The rationale behind surgical approaches to ankle fractures

Ankle fractures and fracture dislocations are one of the commonest injuries seen by orthopaedic surgeons. Decisions around the surgical fixation of ankle fractures require an understanding of the bony and ligamentous anatomy of the joint as well as an appreciation of the normal ankle joint biomechanics. The operative treatment of these injuries aims to hold the joint securely in an anatomically reduced position throughout the period of healing, and allow initiation of joint motion as soon as possible. If these treatment goals are met, a good outcome is a reasonable expectation, given the proviso that disruption of any articular surface can result in permanent damage. However the functional outcome of fractures involving a posterior malleolar fragment is often not satisfactory and recent debate has surrounded ankle fracture fixation, with the posterior malleolus in particular being subject to increased scrutiny for its contribution towards long-term ankle stability. With the advent of excellent results from the use of open reduction and rigid internal fixation, the gold standard of treatment for displaced ankle fractures has become surgical fixation. This article explores the evidence behind commonly used surgical approaches to ankle fracture fixation and the rationale behind their use.     

Diagnosis and management of the acute hot diabetic foot

Diabetes is an increasing problem in the modern world. Along with the rise in prevalence of the disease the number of diabetic complications presenting is increasing and amongst these is diabetic foot issues. Foot infection and Charcot arthropathy are the two key pathologies that present acutely with a hot swollen foot. Both require timely diagnosis and management to prevent disastrous long-term sequelae.Acutely presenting foot infections are both limb and life threatening and require urgent intervention to improve the chance of limb salvage. The ability to recognize and acutely deal with a diabetic foot requiring urgent surgical drainage is relevant to all orthopaedic surgeons with an on-call commitment and not solely to the foot and ankle specialist.Charcot arthropathy results in foot deformity that increases the likelihood of future ulceration and infection. The differentiation and acute management of the two conditions will be discussed.     

Avascular necrosis of the foot and ankle: aetiology,investigation and management

Avascular necrosis (AVN) of the foot and ankle can pose both a diagnostic challenge, and a management dilemma. This paper seeks to describe the various types of AVN in the foot and ankle and clarify the expected presentation, examination findings, investigations and management strategies available. In addition, discussion of the relevant basic sciences, and the process of bone healing will facilitate a broader understanding of the condition, and the risk factors for its development. AVN can be secondary to trauma, as in most cases of talar AVN, or secondary to factors such as steroid use, alcohol excess, metabolic diseases, repetitive microtrauma, and abnormal biomechanics. Usually, a combination of the above is thought to be responsible. Many of the conditions described are established in childhood, either presenting at the time, or in the third or fourth decade. Management ranges from exercise limitation and offloading footwear, to surgical decompression, osteotomy, fusion or excision. AVN has a high morbidity and affects a young demographic, causing a substantial burden on healthcare. Early recognition of symptoms, and appropriate investigation and management could reduce the number of patients progressing to advanced disease, avoiding the frequently unsatisfactory surgical outcomes associated with options such as fusion and excision.     

Meniscal repair and replacement

Viewed for many years as just vestigial organs, a lack of appreciation of the importance of the menisci led to the widespread practice of total meniscectomy. The realization that removal of these important structures leads to accelerated arthritis took some time. It is now recognized that the menisci play an important role in load distribution, joint stability and lubrication, protecting the joint surfaces from degenerative change. As awareness of the true importance of these important structures has increased, and so has the understanding of different patterns of meniscal injury and the interaction of additional factors, such as alignment and ligamentous stability, in determining long-term meniscal and knee function. This has led to an integrated approach to meniscal surgery as part of an overall strategy to preserve and restore knee function, incorporating a shift towards meniscal preserving surgery whenever possible. This article will review knee anatomy and biomechanics as a basis for understanding the mechanism and classification of meniscal tears and associated injuries. Assessment, surgical decision-making and repair techniques, including the role of biological augmentation to increase the scope of repairable injuries, will also be reviewed. Options to reconstruct the meniscus using meniscal allograft transplantation for patients with symptomatic meniscal deficiency will be discussed.     

Management of osteoarthritis of the wrist and hand

Osteoarthritis of the wrist and hand can cause significant functional impairment and disability. Its management is as much an art as it is science, as one has to consider increasing patient expectations, functional demands, pain relief and preserving motion. A sound knowledge of the wrist and hand anatomy, biomechanics, appreciation of the specific location and grade of wrist and hand joints arthritis and various treatment options and their pros and cons is important to successfully manage patients with this condition. Wrist osteoarthritis can be idiopathic, however more commonly it is secondary to distal radius and/or carpal fractures and ligamentous injuries. A small proportion still can occur due to avascular necrosis of carpus or congenital and developmental causes. Osteoarthritis of the hand is often idiopathic with a high familial tendency, especially in younger patients but can be secondary to other causes such as trauma, gout and ligamentous laxity. Once the non-surgical management options such as analgesia, activity modifications, steroid injections and splints have been exhausted, then there are various surgical options available for wrist and hand osteoarthritis. These are tailored to the exact location of arthritis and patient factors. For the wrist, these include anterior and posterior interosseous nerve neurectomy, arthroscopic debridement, selective bony excisions, wrist arthroplasty and focal or total fusion. Whilst for finger osteoarthritis, surgical options include arthroplasty and arthrodesis. This article aims to describe the pathology of wrist and hand arthritis and various treatment options available.     

(ii) The cavo-varus foot

Cavo-varus foot deformity has many causes but the final common pathway is an imbalance of the muscles acting on the foot. The commonest cause of bilateral deformity is Charcot Marie Tooth disease. Unilateral deformity may arise from spinal pathology. Symptoms range from ankle instability and fatigue fractures to abnormal gait and the effects of joint overload.As well a clinical assessment, patients may require neuro-physiological investigation, and foot and spinal imaging. Treatment ranges from footwear modifications and orthoses to surgical treatment which may include combination of soft tissue releases, tendon transfers or a variety of osteotomies. Severe or recurrent deformities may require joint arthrodesis.     

Management of injuries to the triangular fibrocartilage complex and distal radioulnar joint

Injuries to the triangular fibrocartilage complex (TFCC) and distal radioulnar joint (DRUJ) require careful consideration and management to ensure an optimal outcome. These complex injuries can be effectively managed by having a fundamental understanding of the anatomy of the structures involved in addition to an appreciation of the biomechanical modes of failure in the context of wrist trauma. The principles of managing these injuries are addressed in this article by focusing on the relevant anatomy and highlighting the key features of clinical and radiological assessment. An outline of the surgical treatment options is included to help the clinician select the most appropriate treatment ranging from soft tissue repair to salvage measures.     

Clinical observations of cleft lip and palate

In surgical management of cleft lip and palate, appreciation of the special anatomy and physiology of the human premaxilla is more important than the question of whether it is a separate bone. To take advantage of the potential of the premaxilla, both primary and secondary surgical procedures must strive to establish a nearly normal medial septal system and nasolabial musculature. To complement accurate muscle surgery of the lip and soft palate, the characteristics and functions of the mucoperiosteum that covers the palate must be respected. The quality of subsequent facial growth can be monitored with the architectural craniofacial cephalometric analysis. By adopting a physiologic approach to cephalometrics, the clinician can avoid some common errors of interpretation.     

The distal radio-ulnar joint

The distal radio-ulnar joint can be a source of ulnar-sided wrist pain. The complex anatomy in this region of the wrist can make diagnosis of distal radio-ulnar joint problems challenging. An understanding of the anatomy can aid an accurate diagnosis. An overview of the anatomy, biomechanics and conditions of the distal radio-ulnar joint is provided, together with other common causes of ulnar-sided wrist pain.     

Cryogenically preserved adult and juvenile goat mandibular condylar transplantation

Loss of a functional temporomandibular joint (TMJ) has long been a clinical challenge in both children and adults. Although reconstruction to date has been performed with various prosthetic devices or autogenous costochondral grafts, these procedures have a potential for complications and morbidity. Our studies were performed to determine the feasibility of healing, growth, and long-term function of TMJ reconstruction techniques with cryogenically preserved mandibular allografts in the goat model. This species was chosen because the surgical anatomy and biomechanics of the goat TMJ are very similar to those of the human TMJ. The positive results of the studies and their relevance will be described.     

Forearm fracture dislocations

Foerearm stability is provided by a complex interplay of the bony and osseo-ligamentous structures which constitute the forearm unit. Consequently, fractures of the radius and/or ulna with concurrent injuries to the stabilizing ligamentous structures can lead to chronic instability and dysfunction if treated incorrectly. Seen in both the adult and paediatric populations, correct diagnosis and management are essential to prevent long-term forearm pain and instability. This article covers the three main instability pattern injuries of the forearm with a focus on anatomy, biomechanics and surgical principles of acute and chronic reconstruction.     

(ii) Thoracolumbar spinal fractures: review of anatomy,biomechanics, classification and treatment

The management of thoracolumbar spine fractures remains a controversial issue. There is disagreement both as to how to describe these injuries and how to manage them.No ideal classification system, accepted by the world of spinal surgery, exists and such systems are under on-going development. While the majority of these injuries can be managed conservatively, new surgical techniques have been developed alongside the evolution of diagnostic tools classification systems.This article aims to revise important concepts that may help surgeons in training to understand spinal injuries and the modern approach to the management of thoracolumbar trauma.We describe relevant thoracolumbar spine anatomy and biomechanics followed by a discussion of historical and modern classification systems, and the treatment methods available to surgeons.     

The foot in systemic disease: management of the patient with rheumatoid arthritis or diabetes mellitus

The foot is commonly affected in systemic diseases such as rheumatoid arthritis and diabetes mellitus. Treating patients who suffer with foot pathology secondary to systemic diseases requires a multidisciplinary approach, following the principles outlined within this review. There is little high level evidence in this field, such as prospective controlled clinical trials, hence much of what we know and practise is based upon the expert opinion of key individuals in specialist centres, to whom we owe a great debt.     

Meniscocondylar plication: a modified operation for surgical repositioning of the ectopic temporomandibular joint meniscus. Rationale and operative technique

A historical review of temporomandibular joint (TMJ) surgical meniscal repositioning procedures is presented, and three operations that are currently used to manage this problem are compared and contrasted. Each operation produces iatrogenic deviations in intra-articular anatomy and retains the potential to create significant alterations in TMJ biomechanics. Meniscocondylar plication has been performed on 84 patients (89 joints) with arthrographically confirmed internal derangement of the TMJ. A 90.7% success rate was achieved. The operation is technically facile, surgically uncomplicated and clinically effective. It should rank as a justifiable and viable alternative to those operations that are presently being performed to treat patients with internal derangement of the TMJ.     

Consent in foot and ankle surgery

The process of consent for surgical procedures has undergone a fundamental change since the landmark Montgomery vs Lanarkshire Health Board Case. The judge in that case determined that consent should focus on the risks that are material to the patient, and not purely those that a body of expert opinion feels are prudent to mention. This is a change from a paternalistic to a patient-centred approach. Ideally the consenting process should be done by the operating surgeon, or other doctor who has adequate knowledge of the risks and potential complications of the procedure. Taking consent is a process that occurs over several patient contacts, rather than being a singular consenting event. In this article we discuss several of the particular risks of each foot or ankle procedure and their relative incidence, as well as providing guidance regarding optimizing the consent process.     

(iii) Arthroscopy of the foot and ankle

The role of arthroscopy in the management of articular pathology is now well established. Its use in the management of foot and ankle pathology is relatively new, but with innovative techniques and modern equipment, the indications are expanding. Procedures that were previously performed through an open approach can now be done using a pure arthroscopic, or arthroscopically assisted, method with the aim of earlier rehabilitation, reducing complications and scarring, and improving outcome. We describe the history, current role and potential future uses of arthroscopy in the treatment of foot and ankle conditions.     

Imaging of the foot and ankle

There are a number of imaging modalities available to assist in assessment of the foot and ankle. The variety of techniques will be described with emphasis on the particular advantages and limitations of each. Recent advances and variations relating to the individual modalities are reviewed together with specific clinical scenarios.     

Surgical reconstruction of the posterior cruciate ligament: current perspectives

After over a century of orthopaedic attention, injuries to the posterior cruciate ligament (PCL) continue to pose a significant management challenge. Isolated PCL tears constitute the minority of cases, with multiligament trauma (most commonly posterolateral corner injuries) predominating. Surgical reconstruction of the PCL remains technically demanding. Historical long-term outcomes have been associated with persisting knee instability and secondary degenerative arthrosis, irrespective of surgical intervention. The past two decades have witnessed a renewed focus on understanding the anatomy and biomechanics of the PCL, and its spectrum of injury. This, along with advancements in surgical technology and techniques, has heralded a renewed impetus for operative reconstruction. While there remains no clinically demonstrated difference in outcomes of double-bundle surgery over single-bundle reconstruction, many prefer a double bundle approach due to empirical data supporting its biomechanical superiority. Concomitant bony realignment in the coronal and sagittal plane should be considered where necessary. Graft reinforcement is an emerging concept that may aid in protecting the neoligament during the early healing phase. With modern approaches, there are increasing reports of more favourable short and mid-term post-operative outcomes. Despite this, most studies remain of a low level of evidence, with relatively small case series, and there is a paucity of well-designed controlled studies contrasting operative techniques.     

根折影响因素及诊治

一旦发生根折则预后非常差。根折与牙齿的解剖形态、因素、生物力学、医源性等因素密切相关。国内外学者对根折原因进行了大量的研究。本文对根折病因及发生机制、诊断和治疗进行综述,为临床治疗提供一定参考。