Ankle arthroscopy has seen increased utilization and application in recent years. Through the advent of improved instrumentation and techniques, indications have been expanded to include the management of traumatic, degenerative, inflammatory, and neoplastic conditions. It is important to review anterior and posterior ankle arthroscopies along with the history, pertinent anatomy, techniques, indications, and complications as well as gain insight into the future of ankle arthroscopy.

Background: Foot and ankle surgeons often perform minor surgeries on the preoperative stretcher instead of the operating room table. We examined whether stretcher-based and operating room table-based procedures differed with respect to operating room efficiency and staff perceptions. Methods: We retrospectively reviewed medical records of patients undergoing minor foot and ankle surgery at an ambulatory surgery centre. We collected ‘time to start’, the duration between patient arrival in the operating room and incision time, and ‘time to exit’, the duration between procedure end time and patient exit from the operating room. Staff were surveyed regarding their perceptions of stretcher-based and operating room table-based procedures. Results: ‘Time to start’ was significantly shorter for stretcher-based procedures, but ‘time to exit’ was not. Seventeen (81%) staff members thought stretcher-based procedures increased operating room efficiency. Thirteen (62%) thought stretcher-based procedures bettered staff safety. Nineteen (91%) thought stretcher-based procedures were equivalent to or better than operating room table-based procedures for patient safety. Most (67%) would recommend stretcher-based procedures. Conclusion: We found small but significant time savings associated with stretcher-based procedures. Without adapting surgical scheduling practices, the impact of stretcher-based procedures on overall operating room efficiency is questionable. Nevertheless, the majority of OR staff think stretcher-based procedures increase OR efficiency and are safer for staff. Level of Evidence: Level IV, Retrospective case series.

Category: Ankle Arthritis Introduction/Purpose: Despite advancements in surgical techniques, implants, and biologics, nonunion remains the most common major complication of ankle arthrodesis. While previous studies have reported delayed union or nonunion rates, few have elaborated on the clinical course of patients experiencing delayed union. We sought to better understand the trajectory of patients with delayed union by determining the rate of clinical success and failure and whether the extent of fusion on computed tomography (CT) was associated with outcomes. Methods: Delayed union was defined as incomplete ( < 75%) fusion seen on CT scan between 2 and 6 months postoperative. A total of 36 patients met inclusion criteria: isolated tibiotalar arthrodesis with delayed union. Patient-reported outcomes were obtained and patients were asked about satisfaction with their fusion. Success was defined as patients who were not revised and reported satisfaction with the procedure. Failure was defined as patients who progressed to revision or reported being not satisfied. Fusion was assessed by measuring the percent of osseous bridging across the joint on CT scan. The extent of bony bridging was categorized as absent (0%-24%), minimal (25%-49%), or moderate (50%-74%). Results: We determined the clinical outcome in 28 of the 36 eligible patients (78%) with mean follow-up of 5.6 years (range, 1.3 to 10.2 years). The majority (71%) of patients failed. A mean of 3.9 months (standard deviation, 1) elapsed between time of surgery and CT scan. Patients with minimal or moderate fusion on CT were more likely to succeed clinically than those with ‘absent’ fusion (X2 = 4.215, p = 0.040). Of those with absent ( < 25%) fusion, 11 of 12 (92%) failed. In patients with minimal or moderate fusion, 9 of 16 (56%) failed. Conclusion: We found that 71% of patients with a delayed union at roughly 4 months after ankle fusion required revision or were not satisfied. Patients with less than 25% osseous bridging on CT had an even lower rate of clinical success. These findings may help surgeons in counseling and managing patients experiencing a delayed union after ankle fusion.

There is rapidly growing interest in minimally invasive surgery (MIS) of the foot and ankle. Technological advances, specifically with the advent of low-speed high-torque burrs, have enabled the expansion of MIS techniques. Accordingly, there is growing literature reporting excellent outcomes of MIS surgery to address many different pathologies of the foot and ankle. MIS techniques are particularly useful for conducting percutaneous osteotomies and bony débridement. These can be used to address bunion deformity, hammertoes, metatarsalgia, bunionette deformity, bone spurs, and hindfoot deformity. A detailed understanding of the technology, equipment, and techniques is crucial to safely conduct MIS of the foot and ankle. When done safely, MIS provides favorable outcomes with an expedited recovery and limited complications.

A retrospective review of consecutive patients diagnosed with insertional Achilles tendinopathy (IAT) was performed. Outcomes included Visual Analog Scale (VAS) pain scores, return to run rates, and return to military duty rates. Our data analysis included 113 patients; 58 (55%) patients required surgery. Mean duration of follow-up was 42 months (range, 12-143). Mean age at the time of surgery was 37.2 years (range, 21-54). VAS scores significantly improved from 5.4 at the preoperative visit to 2.9 at 24 months. There was no significant improvement in VAS scores after the 3-month postoperative visit. Mean return to run time was 9 months (range, 4.5-16). At 1 year, 80% (46/58) of patients returned to military duty. Complications requiring return to the operating room were observed in 6 patients (9%). The high rate of return to duty and significant improvement in pain scores demonstrate that the surgical management of IAT is a viable treatment option for patients who could not otherwise remain on active duty. With that said, the complication rate of 27% is high. Patients and providers should consider the risks, benefits, and duration of therapy during their shared decision-making process.Level of Evidence: Level IV.

Background: Malreduction after syndesmotic stabilization occurs in as many as 52% of cases and has been shown to detrimentally affect clinical outcomes. We propose that the modified Glide Path technique reduces the occurrence of syndesmotic malreduction. Methods: This study is a prospective series comparing 16 patients reduced with the modified Glide Path technique with a retrospectively reviewed series of 25 patients reduced with a traditional technique using fluoroscopy and a clamp. The modified Glide Path technique consists of manual reduction of the fibula and placement of a Kirschner wire through the fibula and tibia along the transmalleolar axis. The syndesmosis can then be reduced along the glide path created by the Kirschner wire to prevent posterior or anterior malreduction. Computed tomographic scans of the repaired and contralateral ankles were obtained postoperatively to assess reduction. Results: We found a statistically significant decrease of syndesmotic malreductions using the modified Glide Path technique when compared with technique that did not use a glide path. In our study, 2 of 16 patients (12.5%) had syndesmotic malreductions using the modified Glide Path technique, compared with 11 of 25 patients (44%) with syndesmotic malreductions in the historical cohort. Conclusion: The modified Glide Path technique is a simple method for ankle syndesmotic reduction. The technique has lower rates of malreduction compared with historical methods and may be useful for most operative syndesmotic injuries. Level of Evidence: Level II, prospective cohort study.

Tenosynovial giant-cell tumor (TGCT) is an intraarticular giant-cell tumor of the synovial tissue and tendon sheaths which often mimics multiple conditions on presentation. This case report describes a previously asymptomatic 67-year-old man with preliminary clinical and laboratory evaluation suggestive of septic arthritis; however, arthroscopy revealed diffuse synovitis, and biopsy confirmed TGCT. To our knowledge, this is the first report of TGCT presenting as septic arthritis in an adult patient. This diagnosis should be considered in evaluation of acute, atraumatic knee pain with associated inflammatory marker elevation.

Anterior cruciate ligament reconstruction failure remains a commonly seen outcome despite advances in technique and graft options. Recent studies have shown that the declination of the tibial plateau slope in the sagittal plane affects the in situ stress on the anterior cruciate ligament. The native posterior tibial slope has been described to range from 7° to 10°. However, several authors have suggested that a posterior tibial slope >12° should be considered pathologic. Given the recent evidence, our institution has begun performing a tibial tubercle–sparing anterior closing wedge proximal tibial osteotomy with cross screw fixation to decrease sagittal plane tibial slope.

As the health care delivery system in the United States changes, there has been an increase in the presence of specialized medical centers, translating into increased travel distance for patients. Tripler Army Medical Center in Honolulu, Hawai'i serves a unique population of local patients and those traveling from neighboring Hawaiian Islands and from across the Pacific Basin and Asia. Previous studies have examined the role of distance traveled, but no study has looked at patients routinely flying in the immediate postoperative period. The purpose of this study is to investigate if increased travel distance is associated with a higher probability of complications after a total joint arthroplasty (TJA). A retrospective review of all patients receiving TJA at a single medical institution was performed. After meeting the inclusion criteria, 126 consecutive patients were reviewed for 30-day complications. Sixty-four patients were local (from O'ahu, Hawai'i), and 13 from neighboring Hawaiian Islands, while 49 were international. There were no significant differences in complications between the groups. Length of stay was not affected by distance. A significant risk factor for short-term complications was having a higher score based on the American Society of Anesthesiologists Physical Status Classification System (ASA), ASA 3 vs ASA 1&2 (14% vs 1%, P = .015). There were no findings in our population to support inferior outcomes in patients traveling from the outer Pacific Basin during their initial postoperative course compared to the local population. No patient sustained a short-term complication after a patient returned to their island or country of origin. The results of this study will help to guide clinical decision making and effective resource management for patients seeking TJA traveling from a significant distance.

Introduction:Septic arthritis of a native hip is a relatively uncommon condition in adults. Prompt diagnosis and treatment of septic hip arthritis are imperative to preserve joint integrity, as failure to quickly intervene can allow rapid degenerative changes.Case Report:This is a case report of a 50-year-old male that presented with right septic hip arthritis in the acute setting. He complained of pain with attempted range of motion and log-roll. Laboratory workup demonstrated no leukocytosis, but elevated inflammatory markers. A hip aspiration under fluoroscopy was performed, revealing a cell count of 100,600/cm3 with 91% neutrophils. His right hip underwent irrigation and debridement with a muscle-sparing anterolateral approach (Rottinger).Conclusion:This case report describes the successful use of the anterior based muscle-sparing approach for incision and drainage of septic arthritis of the native hip joint in an adult patient. Advantages to this strategy include lower rate of nerve injury compared to classical anterior and lateral approaches, less muscle damage than the posterior approach, and no requirement for special skills or equipment as in the case of hip arthroscopy.

BACKGROUND Stress radiographs have demonstrated superior efficacy in the evaluation of ankle instability. AIM To determine if there is a degree of instability evidenced by stress radiographs that is associated with pathology concomitant with ankle ligamentous instability. METHODS A retrospective review of 87 consecutive patients aged 18-74 who had stress radiographs performed at a single institution between 2014 and 2020 was performed. These manual radiographic stress views were then correlated with magnetic resonance imaging and operative findings. RESULTS A statistically significant association was determined for the mean and median stress radiographic values and the presence of peroneal pathology (P = 0.008 for tendonitis and P = 0.020 for peroneal tendon tears). A significant inverse relationship was found between the presence of an osteochondral defect and increasing degrees of instability (P = 0.043). CONCLUSION Although valuable in the clinical evaluation of ankle instability, stress radiographs are not an independent predictor of conditions associated with ankle instability.

The Achilles tendon is a common site of anatomical injury among athletes and those participating in recreational sporting activities. Acute Achilles tendon ruptures are often misdiagnosed as a sprained ankle and are more common in the male population. Mechanism of injury is often a noncontact injury, resulting from sudden forced plantar flexion or violent dorsiflexion in a plantar flexed foot. Delays in diagnosis and treatment may complicate the clinical outcome. Because findings may be subtle on history and physical examination, the use of readily available adjunctive studies is important for practitioners. One method is the analysis of Kager's triangle on lateral ankle radiographs. Obscuration of Kager's triangle has been described as a radiographic indicator of Achilles tendon rupture, but the sensitivity and specificity of this finding have been poorly reported. [ Orthopedics . 2020; 43(2): e91–e94.]

The induction of proinflammatory proteins in stimulated endothelial cells (EC) requires activation of multiple transcription programs. The homeobox transcription factor HOXA9 has an important regulatory role in cytokine induction of the EC-leukocyte adhesion molecules (ELAM) E-selectin and vascular cell adhesion molecule 1 (VCAM-1). However, the mechanism underlying stimulus-dependent activation of HOXA9 is completely unknown. Here, we elucidate the molecular mechanism of HOXA9 activation by tumor necrosis factor alpha (TNF-α) and show an unexpected requirement for arginine methylation by protein arginine methyltransferase 5 (PRMT5). PRMT5 was identified as a TNF-α-dependent binding partner of HOXA9 by mass spectrometry. Small interfering RNA (siRNA)-mediated depletion of PRMT5 abrogated stimulus-dependent HOXA9 methylation with concomitant loss in E-selectin or VCAM-1 induction. Chromatin immunoprecipitation analysis revealed that PRMT5 is recruited to the E-selectin promoter following transient HOXA9 binding to its cognate recognition sequence. PRMT5 induces symmetric dimethylation of Arg140 on HOXA9, an event essential for E-selectin induction. In summary, PRMT5 is a critical coactivator component in a newly defined, HOXA9-containing transcription complex. Moreover, stimulus-dependent methylation of HOXA9 is essential for ELAM expression during the EC inflammatory response.

The purpose of this study was to evaluate the use of an oblique obturator radiograph in bone marrow aspiration. The authors retrospectively reviewed 22 patients who underwent bone marrow aspiration guided by the real-time oblique obturator radiograph while in a supine position at their institution between November 2009 and August 2010. The mean duration of bone marrow aspiration was 35±9 seconds. According to the visual analog scale, the postoperative pain score at the site of aspiration was an average 1.6 of 10. No complications were observed. The oblique obturator radiograph can improve the accuracy of the aspiration.

The purpose of this study was to identify the results of ultrasound-guided injection of corticosteroid for biceps brachii tendinitis. In this randomized and prospective study, we evaluated 45 patients who were treated by free-hand injection without ultrasound guidance (group A) and 53 patients who were treated by ultrasound-guided injection (group B). The mean age was 47 y (range, 28 to 72). The average follow-up was 33 weeks (range, 24 to 56). The visual analog scale score decreased from 7.1 +/- 2.3 before injection to 4.2 +/- 3.1 at follow-up in group A and from 6.9 +/- 2.6 to 2.1 +/- 1.9 in group B (p < 0.05). The Constant-Murley score improved from 31.4 +/- 11.6 before injection to 73.5 +/- 19.2 at follow-up in group A and from 32.5 +/- 14.7 to 85.5 +/- 10.3 (p < 0.01). The ultrasound-guided injection therefore demonstrated a statistically significantly greater degree of pain relief. However, the outcome of injection was not satisfactory for the patients who demonstrated severely frayed tendons at arthroscopy. There were no complications related to the injection in both groups. Corticosteroid injection under ultrasound guidance is a safe and well-tolerated procedure with a satisfactory rate of symptom relief in patients with biceps brachii tendinitis. (E-mail: awei3@sohu.com) (C) 2011 World Federation for Ultrasound in Medicine & Biology.

Background: The treatment of unstable displaced proximal humeral fractures remains challenging and controversial. Reports about the application of a minieexternal fixator in the treatment of proximal humeral fractures are rare. The objective of this retrospective study was to evaluate the efficacy and complications of surgical treatment of proximal humeral fractures by closed reduction and external fixation with application of a minieexternal fixator.Methods: Thirty-two patients with displaced proximal humeral fractures were surgically treated by closed reduction and external fixation with minieexternal fixators at our institute between March 2007 and June 2009. There were 22 men and 10 women who had a mean age of 56 years (range, 23-81 years). The Neer scoring system related to pain, function, and range of motion was used to assess the outcome.Results: All the patients were followed up at an mean of 18 months (range, 13-27 months). The duration of surgery was 29 +/- 12 minutes. The accumulative fluoroscopy time was 12 +/- 3.5 exposures. The mean time of fracture union was 13 +/- 3.6 weeks. The mean Neer score was 83.2 +/- 12.5 points at final follow-up. The incidence of excellent and good results was 81%. Two patients had loosening of the pins. One patient had a collapsed humeral head. There was no infection and impingement.Conclusion: The surgical treatment of displaced proximal humeral fractures with a minieexternal fixator is characterized by minimal invasion, a shorter duration of surgery, and easy manipulation, making application of the minieexternal fixator a good option for some selected patients.Level of evidence: Level IV, Case Series, Treatment Study. (C) 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.

BACKGROUND:Intra-articular calcaneal fractures are more likely to suffer consequences in terms of pain and disability. Many studies have suggested that operative treatment for these fractures may result in better outcomes than nonoperative treatment. The metallic screws and plates are among the most common alternatives to stabilize calcaneal fractures. However, the complications of plating of calcaneal fractures are not uncommon. Complications such as infection, poor wound healing, and soft tissue irritation exist. With the advent of bioabsorbable screws, many reports have demonstrated favorable results in treating intra-articular fractures with these screws. The comparative outcomes of operative treatment of calcaneal fractures stabilized with plates and absorbable screws are rarely reported. The purpose of this study is to compare the clinical outcomes and complications related to fracture stabilization with plates and absorbable screws.METHODS:Ninety-seven patients with intra-articular calcaneal fractures were managed at our institution between February 2007 and March 2009. In this prospective, randomized study, the plates were used in 52 cases (group A), and the absorbable screws were used in 47 cases (group B). There were 71 men and 26 women who had a mean age of 41 years (range, 19–67 years). The clinical outcome and complications were assessed and compared. The adjusted American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (subjective component only), Foot Function Index, and the calcaneal fracture scoring system were used to assess the results.RESULTS:The patients were followed up at an average of 23 months (range, 15–32 months). Radiographically, there were no nonunions in either group. One year after operation, in group A and B, the mean adjusted American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score were 71.6 ± 12.5 and 72.3 ± 17.4, respectively (p > 0.05); the mean Foot Function Index score were 21.4 ± 6.6 and 22.7 ±5.2, respectively (p > 0.05); and the mean calcaneal fracture scoring system score were 73.5 ± 8.3 and 75.1 ± 6.9, respectively (p >0.05). In group A, there were six cases of poor wound healing, one case of deep infection, and four cases of peroneal tendon irritation.In group B, there was one case of superficial infection, and no deep infection and soft tissue irritation.CONCLUSIONS:In this report, the outcomes of operative treatment with absorbable screws are comparable with the outcomes of operative treatment with plates. Both plates and absorbable screws showed favorable results in the surgical treatment of calcaneal fractures. However,the metallic plates were associated with increased complications. The stabilizations of displaced intra-articular calcaneal fractures with bioabsorbable screws are reasonable with advantages of fewer complications and without the need for screw removal.