattfusses

Zusammenfassung. Der sogenannte «Plattfuss» kann in der deutschen Sprache treffender als «Knick-Senkfuss» beschrieben werden. Dabei bezieht sich der «Knick» auf die Rückfussachse als solche, die durch die Intersektion der longitudinalen Achsen der Achillessehne und des Tuber calcanei identifiziert werden kann. Die Bezeichnung «Senkfuss» markiert das Erscheinungsbild der longitudinalen Achse, das heisst des medialen Längsgewölbes, welches klinisch einfach zu bestimmen ist. Die Formen eines Knick-Senkfusses sind mannigfaltig, genauso wie die dafür infrage kommenden Ursachen. Aus diesem Grund sind auch die anzuwendenden Therapieformen häufig nicht sehr einfach und müssen gut überlegt und appliziert werden. Nicht immer sind Knick-Senkfüsse behandlungsbedürftig. Das heisst es gibt Menschen, die schon immer solche Fehlstellungen aufgewiesen haben, aber nie Symptome entwickeln. Aus diesem Grund bedürfen nur symptomatische Patienten mit Knick-Senkfussdeformität einer Behandlung. Die Ausprägung der Behandlung und deren Erfolg knüpft an die sorgfältige Untersuchung und Interpretation der Befunde durch den behandelnden Spezialisten. Der vorliegende Artikel befasst sich mit der Behandlung des Knick-Senkfusses und versucht, einen logischen Überblick zu liefern.

Synchronous primary cutaneous melanomas: a descriptive study of their clinical features, histology, genetic background of the patients and clinical outcomes

BACKGROUND

Around 0.5% cutaneous melanoma (CM) patients will present with synchronous melanomas when first seen. Moreover, 26%-40% of patients with multiple primary melanomas present with synchronous lesions.

OBJECTIVES

To assess the prevalence, clinical and histopathological characteristics, germline mutations and outcome in patients with synchronous melanoma.

METHODS

Clinical and histopathological data from 4703 melanoma patients were included. Clinical, histological and genetic mutational status information was analyzed. Kaplan-Meier curves were used to investigate survival outcomes.

RESULTS

A total of 144 patients (3.06%) presented simultaneously with 2 or more primary melanomas. During follow-up, 25.7% of patients with synchronous melanoma developed a new primary melanoma compared to 8.6% of patients diagnosed with single melanoma (p < 0.001). Germinal CDKN2A mutations were identified in 10.7% of patients with synchronous melanomas and genetic variants in MC1R in 72%. No significant differences in all survival outcomes between patients with synchronous melanomas and single melanomas were found.

CONCLUSION

Synchronous melanomas are more frequent than previously reported and are more frequent in older patients compared to single melanomas. Moreover, these patients have a higher risk of developing a new primary melanoma during follow-up and have higher rates of germline susceptibility variants. Nevertheless, these findings were not associated with worse outcomes.

Failed Cavovarus Reconstruction: Reconstructive Possibilities and a Proposed Treatment Algorithm

This article provides an overview of the techniques and strategies to address a failed cavovarus deformity correction. These problems pose significant challenges to the treating surgeons and should be accurately planned before embarking on surgery.

The Failed Deltoid Ligament in the Valgus Misaligned Ankle-How to Treat?

This article deals with the treatment of a chronically failed deltoid ligament complex in the valgus misaligned ankle. This is a challenging task in every orthopedic foot and ankle surgery. Before embarking on any surgery that relates to the deltoid ligament complex, it is mandatory to analyze any underlying cause that could promote the impairment. Once this is done, it might be of value in considering anatomic reconstructions. The article provides an anatomic reconstruction technique, which should help address the problem.

Long-term Prognosis After Successful Nonoperative Treatment of Osteochondral Lesions of the Talus: An Observational 14-Year Follow-up Study

Background:

Little is known about the long-term prognosis of osteochondral lesions of the talus (OLTs) after nonoperative treatment.

Purpose:

To evaluate the clinical and radiological long-term results of initially successfully treated OLTs after a minimum follow-up of 10 years.

Study Design:

Case series; Level of evidence, 4.

Methods:

Between 1998 and 2006, 48 patients (50 ankles) with OLTs were successfully treated nonoperatively. These patients were enrolled in a retrospective long-term follow-up, for which 24 patients could not be reached or were available only by telephone. A further 2 OLTs (6%) that had been treated surgically were excluded from the analysis and documented as failures of nonoperative treatment. The final study group of 22 patients (mean age at injury, 42 years; range, 10-69 years) with 24 OLTs (mean size, 1.4 cm²; range, 0.2-3.8 cm²) underwent clinical and radiological evaluation after a mean follow-up of 14 years (range, 11-20 years). Ankle pain was evaluated with a visual analog scale (VAS), ankle function with the American Orthopaedic Foot and Ankle Society (AOFAS) score, and sports activity with the Tegner score. Progression of ankle osteoarthritis was analyzed based on plain ankle radiographs at the initial presentation and the final follow-up according to the Van Dijk classification.

Results:

At final follow-up, the 24 cases (ie, ankles) showed a median VAS score of 0 (IQR, 0.0-2.25) and a median AOFAS score of 94.0 (IQR, 85.0-100). Pain had improved in 18 cases (75%), was unchanged in 3 cases (13%), and had increased in 3 cases (13%). The median Tegner score was 4.0 (IQR, 3.0-5.0). Persistent ankle pain had led to a decrease in sports activity in 38% of cases. At the final follow-up, 11 cases (73%) showed no progression of ankle osteoarthritis and 4 cases (27%) showed progression by 1 grade.

Conclusion:

Osteochondral lesions of the talus that successfully undergo an initial nonoperative treatment period have minimal symptoms in the long term, a low failure rate, and no relevant ankle osteoarthritis progression. However, a decrease in sports activity due to sports-related ankle pain was observed in more than one-third of patients.

The Use of Virtual Planning and Patient-specific Guides to Correct Complex Deformities of the Foot and Ankle

This article provides an overview regarding the virtual planning and precise execution of corrective osteotomies around the foot and ankle. Based on 3-dimensional data obtained from CT scans, surgeons are able to create a virtual plan of how to correct a complex deformity. This plan is transferred into the production of true patient-specific guides, designed to perform a specific surgical intervention. The authors have extensive experience with this technique and were involved in the development of the method. The current article provides an overview regarding the virtual planning and precise execution of corrective osteotomies around the foot and ankle.

Scientific Evidence in the Treatment of Metatarsalgia

Metatarsalgia is a common foot disease with a multitude of causes. Proper identification of underlying diseases is mandatory to formulate an adequate treatment. Multiple surgical solutions are available to treat metatarsalgia. Only limited scientific evidence is available in the literature. However, most of the techniques used in the treatment of metatarsalgia seem to be reasonable with acceptable results.

Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus: A Clinical and Radiological 2- to 8-Year Follow-up Study

BACKGROUND

Autologous matrix-induced chondrogenesis (AMIC) has become an interesting treatment option for osteochondral lesions of the talus (OLTs) with promising clinical short- to midterm results.

PURPOSE

To investigate the clinical and radiological outcome of the AMIC procedure for OLTs, extending the follow-up to 8 years.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty-three patients (mean age, 35.1 years; body mass index, 26.8) with osteochondral lesions of the medial talar dome were retrospectively evaluated after open AMIC repair at a mean follow-up of 4.7 years (range, 2.3-8.0 years). Patients requiring additional surgical procedures were excluded. All OLTs (mean size, 0.9 cm²; range, 0.4-2.3 cm²) were approached through a medial malleolar osteotomy, and 28 patients received subchondral autologous bone grafting. Data analysis included the visual analog scale for pain, the American Orthopaedic Foot and Ankle Society score for ankle function, the Tegner score for sports activity, and the MOCART (magnetic resonance observation of cartilage repair tissue) scoring system for repair cartilage and subchondral bone evaluation.

RESULTS

Mean ± SD visual analog scale score improved significantly from 6.4 ± 1.9 preoperatively to 1.4 ± 2.0 at latest follow-up ( P < .001). The mean American Orthopaedic Foot and Ankle Society score was 93.0 ± 7.5 (range, 75-100). The Tegner score improved significantly from 3.5 ± 1.8 preoperatively to 5.2 ± 1.7 at latest follow-up ( P < .001), and 79% returned to their previous sports levels. The MOCART score averaged 60.6 ± 21.2 (range, 0-100). Complete filling of the defect was seen in 88% of cases, but 52% showed hypertrophy of the cartilage layer. All but 1 patient showed persistent subchondral bone edema. The patient's age and body mass index, the size of the osteochondral lesion, and the MOCART score did not show significant correlation with the clinical outcome. There were no cases of revision surgery for failed AMIC. Fifty-eight percent underwent reoperation, mainly for symptomatic hardware after malleolar osteotomy.

CONCLUSION

AMIC for osteochondral talar lesions led to significant pain reduction, recovery of ankle function, and successful return to sport. The MOCART score did not correlate with the good clinical results; the interpretation of postoperative imaging remains therefore challenging.

The Role of Plantar Fascia Tightness in Hallux Limitus: A Biomechanical Analysis

Restriction of greater toe dorsiflexion without degeneration of the first metatarsophalangeal joint is defined as hallux limitus. We assume that in hallux limitus the limitation of greater toe dorsiflexion takes place in the terminal stance phase because of massive tightening of the calf and plantar structures. The current study investigated the role of a tight plantar fascial structure in impairing dorsiflexion of the greater toe. For the purpose of the study, 7 lower limbs from Thiel-fixated human cadavers were evaluated. To simulate double-limb standing stance, the tibia and fibula were mounted on a materials testing machine and constantly loaded with 350N. Additionally, the tendons of the specimens were loaded using a custom-made system. The plantar fascia was fixed to a clamp and tensioned using a threaded bar. Four different tensile forces were then applied to the plantar fascia (approximately 100, 200, 300, and 350 N) and the extension of the first toe was measured. The results show a significant positive correlation between the decrease in extension of the hallux and the tension applied to the plantar fascia reaching a maximum mean decrease of 4.2° (117% compared with the untightened situation) for an applied tension of 364N.

Coalitions of the Tarsal Bones

Tarsal coalitions are the result of impaired mesenchymal separation of the tarsal bones. The most common types include calcaneonavicular or talocalcaneal coalitions. Subtalar stiffness results in pathologic kinematics with increased risk of ankle sprains, planovalgus foot deformity, and progressive joint degeneration. Resection of the coalition yields good results. Tissue interposition may reduce the risk of reossification, and concomitant deformity should be addressed in the same surgical setting.

Subtalar Distraction Arthrodesis

The subtalar joint can be altered in its anatomy and biomechanical behavior. It is important to know how to assess the talar declination angle in order to assess the deformity at the subtalar joint. Consider a straight posterior approach to the subtalar joint and remain liberal in the use of z-shaped Achilles tendon lengthening. A structural bone graft should be used to elevate the talus. Positioning screws should be used to lock the construct.

Three-Dimensional Correction of Complex Ankle Deformities With Computer-Assisted Planning and Patient-Specific Surgical Guides

Three-dimensional computer-assisted preoperative planning, combined with patient-specific surgical guides, has become an effective technique for treating complex extra- and intraarticular bone malunions by corrective osteotomy. The feasibility and accuracy of such a technique has not yet been evaluated for ankle deformities. Four surgical cases of varying complexity and location were selected for evaluation. Three-dimensional bone models of the affected and contralateral healthy lower limb were generated from computed tomography scans. The preoperative planning software permitted quantification of the deformity in 3 dimensions and subsequent simulation of reduction, yielding a precise surgical plan. Patient-specific surgical guides were designed, manufactured, and finally applied during surgery to reproduce the preoperative plan. Evaluation of the postoperative computed tomography scans indicated adequate reduction accuracy with residual translational and rotational errors of <3 mm and <6°, respectively. Two patients required revision surgery owing to anterior osseous impingement or delayed union of the osteotomy. All patients were satisfied with the postoperative course and were pain free at a mean follow-up period of 2.5 (range 1 to 4) years. These promising results require confirmation in a clinical study with a larger sample size.

The V Sign in Lateral Talar Process Fractures

Category:

Ankle, Hindfoot, Trauma

Introduction/Purpose:

Lateral talar process fractures (LTPF) constitute 15% of ankle injuries in snowboarders. They are often misdiagnosed on conventional radiographs, which are also susceptible to rotational malpositioning due to pain. A positive V sign is an interruption of the contour of the lateral talar process. It has been suggested to be pathognomonic for LTPF. However, there are very few studies about this topic. The objectives were to study whether the V sign is useful in diagnosing LTPF.

Methods:

In an experimental study, two investigators evaluated lateral radiographs (n=108) of high resolution, solid foam, radiopaque distal foot and ankle models. Two other investigators, who obtained the radiographs, defined the gold standard. Four different models (no fracture, type A, B, or C fractures according to Hawkins) and three varying ankle joint positions (0°, 20°, and 40° of inversion, plantar flexion, and internal rotation) were the independent variables. The correct detection of a V sign on lateral radiographs (Figure 2 showing a positive V sign on a lateral radiograph in a type B LTPF) was the primary dependent variable and the detection of the fracture type and uncertainty in making this decision were the secondary dependent variables. The chosen study size surpassed the sample size calculation. The chi-squared test was used for categorical data.

Results:

There were fair interobserver agreements on the V sign and fracture types (kappa coefficient [k]=0.35, 95% confidence interval [CI] 0.18-0.53, p<0.001 and k=0.37, 95% CI 0.26-0.48, p<0.001). For the detection of the V sign, the mean sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio, and mean uncertainty were 77% (95% CI 67-86%), 59% (95% CI 39-78%), 85% (95% CI 75-92%), 46% (95% CI 29-63%), 2, and 38%. Increased inversion and type B fractures were associated with better detection of the V sign (p=0.035 and p=0.011 as well as p=0.001 and p=0.013, for each investigator). Plantar flexion and internal rotation were not associated with the V sign (p=0.31 and 0.33 as well as 0.35 and 0.53, for each investigator).

Conclusion:

It is not recommended to exclusively use the V sign for the evaluation of LTPF. If negative, LTPF cannot be excluded. However, if positive, it may be a helpful surrogate parameter for the presence of LTPF, especially type B fractures. Inversion may lead to better visualization of the V sign. This knowledge about the V sign is a valuable asset for the diagnostic skillset of an orthopaedic surgeon. Future clinical studies may focus on validating these experimental findings. [Notes: Level of evidence is not applicable to this study. This abstract has also been submitted to the swiss orthopaedics congress 2017.]

The V sign in lateral talar process fractures: an experimental study using a foot and ankle model

Background

Lateral talar process fractures (LTPF) are often missed on conventional radiographs. A positive V sign is an interruption of the contour of the LTP. It has been suggested, but not proven to be pathognomonic for LTPF. The objective was to study whether the V sign is pathognomonic for LTPF and if it can be properly assessed in different ankle positions and varying fracture types.

Methods

An experimental study was conducted. Two investigators assessed lateral radiographs (n = 108) of a foot and ankle model. The exposure variables were different ankle positions and fracture types. The primary outcome was the correct detection of a V sign. The secondary outcomes were the detection of the V sign depending on ankle position and fracture type as well as the uncertainty.

Results

The interobserver agreement on the V sign and type of fracture were fair (κ = 0.35, 95% CI 0.18–0.53, p < 0.001 and κ = 0.37, 95% CI 0.26–0.48, p < 0.001). The mean sensitivity, specificity, PPV, NPV, and likelihood ratio for the detection of the V sign were 77% (95% CI 67–86%), 59% (95% CI 39–78%), 85% (95% CI 75–92%), 46% (95% CI 29–63%), and 2. The mean uncertainty in the V sign detection was 38%. The V sign identification stratified by ankle position and fracture type showed significant better results with increasing inversion (p = 0.035 and p = 0.011) and type B fractures (p = 0.001 and p = 0.013).

Conclusions

The V sign may not be pathognomonic and is not recommended as the only modality for the detection of LTPF. It is better visualized with inversion, but does not depend on plantar flexion or internal rotation. It is also better seen in type B fractures. It is difficult to detect and investigator-dependent. It may be helpful in a clinical setting to point into a direction, but a CT scan may be used if in doubt about a LTPF.

Osteolysis in Total Ankle Replacement: How Does It Work?

Aseptic loosening of implants remains the most common reason for revision surgery for hip, knee, or ankle prostheses. Although a great scientific effort has been made to explain the underlying mechanisms it remains poorly understood, complex, and multifactorial. Many factors, including age, body weight, activity lesions, implant design, fixation methods, material proprieties, immunologic responses, and biomechanical adaptations to total ankle replacement all contribute to the development of periprosthetic osteolysis.

Quality of Early Union After First Metatarsophalangeal Joint Arthrodesis

The aim of the present retrospective cohort study was to assess the quality of union and the clinical outcomes in patients who had undergone first metatarsophalangeal joint (MTPJ) fusion using a dorsal plate and plantar lag screw. From March 2011 to December 2012, the clinical and radiographic data of 39 patients (41 feet) who had undergone first MTPJ fusion using a compressive locking plate were retrospectively reviewed. All patients had undergone postoperative computed tomography at 6 weeks postoperatively to assess union. The average metatarsophalangeal angles improved from 23° ± 16° preoperatively to 14° ± 5° postoperatively. The dorsiflexion of the hallux at the preoperative assessment averaged 17° ± 11° and 23° ± 5° postoperatively. At 6 weeks postoperatively, the computed tomography scans demonstrated 3 complete fusions (7.3 %) and 38 partial unions (92.7%). Also at 6 weeks, the mean ± standard deviation joint bridging was 54% ± 14.6%. The forefoot American Orthopaedic Foot and Ankle Society scale score had improved significantly from 50 ± 13 preoperatively to 80 ± 7 at >1 year of follow-up (p = .001). Hardware removal was performed in 8 cases because of pain in 7 and infection in 1. Revision arthrodesis was required in 2 cases because of nonunion. At 6 weeks postoperatively, partial bony joint bridging could be observed in most cases after arthrodesis of the first MTPJ with the dorsal fusion plate.

Cerebral Hemodynamics Patterns by Transcranial Doppler in Patients With Acute Liver Failure

INTRODUCTION

About half of patients with acute liver failure (ALF) show clinical signs of cerebral edema and intracranial hypertension. Neuroimaging diagnostics and electroencephalography have poor correlation with intracranial pressure measurement.

OBJECTIVE

The objective of this study was to characterize the cerebral hemodynamics patterns with transcranial Doppler (TCD) sonography in patients with ALF.

METHOD

We studied 21 patients diagnosed with ALF, admitted to the intensive care unit (ICU) at the Centro de Investigaciones Médico Quirúrgicas of Cuba. All of these patients had a TCD performed on arrival at ICU, evaluating the following: systolic (SV), diastolic (DV), and medium (MV) flows velocities and pulsatility index (PI) in right middle cerebral artery (RMCA) via temporal windows.

RESULTS

The sonographic patterns of cerebral hemodynamics were as follows: low-flow, 12 patients (57.1%); high resistance, 5 patients (23.8%); and hyperemic, 4 patients (19%). Patients who died while waiting had lower MV RMCA (56.1 vs 58.1 cm/s) and higher PI (1.71 vs 1.41) than patients who could undergo transplantation (P = .800 and P = .787, respectively).

CONCLUSIONS

In patients diagnosed with ALF admitted to the ICU the predominating cerebral hemodynamic pattern was low-flow with resistance increase. The TCD was shown to be a useful tool in the initial evaluation for prognosis and treatment.

Peroneal tendon dislocation

INTRODUCTION

Peroneal tendon instability goes often mis- or undiagnosed in the acute setting of evaluation of ankle sprains. The current article provides a concise overview regarding peroneal tendon instability.

METHODS

A proper history, clinical assessment and imaging help to establish the correct diagnosis. Conventional radiography, ultrasound, magnetic resonance imaging and sometimes computed tomography may help to elucidate the pattern of injury.

RESULTS

Nonoperative treatment can be considered in the acute setting. However, high failure rates up to 50 % have been reported in the literature. This is even better reflected in the chronic stage of peroneal instability, in which most of the patients need surgical treatment. In contrast, surgical treatment attempts to restore structural stabilization of the peroneal tendon and retinacular complex. The simple reconstruction and repair of the damaged retinacular structures and tendons achieve excellent results. In patients with structural abnormalities of the retromalleolar groove, groove-deepening procedures may be considered. Most of chronic personal tendon instabilities need to be addressed by surgery due to the frustrating results obtained by nonoperative measures. However, reconstruction of the tendinous and retinacular structures can yield good-to-excellent outcomes.

Stage I and II Posterior Tibial Tendon Dysfunction: Return to Running?

Posterior tibial tendon dysfunction can be a difficult entity to treat in the athletic population. Understanding the deformity components allows the physician to maximize nonoperative intervention with orthotics and physical therapy. Not all patients improve with nonoperative treatment, and surgical intervention can be successful in minimizing symptoms. Although return to full athletic activity is not universally possible, an active lifestyle is possible for many after surgical reconstruction.

Inferior results of salvage arthrodesis after failed ankle replacement compared to primary arthrodesis

BACKGROUND

Up to now, there has been no evidence that salvage arthrodesis would perform inferior when compared with primary ankle arthrodesis. The purpose of this study was to compare their clinical and radiographic results.

METHODS

A retrospective analysis was performed using 2 validated scores and assessment of radiographic union by comparing 23 patients who underwent salvage ankle arthrodesis (group SA = salvage arthrodesis) after failed total ankle replacement with 23 matched patients who received primary ankle arthrodesis (group PA = primary arthrodesis). The mean follow-up period was 38 (range 16-92) months in group SA and 56 (23-94) months in group PA.

RESULTS

Complete union was achieved in 17 patients (74%) after a mean time of 50 (13- 114) weeks in group SA and in 16 patients (70%) after a mean time of 23 (10-115) weeks in group PA. The SF-36 score averaged 48 points (7-80) in SA and 66 points (14-94; P = .006) in group PA. In group SA the mean FFI was 57% (22-82) for pain and 71% (44-98) for function. In group PA significantly better results for pain with 34% (0-88; P = .002) and function with 48% (1-92; P = .002) were found.

CONCLUSION

Salvage arthrodesis led to impaired life quality and reduced function combined with significantly higher pain when compared with primary ankle arthrodesis. These findings can be used to counsel our patients preoperatively.

LEVEL OF EVIDENCE

Level III, retrospective case series.

Natural history of nonoperatively treated osteochondral lesions of the talus

BACKGROUND

We hypothesized that patients undergoing nonoperative treatment for asymptomatic or minimally symptomatic osteochondral lesions of the talus (OLTs) would not deteriorate clinically or radiologically over time.

METHODS

Forty-eight patients (mean age = 48 years; range, 13-78 years) with an OLT confirmed by magnetic resonance imaging (MRI) who had not undergone ankle joint surgery were retrospectively reviewed. All patients were evaluated after a minimum follow-up of 2 years (mean = 52 months; range, 27-124 months). All patients filled out an individual questionnaire and underwent a physical and radiographic assessment (radiograph and hindfoot MRI).

RESULTS

At final follow-up, 43 ankles (86%) in 41 patients were pain-free (visual analogue scale [VAS] 0, n = 12) or less painful (VAS 1-3, n = 31). Radiographically, osteoarthritis was absent in 47%, and grade 1 and 2 osteoarthritis each were found in 27% (van Dijk classification). Magnetic resonance imaging revealed no substantial progression in staging or lesion size. Pain at time of follow-up correlated with the depth of the lesion at initial MRI (P < .05) and with subchondral cyst formation and presence or change of bone marrow edema at follow-up MRI (P < .05).

CONCLUSION

Minimally symptomatic OLTs did not appear to progress or worsen over time when treated nonoperatively.

LEVEL OF EVIDENCE

Level IV, case series.

What leads to failure of joint-preserving surgery for ankle osteoarthritis?: when this surgery fails, what next?

This article discusses the lack of scientific evidence regarding the treatment of failed joint-preserving surgery. Most of the concepts of treatment derive from treatment modalities in trauma and orthopedic surgery. The main question for the foot and ankle specialist is whether the joint can be salvaged. The definition of failure is difficult. Therefore pain reported by the patient is the main symptom that dictates the course of treatment. Whenever possible the joint should be maintained. However, if pain is associated with global radiographic osteoarthritis, total ankle replacement or fusions are the only means to solve the problem.

Primary stability and stiffness in ankle arthrodes-crossed screws versus anterior plating

BACKGROUND

Ankle arthrodesis is commonly used for the treatment of osteoarthritis or failed arthroplasty. Screw fixation is the predominant technique to perform ankle arthrodesis. Due to a considerable frequency of failures research suggests the use of an anatomically shaped anterior double plate system as a reliable method for isolated tibiotalar arthrodesis. The purpose of the present biomechanical study was to compare two groups of ankle fusion constructs - three screw fixation and an anterior double plate system - in terms of primary stability and stiffness.

METHODS

Six matched-pairs human cadaveric lower legs (Thiel fixated) were used in this study. One specimen from each pair was randomly assigned to be stabilized with the anterior double plate system and the other with the three-screw technique. The different arthrodesis methods were tested by dorsiflexing the foot until failure of the system, defined as rotation of the talus relative to the tibia in the sagittal plane. Experiments were performed on a universal materials testing machine. The force required to make arthrodesis fail was documented. For calculation of the stiffness, a linear regression was fitted to the force-displacement curve in the linear portion of the curve and its slope taken as the stiffness.

RESULTS

For the anatomically shaped double-plate system a mean load of 967N was needed (range from 570N to 1400N) to make arthrodesis fail. The three-screw fixation method resisted a mean load of 190N (range from 100N to 280N) (p=0.005). In terms of stiffness a mean of 56N/mm (range from 35N/mm to 79N/mm) was achieved for the anatomically shaped double-plate system whereas a mean of 10N/mm (range from 6N/mm to 18N/mm) was achieved for the three-screw fixation method (p=0.004).

CONCLUSIONS

Our biomechanical data demonstrates that the anterior double-plate system is significantly superior to the three-screw fixation technique for ankle arthrodesis in terms of primary stability and stiffness.

Operative treatment of chronic irreparable Achilles tendon ruptures with large flexor hallucis longus tendon transfers

BACKGROUND

Transfer of the flexor hallucis longus (FHL) tendon aims to restore function and relieve pain in chronic Achilles tendon (AT) disease. The goal of the present study was to investigate the clinical and radiographic outcomes of FHL transfer to the AT and to compare the transtendinous technique to the transosseous technique. We hypothesized that the type of technique would have a notable impact on outcome.

METHODS

Forty patients (42 ankles) were retrospectively reviewed and divided into group 1 (transtendinous technique, 22 patients/24 ankles) and group 2 (transosseous technique, 18 patients/18 ankles). Outcome parameters included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Victorian Institute of Sports Assessment-Achilles (VISA-A) score, Foot Function Index (FFI), and Short Form-36 (SF-36) scores. Magnetic resonance imaging of the lower leg was performed preoperatively to assess muscle quality and fatty infiltration. Postoperatively, isokinetic plantar flexion strength was assessed using a Con-Trex dynamometer.

RESULTS

In group 1 (follow-up, 73 months; age, 52 years), the AOFAS score improved from 66 points to 89 points (P < .001) with average values for the VISA-A of 76 points, FFI-D pain 15%, and FFI-D function 22%. In group 2 (follow-up, 35 months; age, 56 years), the AOFAS score increased from 59 points to 85 points (P < .001) with mean values for the VISA-A 76 points, FFI-D pain 25%, and FFI-D function 24%. At follow-up, the average SF-36 score in group 1 was 66% and in group 2 was 77%. Isokinetic testing at 30 deg/s in group 1 revealed notable weakness in the operated ankle averaging 54.7 N·m (75% of normal), and in group 2 the average was 58.2 N·m (77% of normal). No statistically significant differences were found between the groups.

CONCLUSION

The hypothesis was disproved. Both techniques for FHL transfer to AT, intratendinous and transosseous, provided good to excellent clinical and functional outcome in the treatment of irreparable AT disease.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Three-dimensional hindfoot alignment measurements based on biplanar radiographs: comparison with standard radiographic measurements

OBJECTIVE

To establish a hindfoot alignment measurement technique based on low-dose biplanar radiographs and compare with hindfoot alignment measurements on long axial view radiographs, which is the current reference standard.

MATERIALS AND METHODS

Long axial view radiographs and low-dose biplanar radiographs of a phantom consisting of a human foot skeleton embedded in acrylic glass (phantom A) and a plastic model of a human foot in three different hindfoot positions (phantoms B1-B3) were imaged in different foot positions (20° internal to 20° external rotation). Two independent readers measured hindfoot alignment on long axial view radiographs and performed 3D hindfoot alignment measurements based on biplanar radiographs on two different occasions. Time for three-dimensional (3D) measurements was determined. Intraclass correlation coefficients (ICC) were calculated.

RESULTS

Hindfoot alignment measurements on long axial view radiographs were characterized by a large positional variation, with a range of 14°/13° valgus to 22°/27° varus (reader 1/2 for phantom A), whereas the range of 3D hindfoot alignment measurements was 7.3°/6.0° to 9.0°/10.5° varus (reader 1/2 for phantom A), with a mean and standard deviation of 8.1° ± 0.6/8.7° ± 1.4 respectively. Interobserver agreement was high (ICC = 0.926 for phantom A, and ICC = 0.886 for phantoms B1-B3), and agreement between different readouts was high (ICC = 0.895-0.995 for reader 1, and ICC = 0.987-0.994 for reader 2) for 3D measurements. Mean duration of 3D measurements was 84 ± 15/113 ± 15 s for reader 1/2.

CONCLUSION

Three-dimensional hindfoot alignment measurements based on biplanar radiographs were independent of foot positioning during image acquisition and reader independent. In this phantom study, the 3D measurements were substantially more precise than the standard radiographic measurements.

Posterior pilon fractures: a retrospective case series and proposed classification system

BACKGROUND

Posterior malleolus fractures occur in 7% to 44% of ankle fractures and are associated with worse clinical outcomes. Fractures that involve the posteromedial plafond extending to the medial malleolus have been described previously in small case series. Failure to identify this fracture pattern has led to poor clinical outcomes and persistent talar subluxation. The purpose of this study was to report our outcomes following fixation of this posterior pilon fracture and to describe a novel classification system to help guide operative planning and fixation.

METHODS

Eleven patients were identified following fixation of a posterior pilon fracture over a 4-year span; 7 returned at minimum 1-year follow-up to complete a physical examination, radiographs, and RAND-36 (health-related quality of life score developed at RAND [Research and Development Corporation] as part of the Medical Outcomes Study) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot questionnaires. Patient records were reviewed to evaluate for secondary complications or operative procedures.

RESULTS

Our mean postoperative AOFAS ankle/hindfoot score was 82. Anatomical reduction of the plafond was noted radiographically in 7 of 11 patients, with the remainder demonstrating less than 2 mm of articular incongruity. Five of 7 patients demonstrated ankle and hindfoot range of motion within 5 degrees of the uninvolved extremity. Four complications required operative intervention; 2 patients reported continued pain secondary to development of CRPS.

CONCLUSION

The posterior pilon fracture is a challenging fracture pattern to treat, and it has unique characteristics that require careful attention to operative technique. Our results following fixation of this fracture pattern are comparable with results in the literature. In addition, a novel classification scheme is described to guide recognition and treatment of this fracture pattern.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Biomechanics of the normal and arthritic ankle joint

Understanding biomechanics of the normal and arthritic ankle joint can aid in analysis of an underlying clinical problem and provide a strategic basis for a more optimal management. The challenge to the clinician and the biomechanist is that the mechanical complexity of the ankle joint still clouds current understanding. This article provides an overview of current understanding of functional ankle anatomy, how this function can be altered in the degenerated ankle, and how surgical intervention further affects foot and ankle biomechanics. The focus is on how altered loading of neighboring joints in the midfoot and hindfoot may induce postoperative joint remodeling and can manifest in secondary clinical problems.

Precision of targeting device for subtalar screw placement

BACKGROUND

When performing subtalar arthrodesis, proper screw placement is fundamental to provide primary stability and to help ensure bone healing. In inexperienced hands this step can be time-consuming and exposes surgeons and patients to radiation. By means of a targeting device these potential drawbacks and dangers could be reduced. It was hypothesized that a specifically designed targeting device would reduce radiation exposure while improving screw placement when compared with the conventional "free-hand'' method.

METHODS

Twenty matched-pairs of cadaveric hindfoot specimens (Thiel fixation) were prepared for the purpose of the study. The specimens were randomly assigned into two groups consisting of 10 specimens each: in Group 1 screw placement was performed with the targeting device and in Group 2 screw placement was performed under fluoroscopic control. Screw placement was radiographically judged to be optimal, suboptimal and poor. An experienced, fellowship-trained foot and ankle surgeon and a resident, who had never done subtalar fusions performed the screw placements. Exposure to radiation was assessed by means of the dose area product given by the fluoroscope.

RESULTS

Optimal screw positioning was achieved in both groups in ten out of 20 specimens (Group 1, n=5; Group 2, n=5). Suboptimal screw placement was found in eight cases (Group 1, n=4; Group 2, n=4). There were two failures which occurred in fusions performed by the resident (Group 1, n=1; Group 2, n=1). Exposure to radiation was significantly reduced in Group 1 when compared with Group 2 (4.1cGy* cm2 versus 8.1cGy* cm2; p=0.012). No lesion of neurovascular structures due to aiming device placement occurred in Group 1.

CONCLUSION

A target-device for screw-placement did not provide a significant technical advantage but did result in less radiation exposure.

Early complications and recurrence rates after Kirschner wire transfixion in lesser toe surgery: a prospective randomized study

BACKGROUND

Prolonged percutaneous Kirschner wire transfixion after correction of lesser toe deformities has been associated with an increased rate of complications such as infection, wire breakage or loosening. Currently, the duration of wire transfixion is based on the surgeons' opinion rather than on evidence. We hypothesized that a transfixion time of 3 weeks when compared to 6 weeks would decrease complication rates without an increase in the rate of recurrent deformity.

METHODS

We prospectively randomized 52 lesser toes corrected for a moderate hammer- or claw toe deformity by means of resectional arthroplasty of the proximal interphalangeal joint into two groups with 3 and 6 weeks of Kirschner wire transfixion, respectively. Kirschner wire-associated complication rates and incidence of early recurrence of malalignment in a short term followup of three months were assessed. Forty-six toes, 23 in each group, were available for final followup.

RESULTS

No statistically significant differences were found in pre- and postoperative total AOFAS scores between the groups. No Kirschner wire associated complications occurred. Recurrent malalignment was more often documented in the group with 3 weeks of transfixion (11 of 23 toes, 47.8%) when compared to 6 weeks (two of 23 toes, 8.7%) at 3 months followup. Interphalangeal joint motion was significantly reduced with prolonged Kirschner wire transfixion, indicating a more stable fibrous union (p = 0.038).

CONCLUSION

At short-term followup, Kirschner wire transfixion of 6 weeks as opposed to 3 weeks showed a lower rate of recurrent malalignment without an increase in Kirschner wire associated complications.

Alcohol sclerosing therapy is not an effective treatment for interdigital neuroma

BACKGROUND

Alcohol sclerosing therapy has been reported as a safe and effective means of treating interdigital neuromas, both with or without ultrasound. The use of ultrasound introduces beside the ultrasound device, increased cost, and the need for skilled technicians and may reduce usability, especially in the outpatient clinic. We report a series of patients with interdigital neuroma treated using ethanol sclerosing therapy in a clinic setting without the use of ultrasound.

MATERIALS AND METHODS

We retrospectively reviewed charts of 32 consecutive patients who were enrolled to receive a series of sclerosing ethanol injections from June 2009 to April 2010 for the treatment of a painful interdigital neuroma. Plain radiographs and MRI scans were obtained if clinically indicated to assistance with the diagnosis. Duration and quality of symptoms were recorded and current pain levels were evaluated on a visual analog pain scale. Previous treatments, including orthotic use, corticosteroid injection, or prior neuroma resection were reported. A solution of 1 ml consisting of 20% ethanol and 0.25% bupivacain solution was injected without the use of ultrasound into the affected webspace. The mixture was provided by the local pharmacy. Technical success was confirmed by the temporary resolution of pain following local anesthetic infiltration. If still symptomatic, an injection was repeated every 2 weeks, with most patients receiving a series of four injections. Pain was evaluated on a visual analog pain scale at each visit. Treatment success was defined as resolution of pain as expressed by the patient.

RESULTS

Of the 32 patients successful relief of symptoms was only achieved in seven patients, while 25 showed no significant reduction of symptoms and considered or underwent a surgical excision.

CONCLUSION

Alcohol sclerosing therapy administered in the clinic setting without alcohol is not an effective treatment in the nonoperative management of painful interdigital neuromas and has been abandoned in our clinic.

Tarsometatarsal arthrodesis for management of unstable first ray and failed bunion surgery

This article focuses on arthrodesis of the first tarsometatarsal joint as the primary intervention to treat hypermobility of the first ray or as a salvage procedure to treat prior failed bunion surgery and provides a concise review including historical perspective, definitions, pathomechanics, and treatment of specific forefoot disorders (ie, hypermobility of the first ray and failed bunion surgery).

Anatomical considerations of the internal iliac artery in association with the ilioinguinal approach for anterior acetabular fracture fixation

INTRODUCTION

Vascular injury may be encountered during an anterior approach to the pelvis or acetabulum-be it due to hematoma decompression, clot dislodgement during fracture manipulation, or iatrogenic. This can be associated with significant bleeding, hemodynamic instability, and subsequent morbidity. If the exact source of bleeding cannot be easily identified, compression of the internal iliac artery may be a lifesaving procedure.

MATERIALS AND METHODS

We describe an extension of the lateral window of the ilioinguinal (or Olerud) approach elaborated on cadavers.

RESULTS

The approach allows emergent access the internal iliac artery and intraoperative cross-clamping of the internal iliac vessels to control bleeding.

CONCLUSION

The approach allows rapid access to the internal iliac artery. The surgeon should be familiar, however, with the surgical anatomy of this region to avoid potential injury to the ureter, peritoneum, lymphatics, and sympathetic nerves overlying the vessels when using the approach described.