Showing papers by "Victor Valderrabano published in 2014"

Fractures of the ankle joint: investigation and treatment options.

Abstract: Fractures of the ankle joint are among the commonest fractures in adults, with an incidence of up to 174 cases per 100 000 persons per year (1). For a good long-term functional outcome to be achieved, reliable early evaluation is crucial so that it can be determined whether the problem is a distorsion (sprain), ligament rupture, bony ligament avulsion, or fracture of the talocrural joint. The proper treatment is chosen on the basis of the mechanism of the accident and the correct classification of the injury and accompanying soft-tissue damage. The goal of treatment is to enable the patient to put his or her full weight on the joint once again without pain and to prevent permanent damage.

All-Inside Meniscal Repair Devices Compared With Their Matched Inside-Out Vertical Mattress Suture Repair Introducing 10,000 and 100,000 Loading Cycles

Abstract: Background:All-inside arthroscopic meniscal repairs are favored by most clinicians because of their lower complication rate and decreased morbidity compared with inside-out techniques. Until now, only 1000 cycles have been used for biomechanical testing.Hypothesis:All-inside meniscal repairs will show inferior biomechanical response to cyclic loading (up to 100,000 cycles) and load-to-failure testing compared with inside-out suture controls.Study Design:Controlled laboratory study.Methods:Bucket-handle tears in 72 porcine menisci were repaired using the Omnispan and Fast-Fix 360 (all-inside devices) and Orthocord 2-0 and Ultrabraid 2-0 sutures (matched controls). Initial displacement, displacement after cyclic loading (100, 500, 1000, 2000, 5000, 10,000, and 100,000 cycles) between 5 and 20 N, ultimate load to failure, and mode of failure were recorded, as well as stiffness.Results:Initial displacement and displacement after cyclic loading were not different between the groups. The Omnispan repair demonst...

Commercially available trabecular metal ankle interpositional spacer for tibiotalocalcaneal arthrodesis secondary to severe bone loss of the ankle.

Abstract: Retrograde tibiotalocalcaneal nailing arthrodesis has proved to be a viable salvage procedure; however, extended bone loss around the ankle has been associated with high rates of nonunion and considerable shortening of the hindfoot We present the surgical technique and the first 2 cases in which a trabecular metal™ interpositional spacer, specifically designed for tibiotalocalcaneal nailing arthrodesis, was used The spacer can be implanted using either an anterior or a lateral approach An integrated hole in the spacer allows a retrograde nail to be inserted, which provides excellent primary stability of the construct Trabecular metal™ is a well-established and well-described material used to supplement deficient bone stock in surgery of the spine, hip, and knee It has shown excellent incorporation and reduces the need for auto- and allografts The trabecular metal™ interpositional ankle spacer is the first trabecular metal spacer designed specifically for ankle surgery Its shape and variable size will make it a valuable tool for reconstructing bone loss in tibiotalocalcaneal nailing arthrodesis

Forearm pressure distribution during ambulation with elbow crutches: a cross-sectional study

Abstract: Background: Increasing numbers of patients require permanent walking aids to maintain mobility. Current elbow crutches are not designed for long-term use, and overuse is often associated with hematoma formation and pain along the forearm. We therefore hypothesized that the highest pressures between the forearm and crutch cuff during walking and stance are located in the ulnar region and that the level of weight-bearing, forearm circumference and kinematic parameters influence peak pressure values and pressure distribution. Methods: Ten healthy adults participated in a cross-sectional study. A pressure sensor array was attached to the forearm of each participant separating the forearm into four quadrants (lateral, ulnar, intermediate and medial). Measurements were taken during crutch gait and during partial and full weight-bearing stance. A three-dimensional motion analysis system with reflective markers attached to the subject’s body and to the crutches was used to obtain kinematic data. Results: The mean pressure on the forearm during crutch gait was 37.5 kPa (SD 8.8 kPa). Highest mean pressure values were measured in the ulnar (41.0 kPa, SD 9.6 kPa) and intermediate (38.0 kPa, SD 9.0 kPa) quadrants. The center of pressure was mainly located in an oblique lamellar area in these two quadrants. With increasing weight-bearing on the crutches during stance, we observed a shift of the peak pressures towards the ulnar quadrant. The circumference of the forearm correlated with the peak pressure in the medial and intermediate quadrants during crutch gait (P < 0.05). Peak pressures on the forearm showed a trend towards correlation with crutch abduction, but no association with other kinematic parameters was detected. Conclusion: The pressure load on the forearm during crutch-assisted gait is located predominantly over the ulna and may be linked to a range of secondary conditions caused by crutch use including hematoma formation and pain.

The painful primary hip replacement - review of the literature.

Abstract: Summary Total hip replacement is one of the most successful surgical procedures of the 20th century (World Health Organisation). The success rate is dependent on the chosen endpoint. Evaluation of the outcome in joint replacement surgery has shifted from the revision rate toward patient satisfaction and quality of life. Patient satisfaction is reported to be up to 96% 16 years postoperatively, but the prevalence of groin pain after conventional total hip replacement ranges from 0.4% to 18.3% and activity-limiting thigh pain is still an existing problem linked to the femoral component of uncemented hip replacement in up to 1.9% to 40.9% of cases in some series. The aim of our article is to review the aetiology, diagnostic procedures and treatment of the painful primary total hip replacement. We discuss the most relevant intrinsic and extrinsic aetiological factors responsible for chronic pain after total hip arthroplasty focusing on comparative studies and randomised controlled trials including diagnostics and management. Detailed analysis of history, clinical examination, imaging and laboratory tests are required prior to any revision for painful total hip arthroplasty. Revision surgery without knowing the underlying pathology should be avoided.

Ankle Salvage Surgery with Autologous Circular Pillar Fibula Augmentation and Intramedullary Hindfoot Nail

Abstract: Tibiotalocalcaneal arthrodesis with an intramedullary hindfoot nail is an established procedure for fusion of the ankle and subtalar joints. In cases involving ankle bone loss, such as in failed total ankle replacement, it can be difficult to salvage with sufficient bone restoration stability and a physiologic leg length and avoiding below the knee amputation. In addition to the alternatives of using a structural allograft or metal bone substitution, we describe the use of autologous ipsilateral circular pillar fibula augmentation in tibiotalocalcaneal retrograde nail arthrodesis combined with a ventral (anterior) plate in a prospective series of 6 consecutive cases with a mean follow-up duration of 26 ± 9.95 (range 12 to 34) months. The 6 patients (3 female and 3 male), with a mean age of 55 ± 13.89 (range 38 to 73) years were treated with revision surgery of the ankle (1 after talectomy, 5 [83.33%] after failed ankle replacement). The visual analog scale for pain and the American Orthopaedic Foot and Ankle Society hindfoot score were used to assess functional outcome, and radiographs and computed tomography scans were used to determine the presence of fusion. All patients improved clinically from pre- to postoperatively in regard to the mean pain visual analog scale score (from 7.5 to 2.0) and American Orthopaedic Foot and Ankle Society hindfoot score (from 29 to 65 points, of an 86-point maximum for fused joints). Radiologically, no loss in the reduction or misalignment of the hindfoot was detected, and all cases fused solid. One patient (16.67%) required hardware removal. The fixation construct provided good clinical and radiologic outcomes, and we recommend it as an alternative to structural allografts or metallic bone grafts for revision ankle surgery with severe bone loss.

Lateral Patellar Facetectomy and Medial Reefing in Patients With Lateral Facet Syndrome After Patellar-Retaining Total Knee Arthroplasty

Abstract: We analyzed clinical outcomes of partial lateral patellar facetectomy and medial reefing in patients with lateral patellar facet syndrome with painful patellar-retaining total knee arthroplasty. 34 patients were followed for a mean of 40 months. All 34 patients were matched with those having secondary patellar resurfacing without facetectomy. Both groups experienced significant pain relief and range of motion improvement. The facetectomy group had higher Kujala scores than those in patellar resurfacing group. Patients with facetectomy had significantly less pain postoperatively. There were significant differences in postoperative lateral patellar tilt and congruency angle in both groups. The mid-term results for LPF with medial reefing are promising to resolve pain in patients with lateral patellar facet syndrome in patellar-retaining TKA. Therapeutic level III (retrospective comparative study).

Influence of tibial slope on extension and flexion gaps in total knee arthroplasty: increasing the tibial slope affects both gaps.

Abstract: Increasing the tibial slope is often performed if the flexion gap is narrower than the extension gap. The main hypothesis of this study is that increasing the tibial slope coincidentally enlarges the extension gap. Twenty formalin-fixed cadaveric knees were obtained for study. After CT in full extension and 90° flexion, the data of each specimen were entered into a standardized coordinate system and virtual bone cuts were performed with incrementally increasing the posterior slope. Gaps were measured at tibiofemoral contact points in 90°-flexion and full extension in the medial and lateral compartment. Increasing the tibial slope did significantly widen both the extension and the flexion gaps (p < 0.001). In extension, the opening rates, i.e. the gap increase per degree of slope increase, were equal medially and laterally (0.5 mm ±0.1) medial vs 0.6 mm (±0.0) lateral), whereas in flexion the lateral gap did open significantly more than the medial one (0.6 mm ±0.1) medial vs 0.9 mm (±0.1) lateral (p < 0.001), resulting in a significantly greater flexion gap laterally. Increasing the tibial slope beyond the pre-operative planning in order to widen a tight flexion gap intra-operatively is not recommended as doing so will increase the extension gap simultaneously and will make the medial and lateral flexion gaps unequal.

Osteonecrosis of distal tibia in open dislocation fractures of the ankle.

Abstract: Introduction Open ankle dislocation fractures are one of the most severe injuries of the ankle. Development of posttraumatic arthrosis is well known. However, there are just a few case reports describing evidence of posttraumatic osteonecrosis (PON) of distal tibia. The pathophysiological mechanism remains unclear and the question of morphologic or personal risk factors cannot be answered. The goal of this study was to evaluate the morphologic characteristics of open dislocated ankle fractures in correlation with the development of PON to facilitate early identification of patients with higher risk of posttraumatic osteonecrosis. Material and methods In this study data from 28 patients with open dislocation fractures of the ankle between 1975 and 2006 found at our databases were evaluated retrospectively. For each patient we documented personal data, mechanism of injury, type of lateral malleolar fracture, severity of open fracture, degree of tibiotalar dislocation, presence of medial malleolar fracture, presence of deltoid ligament rupture, time until joint reduction and kind of surgical treatment. We also documented clinical complications and number of surgeries. Presence of PON was examined by radiographs, magnetic resonance imaging (MRI) or histological analysis. Results Within 12 out of 28 patients with open ankle dislocation fractures a PON of the distal tibia could be found. Nine out of 15 patients with high-energy trauma and 12 out of 19 patients with type C fibular fracture developed PON. 73% of male patients and 88% of the patients with type III soft tissue damage according to Gustillo developed PON. However, if patients suffered from type C fibular fracture, total talus dislocation and grade III soft tissue damage (“necrotic triad”) PON was developed in 100% of cases. Other patient's characteristics like late joint reduction, postoperative infection or bimalleolar fracture showed no higher proportion of patients with PON. Conclusion In this study we were able to identify clinical manifestations and risk factors for the development of PON of the distal tibia. All indentified risk factors were associated with heavy fracture mechanisms leading most likely to a serious devascularisation of at least parts of the distal tibial epiphysis. With regard to presented results early identification of patients with higher risk of PON might be possible and maybe additional treatment options can be initialised to protect patients from this process.

Bony periosteum-covered iliac crest plug transplantation for severe osteochondral lesions of the talus: a modified mosaicplasty procedure.

Abstract: This study reports first evidence of a modified procedure for osteochondral autologous transplantation where bony periosteum-covered plugs are harvested at the iliac crest and transplanted into the talar osteochondral lesion. Thirteen out of 14 patients, average age 39.6 (SD 14.4) years, were followed clinically and radiographically for a median of 25 (24–28) months (minimal follow-up, 24 months). For these 13 patients, the American Orthopaedic Foot and Ankle Society hindfoot score increased from 47 (SD 11) points pre-operatively, to 81 (SD 14) points postoperatively (p < 0.0001). The average pain score decreased from 6.6 (SD 1.3) points pre-operatively, to 1.4 (SD 1.9) points postoperatively (p < 0.0001). Seven patients returned to sports activity. Radiographically good plug osteointegration was observed in nine out of 11 ankles. Follow-up arthroscopy showed fibrous cartilage in four ankles, periosteum hypertrophy in five ankles, and partial or total missing of coverage of the bone in three ankles. Three revision surgeries had to be performed. This modified mosaicplasty might be recommended for severe and recurrent osteochondral lesions of the talus and may lead to restoration of the subchondral bone stock, formation of fibro-cartilage, and stable joint function. IV.

Retrograde Synovial Biopsy of the Knee Joint Using a Novel Biopsy Forceps

Abstract: Synovial biopsies of the knee joint are commonly performed arthroscopically with the patient under full or regional anesthesia. To overcome the effort, costs, and potential risks of surgery, we developed an office-based technique for retrograde synovial biopsy using a designated novel biopsy forceps. Using this technique, no arthroscopic or radiologic control is needed to perform rapid synovial biopsies of the knee joint. Concomitant aspiration of synovial fluid can be performed. A technical description of the procedure is given.

Osteochondral lesions of the ankle joint in professional soccer players: treatment with autologous matrix-induced chondrogenesis.

Abstract: Acute and recurrent ankle sprains and other trauma to the ankle joint are common injuries in soccer and can be accompanied by or result in osteochondral lesions of the ankle joint, majorly of the talus. Conservative treatment frequently fails. Several operative treatment techniques exist; however, the choice of the right procedure is difficult due to lack of literature with a high level of evidence. We present our treatment method for acute and chronic ankle osteochondral lesions with cystic formation approached by a new surgical technique combining bone plasty and a collagen matrix (autologous matrix- induced chondrogenesis).

Intraoperative positioning of the hindfoot with the hindfoot alignment guide: a pilot study.

Abstract: Background:In a previous study, intraoperative positioning of the hindfoot by visual means resulted in the wrong varus/valgus position by 8 degrees and a relatively large standard deviation of 8 degrees. Thus, new intraoperative means are needed to improve the precision of hindfoot surgery. We therefore sought a hindfoot alignment guide that would be as simple as the alignment guides used in total knee arthroplasty.Methods:A novel hindfoot alignment guide (HA guide) has been developed that projects the mechanical axis from the tibia down to the heel. The HA guide enables the positioning of the hindfoot in the desired varus/valgus position and in plantigrade position in the lateral plane. The HA guide was used intraoperatively from May through November 2011 in 11 complex patients with simultaneous correction of the supramalleolar, tibiotalar, and inframalleolar alignment. Pre- and postoperative Saltzman views were taken and the position was measured.Results:The HA guide significantly improved the intraoper...

Behandlung von isolierten Olekranonfrakturen

Abstract: Olekranonfrakturen gehoren mit 7–10 % zu den mittelhaufigen Bruchen des Erwachsenen. In der Regel werden diese Frakturen operativ mittels konventioneller Zuggurtungsosteosynthese behandelt. Eine perkutane minimal-invasive Doppelschraubenosteosynthese ist eine alternative Technik bei einfacher Zwei-Fragment-Fraktur mit moglichen Vorteilen fur diese selektierten Patienten. Es wurden 13 Patienten mit einer isolierten Olekranonfraktur vom Typ A nach Schatzker-Schmelling mittels perkutaner Doppelschraubenosteosynthese behandelt und in diese prospektive Studie eingeschlossen. Das Durchschnittsalter betrug 43,6 ± 11,0 Jahre. Die intra- und postoperativen Komplikationen wurden erfasst. Die funktionellen Ergebnisse wurden nach einer mittleren Nachuntersuchungszeit von 38,2 ± 11,5 Monaten mittels Quick-DASH („disability of shoulder, arms and hand questionnaire“) erfasst. Die Ergebnisse wurden mit einer Kontrollgruppe verglichen, bestehend aus 26 Patienten, welche beim gleichen Frakturtyp mit der konventionellen Zuggurtungsosteosynthese behandelt wurden. In beiden Gruppen kam es zu keinen intraoperativen Komplikationen. In der Gruppe der perkutanen Doppelschraubenosteosynthese war die Narbe signifikant kurzer (2,4 ± 0,4 vs. 11,0 ± 1,8 cm; p < 0,001), das Osteosynthesematerial musste signifikant weniger haufig entfernt werden (38,5 % vs. 73,1 %). Nach einer Mindestnachbeobachtungszeit von 2 (Mittelwert 3,2) Jahren wurden in beiden Gruppen vergleichbare funktionelle Ergebnisse erzielt (Quick-DASH-Score: 2,3 vs. 0,0 Punkte; p = 0,155), wobei der Bewegungsumfang in der Gruppe der Doppelschraubenosteosynthese signifikant groser fur Extension/Flexion (145 ° vs. 130 °; p < 0,001) und Pro/-Supination (165 ° vs. 155 °; p < 0,001) war als in der Gruppe der konventionellen Zuggurtung. Bei Patienten mit einer einfachen Olekranonfraktur vom Typ A nach Schatzker-Schmelling liefert die perkutane Doppelschraubenosteosynthese vergleichbare Ergebnisse im DASH-Score im Vergleich zum Goldstandard, hat jedoch den Vorteil einer geringeren Revisionsrate mit besserer Beweglichkeit und Kosmetik.

Effectiveness of the addition of Lidocaine to a hemostatic, bioresorbable putty in the treatment of iliac crest donor site pain

Abstract: The harvest of iliac crest bone grafts (ICBG) is associated with relevant donor site pain, but may be lowered by the application of lidocaine loaded on biodegradable, hemostatic putty for sustained local analgesic release. The goal of this double-blind controlled trial was to assess the efficacy of adding lidocaine to a hemostatic putty (Orthostat ™) to treat donor site pain following harvest of ICBG in foot and ankle procedures. After ICBG harvest during a foot and ankle procedure, the resulting bone defect was either filled with Orthostat™ (n = 7) or with the same hemostatic putty loaded with lidocaine (Orthostat-L™, n = 7). During the first 72 postoperative hours, donor site and surgical site pain were managed by patient controlled morphine delivery and a peripheral nerve block. Donor site pain was periodically quantified on a Visual Analog (VAS) and a Wong Baker FACES scale. Pain scores were plotted over time to calculate the area under the curve (AUC) to quantify the overall pain experienced in specific time intervals. Orthostat-L™ significantly reduced donor site pain over the first 12 hours postoperatively as evidenced by a significant decrease of the AUC in both VAS (p = 0.0366) and Wong Baker FACES pain score plots (p = 0.0024). Cumulated morphine uses were not significantly decreased with Orthostat-L™. The addition of lidocaine to a hemostatic putty offers a significant ICBG donor site pain reduction over the first 12 postoperative hours. ClinicalTrials.gov NCT01504035 . Registered January 2nd 2012.

Total Ankle Replacement in Varus Ankle Osteoarthritits

Abstract: About 50% of the cases with degenerative osteoarthritis of the ankle are asymmetric. Varus ankle osteoarthritis is far more frequent than valgus ankle osteoarthritis. Most of the cases of ankle osteoarthritis have posttraumatic aetiology. It is important to understand the deformity completely, and to distinguish simple deviations in the coronal plane from more-dimensional, complex cavovarus deformities involving the midfoot and the forefoot. Concomitant ligament and tendon imbalances and pathologies need to be identified and analysed. Correction planning needs to include the mechanical axis of the complete leg. Muscular imbalances need to be identified. Even substantial deformities in varus ankle osteoarthritis can be treated with total ankle replacement successfully, if a plantigrade foot with balanced ligaments and tendons can be achieved. The corrective procedure may include realigning osteotomies, fusions, and correction of tendon and ligament pathologies.

Der Karpaltunnel der Schulter / The Carpal Tunnel of the Shoulder: Die arthroskopische Dekompression des N. suprascapularis

Abstract: Zusammenfassung Bei posterioren Schulterschmerzen sollte an eine Pathologie im Bereich des N. suprascapularis gedacht werden. Der Nerv kann in seinem Verlauf an der Incisura scapulae eingeklemmt werden oder durch eine Ruptur der Rotatorenmanschette von seinem anatomischen Verlauf abweichen und unter Zug geraten. Dies kann ein Grund fur persistierende Schmerzen auch nach erfolgreicher Rotatorenmanschettennaht sein. Diagnostisch ist die klinische und neurologische Untersuchung wegweisend, wahrend die diagnostische, radiologisch kontrollierte Testinfiltration (Sonographie oder Durchleuchtung) den aktuellen Goldstandard darstellt. Die arthroskopische Dekompression an der Incisura scapulae ist eine sichere und zuverlassige Methode, den Nerv zu befreien. Verschiedene Studien zeigen eine Verbesserung der Muskelfunktion und fuhren zu einer Schmerzreduktion.

Posterior Hindfoot Endoscopy in Athletes

Abstract: Zusammenfassung Hintergrund Ziel dieser Arbeit war es, die mittelfristigen Ergebnisse der posterioren Ruckfusendoskopie bei Sportlern zu prasentieren. Material und Methoden Insgesamt wurden 17 Patienten mit einem mittleren Alter von 27,9 ± 4,3 Jahren in diese retrospektive Studie eingeschlossen. Die mittlere Nachuntersuchungszeit betrug 5,4 ± 1,3 Jahre. Klinische Ergebnisse wurden untersucht anhand einer visuellen Punkteskala (VAS) sowie eines AOFAS (American Orthopaedic Foot & Ankle Society)-Hindfoot-Score. Auserdem analysierten wir die praoperativen und die postoperativen sportlichen Aktivitaten. Ergebnisse Zu den praoperativen Diagnosen gehorten schmerzhaftes Os trigonum (n = 9), Sehnenentzundung des M. flexor hallucis longus (n = 4), posteriores Ruckfusimpingement (n = 3) und Impingement der Peronealsehnen (n = 1). Das durchschnittliche Schmerzniveau verringerte sich von praoperativ VAS 5,6 ± 1,7 zum 0,6 ± 1,0 postoperativ (p Schlussfolgerungen Die posteriore Ruckfusendoskopie bei Sportlern fuhrt zu einer deutlichen Schmerzlinderung, funktionellen Verbesserung und Wiederaufnahme der sportlichen Aktivitaten. Evidenzebene Level IV