Pre-requisites for optimum centering of a tibiotalocalcaneal arthrodesis nail

BackgroundPurpose of study was to compare nail alignment, incidence of stress riser and fracture with straight and curved nails of different lengths.MethodsWe conducted a retrospective review of consecutive, initially 13 straight and subsequently 15 curved nails implanted in 17 men and 11 women. Angles of incidence and reflection subtended by nail tip with inner tibial cortex were measured. Cortical hypertrophy was assessed on follow-up radiographs.ResultsAngles of incidence and reflection were greater with short straight nails, less with long straight nails and stayed close to zero with long curved nails.Stress fractures occurred in 2 patients with straight nails at the level of the proximalmost tibial screw. Cortical hypertrophy was present in 7 patients with straight nails and in only 1 patient with a curved nail (p = 0.01).ConclusionsBoth nail length and inbuilt valgus contribute to better central positioning within the tibia. However, cortical stress reactions occur less frequently with curved nails.     

Uncontrolled diabetes as a potential risk factor in tibiotalocalcaneal fusion using a retrograde intramedullary nail

Background

Tibiotalocalcaneal (TTC) fusion using a retrograde intramedullary (IM) nail is an effective salvage option for terminal-stage hindfoot problems. However, as many patients who receive TTC fusion bear unfavorable medical comorbidities, the risk of nonunion, infection and other complications increases. This study was performed to identify the factors influencing outcomes after TTC fusion using a retrograde IM nail.

Conversion of painful tibiotalocalcaneal arthrodesis to total ankle replacement using a 3-component mobile bearing prosthesis

BackgroundThe aim of this study was to assess the short-term clinical and radiographic outcomes in patients who underwent conversion of a painful tibiotalocalcaneal arthrodesis to a total ankle replacement.MethodsSix patients with painful ankle arthrodesis after tibiotalocalcaneal arthrodesis were included in this study. In all patients, conversion to total ankle replacement was performed using a 3^rd-generation, non-constrained, cementless three-component prosthesis. The outcomes were analyzed at a mean follow-up of 3.4 ± 1.9 years (range 1.0–6.5).ResultsOne patient with painful arthrofibrosis underwent two open arthrolysis procedures at 1.2 and 5.6 years post index surgery, respectively. No revision of tibial or talar prosthesis components was necessary in this study. All patients reported significant pain relief and significant improvement in functional status.ConclusionIn the present study, the conversion of a painful ankle arthrodesis following tibiotalocalcaneal arthrodesis to a total ankle replacement was a reliable surgical treatment.     

Biomechanical comparison of stability of tibiotalocalcaneal arthrodesis with two different intramedullary retrograde nails

BackgroundThe aim of the study was to compare the initial construct stability of two retrograde intramedullary nail systems for tibiotalocalcaneal arthrodesis (TTCF) (A3, Small Bone Innovations; HAN, Synthes) in a biomechanical cadaver study.MethodsNine pairs of human cadaver bones were instrumented with two different retrograde nail systems. One tibia from each pair was randomized to either rod. The bone mineral density was determined via tomography to ensure the characteristics in each pair of tibiae were similar. All tests were performed in load-control. Displacements and forces were acquired by the sensors of the machine at a rate of 64 Hz. Specimens were tested in a stepwise progression starting with six times ±125N with a frequency of 1 Hz for 250 cycles each step was performed (1500 cycles). The maximum load was then increased to ±250N for another 14 steps or until specimen failure occurred (up to 3500 cycles).ResultsAverage bone mineral density was 67.4 mgHA/ccm and did not differ significantly between groups (t-test, p = .28). Under cyclic loading, the range of motion (dorsiflexion/plantarflexion) at 250N was significantly lower for the HAN-group with 7.2 ± 2.3 mm compared to the A3-group with 11.8 ± 2.9 mm (t-test, p < 0.01). Failure was registered for the HAN after 4571 ± 1134 cycles and after 2344 ± 1195 cycles for the A3 (t-test, p = .031). Bone mineral density significantly correlated with the number of cycles to failure in both groups (Spearman-Rho, r > .69, p < 0.01).ConclusionsThe high specimen age and low bone density simulates an osteoporotic bone situation. The HAN with only lateral distal bend but two calcaneal locking screws showed higher stability (higher number of cycles to failure and lower motion such as dorsiflexion/plantarflexion during cyclic loading) than the A3 with additional distal dorsal bend but only one calcaneal locking screw. Both constructs showed sufficient stability compared with earlier data from a similar test model.Clinical relevanceThe data suggest that both implants allow for sufficient primary stability for TTCF in osteoporotic and consequently also in non-osteoporotic bone.Level of evidenceNot applicable, experimental basic science study.     

踝后正中入路锁定钢板内固定行胫距跟关节融合术

目的评估踝后经跟腱正中入路植骨锁定钢板内固定行胫距跟关节融合术的手术技巧和临床效果。方法从2008年1月至2012年12月,共收治123例踝关节合并距下关节创伤性关节炎,其中13例因踝周软组织条件不佳而选用踝关节后方入路胫距、距下关节清理、植骨、4.5 mm干骺端锁定钢板内固定行胫距跟关节融合术。其中男9例,女4例,平均年龄47.8岁（30~65岁）;平均病程7年（1~15年）。术后定期随访复查X线片以明确骨愈合情况,并采用直观模拟量表（Visual Analog Scale,VAS）评估术后疼痛改善情况,美国骨科足踝外科（American Orthopaedic Foot and Ankle Society,AOFAS）踝关节与后足评分及简明健康量表SF-36评分评估恢复效果,并记录相关并发症。结果术后所有患者伤口均一期愈合,未见感染、皮肤坏死等软组织并发症。11例获得最终随访,平均随访时间24个月（12~36个月）。随访复查X线片示术后平均12周融合端骨性愈合（10~15周）。末次随访时,AOFAS踝与后足评分及SF-36评分均较术前明显改善,疼痛症状明显缓解。随访期间未见内固定失效、融合失败等并发症,2例患者术后出现距舟关节骨关节炎,伴轻度疼痛,口服药物对症治疗后缓解。结论经踝后正中入路锁定钢板内固定行胫距跟关节融合安全、有效,特别适合于踝周软组织条件不佳的病例。     

应用逆置交锁髓内钉行微创胫距跟关节融合术

目的 探讨逆置交锁髓内钉行胫距跟关节融合术治疗严重踝关节病变的疗效. 方法2003年1月至2007年11月应用逆置交锁髓内钉行胫距跟关节融合术治疗12例踝关节病变患者;男9例,女3例;年龄25～68岁,平均47.2岁.创伤后踝关节骨性关节炎7例,严重类风湿踝关节炎3例,马蹄足内翻2例.手术距原发病时间5～25年,平均13.6年.通过体格检查、问卷调查、踝负重下摄片和美国足踝协会(AOFAS)踝与后足功能评分标准进行临床和影像学评估. 结果所有患者获得18.3个月(10～36个月)随访.未出现血管神经损伤、骨不连和感染等并发症.患者均获得骨性融合,融合时间17周(12～21周).最后一次随访结果显示:无疼痛8例,轻度疼痛4例.7例运动和日常生活不受影响,5例运动受影响但不影响日常生活.7例在任何路面行走不受影响,5例在不平整的路面行走困难,无一例患者明显跛行.根据AOFAS踝与后足功能评分标准,术前平均47.3分(40～57分),术后平均74.2分(50～87分). 结论逆置交锁髓内钉行胫距跟关节融合术是治疗严重踝关节病变的一种微创、安全、有效的方法.     

Tibiotalocalcaneal arthrodesis with distal tibial allograft for massive bone deficits in the ankle

BackgroundThe purpose of this study was to assess the outcomes of distal tibial structural allograft to obtain a stable TTC fusion.MethodsRetrospectively, ten patients were carried out with a minimum one year follow-up. The median age was 72 (33–81). The median BMI was 28 (24–33). Indications for TTC arthrodesis included failed total ankle arthroplasty (n = 7 patients), prior nonunion (n = 2 patients), and a trauma injury.ResultsUnion rate was 80%. The median initial height of the distal tibial allograft was 19 mm (14–24 mm). In seven cases the allograft did not lose height. The AOFAS score median was 69 (31–84). SF-12 median physical component was 39 (30–53), and 59 (23–62) for mental component. The VAS median was 2 (0–8).ConclusionsTTC using distal tibial allograft shows a lower rate of collapse than other structural grafts and provides a fusion rate higher or in accordance with the literature.Level of evidenceLevel IV, retrospective case series.     

Obesity is associated with increased postoperative complications after operative management of tibial shaft fractures

ObjectivesTo assess the association of obesity and postoperative complications after operative management of tibial shaft fractures.MethodsPatients who underwent operative management of a tibial shaft fracture were identified in a national database by Current Procedural Terminology (CPT) codes for: (1) open reduction and internal fixation (ORIF) and (2) intramedullary nailing (IMN) procedures in the setting of International Classification of Diseases, Ninth Revision (ICD-9) codes for tibial shaft fracture. These groups were then divided into non-obese, obese, and morbidly obese cohorts using ICD-9 codes. Each cohort was then assessed for grouped complications within 90 days, removal of implants within 6 months, and nonunion within 9 months postoperatively. Odds ratios and 95% confidence intervals were calculated.ResultsFrom 2005 to 2012, 14,638 patients who underwent operative management of tibial shaft fractures were identified, including 4425 (30.2%) ORIF and 10,213 (69.8%) IMN. Overall, 1091 patients (7.4%) were coded as obese and 820 (5.6%) morbidly obese. In each operative group, obesity and morbid obesity was associated with a substantial increase in the rate of major and minor medical complications, venous thromboembolism, infection, procedures for implant removal, and nonunion.ConclusionsIn patients who undergo either ORIF or IMN for tibial shaft fractures, obesity and its related medical comorbidities are associated with significantly increased rates of postoperative medical complications, infection, nonunion, and implant removal compared to non-obese patients.     

Factors associated with nonunion of the posttraumatic subtalar arthrodesis after displaced intra-articular calcaneal fractures

BackgroundThis study investigated the incidence of and risk factors for nonunion in patients with posttraumatic subtalar arthrodesis (SA).MethodsWe retrospectively reviewed 165 posttraumatic SA cases. Nonunion was diagnosed at 6 months after surgery based on the findings of clinical evaluations, plain radiographs, and CT scans. Patient-specific factors and surgeon-specific factors were evaluated as potential risk factors.ResultsThe overall nonunion rate was 13.3 % (22 of 165 cases). In the final multivariate logistic regression analysis, smoking (odds ratio [OR] = 3.64; 95 % confidence interval [CI] = 1.23–10.75), parallel screw configuration (OR = 5.70; 95 % CI = 1.62–20.06), and freeze dried iliac crest (OR = 9.16; 95 % CI = 2.28–36.79) were demonstrated as risk factors for nonunion of posttraumatic SA.ConclusionPatients with a history of smoking, parallel screw configuration fixation, and those who received freeze dried iliac crest as an interpositional graft, had a significantly higher rate of nonunion.     

Minimally invasive ankle arthrodesis with a retrograde locking nail after failed fusion

Abstract 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.     

克罗恩病复发再手术的并发症危险因素分析

目的探讨克罗恩病（CD）复发再手术后并发症的危险因素及其疗效。方法回顾性收集1995-2009年间在福建医科大学附属第一医院65例CD复发再手术患者的临床资料（再手术组）,对其术后并发症的危险因素进行分析。同时选取同期年龄匹配的65例CD初次手术患者（初次手术组）。比较再手术与初次手术的术中及术后情况。结果再手术组复发再手术后有25例（38．5％）出现并发症,显著高于初次手术者（12．3％）。术中行预防性肠造口的19例患者术后仅3例（15．8％）出现并发症,而未行预防性肠造口的46例患者有22例（47．8％）出现并发症,差异有统计学意义（Х^2=5．831,P=0．016）。与初次手术相比,再手术组手术时间更长、腹膜粘连更严重、术后住院时间更长（均P〈0．05）。结论CD复发再手术术式复杂．有着较高的术后并发症发生率。预防性肠造口有助于降低术后并发症发生率。     

Intramedullary nail fixation with posterior-to-anterior compared to transverse distal screw placement for tibiotalocalcaneal arthrodesis: a biomechanical investigation

BACKGROUND: Biomechanical studies on retrograde intramedullary fixation for tibiotalocalcaneal fusion have been reported, but no studies have investigated dorsiflexion stiffness, load-to-failure, fatigue endurance, and plastic deformation using different distal screw orientations. Also, no studies have examined the effect of bone density on different distal screw orientations while using a fatigue loading mode. METHODS: Eight matched pairs of cadaver legs were used. In one leg from each pair an intramedullary nail was inserted with lateral-to-medial distal screws and in the other with posterior-to-anterior screws. These samples underwent dorsiflexion fatigue testing with determination of initial and final stiffness, load-to-failure, and degree of plastic deformation at failure. DEXA scanning was done of each cadaver specimen to determine bone mineral density. Statistical analysis was performed using the Student t-test and a Pearson correlation. Significance level was set at p < 0.05. RESULTS: The specimens with posterior-to-anterior screws had a significantly higher fatigue endurance load-to-failure (1130.0 +/- 362.0 N compared to 801.0 +/- 227 N, p = 0.01). They also had significantly higher final stiffness (203.1 +/- 23.1 N/mm compared to 146.6 +/- 46.2 N/mm, p = 0.05) and lower plastic deformation (2.4 +/- 1.5 mm compared to 3.8 +/- 2.3 mm, p = 0.04). There was a statistically significant correlation between bone mineral density and the difference in construct deformation with posterior-to-anterior and lateral-to-medial screw orientation (r = 0.76, p = 0.03). CONCLUSIONS: In this biomechanical investigation of tibiotalocalcaneal arthrodesis with intramedullary nail fixation, posterior-to-anterior distal screw orientation provided more stable fixation than lateral-to-medial screw orientation.     

Influencing factors of functional result and bone union in tibiotalocalcaneal arthrodesis with intramedullary locking nail: a retrospective series of 30 cases

Background

Initially considered as an established salvage procedure for tibiotalocalcaneal arthrodesis (TTCA), intramedullary nailing indications have expanded as evidenced in recent literature. We have tried to identify factors influencing functional result and bone union.

Methods

In a retrospective study, 30 patients were treated by a TTCA between January 2006 and November 2011. Indications, operative technique, bone fusion, X-rays and functional result [American Foot and Ankle Society (AOFAS) and short-form health survey (SF-36) scores] before and after surgery were registered and analyzed.

Results

Thirty cases of TTCA were included. The patient’s average age was 52 (range 24–90). Union rate was 86 % for the tibiotalar joint and 74 % for the subtalar joint with an average follow-up of 25.4 months (8–67). The mean AOFAS’ score significantly improved (from 37 to 59) as the SF-36’ score. Global complication rate was about 56 %. It has not been possible to identify factors significantly influencing bone fusion or functional results. All septic cases achieved fusion without any septic resurgence.

Conclusion

Retrograde intramedullary nailing in TTCA is an effective technique, which allows good clinical results even in case of septic history of the patient. Fusion rate and functional results were not significantly influenced by any of the factors examined in this study.     

Retrograde nail for tibiotalocalcaneal arthrodesis as a limb salvage procedure for open distal tibia and talus fractures with severe bone loss

The treatment of complex fractures of the distal tibia, ankle, and talus with soft tissue damage, bone loss, and nonreconstructable joints for which the optimal timing for reduction and fixation has been missed is challenging. In such cases primary arthrodesis might be a treatment option. We report a series of multi-injured patients with severe soft tissue damage and bone loss, who were treated with a retrograde tibiotalocalcaneal arthrodesis nail as a minimally invasive treatment option for limb salvage. After a median follow-up of 5.4 years, all patients returned to their former profession. The ankle and bone fusion was complete, with moderate functional results and quality of life. Calcaneotibial arthrodesis using a retrograde nail is a good treatment option for nonreconstructable fractures of the ankle joint with severe bone loss and poor soft tissue quality in selected patients with multiple injuries, in particular, those involving both lower extremities, as a salvage procedure.     

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.     

Use of a headless compressive screw for distal interphalangeal joint arthrodesis in digits: clinical outcome and review of complications

PURPOSE: Arthrodesis of the distal interphalangeal joint (DIPJ) or thumb interphalangeal joints can be necessary to treat pain, deformity, or instability associated with arthritis. Compression and rigid fixation are thought to influence fusion rates and time to union favorably. The purpose of the study was to review the clinical outcome and complications associated with the use of a fully threaded headless compression screw for DIPJ arthrodesis. METHODS: Twenty-seven distal interphalangeal or thumb interphalangeal fusions were performed with an axial Mini-Acutrak screw in 22 patients. Charts, surgical reports, and preoperative and postoperative x-rays were reviewed to determine the incidence, time to union, and complications. The minimal follow-up period was 3 months. RESULTS: Twenty-three of the 27 arthrodeses achieved bony union. Complications included symptomatic nonunion (n=1, treated with secondary fusion), asymptomatic nonunion (n=2, left untreated), infection (n=4; 2 patients required implant removal that resulted in nonunion but declined revision) and nail bed injury (n=3). CONCLUSIONS: The Mini-Acutrak screw technique achieves healing rates that are comparable with but not superior to other techniques. Its main advantages are ease of execution, fully buried hardware, and early mobilization; however, the procedure is associated with complications and meticulous technique is required to avoid them. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

腹腔镜脾切除术治疗门静脉高压症术后并发症及相关因素分析

目的探讨腹腔镜脾切除术治疗门静脉高压症术后并发症及其相关因素。方法选取2012年1月至2015年6月于武汉市武昌区院85例行腹腔镜脾切除术的门静脉高压症病人,分析术后并发症及相关危险因素。结果术后16例病人出现24例次并发症,发生率为18.82%。按照Clavien-Dindo分级标准,Ⅰ、Ⅱ、Ⅲa、Ⅲb、Ⅳa、Ⅳb和V级并发症病人例数分别为3、7、1、3、1、0、1例。单因素分析显示术后并发症的发生与ASA分级、Child-Pugh分级、手术方式、联合贲门周围血管离断术、术者经验有关(均P0.05),而与年龄、性别、术前胆红素升高、术前血浆白蛋白水平和脾脏长径无关(P均0.05)。多因素分析显示,ASAⅢ级、Child-Pugh B级和术者经验20例是术后并发症发生的独立危险因素(P均0.05)。结论腹腔镜脾切除术治疗门静脉高压症术后并发症发生率较高,其发生与ASAⅢ级、Child-Pugh B级和术者经验20例的病人。     

肝移植术后胆道并发症的危险因素分析

目的 探讨肝移植术后胆道并发症的临床特点及危险因素.方法 回顾性分析施行的172例肝移植患者的临床资料.选取围手术期45个独立变量进行单因素分析及Logistic回归分析,筛选出与肝移植术后胆道并发症相关的危险因素.结果 32例发生胆道并发症,患病率为18.6%,包括10例胆瘘,14例无胆瘘的胆管狭窄,5例无胆瘘或胆管狭窄的胆道结石,2例单纯胆道感染,1例单纯胆道出血.其发生的中位时间为22(3～585 d)d.Logistic回归分析显示急性排斥反应(P＜0.001),慢性排斥反应(P=0.030),留置T管(P=0.005),术后1个月的肝动脉阻力指数(RI)≤0.66(P=0.026)是术后胆道并发症的独立危险因素.结论 肝动脉血流动力学的严密监测、必要的预防性抗凝治疗、规范的抗排斥治疗、不留置T管的胆管重建方式有助于降低胆道并发症发生率.