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Category: Arthroscopy; Ankle; Sports; Trauma Introduction/Purpose: The deltoid ligament complex is the main stabilizing structure of the ankle mortise and is often disrupted in rotational ankle injuries. Current treatment involves open techniques for the acute repair of the superficial deltoid layer, however, repair or reconstruction of the deep deltoid ligament (DDL) has proven to be challenging using open techniques. Our described arthroscopically-assisted technique allows for better intra-articular visualization and durable reconstruction of the ruptured DDL with suture and knotless bone anchors. The goal of this new, minimally invasive approach is to facilitate a faster and more reliable recovery and prevent long-term dysfunction and degeneration from medial and rotational ankle instability. We believe it has the potential to provide improved immediate ankle stability and decrease overall surgical morbidity compared to open treatments. Methods: Case of a 48-year-old male with ligamentous-equivalent Massioneuve fracture with medial clear space (MCS) measuring 11 millimeters. Arthroscopy revealed unstable syndesmosis and rupture of the DDL. After syndesmotic fixation, there was persistent MCS widening on stress exam. Arthroscopically-assisted DDL reconstruction was performed using an accessory anteromedial (AAM) portal between the tibialis anterior tendon and posterior tibial tendon. Needle localization identified the sagittal midpoint of the medial wall of the talus, inferior to articular cartilage. Anchor sites at both the medial talar wall and midportion of the distal medial malleolus (insertion and origin of the DDL, respectively) were then drilled via the AAM portal under arthroscopic and fluoroscopic guidance respectively at the isometric point. A suture anchor was placed into the talus and tails were loaded and secured to the medial malleolus with a bioabsorbable anchor. Ankle mortise was stable to stress exam and there were no restraints to physiologic motion. Results: The patient was kept non-weight bearing on his right lower extremity for a total of 6 weeks postoperatively and was seen in the clinic for routine follow-up visits at 2 weeks, 6 weeks, and 3 months post-procedure. Sutures were removed at 2 weeks, without any wound complications, and he was transitioned from splint to a short leg cast. He required only three days of oral narcotic analgesia. Weight-bearing in a controlled ankle motion (CAM) boot and physical therapy were both initiated at 6 weeks post-op. Radiographs at each follow-up visit were without abnormalities. At 3 months post-op, he was graduated from the CAM boot into a lace-up ankle brace, without any complaints of ankle pain or instability. The patient progressed well with full weight-bearing and physical therapy and was seen for a final visit at 5 months post-op with stable MCS. No complications were encountered. Conclusion: Acute DDL rupture is a common occurrence in ankle fractures and can be diagnosed radiographically and by arthroscopy. Known sequelae of untreated DDL disruption include medial instability and late valgus collapse. This case report demonstrates a novel, minimally invasive technique to successfully reconstruct the DDL, which may minimize the surgical morbidity compared to open dissection methods and allow for decreased recovery time postoperatively. This approach may also be utilized for cases of chronic instability. Future work includes larger case series with long-term follow-up and refinement of the technique as instrumentation advances.

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Category: Trauma Introduction/Purpose: Opioid pain medications are frequently prescribed after orthopedic surgery as effective tools for pain relief, but with adverse consequences such as addiction and overdose. Postoperative pain control can vary depending on patient opioid prescription history and pain expectations. There are limited studies regarding pain and anxiety levels following orthopedic foot and ankle trauma surgery, with a lack of formal guidelines in prescribing opioid medications to this patient population. The overall purpose of this study was to gain an understanding of postoperative pain and anxiety in patients undergoing outpatient foot and ankle trauma surgery. This study additionally sought to identify any risk factors that may predispose a patient to increased postoperative pain and anxiety, resulting in a potentially increased pain medication requirement. Methods: A subanalysis of 50 patients from a prospective, observational study was performed, examining adult patients undergoing outpatient foot and ankle trauma surgery performed by trauma fellowship-trained senior investigators. Patients were enrolled and given pertinent reference materials including access to an automated texting survey platform to collect data regarding their postoperative pain, anxiety, and opioid medication use. Patients were stratified by procedure type (irrigation & debridement/hardware removal, foot/syndesmosis ORIF, ankle ORIF, pilon ORIF) and by receiving perioperative regional anesthetic block versus local anesthetic. Pain and anxiety were measured with the Numeric Rating Scale for Pain (scale of 1-10) and the Visual Facial Anxiety Scale (scale of 1-5), respectively. The primary outcome measured was the number of days on average for a patient to discontinue opioid medication. Secondary endpoints consisted of pain level < 4, anxiety level < 2, patient-specific and surgery-related factors that may affect these variables. Results: Postoperatively, it took an average of 9.6 days until opioids were discontinued, 8.2 days for pain to subside below 4, and 6.6 days until anxiety reduced under 2. Foot/syndesmosis ORIF and older age were associated with prolonged pain medication use (p<0.05). Drug use and older age limited the chance of obtaining a pain score under 4 (p<0.05). Psychiatric history and older age decreased the odds of obtaining an anxiety score under 2 (p<0.05). White race improved the chance of obtaining an anxiety score under 2 and tapering off pain medications (p<0.05). When stratified by procedure type or analgesic adjuvants (regional block vs local), there were no significant differences in pain and anxiety scores. Conclusion: Our study shows that regardless of procedure type or analgesic adjuvant used, it takes approximately eight days for postoperative pain levels to decrease to 4 out of 10 and six days for anxiety levels to decrease to 2 out of 5, with patients requiring opioid pain medications for an average of 10 days. Risk factors such as older age, prior drug use, and psychiatric history increased postoperative pain, anxiety, and use of opioid pain medications. This data may be utilized by orthopedic surgeons in providing safe, effective, and evidence-based pain management prescribing practices in anticipating postoperative pain and anxiety.

Isolated greater trochanter fractures have been infrequently described in the literature and are typically managed conservatively. Functional strength after injury to the abductor complex can be markedly affected resulting in a Trendelenburg gait and overall abductor weakness. We present a case of a 35-year-old athlete who underwent surgical fixation because of notable fracture displacement and function debility. This case vignette demonstrates the importance of using all available interdisciplinary orthopaedic surgery literature to provide a patientspecific surgical construct. Our patient benefitted from arthroscopic, arthroplasty, and trauma evidence-based medicine to successfully treat his displaced greater trochanteric hip fracture. Successful surgical fixation was enhanced by combining three different methods of fixation: osteosynthesis with partially threaded screws and washers (DePuy Synthes), suture anchor (Arthrex) direct fracture approximation and tendon reinforcement, and a knotless double-row suture bridge (Arthrex) tension band construct. The patient was able to return weightlifting at 4 months postoperatively with no evidence of weakness or trendelenburg gait. I solated greater trochanter (GT) fractures are rare injuries, and recent literature has mainly focused on the incidence and treatment of intertrochanteric fracture extension in the elderly and periprosthetic fractures. [1][2][3][4][5] Magnetic resonance imaging (MRI) is recommended to fully evaluate the extent of the injury and identify notable intertrochanteric extension. 1,4,[6][7][8][9] Surgical indications for isolated greater trochanteric fractures without notable intertrochanteric extension are not clearly defined because of the lack of evidence on the topic. [4][5][6][7] Young, active patients with large, displaced GT fragments may benefit from surgical fixation as opposed to nonsurgical treatment due to the risk of diminished abductor function. 10 In this clinical vignette, we describe the clinical course and novel triple fixation surgical technique of a young, active patient who sustained an isolated displaced GT fracture after a motor vehicle collision.