Surgical repair of the Achilles tendon is a common procedure in cases of acute rupture. Open Achilles tendon surgery with a traditional extensile approach is most often performed in the prone position, but this can lead to numerous complications. The mini-open approach for repair in the supine position may avoid the risks of the prone position. The purpose of this study is to compare perioperative outcomes and differences in cost between patients undergoing acute Achilles rupture repair with mini-open approach, incision of approximately 3 cm, in the supine position versus traditional approach in the prone position. MethodsPatients who underwent surgical repair of acute Achilles rupture at a single institution were retrospectively identified using Current Procedural Terminology (CPT) code 27650. Complication rates and the total cost charged to the insurance companies of both the supine and prone groups were calculated. ResultsA total of 80 patients were included for analysis, 26 supine and 54 prone. The difference in average total time in the operating room was statistically significant. The prone position took approximately 15% more time (118.7 minutes) compared to the supine position (100 minutes) (p = 0.001). While not statistically significant, the total cost for the supine group ($19,889) was less than the for the prone group ($21,722) (p = 0.153) Average postoperative pain score, infection rate, dehiscence rate, sepsis rate, and deep vein thrombosis (DVT) rate were also similar between the two groups. No patient in either group experienced rerupture of the Achilles tendon within the first year of primary repair. ConclusionThe mini-open approach in the supine position may be advantageous in the repair of acute Achilles rupture in that it reduces total time in the operating room and total cost while maintaining positive patient outcomes. Prospective clinical studies are warranted to validate these assessments.

Electrosurgical devices are routinely employed during surgery. The use of a Bovie Electrosurgical Unit (ESU) to facilitate the passage of a suture needle through bone has not been studied in the literature. This study aimed to identify force reduction with the application of Bovie ESU to the suture needle through the bone. Peak and the average axial force required for a suture needle to penetrate cadaveric proximal humeri were measured using a custom setup. Twenty-four trials were conducted without electricity, and 72 trials were conducted with a Bovie ESU applying current. Needle size and Bovie ESU power settings were varied. t Tests and analysis of variance were used with p ≤ 0.05 denoting statistical significance. The application of electricity reduced the peak and average axial force needed for a needle to pierce bone, regardless of the Bovie ESU power setting (p < 0.001). The average peak force with the Bovie ESU was 65.7 N, compared with 126.0 N without (p < 0.001), a 47.9% reduction. The average axial force with the Bovie ESU was 38.2 N compared with 81.8 N without (p < 0.001), a 53.3% reduction. There was no significant difference in peak or average axial forces between power settings. At 30 and 90 W of power, larger needle size was associated with significantly lower peak (p = 0.001 and p < 0.001, respectively) and axial (p = 0.002 and p = 0.004, respectively) force. The Bovie ESU reduces the axial force required to pass a suture needle through bone. The use of this technique may allow for the avoidance of drilling for soft tissue repair.*A resident brought this technique back with him to our institution.

Introduction. The open, lateral sinus tarsi approach is the most commonly used technique for subtalar arthrodesis. In this cadaver study, we measured the maximum joint surface area that could be denuded of cartilage and subchondral bone through this approach. Methods. Nine fresh frozen above-knee specimens were used. The subtalar joint was accessed through a lateral incision from the fibular malleolus distally over the sinus tarsi area to the level of the calcaneocuboid joint. Cartilage was removed from the anterior, middle, and posterior facets of the calcaneus and talus using an osteotome and/or curette. ImageJ was used to calculate the surface areas of undenuded cartilage. Results. No specimens were 100% denuded of cartilage on all 6 measured surfaces. The greatest percentages of unprepared surface area remained on the middle facet of the talus (18.66%) and the middle facet of the calcaneus (14.51%). The anterior facet of the talus was 100% denuded in 6 specimens, while the middle and posterior facets were 100% denuded in 3 specimens. The anterior facet of the calcaneus was also 100% denuded in 6 specimens, while the middle and posterior facets were 100% denuded in 3 and 4 specimens, respectively. The average total unprepared surface area per specimen was 8.67%. Conclusion. The lateral sinus tarsi approach provides adequate denudation of cartilage of the subtalar joint in most cases. Total percentage of unprepared joint surface may range from approximately 2% to 18%. Future clinical studies are warranted to assess whether this technique results in optimal union rates. Levels of Evidence:V, Cadaveric Study

Background: No study has examined the incidence of risk factors for postoperative falls following foot and ankle surgery. We investigated the incidence and risk factors for postoperative falls in foot and ankle surgery using inpatient and outpatient population. Methods: A single fellowship-trained foot and ankle surgeon instituted collection of a postoperative fall questionnaire at 2 and 6 weeks postoperatively. A retrospective review of 135 patients with complete prospectively collected fall questionnaire data was performed. Patient demographic information, injury characteristics, comorbidities, baseline medications, length of hospital stay, visual analog scale (VAS) pain scores were collected. After univariable analysis, a multivariable binary logistic regression was conducted to assess independent risk factors for postoperative falls. Results: The median (interquartile range) age was 52 (21) and body mass index was 32.7 (11.1). A total of 108 patients (80%) underwent outpatient procedures. Thirty-nine of the 135 patients (28.9%) reported experiencing a fall in the first 6 weeks after surgery. In multivariable analysis, antidepressant use (adjusted odds ratio 3.41, 95% CI 1.19-9.81) and higher VAS pain scores at 2 weeks postoperatively (adjusted odds ratio 1.27, 95% CI 1.08-1.50) were found to be independent risk factors for postoperative falls. Conclusion: This study found a high incidence of postoperative falls in the first 6 weeks after foot and ankle surgery. Baseline antidepressant use and higher 2-week VAS pain scores were associated with postoperative falls. Foot and ankle surgeons should discuss the risk of falling with patients especially those with risk factors. Level of Evidence: Level III, retrospective cohort study at a single institution.

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Introduction:The direct anterior approach (DAA) to total hip arthroplasty (THA) has a known learning curve, largely due to difficulty achieving exposure and visualization of the acetabulum and proximal femur for joint preparation. There is paucity of information on limb positioning and the degree of angulation at which the limb is positioned for adequate visualization. This study aimed to identify the mean angles of limb positioning necessary for adequate exposure when using two Mueller retractors for femoral preparation using traditional table.Materials & methods: A surgeon performed a DAA THA on 11 cadaveric hemipelves, exposing the femoral canal with two simple, robust Mueller retractors. The degree of external rotation and extension of the hip was measured. Results: Of the 11, the mean age was 77.6 years and mean BMI was 27.95. The mean external rotation angle was 56.5 ± 13.5 . The mean extension angle was 19.9 ± 6.6 . Discussion & conclusion: The key technical step in this study incorporated a second robust Mueller retractor on the posterior aspect of the greater trochanter, providing maximum leverage to deliver the femur and achieve visibility while reducing angles of limb positioning thereby reducing complications, and ultimately lessening the learning curve.

The standard surgical approach for the fusion of the tarsometatarsal (TMT) joint involves a two-incision approach. Philpott et al. proposed a modified, single-incision dorsal approach that yields a similar exposure. This study compares the joint preparation between the standard and modified dorsal approach. Ten fresh frozen cadaver specimens were randomly assigned to receive either a standard or modified dorsal operative approach to the TMT joint. The joint surface was prepared, and the joint was disarticulated. Image analysis, using ImageJ, was performed by two blinded reviewers to assess the joint surface preparation and this was compared by surgical approach. There was no significant difference in the amount of joint prepared when comparing the standard versus modified dorsal approach for TMT joints one through three (p = 0.548, p = 0.310, p = 0.548). First, TMT was 67.6% prepared by the standard approach vs 71.7% by the modified dorsal approach, second TMT was 67.9% vs. 65.7%, and third TMT was 65.9% vs. 59.6%. With our findings, we demonstrate that a modified dorsal approach with a single incision did not limit the ability to prepare the joint space. This study adds credibility backed by data to those set forth by Philipott et al.

Category: Ankle Introduction/Purpose: Isolated lateral malleolus fractures are a common ankle fracture that a foot and ankle surgeon will encounter. Retrograde intramedullary fixation for unstable lateral malleolus fractures has become a viable option for patients at higher risk for potentially devastating wound complications. The aim of this cadaveric study was to assess the relative risk of injuring adjacent anatomic structures with percutaneous implantation of an intramedullary fibular screw for lateral malleolus fractures to minimize iatrogenic injury. Methods: Seven fresh-frozen below-the-knee cadaver specimens were used for this study. Prior to investigations, specimens were inspected with fluoroscopic radiographs for preexisting pathology or prior surgical intervention. Lateral dissection of the lateral malleolus was performed after screw placement to determine the proximity of the peroneus longus (PL), peroneus brevis (PB), and sural nerve (SN) to the inserted hardware. The mean, standard deviation, and range for distances were calculated for all structures. Analysis of variance (ANOVA) was used to determine statistical significance. Results: Percutaneous intramedullary fibular screw placement was performed in seven specimens, six females and one male, with an average age of 79.3 +- 8.1 years. Amongst the seven specimens, only one resulted in an injury to a structure of interest (sural nerve). The peroneus longus and peroneus brevis were not injured in any of the specimens. Table 1 shows the average distance between the guidewire and each structure of interest. Conclusion: This study shows the potential risks to lateral structures when placing an intramedullary fibular screw for unstable lateral malleolus fractures. We suggest that orthopedic surgeons exercise caution when performing critical steps of the procedure to minimize avoidable injury to structures of importance that may increase the morbidity of the patient.