Foot & ankle international
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The objective of this study was to determine the mechanisms of injury and pattern of associated foot and ankle injuries and systemic injuries associated with subtalar dislocations, and, correlate these data with the radiographic and clinical/functional outcome of patients after subtalar dislocation. ⋯ Twenty-five patients with a subtalar dislocation were identified over a seven year period. The mean patient age was 38 years. Males (n=19) comprised 76% of patients, with a mean age of 36 years. High energy mechanisms (motor vehicle accidents, falls) accounted for 68% of subtalar dislocations. Although high energy mechanisms showed a strong trend toward open subtalar dislocations, the association was not statistically significant (p=0.0573, Fisher's exact test). Closed dislocations predominated (75%). Left and right-sided dislocations were nearly equally distributed, even among motor vehicle accidents. Medial dislocations predominated (65%): these were not influenced by mechanism of injury and did not result in statistically lower AOFAS ankle/hindfoot scores. Subtalar dislocation was irreducible (requiring open reduction) in 32%, with higher energy mechanisms of injury being statistically associated with an irreducible subtalar dislocation (p=0.0261, Fisher's exact test). Block to reduction was evenly distributed among soft tissue elements (posterior tibial tendon, flexor hallucis longus tendon, capsule, extensor retinaculum) and osseous elements. Eighty-eight percent of patients incurred concomitant injuries to the foot and ankle (95% of which were closed injuries), namely, the ankle and talus. Systemic injuries occurred in 88% of patients. At a mean follow-up of five years, the mean AOFAS score of the subtalar dislocation side was significantly lower (mean=71 vs. 93, p=0.0007, unpaired Student's t-test). No statistical relation was found between the number of associated extremity injuries and AOFAS score (Spearman correlation coefficient, r=(-)0.236, p=0.331). Radiographic follow-up demonstrated 89% of ankles with radiographic changes (31% symptomatic); however, the majority of these patients (61%) had an associated ankle injury. The subtalar joint demonstrated radiographic changes in 89% of patients, with 63% being symptomatic; 75% of patients with subtalar joint changes incurred a fracture about the subtalar joint at the time of dislocation. Four patients went on to subtalar fusion at an average of 8.8 months post-dislocation. The midfoot showed radiographic changes in 72% of patients, with only 15% of these patients being symptomatic. All patients with midfoot symptoms were well controlled by nonsurgical measures.
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Avulsion fracture of the medial tubercle of the posterior process of the talus occurs after forceful dorsiflexion-pronation of the ankle. We evaluated five patients who had sustained this fracture while participating in sporting activities. Two patients were correctly diagnosed acutely and treated with immobilization and limited weightbearing. ⋯ Our results suggest that prompt diagnosis and appropriate management yields reliably good outcomes. Untreated avulsion fractures predictably do poorly. For these patients, late excision can provide significant functional and symptomatic improvement.
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Randomized Controlled Trial Clinical Trial
The role of pulsatile cold compression in edema resolution following ankle fractures: a randomized clinical trial.
Twenty-four patients with displaced ankle fractures awaiting surgery were randomized to a study (n=11) or a control group (n=13). In the study group, patients had a pulsatile cold compression (PCC) device applied to their ankle, and remained at bed rest with the extremity elevated while awaiting surgery. In the control group patients remained in a posterior molded splint instead of the PCC device. ⋯ All patients in the PCC group were satisfied with the device (median satisfaction score = 4). The PCC device was well tolerated and resulted in a significantly greater reduction of ankle circumference at 24, 48, and 72 hours after its application, compared to splinting and elevation alone. The PCC device facilitates edema resolution following ankle fractures.
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The purpose of this study is to report our experience with the Vacuum Assisted Closure (VAC) negative pressure technique in patients with non-healing wounds of the foot, ankle, and lower limb. We retrospectively reviewed 17 patients with non-healing wounds of the lower extremity who underwent treatment using the Vacuum Assisted Closure (VAC) device. Thirteen of 17 (76%) had diabetes mellitus, nine of whom were insulin-dependent, and 10 of whom had associated peripheral neuropathy. ⋯ Our results indicate that the Vacuum Assisted Closure negative pressure technique is emerging as an acceptable option for wound care of the lower extremity. Not all patients are candidates for such treatment; those patients with severe peripheral vascular disease or smaller forefoot wounds may be best treated by other modalities. Larger wounds seem to be better suited for skin grafting or two-stage primary closure.
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A wealth of clinical and experimental data suggests, that anatomical restoration of the posterior calcaneal facet is a major predictor of outcome after intra-articular calcaneus fractures. The value of subtalar arthroscopy was examined in three clinical study groups (I-III. ⋯ Subtalar arthroscopy provides a most precise and thorough view of the posterior facet of the calcaneus both in assessing the quality of initial reduction as well as evaluation during hardware removal after intra-articular calcaneus fractures. It is more precise than intra-operative fluoroscopy and less time consuming than standard Brodén views during surgery. The use of arthroscopy allows anatomical percutaneous reduction and screw fixation of Sanders II fractures. It therefore provides a useful additional tool in treating intra-articular calcaneus fractures.