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1.  Minimally invasive ankle arthrodesis with a retrograde locking nail after failed fusion 
A retrograde nail with posterior-to-anterior (PA) locking into os calcis, talus and tibia was used to correct deformity and achieve fusion after failed fusion. A variety of methods have been published to achieve union of the ankle and subtalar joint in a failed fusion situation. We have studied a retrograde locking nail technique through a 2.5-cm incision in the non-weightbearing part of the sole of the foot. Remaining cartilage in the ankle joint, where necessary, was percutaneously removed through an anterior approach and the locking nail was inserted after reaming of os calcis, talus and tibia. Locking screw insertion was in the sagittal plane (p.a. direction), in talus os calcis and tibial diaphysis using a nail mounted jig. Ten patients were entered in the study (age 27-60 years). The initial aetiology for attempted fusion was post-traumatic in nine cases and rheumatic in one case. There were 25 previous operations in the cohort not leading to fusion. An additional temporary external fixator was used in four cases to reach and maintain the optimum position for the procedure. The intervention time was 30-75 min. Dynamisation of the nail was performed after four months under local anaesthesia. The mean duration of follow-up was 4 years (3-5.5 years). Radiologically and clinically, fusion was achieved in 16 weeks (range, 12-20 weeks). There was no loosening of the implant or implant failure. A leg length discrepancy was avoided using this technique. There was one complication with varus malunion in a heavy smoker which united after corrective osteotomy, revision nailing and bone grafting. Patient satisfaction was measured on a scale (not visual analogue) of 0 (not satisfied) to 10 (completely satisfied); overall satisfaction averaged 9.5 points (range, 6-10 points). The postoperative ankle-hindfoot score of the American Orthopedic Foot and Ankle Society averaged 73.5 points (range, 61-81 points). Retrograde locked nailing with locking in the sagittal plane is a reliable minimally invasive procedure to achieve fusion of the ankle and the subtalar joint after failed fusion.
PMCID: PMC2321722  PMID: 18427914
Ankle arthrodesis; Failed fusion; Retrograde nail; Calcaneotalotibial arthrodesis
2.  The use of a retrograde fixed-angle intramedullary nail for tibiocalcaneal arthrodesis after severe loss of the talus 
Tibiocalcaneal arthrodesis may be the only means of obtaining a painless and stable limb when there is loss of the talus. We present the early results of a prospective study on tibiocalcaneal arthrodesis using a latest-generation retrograde intramedullary nail. In the period 2006–2007, nine patients underwent tibiocalcaneal arthrodesis with retrograde intramedullary nailing. Five of these patients had infection-related loss of the talus. SF-36, AOFAS ankle-hindfoot, and Mazur Ankle Arthrodesis scores were obtained pre-fusion, and at 6 weeks, 6 months and 1 year post-fusion. The patients were also followed up clinically and radiologically. Previous surgical procedures, chronic musculoskeletal problems and other comorbidities, and complications were recorded and analyzed. All patients were available for initial follow-up and were subjectively satisfied with their outcomes. Solid fusion was achieved and fully confirmed in nine cases. One subject died 8 weeks postoperatively of a pulmonary embolism. One patient had recurrent infection. At 1 year, only one patient still needed NSAIDs regularly for pain relief. The AOFAS score improved significantly (P = 0.012) from 32.1 pre-fusion to 71.5 points at 1 year as did the Mazur score, which rose by 31.2 to 72.5 points at 1 year (P = 0.012). The SF-36 score improved significantly in the domains physical functioning, role limitations due to physical problems, bodily pain, vitality, social functioning and mental health, as did the Physical Component Summary Score. Retrograde intramedullary nailing for tibiocalcaneal arthrodesis can produce a good outcome. However, in the presence of infection, patient selection for intramedullary procedures must be carefully considered on a case-by-case basis.
PMCID: PMC2746277  PMID: 19756949
Talectomy; Tibiocalcaneal arthrodesis; Retrograde; Intramedullary nail; Ankle arthrodisis; Hindfoot
3.  The use of a retrograde fixed-angle intramedullary nail for tibiocalcaneal arthrodesis after severe loss of the talus 
Tibiocalcaneal arthrodesis may be the only means of obtaining a painless and stable limb when there is loss of the talus. We present the early results of a prospective study on tibiocalcaneal arthrodesis using a latest-generation retrograde intramedullary nail. In the period 2006–2007, nine patients underwent tibiocalcaneal arthrodesis with retrograde intramedullary nailing. Five of these patients had infection-related loss of the talus. SF-36, AOFAS ankle-hindfoot, and Mazur Ankle Arthrodesis scores were obtained pre-fusion, and at 6 weeks, 6 months and 1 year post-fusion. The patients were also followed up clinically and radiologically. Previous surgical procedures, chronic musculoskeletal problems and other comorbidities, and complications were recorded and analyzed. All patients were available for initial follow-up and were subjectively satisfied with their outcomes. Solid fusion was achieved and fully confirmed in nine cases. One subject died 8 weeks postoperatively of a pulmonary embolism. One patient had recurrent infection. At 1 year, only one patient still needed NSAIDs regularly for pain relief. The AOFAS score improved significantly (P = 0.012) from 32.1 pre-fusion to 71.5 points at 1 year as did the Mazur score, which rose by 31.2 to 72.5 points at 1 year (P = 0.012). The SF-36 score improved significantly in the domains physical functioning, role limitations due to physical problems, bodily pain, vitality, social functioning and mental health, as did the Physical Component Summary Score. Retrograde intramedullary nailing for tibiocalcaneal arthrodesis can produce a good outcome. However, in the presence of infection, patient selection for intramedullary procedures must be carefully considered on a case-by-case basis.
PMCID: PMC2746277  PMID: 19756949
Talectomy; Tibiocalcaneal arthrodesis; Retrograde; Intramedullary nail; Ankle arthrodisis; Hindfoot
4.  Surgical Technique: Static Intramedullary Nailing of the Femur and Tibia Without Intraoperative Fluoroscopy 
On a recent mission directed at definitive care for victims of the Haitian earthquake, the orthopaedic team developed a technique for freehand distal locking of femoral and tibial nails without intraoperative fluoroscopy or proximally mounted targeting jigs.
Description of Technique
After performing open antegrade or retrograde nailing by standard techniques, the freehand lock must be obtained before doing standard outrigger locking. This allows the surgeon to control the nail and deliver the locking hole in the nail to a unicortical drill hole in the femur. Before nail insertion, the distance of the desired locking hole is measured from the outrigger in a standard way such that it can be reproduced after the nail is inserted. Through a unicortical drill hole, the nail is palpated with the tip of a Kirschner wire and systematic maneuvers allow the Kirschner wire to palpate and fall into the locking hole. The Kirschner wire is tapped across the second cortex before drilling. The screw is inserted, and the ball-tipped insertion guidewire is placed back into the nail to palpate the crossing screw confirming position.
Patients and Methods
We treated 16 patients with 18 long bone fractures using the described technique. We assessed patients clinically and radiographically immediately postoperatively.
A total of 19 blind freehand interlocks were attempted, and 17 were successful as assessed by direct intraoperative observations and by postoperative radiographs.
We describe a simple technique for performing static locked intramedullary nailing of the femur and tibia without fluoroscopy. This technique was successful in most cases and is intended for use with any nailing system only when fluoroscopy or specialized systems for nailing without fluoroscopy are not available.
PMCID: PMC3210293  PMID: 21369767
5.  Clinical and radiological midterm results from using the Fixion expandable intramedullary nail in transverse and short oblique fractures of femur and tibia 
A locked nail is the principal method used to eliminate rotatory components in femoral and tibial fractures. Nevertheless, weight bearing is not directed onto the fracture site, slowing down the healing process; another possibility is to use a large-diameter nail and ream the canal to obtain as much adherence as possible and increase the grip, but this can cause a number of complications. The expandable nail is a new option that in theory should remove some problems with previous techniques.
Materials and methods
This was a retrospective nonrandomized study encompassing 21 femoral fractures and 27 tibial fractures in 45 patients. They were classified according to the AO classification. Clinical and radiological checks were done at one, three, and six months and at one year from the surgery in order to check for signs of clinical and radiological healing. A good alignment was considered to be the presence of a deformity of less than 5° in the sagittal and lateral planes and the absence of rotatory clinically evident problems. This protocol was adhered to up to six months after surgery by all of the patients, while only 62.2% performed the last control. The mean follow-up was 15 months. A second group of 48 consecutive fractures (24 femural and 24 tibial) treated with locked nail was created to compare surgical times.
Appropriate alignment was observed in all cases; the healing process appeared slower: radiological healing occurred in most cases at six months. The following complications were reported: a case of intraoperative fracture widening with no effect on the treatment; a case of a lesion of the tip of the nail with pneumatic system rupture that necessitated nail substitution; two cases of retarded consolidation at six months, with both tibial fractures treated successfully by intralesion platelet gel; a case of incarcerated nail on 17 removals, resolved by shearing. We had no cases of clinically evident compartment syndrome or pulmonary embolism.
The expandable Fixion nail presents significant advantages in the treatment of transverse and short oblique fractures of femur and tibia because it is easy to use, involves minimal X-ray exposure and can control rotations. Nevertheless, it high cost limits its use. We consider it as an alternative to locked nail.
PMCID: PMC2656989  PMID: 19384607
Fixion nail; Expandable nail; Trasverse fracture osteosynthesis
6.  Effect of anterior translation of the talus on outcomes of three-component total ankle arthroplasty 
Ankle osteoarthritis commonly involves sagittal malalignment with anterior translation of the talus relative to the tibia. Total ankle arthroplasty has become an increasingly popular treatment for patients with symptomatic ankle osteoarthritis. However, no comprehensive study has been conducted on the outcomes of total ankle arthroplasty for osteoarthritis with preoperative sagittal malalignment. The purpose of this study was to evaluate the effect of anterior translation of the talus on outcomes of three-component total ankle arthroplasty.
One hundred and four osteoarthritic ankles in 104 patients who underwent three-component total ankle arthroplasty were included in this study. The 104 ankles were divided into 2 groups: ankles with anteriorly translated talus (50 ankles), and ankles with non-translated talus (54 ankles). Clinical and radiographic outcomes were assessed in both groups. The mean follow-up duration was 42.8 ± 17.9 months (range, 24 to 95 months).
Forty-six (92%) of 50 ankles with anterior translation of the talus showed relocation of the talus within the mortise at 6 months, and 48 (96%) ankles were relocated at 12 months after total ankle arthroplasty. But, 2 (4%) ankles were not relocated until the final follow-up. The AOFAS scores, ankle range of motion, and radiographic outcomes showed no significant difference between the two groups at the final follow-up (p > 0.05 for each).
In majority of cases, the anteriorly translated talus in osteoarthritic ankles was restored to an anatomical position within 6 months after successful three-component total ankle arthroplasty. The clinical and radiographic outcomes in the osteoarthritic ankles with anteriorly translated talus group were comparable with those in non-translated talus group.
PMCID: PMC3766657  PMID: 24007555
Osteoarthritis; Total ankle arthroplasty; Three-component prosthesis; Anterior translation of the talus
7.  Comparative analysis of uniplanar external fixator and retrograde intramedullary nailing for ankle arthrodesis in diabetic Charcot's neuroarthropathy 
Indian Journal of Orthopaedics  2011;45(4):359-364.
Charcot's neuroarthropathy of ankle leads to instability, destruction of the joint with significant morbidity that may require an amputation. Aim of surgical treatment is to achieve painless stable plantigrade foot through arthrodesis. Achieving surgical arthrodesis in Charcot's neuroarthropathy has a high failure rate. This is a retrospective nonrandomized comparative study assessing the outcomes of tibio-talar arthrodesis for Charcot's neuroarthropathy treated by uniplanar external fixation assisted by external immobilization or retrograde intramedullary interlocked nailing.
Materials and Methods:
Records of the authors′ institution were reviewed to identify those patients who had undergone ankle fusion for diabetic neuroarthropathy from January 1998 to December 2008. A total of11 patients (six males and five females) with a mean age of 56 year and diabetes of a mean duration of 15.4 years with ankle tibio-talar arthrodesis using retrograde nailing or external fixator for Charcot's neuroarthropathy were enrolled for the analysis. Neuropathy was clinically diagnosed, documented and substantiated using the monofilament test. All procedures were performed in Eichenholz stage II/III.Six patients were treated with uniplanar external fixator, while the remaining five underwent retrograde intramedullary interlocking nail. The outcomes were measured for union radiologically, development of complications and clinical follow-up, according to digital archiving systems and old case notes.
All five (100%) patients treated by intramedullary nailing achieved radiological union on an average follow-up of 16 weeks. The external fixation group had significantly higher rate of complications with one amputation, four non unions (66.7%) and a delayed union which went on to full osseous union.
The retrograde intramedullary nailing for tibio-talar arthrodesis in Charcot's neuroarthropathy yielded significantly better outcomes as compared to the use of uniplanar external fixator.
PMCID: PMC3134023  PMID: 21772631
Charcot's diabetic neuropathy; retrograde intramedullary nailing; tibio-talar arthrodesis; uniplanar external fixator
8.  Implantation of INTERTAN™ nail in four patients with intertrochanteric fractures leading to single or comminute fractures: pitfalls and recommendations: a case series 
Intraoperative technical complications are occasionally encountered while implanting INTERTAN™ nails for intertrochanteric fractures. Surgeons need to pay attention to the difficulties they may encounter during the implantation of an INTERTAN™ nail.
Case presentation
We report four cases with intraoperative difficulties during the implantation of INTERTAN™ nails among Han Chinese patients from mainland China. In Case 1, during the operation on a 75-year-old woman, an anatomical specificity of excessive femoral shaft curvation at the coronal and sagittal planes was observed; a relatively smooth implantation was achieved by adjusting the entry point. In Case 2, due to fat obstruction, an INTERTAN™ nail was implanted at an oblique angle in 64-year-old obese woman, which resulted in an iatrogenic fracture of the proximal femur. In Case 3, an iatrogenic fracture of the distal femur developed in an 83-year-old woman because of violent hammering and underestimating of bone fragility. In Case 4, an iatrogenic fracture occurred in a 40-year-old woman around the distal locking slot during the drilling process.
Preoperative evaluation should be considered as an important preparation for the implantation of an INTERTAN™ nail. Full-length anteroposterior and lateral radiographs of the injured femur are necessary to confirm the anatomical specificity. The vertical trajectory as well as sufficient reaming is important in reducing the possibility of iatrogenic fractures, particularly for obese patients. In older patients, violent hammering should be avoided and full reaming is recommended even if the canal seems to be wide enough. For cases where hard fracture reduction is predicted, the strategy of open reduction and fixation with a dynamic hip screw seems to be more rational and should be considered as an alternative method.
PMCID: PMC4275765  PMID: 25416923
Implantation difficulties; Intertrochanteric fracture; Intertain; China; Reaming; Obese; Older
9.  Reconstruction after wide resection of the entire distal fibula in malignant bone tumours 
International Orthopaedics  2009;35(1):87-92.
In this study we present a series of patients (n = 11) with resection of the entire distal fibula in the case of sarcoma or metastasis. Moreover, we describe a new method to restore ankle stability with a tibiotalocalcaneal arthrodesis using a retrograde hindfoot nail (n = 4) in contrast to tibiotalar arthrodesis with screws (n = 5). The screw fixation failed in two patients due to osteopoenic bone. The crucial benefits of an arthrodesis with a retrograde nail are a stable arthrodesis, intramedullary stabilisation of the tibia and avoidance of extrinsic material in the wound area. An arthrodesis with a retrograde nail is a good alternative for reconstruction after a wide distal fibula resection. The additional arthrodesis of the subtalar joint was not associated with worse functional results in the MSTS and TESS scores.
PMCID: PMC3014490  PMID: 20039038
10.  Adjacent tissue involvement of acute inflammatory ankle arthritis on magnetic resonance imaging findings 
International Orthopaedics  2013;37(10):1943-1947.
The ankle joint and surrounding subtalar joint have several tendons in close proximity. This study was performed to investigate the concurrent adjacent tissue involvement on MRI findings when the surgical treatment is considered for an acute inflammatory arthritis of the ankle joint.
Consecutive patients with acute inflammatory ankle arthritis who visited the emergency room and underwent MRI were included. After interobserver reliability testing of MRI findings, adjacent tissue involvement in the acute inflammatory ankle arthritis were evaluated including flexor hallucis longus (FHL), flexor digitorum longus (FDL), tibialis posterior (TP), peroneus longus (PL), peroneus brevis (PB), extensor digitorum longus (EDL), tibialis anterior (Tib Ant), extensor hallucis longus (EHL), subtalar joint, talus, tibia, and calcaneus.
Twenty-five patients (mean age 57.8 years; 16 males and nine females) were included. Of the 25 patients, 23 showed FHL involvement, 21 FDL, 21 TP, 15 PL, 15 PB, three EDL, 21 subtalar joint, six talus, six tibia, and five calcaneus on MR images. No Tib Ant or EHL involvement was observed on MR findings in acute inflammatory ankle arthritis.
Patients with acute inflammatory ankle arthritis showed frequent concomitant surrounding tissue involvement on MRI, which included FHL, FDL, TP, and subtalar joint. This needs to be considered when surgical drainage is planned for acute inflammatory ankle arthritis.
PMCID: PMC3779583  PMID: 23703539
11.  Biomechanical and Neuromuscular Effects of Ankle Taping and Bracing 
Journal of Athletic Training  2002;37(4):436-445.
Objective: An extensive review of clinically relevant research is provided to assist clinicians in understanding the underlying mechanisms by which various ankle-support systems may provide beneficial effects. Strategies for management of different types of ankle ligament conditions are also discussed.
Background: Much of the literature pertaining to ankle instability and external support has focused on assessment of inward displacement of the hindfoot within the frontal plane. Some researchers have emphasized the importance of (1) pathologic rotary displacement of the talus within the transverse plane, (2) the frequent presence of subtalar joint ligament lesions, and (3) the interrelated effects of ankle support on deceleration of inversion velocity and facilitation of neuromuscular response.
Description: The traditional method for application of adhesive tape to the ankle primarily restricts inward displacement of the hindfoot within the frontal plane. The biomechanical rationale for a method of ankle taping that restricts lower leg rotation and triplanar displacement of the foot associated with subtalar motion is presented.
Clinical Advantages: The lateral subtalar-sling taping procedure may limit strain on the anterior talofibular ligament associated with subtalar inversion, restrain anterolateral rotary subluxation of the talus in the presence of ligament laxity, and protect the subtalar ligaments from excessive loading. The medial subtalar sling may reduce strain on the anterior-inferior tibiofibular syndesmosis and enhance hindfoot-to-forefoot force transfer during the push-off phase of the gait cycle.
PMCID: PMC164375  PMID: 12937565
ankle instability; subtalar joint injury; ankle dysfunction
12.  Use of a trabecular metal implant in ankle arthrodesis after failed total ankle replacement 
Acta Orthopaedica  2010;81(6):745-747.
Background and purpose
Arthrodesis after failed total ankle replacement is complicated and delayed union, nonunion, and shortening of the leg often occur—especially with large bone defects. We investigated the use of a trabecular metal implant and a retrograde intramedullary nail to obtain fusion.
Patients and methods
13 patients with a migrated or loose total ankle implant underwent arthrodesis with the use of a retrograde intramedullary nail through a trabecular metal Tibial Cone. The mean follow-up time was 1.4 (0.6–3.4) years.
At the last examination, 7 patients were pain-free, while 5 had some residual pain but were satisfied with the procedure. 1 patient was dissatisfied and experienced pain and swelling when walking. The implant-bone interfaces showed no radiographic zones or gaps in any patient, indicating union.
The method is a new way of simplifying and overcoming some of the problems of performing arthrodesis after failed total ankle replacement.
PMCID: PMC3216087  PMID: 21067435
13.  Tibiotalar arthrodesis for injuries of the talus 
Indian Journal of Orthopaedics  2008;42(1):87-90.
Fracture-dislocation of the talus is one of the most severe injuries of the ankle. Opinion varies widely as to the proper treatment of this injury. Since Blair's original description of the tibiotalar fusion in 1943, there is little mention in the literature of his method. The present study reports the results of tibiotalar arthrodesis with modification in Blair's technique.
Materials and Methods:
Eleven cases of modified Blair's tibiotalar arthrodesis were retrospectively studied. The average age was 32.4 years (range, 26-51 years). Six patients had posttraumatic avascular necrosis; five had neglected fracture-dislocation of the talus.
The mean followup is 8 years (range 3-12 years). Tibiotalar fusion was achieved in all the ankles at an average of 20.5 weeks (range 16-28 weeks). Nine cases having 15°-20° tibiopedal motion had excellent results and two ankles having 10°-15° of tibiopedal motion had good result.
We achieved good long term results with tibiotalar arthrodesis with modification in Blair technique. The principal modification in the present study is retention of the talar body while performing arthrodesis with anterior sliding graft. The retention of the talar body provides intraoperative stability and in the long term, the retained talar body shares the load transmitted to the anterior and middle subtalar joints thus resulting in improved hind foot function and gait.
PMCID: PMC2759590  PMID: 19823662
Anterior tibial sliding graft; arthrodesis; avascular necrosis of talus
14.  Assessment of Ankle-Subtalar-Joint–Complex Laxity Using an Instrumented Ankle Arthrometer: An Experimental Cadaveric Investigation 
Journal of Athletic Training  2002;37(4):467-474.
Objective: To show the relationship between direct measurements of tibial-calcaneal bone motion and instrumented measurements of ankle-subtalar-joint–complex laxity using a portable ankle arthrometer; to assess within and between-tester measurement reliability; and to determine if the ankle arthrometer can detect increased mechanical laxity of the ankle-subtalar-joint–complex after simulated injury of the lateral ankle ligaments.
Design and Setting: We used linear regression analysis to examine the relationship between direct measurements of tibial-calcaneal bone motion and instrumented measurements of ankle-subtalar-joint–complex laxity. An intraclass correlation coefficient (2,1) was calculated to determine intratester and intertester reliability for instrumented measurements of ankle-subtalar-joint–complex laxity. In addition, 2 separate, one-way, repeated-measures analyses of variance were used to compare instrumented measures of anteroposterior displacement and inversion-eversion rotation among the intact ankles after sectioning the anterior talofibular ligament and both the anterior talofibular and calcaneofibular ligaments. Data were collected in a biomechanics laboratory setting.
Subjects: Six fresh-frozen human-cadaver ankle specimens were studied.
Measurements: Testing involved the concurrent measurement of tibial-calcaneal bone motion and ankle-subtalar-joint–complex motion during the application of external loads. An instrumented ankle arthrometer was used to load the ankle in a controlled manner. Two spatial kinematic linkages measured the 3-dimensional motion of the calcaneus relative to the tibia and the motion of the arthrometer's footplate relative to the tibia.
Results: The correlation between tibial-calcaneal bone motion and instrumented measurement for anterior-posterior displacement was .878 (P = .0001). Its linear relationship with bone motion accounted for approximately 77% of the variance of the instrumented measurement. The correlation between tibial-calcaneal bone motion and instrumented measurement for inversion-eversion rotation was .858 (P = .0001), with approximately 74% of the variance of the instrumented measurement accounted for by its linear relationship with bone motion. High intratester and intertester reliability coefficients (ICC [2,1] = .80 to .97) were observed for instrumented measurements of ankle-subtalar-joint–complex laxity. In addition, ligamentous sectioning resulted in significantly increased ankle-subtalar-joint–complex laxity. When compared with the intact condition, sectioning both the anterior talofibular and calcaneofibular ligaments produced significant increases in anterior-posterior displacement (P = .0001) and inversion-eversion rotation (P = .002).
Conclusions: We found a strong relationship between tibial-calcaneal bone motion and arthrometric measurements of ankle-subtalar-joint–complex laxity. The instrumented ankle arthrometer may be suitable as a diagnostic tool for the evaluation of lateral ankle-ligament laxity.
PMCID: PMC164379  PMID: 12937569
mechanical laxity measurement; ankle instability; ankle sprain; ankle displacement
15.  CAM-Type Impingement in the Ankle 
Anterior ankle impingement with and without ankle osteoarthritis (OA) is a common condition. Bony impingement between the distal tibia and talus aggravated by dorsiflexion has been well described. The etiology of these impingement lesions remains controversial. This study describes a cam-type impingement of the ankle, in which the sagittal contour of the talar dome is a non-circular arc, causing pathologic contact with the anterior aspect of the tibial plafond during dorsiflexion, leading to abnormal ankle joint mechanics by limiting dorsiflexion.
A group of 269 consecutive adult patients from the University of Iowa Hospitals and Clinics who were treated for anterior bony impingement syndrome were evaluated as the study population. As a control group, 41 patients without any evidence of impingement or arthrosis were evaluated. Standardized standing lateral ankle radiographs were evaluated to determine the contour of the head/neck relationship in the talus. Two investigators made all the radiographic measurements and intra- and inter-observer reliability were measured.
34% of patients were found to have some anterior extension of the talar dome creating a loss of the normal concavity at the dorsal medial talar neck. A group of 36 patients (13%) were identified as having the most severe cam deformity in order to assess any correlation with coexisting radiographic abnormalities. In these patients, a cavo-varus foot type was more commonly observed. Comparison with a control group showed much lower rates of anterior-medial cam-type deformity of the talus.
Cam type impingement of the ankle is likely a distinct form of bony impingement of the ankle secondary to a morphological talar bony abnormality. Based on the findings of this study, this form of impingement may be related to a cavovarus foot type. In addition, there may be long term implications in the development of ankle OA.
Level of Evidence
Level III
PMCID: PMC3565388  PMID: 23576914
16.  Association of Ilizarov’s technique and intramedullary rodding in the treatment of congenital pseudarthrosis of the tibia 
Many surgical techniques have been published on how to treat congenital pseudoarthrosis of the tibia (CPT). We combined Ilizarov’s fixator with intramedullary nailing of the tibia and developed a procedure which combines the advantages of both methods: Ilizarov’s high fusion rate with alignment control and the protection against refracture provided by the intramedullary nail. The results of this approach are presented and discussed.
Material and methods
Seven boys and three girls aged 3–14 years (mean age 8 years 2 months) were treated using our combined technique. In six cases, the CPT was associated with neurofibromatosis. Two strategies were adopted: in six cases, a compression was applied on the bone defect, and in four cases, segmental bone transportation was performed before the compression procedure. The final follow-up (1.2–6.6 years) included a clinical and radiological examination.
Tibial union was achieved in nine cases without bone grafting. In one case, tibial union still remains uncertain, despite intertibiofibular bone grafting and additional compression procedures. Thirteen overall complications were noted, including three valgus deformity of the ankle. Bone transportation failed to achieve complete limb lengthening in three cases. One deep infection occurred 4 years after removal of the external fixator. The treatment for this included nail removal and antibiotic therapy for 3 months. Despite a permanent protection of orthosis, a refracture occurred 2 years after nail removal, reverting to the initial level of pseudarthrosis. Another surgical attempt using the same method was then performed with a satisfactory result.
The association of Ilizarov’s technique and intramedullary nailing achieved and maintained tibial union in nine of ten patients at final follow-up. It also allowed correction of axial deformities and prevented refracture. Despite the short duration of the follow-up and a high rate of complications in our series, this method can be useful in many cases of CPT in which healing has failed to occur despite many previous surgeries.
PMCID: PMC2656871  PMID: 19308541
Congenital pseudoarthrosis of the tibia; Ilizarov technique; Intramedullary nailing
17.  Fatigue behavior of Ilizarov frame versus tibial interlocking nail in a comminuted tibial fracture model: a biomechanical study 
Treatment options for comminuted tibial shaft fractures include plating, intramedullary nailing, and external fixation. No biomechanical comparison between an interlocking tibia nail with external fixation by an Ilizarov frame has been reported to date. In the present study, we compared the fatigue behaviour of Ilizarov frames to interlocking intramedullary nails in a comminuted tibial fracture model under a combined loading of axial compression, bending and torsion. Our goal was to determine the biomechanical characteristics, stability and durability for each device over a clinically relevant three month testing period. The study hypothesis was that differences in the mechanical properties may account for differing clinical results and provide information applicable to clinical decision making for comminuted tibia shaft fractures.
In this biomechanical study, 12 composite tibial bone models with a comminuted fracture and a 25 mm diaphyseal gap were investigated. Of these, six models were stabilized with a 180-mm four-ring Ilizarov frame, and six models were minimally reamed and stabilized with a 10 mm statically locked Russell-Taylor Delta™ tibial nail. After measuring the pre-fatigue axial compression bending and torsion stiffness, each model was loaded under a sinusoidal cyclic combined loading of axial compression (2.8/28 lbf; 12.46/124.6 N) and torque (1.7/17 lbf-in; 0.19/1.92 Nm) at a frequency of 3 Hz. The test was performed until failure (implant breakage or ≥ 5° angulations and/or 2 cm shortening) occurred or until 252,000 cycles were completed, which corresponds to approximately three months testing period.
In all 12 models, both the Ilizarov frame and the interlocking tibia nail were able to maintain fracture stability of the tibial defect and to complete the full 252,000 cycles during the entire study period of three months. A significantly higher stiffness to axial compression and torsion was demonstrated by the tibial interlocking nail model, while the Ilizarov frame provided a significantly increased range of axial micromotion.
This is the first study, to our knowledge, which compares the biomechanical properties of an intramedullary nail to an external Ilizarov frame to cyclic axial loading and torsion in a comminuted tibia shaft fracture model. Prospective, randomized trials comparing Ilizarov frames and interlocked tibial nails are needed to clarify the clinical impact of these biomechanical findings.
PMCID: PMC1702341  PMID: 17156471
18.  Discriminating Between Copers and People With Chronic Ankle Instability 
Journal of Athletic Training  2012;47(2):136-142.
Differences in various outcome measures have been identified between people who have sprained their ankles but have no residual symptoms (copers) and people with chronic ankle instability (CAI). However, the diagnostic utility of the reported outcome measures has rarely been determined. Identifying outcome measures capable of predicting who is less likely to develop CAI could improve rehabilitation protocols and increase the efficiency of these measures.
To determine the diagnostic utility and cutoff scores of perceptual, mechanical, and sensorimotor outcome measures between copers and people with CAI by using receiver operating characteristic curves.
Case-control study.
Sports medicine research laboratory.
Patients or Other Participants:
Twenty-four copers (12 men, 12 women; age = 20.8 ± 1.5 years, height = 173 ± 11 cm, mass = 78 ± 27 kg) and 24 people with CAI (12 men, 12 women; age = 21.7 ± 2.8 years, height = 175 ± 13 cm, mass = 71 ± 13 kg) participated.
Self-reported disability questionnaires, radiographic images, and a single-legged hop stabilization test.
Main Outcome Measure(s):
Perceptual outcomes included scores on the Foot and Ankle Disability Index (FADI), FADI-Sport, and a self-report questionnaire of ankle function. Mechanically, talar position was quantified by measuring the distance from the anterior tibia to the anterior talus in the sagittal plane. Sensorimotor outcomes were the dynamic postural stability index and directional indices, which were calculated during a single-legged hop stabilization task.
Perceptual outcomes demonstrated diagnostic accuracy (range, 0.79–0.91), with 95% confidence intervals ranging from 0.65 to 1.00. Sensorimotor outcomes also were able to discriminate between copers and people with CAI but with less accuracy (range, 0.69–0.70), with 95% confidence intervals ranging from 0.37 to 0.86. The mechanical outcome demonstrated poor diagnostic accuracy (0.52).
The greatest diagnostic utility scores were achieved by the self-assessed disability questionnaires, which indicated that perceptual outcomes had the greatest ability to accurately predict people who became copers after their initial injuries. However, the diversity of outcome measures that discriminated between copers and people with CAI indicated that the causal mechanism of CAI is probably multifactorial.
PMCID: PMC3418124  PMID: 22488278
self-report disability; positional fault; dynamic postural control
19.  The distal fascicle of the anterior inferior tibiofibular ligament as a cause of tibiotalar impingement syndrome: a current concepts review 
Impingement syndromes of the ankle involve either osseous or soft tissue impingement and can be anterior, anterolateral, or posterior. Ankle impingement syndromes are painful conditions caused by the friction of joint tissues, which are both the cause and the effect of altered joint biomechanics. The distal fascicle of the anterior inferior tibiofibular ligament (AITFL) is possible cause of anterior impingement. The objective of this article was to review the literature concerning the anatomy, pathogenesis, symptoms and treatment of the AITFL impingement and finally to formulate treatment recommendations. The AITFL starts from the distal tibia, 5 mm in average above the articular surface, and descends obliquely between the adjacent margins of the tibia and fibula, anterior to the syndesmosis to the anterior aspect of the lateral malleolus. The incidence of the accessory fascicle differs very widely in the several studies. The presence of the distal fascicle of the AITFL and also the contact with the anterolateral talus is probably a normal finding. It may become pathological, due to anatomical variations and/or anterolateral instability of the ankle resulting from an anterior talofibular ligament injury. When observed during an ankle arthroscopy, the surgeon should look for the criteria described to decide whether it is pathological and considering resection of the distal fascicle. The presence of the AITFL and the contact with the talus is a normal finding. An impingement of the AITFL can result from an anatomical variant or anteroposterior instability of the ankle. The diagnosis of ligamentous impingement in the anterior aspect of the ankle should be considered in patients who have chronic ankle pain in the anterolateral aspect of the ankle after an inversion injury and have a stable ankle, normal plain radiographs, and isolated point tenderness on the anterolateral aspect of the talar dome and in the anteroinferior tibiofibular ligament. The impingement syndrome can be treated arthroscopically.
PMCID: PMC1915597  PMID: 17237964
Ankle; Impingement syndrome; Anterior inferior tibiofibular ligament; Accessory fascicle
20.  Fatigue performance of angle-stable tibial nail interlocking screws 
International Orthopaedics  2012;37(1):113-118.
Tibial nail interlocking screw failure often occurs during delayed fracture consolidation or at early weight bearing of nailed unstable fractures, in general when high implant stress could not be reduced by other means. Is there a biomechanical improvement in long-term performance of angle stable locking screws compared to conventional locking screws for distal locking of intramedullary tibial nails?
Surrogate bones of human tibiae were cut in the distal third and distal locking of the 10 mm intramedullary tibial nail was performed with either two angle stable locking screws or two conventional locking screws in the mediolateral plane. Six specimens per group were mechanically tested under quasi-static and cyclic axial loading with constantly increasing force.
Angle stable locking screw constructs exhibited significantly higher stiffness values (7,809 N/mm ± 647, mean ± SD) than conventional locking screw constructs (6,614 N/mm ± 859, p = 0.025). Angle stable locking screw constructs provided a longer fatigue life, expressed in a significantly higher number of cycles to failure (187,200 ± 18,100) compared to conventional locking screw constructs (128,700 ± 7,000, p = 0.004).
Fatigue performance of locking screws can be ameliorated by the use of angle stable locking screws, being especially important if the nail acts as load carrier and an improved stability during fracture healing is needed.
PMCID: PMC3532652  PMID: 22875484
21.  What is the risk of stress risers for interprosthetic fractures of the femur? A biomechanical analysis 
International Orthopaedics  2012;36(12):2441-2446.
Due to increasing life expectancy we see a rising number of joint replacements. Along with the proximal prosthesis in the femur, more and more people have a second implant on the distal ipsilateral side. This might be a retrograde nail or a locking plate to treat distal femur fractures or a constrained knee prosthesis in the case of severe arthrosis. All these constructs can lead to fractures between the implants. The goal of this study was to evaluate the risk of stress risers for interprosthetic fractures of the femur.
Thirty human cadaveric femurs were divided into five groups: (1) femurs with a prosthesis on the proximal side only, (2) hip prosthesis on the proximal end and a distal femur nail, (3) femurs with both a hip prosthesis and a constrained knee prosthesis, (4) femurs with a hip prosthesis on the proximal side and a 4.5-mm distal femur locking plate; the locking plate was 230 mm in length, with ten holes in the shaft, and (5) femurs with a proximal hip prosthesis and a 4.5-mm distal femur locking plate; the locking plate was 342 mm in length, with 16 holes in the shaft.
Femurs with a hip prosthesis and knee prosthesis showed significantly higher required fracture force compared to femurs with a hip prosthesis and a distal retrograde nail. Femurs with a distal locking plate of either length showed a higher required fracture force than those with the retrograde nail.
The highest risk for a fracture in the femur with an existing hip prosthesis comes with a retrograde nail. A distal locking plate for the treatment of supracondylar fractures leads to a higher required fracture force. The implantation of a constrained knee prosthesis that is not loosened on the ipsilateral side does not increase the risk for a fracture.
PMCID: PMC3508046  PMID: 23132503
22.  Expandable self-locking nail in the management of closed diaphyseal fractures of femur and tibia 
Indian Journal of Orthopaedics  2009;43(3):264-270.
Intramedullary fixation is the treatment of choice for closed diaphyseal fractures of femur and tibia. The axial and rotational stability of conventional interlocking nails depends primarily on locking screws. This method uses increased operating time and increased radiation exposure. An intramedullary implant that can minimize these disadvantages is obviously better. Expandable intramedullary nail does not rely on interlocking screws and achieves axial and rotational stability on hydraulic expansion of the nail. We analyzed 32 simple fractures of shaft of femur and tibia treated by self-locking expandable nail.
Materials and Methods:
Intramedullary fixation was done by using self-locking, expandable nail in 32 patients of closed diaphyseal fractures of tibia (n = 10) and femur (n = 22). The various modes of injury were road traffic accidents (n = 21), fall from height (n = 8), simple fall (n = 2), and pathological fracture (n = 1). Among femoral diaphyseal fractures 16 were males and six females, average age being 33 yrs (range, 18- 62 yrs). Seventeen patients had AO type A (A1 (n = 3), A2 (n = 4), A3 (n = 10)) and 5 patients had AO type B (B1 (n = 2), B2 (n = 2), B3 (n = 1)) fractures. Eight patients having tibial diaphyseal fractures were males and two were females; average age was 29.2 (range, 18- 55 yrs). Seven were AO type A (A1 (n = 2), A2 (n = 3), A3 (n = 2)) and three were AO type B (B1 (n = 1), B2 (n = 1), and B3 (n = 1)). We performed closed (n = 27) or open reduction (n = 5) and internal fixation with expandable nail to stabilize these fractures. The total radiation exposure during surgery was less as no locking screws were required. Early mobilisation and weight-bearing was started depending on fracture personality and evidences of healing. Absence of localised tenderness and pain on walking was considered clinical criteria for union, radiographic criteria of union being continuity in at least in three cortices in both AP and lateral views. Patients were followed for at least one year.
The average operative time was 90 min (range, 55-125 min) for femoral fractures and 53 min (range, 25-115 min) for tibial fractures. Radiation exposure was minimum, average being 84 seconds (range, 54-132) for femoral fractures and 54 seconds (range, 36-78) for tibial fractures. All fractures healed, but few had complications, such as infection (one case with tibial fracture) bent femoral nail with malunion (n = 1), and delayed union (n = 3; 2 cases in femur and 1 case in tibia). Mean time of union was 5.1 months (range, 4-10½ months) for femoral fractures and 4.8 months (range, 3-9 months) for tibial fractures.
We found the nail very easy to use with effective fixation in AO type A and B fractures in our setting. Less surgical time is required with minimum complications. The main advantage of the expandable nail is that if affords. satisfactory axial, rotatory, and bending stability with decreased radiation exposure to operating staff and the patient.
PMCID: PMC2762176  PMID: 19838349
Diaphyseal fracture femur; diaphysial fracture tibia; expandable nail; self-locking nail; radiation risk
23.  Salvage of Diffuse Ankle Osteomyelitis by Single-Stage Resection and Circumferential Frame Compression Arthrodesis 
Salvage of diffuse ankle osteomyelitis, especially in compromised hosts, is a challenging problem. The purpose of this report was to evaluate early complications and results using a standardized salvage protocol. Eight patients with diffuse ankle osteomyelitis were treated by resection of all infected tissue and hybrid-frame compression arthrodesis. At presentation, five had open wounds. According to the Cierny/Mader classification, all had diffuse anatomic involvement and six of eight were compromised hosts. Seven had central distal tibial column involvement and one had primarily talar involvement. Surgical technique involved a two-incision approach, removal of all infected material and application of a compression circumferential frame with five thin wires across the foot, two across the tibia and two half-pins in the tibia. Fusion of eight ankles and four subtalar joints was attempted. All patients received six weeks of intravenous antibiotics. Open wounds were treated with wound vacuum assisted closure (VACs) devices until closure was achieved. Frames were removed at three months and walking casts were applied for one to two more months. Ankle sepsis was eradicated in all patients. Seven of eight ankles fused at an average of 13.5 weeks (range, 10 to 16 weeks). One limb required below-knee amputation (BKA) at five weeks due to nonreconstructible vascular insufficiency. Three of four subtalar joints fused. Fixation problems included two pin-track infections cleared with oral cephalexin and one broken half-pin. Two diabetic Charcot patients required long-term ankle-foot orthosis (AFO) use due to subtalar instability. At average 3.4-year follow-up, none of the seven fused ankles has required further surgery. Use of this standardized salvage treatment protocol for these difficult problems in selected patients was effective with a relatively low associated complication rate.
PMCID: PMC1888789  PMID: 16089072
24.  Low success rate of non-intervention after breakage of interlocking nails 
International Orthopaedics  2005;29(2):105-108.
We followed 12 patients with nailed femoral shaft fractures in which breakage of the static locked nail occurred during fracture treatment. Only two fractures united. The remaining ten fractures had to be treated with exchange nailing after a median of 10 (4–14) months. Nine fractures healed after a median of 5 (4–7) months and one was lost to follow-up. Although breakage of a proximal static reamed femoral locked nail may imitate the effect of dynamisation, the success rate is low. Early exchange nailing is a more successful option to achieve fracture union.
PMCID: PMC3474503  PMID: 15685454
25.  Study to prospectively evaluate reamed intramedually nails in patients with tibial fractures (S.P.R.I.N.T.): Study rationale and design 
Surgeons agree on the benefits of operative treatment of tibial fractures – the most common of long bone fractures – with an intramedullary rod or nail. Rates of re-operation remain high – between 23% and 60% in prior trials – and the two alternative nailing approaches, reamed or non-reamed, each have a compelling biological rationale and strong proponents, resulting in ongoing controversy regarding which is better.
The objective of this trial was to assess the impact of reamed versus non-reamed intramedullary nailing on rates of re-operation in patients with open and closed fractures of the tibial shaft. The study to prospectively evaluate reamed intramedullary nails in tibial fractures (S.P.R.I.N.T) was a multi-center, randomized trial including 29 clinical sites in Canada, the United States and the Netherlands which enrolled 1200 skeletally mature patients with open (Gustilo Types I-IIIB) or closed (Tscherne Types 0–3) fractures of the tibial shaft amenable to surgical treatment with an intramedullary nail. Patients received a statically locked intramedullary nail with either reamed or non-reamed insertion. The first strategy involved fixation of the fracture with an intramedullary nail following reaming to enlarge the intramedullary canal (Reamed Group). The second treatment strategy involved fixation of the fracture with an intramedullary nail without prior reaming of the intramedullary canal (Non-Reamed Group). Patients, outcome assessors, and data analysts were blinded to treatment allocation. Peri-operative care was standardized, and re-operations before 6 months were proscribed. Patients were followed at discharge, 2 weeks post-discharge, and at 6 weeks, 3, 6, 9, and 12 months post surgery. A committee, blinded to allocation, adjudicated all outcomes.
The primary outcome was re-operation to promote healing, treat infection, or preserve the limb (fasciotomy for compartment syndrome after nailing). The primary outcome was a composite comprising the following re-operations: bone grafts, implant exchanges, and dynamizations, in patients with fracture gaps less than 1 cm post intramedullary nail insertion. Infections and fasciotomies were considered events irrespective of the fracture gap. We planned a priori to conduct a subgroup analysis of outcomes in patients with open and closed fractures. S.P.R.I.N.T is the largest collaborative trial evaluating alternative orthopaedic surgical interventions in patients with tibial shaft fractures. The methodological rigor will set new benchmarks for future trials in the field and its results will have important impact on patient care. The S.P.R.I.N.T trial was registered [ID NCT00038129] and received research ethics approval (REB#99-077).
PMCID: PMC2446397  PMID: 18573205

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