T he purpose of this manuscript is to provide current information regarding the examination, conservative treatment, and surgical treatment for individuals with posttraumatic arthritis. The 3 major categories of arthritis are inflammatory, osteoarthritis, and posttraumatic arthritis. Rheumatoid arthritis is the most common form of inflammatory arthritis; however, it does not always affect the ankle.35 It has been reported that 10% to 50% of individuals with rheumatoid arthritis have ankle involvement. 8,16,48,60,83 The mechanical properties of the tibiotalar articular cartilage make it durable and efficient at equalizing stress. These properties may reduce the risk of osteoarthritis at the ankle. 7,37,75,77,80,86 Posttraumatic arthritis is more common than osteoarthritis at the ankle. Saltzman et al 71 reported that osteoarthritis and posttraumatic arthritis accounted for 12% and 70% of ankle arthritis cases, respectively.
The use of the saphenous vein in situ is associated with unique problems that decrease primary graft patency (patency uninterrupted by revision). During the past 5 years, we have performed 192 in situ saphenous vein bypasses in 182 patients, including 61 to the popliteal artery, 128 to infrapopliteal arteries, and three to isolated popliteal artery segments. The operative indications were critical limb ischemia in 178 cases (93%), popliteal aneurysm in eight cases (4%), and disabling claudication in six cases (3%). A progressive decline in primary patency occurred after operation. The primary patency rate at 36 months was only 48% for femoropopliteal bypasses and was 58% for femorotibial bypasses. In contrast, the secondary patency rate (patency maintained by thrombectomy, thrombolysis, or revision) at 36 months was 89% and 80% for femoropopliteal and femorotibial bypasses, respectively. The improved secondary patency was due to postoperative surveillance of graft hemodynamics and the success of graft revision. Problems unique to the in situ technique (incomplete valve incision, residual arteriovenous fistula, graft torsion and entrapment) accounted for 58% of early (less than 30 days) graft revisions and 52% of late revisions. The use of Doppler spectral analysis at operation and duplex scanning after operation can locate unsuspected technical errors and identify grafts with low flow at increased risk for failure. The primary patency of the in situ bypass mandates objective assessment of valve incision sites at operation and a protocol of postoperative surveillance to identify grafts that require revision. Early surgical intervention of hemodynamically abnormal but patent in situ bypasses is rewarded by excellent secondary patency.
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