Acute and chronic lateral ankle instability in the athlete
Chan, Keith W; Ding, Bryan C; Mroczek, Kenneth J
Ankle sprain injuries are the most common injury sustained during sporting activities. Three-quarters of ankle injuries involve the lateral ligamentous complex, comprised of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). The most common mechanism of injury in lateral ankle sprains occurs with forced plantar flexion and inversion of the ankle as the body's center of gravity rolls over the ankle. The ATFL followed by the CFL are the most commonly injured ligaments. Eighty percent of acute ankle sprains make a full recovery with conservative management, while 20% of acute ankle sprains develop mechanical or functional instability, resulting in chronic ankle instability. Treatment of acute ankle sprains generally can be successfully managed with a short period of immobilization that is followed by functional rehabilitation. Patients with chronic ankle instability who fail functional rehabilitation are best treated with a Brostrom-Gould anatomic repair or, in those patients with poor tissue quality or undergoing revision surgery, an anatomic reconstruction
Post-traumatic ankle arthritis
Weatherall, Justin M; Mroczek, Kenneth; McLaurin, Toni; Ding, Bryan; Tejwani, Nirmal
Post-traumatic ankle arthritis can be a very disabling condition especially in young patients. Localization of the pain is important to allow appropriate treatment. Non-surgical treatment options include anti-inflammatory medications and use of bracing. Multiple surgical options range from joint sparing procedures for the younger patient to total ankle replacement for the older, less active patient. Arthrodesis remains the gold standard and is the procedure of choice for younger patients who are heavy laborers and in patients with severe arthritis who are not candidates for a total ankle replacement. Joint sparing operations include allograft resurfacing, arthroscopic debridement and osteophyte resection, joint distraction arthroplasty, and supramalleolar osteotomy. In older low demand patients, the surgeon may consider a total ankle arthroplasty as an alternative to arthrodesis.
Fractures of the proximal fifth metatarsal - keeping up with the joneses
Ding, Bryan C; Weatherall, Justin M; Mroczek, Kenneth J; Sheskier, Steven C
Fractures of the proximal fifth metatarsal are among the most common fractures of the foot. History, physical examination, and subsequent radiographic work-up can help with the diagnosis of such a fracture. Many fractures of the proximal fifth metatarsal can have an associated prodrome, thereby establishing a level of chronicity to the problem. Identification of the location of the fracture plane within the proximal fifth metatarsal can have prognostic implications in regards to fracture union rate and guide treatment options, due to the particular vascular anatomy of the region. Additional findings on physical exam, such as heel varus, can also impact prognosis and treatment options. Treatments can range from nonoperative to operative modalities, and time to weightbearing can vary. Within the realm of operative treatment, identification of certain parameters can aid in successful reduction and fixation of the fracture and thus impact healing. Careful consideration of the patient's particular constellation of social and professional needs, clinical and radiographic parameters, and acceptance of different options can help guide treatment recommendations in the individual patient.
Comparative functional outcome of AO/OTA type C distal humerus fractures: open injuries do worse than closed fractures
Min, William; Ding, Bryan C; Tejwani, Nirmal C
BACKGROUND: Open distal humerus fractures present significant soft-tissue injury and bone devitalization that require prompt irrigation and debridement, temporization, and soft-tissue coverage. METHODS: This case-control comparison of open and closed AO type C fractures of the distal humerus tests the null hypothesis that there is no difference in the outcomes and prognosis of open versus closed distal humerus fractures treated operatively. Outcomes were determined clinically and radiographically and reported by the Short Musculoskeletal Function Assessment, the Short Form-36,and the Mayo Elbow Performance Index. RESULTS: Twenty-eight matched cohort patients treated by operative fixation were identified (14 open and 14 closed injuries), with average follow-up 98.9 weeks (range, 52-160 weeks). The average time to osseous healing after definitive treatment was 24.7 weeks for open fractures, when compared with 18.7 weeks for the closed group (p = 0.085). The average range of motion at final follow-up for open fractures was 82.5 degrees, versus 108.7 degrees for the closed group (p = 0.03). Short form-36 was significantly poorer(p = 0.002) in the open group (57.9) when compared with the closed group (79.0). CONCLUSIONS: When compared with closed fractures, open distal humerus fractures have worse functional outcome scores and decreased range of motion. Patients with open fractures also demonstrated a trend toward having higher complication rates, prolonged times to union, and higher rates of persistent nerve deficits requiring further surgery.
Staged versus acute definitive management of open distal humerus fractures
Min, William; Ding, Bryan C; Tejwani, Nirmal C
BACKGROUND: : Open distal humerus fractures are associated with soft tissue and bony injury. This study compares the results of a staged protocol using initial joint spanning external fixation and delayed definitive fixation to acute definitive fixation. METHODS: : Treated open distal humerus fractures were retrospectively reviewed, with patients examined at 2 weeks, 6 weeks, 12 weeks, 26 weeks, and 52 weeks after definitive surgery. Outcomes were determined radiographically by union rate and clinically by range of motion, Short Musculoskeletal Function Assessment, Short Form-36, and Mayo Elbow Performance Index. RESULTS: : Fourteen treated patients with open AO/OTA type 13-C3 distal humerus fractures, with average patient age 52.7 years and average follow-up 98.6 weeks, were identified. All fractures were treated with initial irrigation and debridement emergently and either spanning external fixation in eight patients or primary definitive internal fixation in six patients. All fractures healed, with average time to osseous healing, in 25.7 weeks versus 23.4 weeks (p = 0.7) in staged versus primary definitive treatment, respectively. Elbow range of motion on final follow-up was 73.75 degrees versus 94.17 degrees (p = 0.22). Complications included nonunions, heterotopic ossification, infection, and persistent ulnar nerve deficit. Average functional outcomes scores for staged management versus primary internal fixation were Short Form-36, 50.2 versus 68.2 (p = 0.065); Short Musculoskeletal Function Assessment, 33.5 versus 12.5 (p = 0.078); and Mayo Elbow Performance Index, 55.6 versus 84.2 (p = 0.011), respectively. CONCLUSIONS: : Open distal humerus fractures had poor outcomes relative to normative functional scores; however, this is possibly due to more severe soft tissue injuries that were felt better managed with staged management at the time of presentation
Technical Tip: Use of the Kerrison Rongeur Through a Single-Incision Exposure for Resection of Haglund's Deformity
Min, William; Ding, Bryan C; Sheskier, Steven
Open distal humerus fractures--review of the literature
Min, William; Anwar, Abbas; Ding, Bryan C; Tejwani, Nirmal C
Fractures of the distal humerus can be difficult to treat due to the periarticular nature of these injuries and the complexity of the elbow joint. Although anatomic and timely repair of the distal humerus with meticulous handling of soft tissues and appropriate postoperative therapy all help to optimize results, an open fracture presents other challenges that may limit successful outcomes in spite of these measures. Open fractures have been found to affect younger males involved in high-energy injuries, as well as older, osteoporotic females involved in lower energy situations. Successful management of these injuries requires urgent and aggressive soft tissue management, skeletal stabilization, and treatment of neurovascular insult (if applicable). This article presents a review of the current literature available concerning the epidemiology, assessment and examination, treatment options, complications, and outcomes of patients with open distal humerus fractures