Increased Risk of Nonunion and Charcot Arthropathy After Ankle Fracture in People With Diabetes

The aim of this study was to evaluate the frequency of complications after an ankle fracture in patients with and without diabetes and to evaluate risk factors for nonunion. We conducted a retrospective study of 439 patients with ankle fractures (31.7% had diabetes) and followed them for 1 year or until the fracture healed. The fracture severity and determination of nonunion and Charcot arthropathy were determined from independent evaluation of radiographs by 2 members of the research team. Nonunion was defined as a fracture that did not heal within 6 months of the fracture. The majority of patients were women (67% in each group). The risk of complications was significantly higher in patients with diabetes compared with those without diabetes. The odds ratio (OR) and 95% confidence interval (CI) for nonunion was 6.5 (3.4 to 12.8); for Charcot arthropathy, 7.6 (2.3 to 21.0); for wounds, 1.8 (1.1 to 2.9); for infection, 2.8 (1.4 to 5.7); and for amputation, 6.6 (0.98 to 80.0). In the logistical regression analysis, 6 factors were associated with fracture nonunion: dialysis (7.7; 1.7 to 35.2), diabetes (3.3; 1.5 to 7.4), fracture severity (bi- and trimalleolar fractures) (4.9; 1.4 to 18.0), beta blockers (2.5; 1.1 to 5.4), steroids (3.1; 1.2 to 7.7), and infection (3.7; 1.2 to 11.3). The results of the study demonstrate the increased risk of complications after an ankle fracture among patients with diabetes, dialysis, or open fractures and those using steroids and beta blockers. Further work is needed to identify areas for risk reduction.     

Why X-rays? The importance of radiographs in spine surgery

Despite the advances made in high-resolution spinal imaging, plain films (radiographs or x-rays) remain a cornerstone of evaluating and caring for spine patients in the preoperative, intraoperative, and postoperative settings. Although often undervalued when compared with more advanced imaging such as MRIs or CT scans, plain films provide surgeons invaluable information that other imaging modalities oftentimes cannot. In addition to their use during surgery for localization or evaluation of hardware placement, x-rays provide an overall image of a patient's spine, are useful in evaluating hardware complications, allow detailed assessment of alignment and stability and allow for repeated images in clinic during follow-up. Plain films continue to provide critical information that cannot be obtained with other imaging modalities, and they remain central to providing optimal care for spine patients.     

Editorial Commentary: Stem Cells in Rotator Cuff Surgery: In Search of the Holy Grail

The use of stem cells in orthopaedics remains a controversial topic, stem cells remain experimental, and significant concerns exist. Studies evaluating diagnoses that may spontaneously resolve could be of low value absent a control group. Only same-day harvest of minimally manipulated stem cells is approved for use in the United States, and these minimally manipulated products may contain insufficient cells to affect outcomes. Extensively cultured cells do not qualify for use in the United States outside of an approved Investigational New Drug Application. Moreover, in other arenas, significant, serious adverse events have been reported after the use of manipulated stem cells. Both the US Food and Drug Administration and American Academy of Orthopaedic Surgeons have recognized the potential for abuse regarding this evolving technology. Published results using stems cells to treat rotator cuff disease are inconsistent, and the optimum source and preparation of the stem cells remains unknown.     

Posterior clearance increases the knee extension angle in cruciate retaining type total knee arthroplasty: Intraoperative evaluation using a navigation system

BackgroundPosterior osteophyte of the femur can impinge on the tibia insert in total knee arthroplasty (TKA). Although osteophyte removal [posterior clearance (PC)] improves the flexion angle, its influence on the gaps and extension angle are unclear. This study investigated the effect of PC on the gaps and range of motion (ROM) using a navigation system, as well as PC's relationship with osteophyte size.MethodsTwenty-seven knees that underwent cruciate-retaining (CR)-type TKA were examined. Before and after PC, the ROM, hip-knee-ankle (HKA) angle, and flexion and extension gaps were recorded using a navigation system. Osteophyte size was measured in the lateral view in radiographs, and in the sagittal and axial planes of computed tomography (CT) images. The effects of PC on the gaps and ROM were analysed statistically.ResultsPC caused the extension gap to increase by 0.7 ± 0.9 mm in the medial (p < 0.001), and 0.9 ± 1.5 mm in the lateral compartment (p = 0.006). The extension angle increased by 4.9 ± 1.6°, flexion angle increased by 6.5 ± 5.0°, and HKA decreased by 0.3°. The increase in extension angle by PC was significantly correlated with the preoperative HKA angle (r = 0.594) and with the osteophyte area in radiographs and CT (r = 0.626 to 0.681).ConclusionsThe extension and flexion gaps increased less than 1 mm in the medial and lateral compartments. PC achieving an additional 5° extension angle could promote full extension in severely deformed knees with a large posterior osteophyte. The extension angle increase by PC was correlated with the preoperative HKA angle and osteophyte size.     

Posterior Tibial Tendinopathy and Osteopenia as Primary Symptoms of Celiac Disease: A Case Report

This case report describes posterior tibial tendon (PTT) tendinopathy, valgus deformity with tenosynovitis, and osteopenia at the medial malleolus as the primary symptoms of a young patient with celiac disease (CD) without gastrointestinal symptoms. CD is an autoimmune condition that is a chronic inflammatory disorder of the small intestine triggered by ingestion of gluten in individuals with a particular genetic background. Without typical gastrointestinal symptoms, CD patients are often misdiagnosed or undiagnosed. The patient was diagnosed with CD by duodenal biopsy. He underwent a surgical procedure, including medial displacement calcaneal osteotomy, tenosynovectomy of the PTT and flexor digitorum longus (FDL), FDL transfer to the navicular for a pes planovalgus deformity, and drilling of the medial malleolus for a stress reaction. The mechanism of the PTT tear and associated heel valgus deformity was assumed to be related to the fact that his heel alignment on the affected side changed gradually from normal to valgus and pes planus owing to CD and mechanical stress, because his normal-side heel alignment was neutral before surgery and at final follow-up. His operated ankle was pain-free, with full range of motion, 1.5 years after surgery. The patient was able to restart running and exercise gradually. Foot and ankle specialists should consider the possibility of CD in patients presenting with a PTT tear without injury or trauma and osteopenia with no obvious reason.     

The value of a pantaloon cast test in surgical decision making for chronic low back pain patients: a systematic review of the literature supplemented with a prospective cohort study

The results of lumbar fusion in chronic low back pain (LBP) patients vary considerably, and there is a need for proper patient selection. Lumbosacral orthoses have been widely used to predict outcome, however, with little scientific support. The aim of the present study was to determine the value of a pantaloon cast test in selecting chronic LBP patients for lumbar fusion or conservative management. First, a systematic review of the literature was carried out in which two independent reviewers identified studies in Medline, Cochrane and Current Contents databases. Three papers met the selection criteria. In the only study with a control group, a significantly better outcome after fusion compared to conservative treatment was found in patients who reported significant pain relief while in a cast (i.e. a positive cast test). The results of lumbar fusion, however, were not significantly different for patients with a positive and those with a negative cast test. In addition to the review, a clinical cohort study of 257 LBP patients, who had been allocated to either lumbar fusion or conservative management by a temporary external transpedicular fixation trial, was performed. Prior to allocation, all had undergone a pantaloon cast test. Patients with no history of prior spine surgery and with a positive pantaloon cast test had a better outcome after lumbar fusion than those treated conservatively (P = 0.002, χ ² test). In patients with previous spine operations the outcomes were poor and the test was of no value. From the literature and the present patient cohort, it was concluded that only in chronic LBP patients without prior spine surgery, a pantaloon cast test with substantial pain relief suggests a favorable outcome of lumbar fusion compared to conservative management. The test has no value in patients who have had previous spine surgery.     

全脊柱截骨矫正严重后凸畸形

[目的]探讨全脊柱截骨矫正脊柱后凸的治疗经验。[方法]全脊柱截骨加椎弓根钉内固定系统闭合及植骨矫正脊柱后凸。[结果]于1984～2005年采用上述方法治疗50例病人。术后全组病例均未发生脊髓损伤，术后临床症状得到不同程度的改善。经历2～15a平均2．4a随访，X线CT复查示螺钉位置良好，无松动断钉。植骨3个月后均达到满意融合。[结论]经全脊柱截骨加有效的内固定手术不仅手术视野开阔操作安全方便；而且截骨和内固定相结合同时完成，是治疗脊柱后凸目前更完善并不断改进一种好方法。     

导航系统辅助下颈椎椎弓根螺钉置钉准确性的实验研究

目的：评价导航系统辅助下颈椎（C3～C7）椎弓根螺钉内固定置钉的准确性.方法：将32具成人尸体颈椎标本随机分为4组,分别采用盲法、透视法、透视导航法和CT导航法进行下颈椎椎弓根螺钉置入.术后采用标本大体解剖观察的方法评价置钉准确性.分优（螺钉完全在椎弓根内）、可（仅有螺纹穿出,对周围组织无损伤）和差（螺钉明显穿出）进行统计.结果：共置入螺钉318枚.盲法80枚,平均手术时间27min,优29枚（36 3%）、可21枚（26.3%）、差30枚（37.5%）;透视法78枚（有1例C4、C5右侧椎弓根均细小,不能容纳3.5mm螺钉）,平均手术时间112min,优35枚（44.9%）、可29枚（37.2%）、差14枚（17.9%）;透视导航法80枚,平均手术时间69min,优34枚（42.5%）,可36枚（45%）,差10枚（12.5%）;CT导航法80枚,平均手术时间98min,优70枚（87.5%）、可10枚（12.5%）.各组间手术时间均有显著性差异（P＜0.05）,透视法与透视导航法的置钉准确率间无显著性差异,其余各组间均有显著性差异（P＜0.05）.结论：单纯根据术前影像结果盲法行下颈椎椎弓根螺钉内固定不安全.透视法和透视导航法可提高置钉准确性,但手术风险仍较大,透视导航法比透视法置钉的手术时间缩短.CT导航法并未比透视法增加手术时间,但置钉准确性显著提高.