Objective: To document angles, from 2 difference starting points, or danger zones that should be avoided to minimize risk of injury or irritation to the saphenous neurovascular bundle (SNVB) during suture button (SB) fixation for distal tibiofibular syndesmosis injuries. Design: Retrospective imaging study. Setting: Academic Level 1 trauma center. Patients: Forty-eight randomly selected patients with healthy ankles and computed tomography scans for nonankle diagnoses. Main Outcome Measures: Computed tomography scans and 3D reconstructed images were used to define the angle between the SNVB and 2 different fibular starting points, using the direct lateral (DL) and the posterolateral (PL) starting points. Descriptive analyses were performed to identify angles that should be avoided during suture button fixation. Distances from the SNVB using preset angles of 0, 10, 20, and 30 degrees were analyzed. In addition, the width of the SNVB, the midsubstance angle of the SNVB, and the distance from the 30-degree point to the tibialis anterior were recorded. Results: The mean angle between the SNVB and the standard DL starting point was 13.7 ± 5.0 degrees (P < 0.05), whereas the mean angle using the alternate PL starting point was 17.2 ± 5.3 degrees (P < 0.05). The SNVB width was 5.2 mm [range, 2.6–9.1 mm] (P < 0.05). The distances from the SNVB were greatest for the DL 30-degree group and the PL 0-degree group. Conclusions: The results document angles that should be avoided when using suture button fixation for syndesmosis injuries. Device characteristics and surgery-related variables may require intraoperative modifications, and knowledge of this anatomical relationship may reduce SNVB injury during those situations. Considering our results, we recommend that surgeons place suture buttons from the DL starting point with a 30-degree trajectory to avoid injuries to the SNVB.

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Objectives: To determine whether there is an association between surgical approach and dislocation risk in patients with cognitive impairment compared with those without cognitive impairment treated with hemiarthroplasty for femoral neck fracture. Design: Retrospective study. Setting: Large, multicenter health system. Patients/Participants: One thousand four hundred eighty-one patients who underwent hemiarthroplasty for femoral neck fractures. 828 hips met inclusion criteria, 290 (35.0%) were cognitively impaired, and 538 (65.0%) were cognitively intact. Intervention: Hemiarthroplasty. Main Outcome Measure: Prosthetic hip dislocation. Results: The overall dislocation rate was 2.1% (17 of 828), 3.4% (10 of 290) in the cognitively impaired group, and 1.3% (7 of 538) in the cognitively intact group with a median time to dislocation of 20.5 days (range 2–326 days), 24.5 days (range 3–326 days), and 19.0 days (range 2–36 days), respectively. In the entire cohort, there were no dislocations (0 of 58) with the direct anterior approach (DA); 1.1% (6 of 553) and 5.1% (11 of 217) dislocated with the modified Hardinge (MH) and posterior approaches (PA), respectively. In the cognitively impaired group, there were no dislocations with the DA (0 of 19); 1.5% (3 of 202) and 10.1% (7 of 69) dislocated with the MH and PA, respectively. In the cognitively intact group, there were no dislocations (0 of 39) with the DA; 0.85% (3 of 351) and 2.7% (4 of 148) dislocated with the MH and PA, respectively. There were statistically significant associations between surgical approach and dislocation in the entire cohort and the cognitively impaired group when comparing the MH and PA groups. This was not observed in the cognitively intact group. Patients who dislocated had 3.2 times (95% CI 1.2, 8.7) (P = 0.0226) the hazard of death compared with patients who did not dislocate. Dislocation effectively increased the risk of death by 221% (HR 3.2 95% CI 1.2, 8.7) (P = 0.0226). Conclusions: In this patient population, the PA has a higher dislocation rate than other approaches and has an especially high rate of dislocation when the patients were cognitively impaired. The authors of this study suggest careful consideration of surgical approach when treating these injuries. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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SummaryThirty-one consecutive patients were treated with injections of Botulinum Neu rotoxin A to rectus muscles for strabismus following retinal detachment surgery. In 14 cases the presenting problem was diplopia and in 17 cases the presenting problem was cosmetic appearance. A total of 67 injections was given. Twenty-seven cases had nine months or more follow-up. Of these, four of 11 cases with diplopia had fusion restored, four were shown to have no fusion potential, and three had temporary improvement only. In 16 cases with a primary cosmetic problem there was no useful effect in two, three had surgery as an alternative, three were realigned long-term, and eight had continuing maintenance therapy with toxin. Over half the series had undergone multiple detachment surgery, often for giant tears and other complex pathology.Ocular motility problems following retinal detachment surgery are not uncommon.Retrospective studies1--l have shown an inci dence of up to 14% of post -operative motility dysfunction, while prospective studies have shown an even higher incidence with up to

Objectives: To assess the effects of Krackow suture technique on the vascularity of the patellar tendon. Methods: Six fresh-frozen matched pair cadaveric knee specimens were used. The superficial femoral arteries were cannulated in all knees. The experimental knee underwent an anterior approach, patellar tendon transection from the inferior pole of the patella, 4-strand Krackow stitch placement, patellar tendon repair via 3-bone tunnels, and standard skin closure. The control knee underwent the identical procedure without Krackow stitching. All specimens then underwent precontrast and postcontrast enhanced quantitative magnetic resonance imaging assessment (with gadolinium-based contrast agent). Region of interest analysis was performed to assess for variation in signal enhancement between the experimental and control limbs in various patellar tendon regions and subregions. Latex infusion and anatomical dissection were performed to further evaluate vessel integrity and assess extrinsic vascularity. Results: Quantitative magnetic resonance imaging analysis demonstrated no statistically significant difference in overall arterial contributions. A small but nonsignificant decrease of 7.5% (SD ± 7.1%) in arterial contributions to the entire tendon was observed. Small nonstatistically significant regional decreases throughout the tendon were also detected. In the regional analysis, the largest to smallest decreases in arterial contributions after suture placement were found in the inferomedial, superolateral, lateral, and inferior tendon subregions. In the anatomical dissection, nutrient branches were seen dorsally and posteroinferiorly. Conclusion: The vascularity of the patellar tendon was not significantly affected by Krackow suture placement. Analysis demonstrated small and not statistically significant decreases in arterial contributions, suggesting this technique does not significantly compromise arterial perfusion.

Acromioclavicular (AC) joint separations are common in both sports and trauma injuries. Many surgical options exist for fixation of these injuries. Although the suture button has become popular, it has a moderately high complication rate. The most common complication is the loss of reduction, but another common complication is knot-related pain. This article outlines a method of suture button fixation that addresses both of these complications with a novel knotless construct using TightRopes.

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