Return to work after foot and ankle injury

A surgeon faces important issues when returning a patient to the workplace, including workers' compensation issues and the need for physician guidance. These patients deserve appropriate diagnosis and treatment protocols, and the other members of the workers compensation treatment team can help maximize the effects of careful guidance by a physician. The speediest possible return to the workplace is usually best for all concerned, the injured worker, the employer and the physician. The treatment team within the workers' compensation system assists in the facilitation and coordination of the medical care and assists in bringing the patient back to work. The team includes the nurse case manager, the insurer, and physical and occupational therapists. Appropriate use of work hardening programs or functional capacity evaluations can be valuable in the return-to-work effort. Physicians who make use of these resources may find it easier to guide this process efficiently to achieve the desired outcome of return to work of the injured worker.     

Thromboembolic disease after foot and ankle surgery

BACKGROUND: The incidence and potential life-threatening complications of thromboembolic disease after major orthopaedic surgery has been extensively studied. However, there are two studies pertaining to the incidence of thromboembolic disease after foot and ankle surgery, the findings of which suggest that the incidence is too low to justify routine thromboprophylaxis. METHODS: This is a retrospective study identifying the incidence of thromboembolic disease after foot and ankle surgery in the practices of two foot and ankle specialists. The purpose of the study was to evaluate the risk factors for the development of thromboembolic disease and to examine the issue of routine thromboprophylaxis. Six hundred and two patients were included in this study. RESULTS: There was a 4% incidence (24 patients) of postoperative thromboembolic complications. Risk factors identified for postoperative thromboembolic disease were a history of rheumatoid arthritis, a recent history of air travel, previous deep vein thrombosis or pulmonary embolism, and limb immobilization. CONCLUSIONS: The incidence of thromboembolic disease after foot and ankle surgery could be higher than that previously reported particularly if a patient has certain risk factors. Prospective randomized clinical trials are needed to establish the true incidence of thromboembolic disease after foot and ankle surgery and to define the indications for routine thromboprophylaxis.     

Anesthesia for foot and ankle surgery.

Regional anesthesia (RA) is the anesthetic of choice for all foot and ankle surgery. Advances in anesthetic equipment and techniques have made peripheral nerve blocks the perfect anesthetic technique for these patients, who should be educated about them in their surgeon's office. The anesthetic alternative of choice is, in the authors' opinion, a neuraxial (i.e. spinal or subarachnoid) technique, rather than a general anesthesia (GA). GA has a higher morbidity and complication rate compared to RA. Performance of a peripheral nerve block, or PNB, requires proper training, equipment, and support personnel in order to handle any and all complications, including general anesthesia.     

Popliteal sciatic nerve blocks after foot and ankle surgery: an adjunct to postoperative analgesia.

The use of sciatic popliteal nerve blocks in conjunction with common peroneal and saphenous nerve blocks can provide prolonged hours of analgesia after foot and ankle surgery. This adjunct to analgesia allows for reduced amounts of postoperative opioids and the undesirable and adverse effects associated with these drugs. The peripheral blocks are technically easy to perform and offer the surgical patient many hours of pain relief. Furthermore, when utilized preoperatively, a lighter depth of anesthesia can be maintained with little demand for opioids so that the postoperative recovery will be accelerated with fewer complications.     

Salivary flow dynamics after parotid surgery: a preliminary report.

BACKGROUND: Tumors in the parotid gland may affect salivary flow. The effects of tumor on glandular function and postoperative changes in both resected gland and contralateral gland were not formerly reported. We prospectively evaluated salivary flow rates and composition in patients undergoing parotidectomy preoperatively and postoperatively. METHOD: Stimulated parotid saliva from 17 patients undergoing parotidectomy was collected bilaterally preoperatively and postoperatively by using a parotid cup. Subjective complaints were recorded. Salivary flow rates, sodium, potassium, and amylase levels were evaluated. RESULTS: None of the patients complained of "dry mouth" before or after surgery. Analysis of the individual results revealed 3 patterns of preoperative and postoperative response, compatible with either a preoperative or postoperative compensatory mechanism in the contralateral gland. The postoperative decrease in flow rate corresponds with the amount of gland removed. Salivary electrolyte composition was unchanged. CONCLUSION: This study is the first to demonstrate the effects of parotid tumors and their surgery on salivary flow and a compensatory response and its different patterns in human parotid glands after their excision.     

Autonomic dysreflexia and foot and ankle surgery.

Autonomic dysreflexia is a syndrome of massive imbalance of reflex sympathetic discharge occurring in patients with spinal cord injury with a lesion above the splanchnic outflow (Thoracic 6). Autonomic dysreflexia is characterized by a sudden and severe rise in blood pressure and is potentially life threatening. Because the onset of this entity is rapid and the potential morbidity is severe, it is important for those caring for spinal cord injury patients to be aware of this syndrome. The paper presents a review of the literature, and familiarizes one with the diagnosis, pathophysiology, and treatment. Two illustrative case reports are also presented.     

New techniques for arthroscopic surgery of the ankle: preliminary report

The history of the development of techniques for arthroscopy of the ankle up to the 1980s was reviewed. The author's early experience with ankle arthroscopy and surgery is analyzed and illustrated to show how the need for better access to this joint, particularly posteriorly, led to the development of these methods. Laboratory work was done to prove their safety. Materials and methods are shown. Steps for performing both techniques are described in detail. A protocol has been developed for study and analysis of a series of patients to be reported at a later date. This should further verify the safety of the above. The end results with the employment of these techniques and of the final operative long-term results will be submitted. Methods for the prevention of complications were developed. This study, therefore, should establish better indications, as well as safer and far better means of performing diagnostic and operative arthroscopy of the ankle joint.     

Bacterial skin contamination after surgical preparation in foot and ankle surgery

An effective presurgical preparation is an important step in limiting surgical wound contamination and preventing infection. The purpose of this study was to evaluate residual bacterial skin contamination after surgical skin preparation in foot and ankle surgery to determine if current techniques are satisfactory in eliminating harmful pathogens. Fifty consecutive patients having surgical procedures of the foot and ankle were studied. Each lower extremity was prepared randomly with either a one-step povidone-iodine topical gel or a two-step iodophor scrub followed by a povidone-iodine paint. After preparation and draping, cultures were obtained at three locations: the hallux nailfold, web space between the second and third, and fourth and fifth toes, and the anterior ankle (control). In the gel group, positive cultures were obtained from 76% of halluces, 68% of toes, and 16% of controls. In the scrub and paint group, positive cultures were obtained from 84% of halluces, 76% of toes, and 28% of controls. Numerous pathogens were cultured, with Staphylococcus epidermidis being the most prevalent. Based on the findings of the current study, presurgical skin preparation with a povidone-iodine based topical bactericidal agent is not sufficient in eliminating pathogens in foot and ankle surgery. The unique environment of the foot and its resident organisms may play a role in the higher infection rates associated with surgery of the foot and ankle.     

The effect of somatostatin on dumping after gastric surgery: a preliminary report

Many of the features of the dumping syndrome may be manifestations of hypovolemia and mechanical distension of the gut, resulting from abnormal fluid secretion in the upper gastrointestinal tract. The object of the present study was to assess the effect of somatostatin, an inhibitor of upper gastrointestinal secretions, on the response to a dumping provocation test, using a double-blind, placebo-controlled method. Four patients were studied; two had undergone total gastrectomy for gastric carcinoma and two had undergone gastric bypass for morbid obesity. Each subject received, on two separate occasions, a challenge of 200 ml of 50% glucose administered orally after an overnight fast. Somatostatin in 150 mm of NaCl (250 micrograms bolus followed by 300 micrograms/hr infusion) was given intravenously during one dumping provocation test and placebo (150 mm of NaCl) during the other according to a Latin square design. When the subjects received the placebo there were significant increases in pulse rate and packed cell volume after oral glucose (p less than 0.05, paired t test), which did not occur when they received somatostatin. The glucose challenge also produced a more rapid increase in serum osmolality and blood glucose during administration of placebo than when somatostatin was given. Marked diarrhea developed in all placebo-treated subjects but in none when they received somatostatin; however, three of the subjects developed marked abdominal pain during dumping provocation tests when treated with somatostatin, which did not occur when placebo was given. Although somatostatin appears to suppress some of the objective responses to a dumping provocation test, it may not prove particularly useful in the treatment of dumping symptoms.     

足踝手术后连续腓肠肌平面阻滞的镇痛效果

目的：探索连续腓肠肌平面阻滞镇痛用于足踝部手术患者术后镇痛效果。
方法：选择全麻下行足踝部择期手术患者42例,男19例,女23例,年龄18～64岁,BMI 18～28 kg/m²,ASAⅠ—Ⅲ级。将患者随机分为两组：连续腓肠肌平面阻滞镇痛组（CN组）和患者自控静脉镇痛（PCIA）组（I组）,每组21例。CN组术毕行连续腓肠肌平面阻滞镇痛,配方为0.125%罗哌卡因300 ml,背景剂量为3 ml/h,单次给药剂量为 8 ml,锁定时间为25 min。I组术毕使用羟考酮PCIA,配方为羟考酮30 mg、托烷司琼6 mg加生理盐水至150 ml,输注速度0.5 ml/h,单次追加剂量5 ml。观察两组术后0～16、16～24、24～48、0～48 h时段静息和活动时NRS评分曲线下面积（AUC）,1、8、16、24、32、48 h静息和活动时NRS评分,CN组术后胫神经和腓总神经运动功能恢复时间、羟考酮滴定量、术后48 h内补救镇痛药物的吗啡当量累计使用量、补救镇痛次数、补救镇痛率、首次下床活动时间、术后恶心呕吐的发生情况和患者满意度评分。
结果：与I组比较,CN组0～16、16～24、24～48、0～48 h静息和活动时NRS评分AUC明显降低（P<0.01）,术后1、8、16、24、32、48 h NRS评分明显降低（P<0.01）,CN组16 h有10例（50%）患者腓总神经运动功能恢复,24 h有17例（85%）患者腓总神经运动功能恢复,32～48 h所有患者腓总神经运动功能恢复,48 h内所有患者胫神经运动功能正常。与I组比较,CN组吗啡当量累计使用量和补救镇痛次数明显减少（P<0.01）,补救镇痛率明显降低（P<0.01）,患者满意度评分明显升高（P<0.01）。两组羟考酮滴定量、首次下床活动时间,恶心呕吐发生率差异无统计学意义。
结论：超声引导下连续腓肠肌平面阻滞可以实现胫神经运动和感觉阻滞分离,可在足踝手术后提供良好且持续的镇痛效果。     

Pigmented villonodular synovitis of the foot and ankle: a report of eight cases.

Eight cases of pigmented villonodular synovitis of the foot and ankle are reported. The purpose of this study was to analyze the manifestation of pigmented villonodular synovitis in the foot and to evaluate treatment options. There were four cases in the ankle and hindfoot, one in the first tarsometatarsal joint, and three in the toes. In seven of eight cases, diagnosis was confirmed by magnetic resonance imaging (MRI) scans. The tenosynovial form was found in the toes and the articular form in the hindfoot and ankle. Surgical treatment was performed in all cases: one arthroscopically assisted synovectomy in the ankle joint, two talocrural arthrodeses, one subtalar arthrodesis, one tarsometatarsal arthrodesis, and tumor removal on the toes with arthrodesis of the distal interphalangeal (DIP) joint in two cases. Average follow-up was 4 years. Recurrence occurred in one toe and led to partial amputation. Malunion in one ankle arthrodesis was operated on again with no sign of recurrence. In the toes, the lesion had a tumoral feature; the bone was infiltrated by soft tissue, and the surgical procedure was local removal of the tumor. In the hind-foot, the lesions were intra-articular and required synovectomy, usually with an arthrodesis. In the midfoot, there was a large extraosseous tumor surrounding tendons with destructive articular lesions.