OKOJ

OKOJ, Volume 10, No. 12


HOT TOPIC: Surgical Treatment of Posterior Malleolar and Syndesmotic Ankle Injuries

In fractures and/or ligamentous injuries about the ankle, it has long been known that even a small change in the position of the talus can cause a significant decrease in tibiotalar contact area. It is also generally accepted that posterior malleolus fractures that incorporate more than 25% of the distal tibial articular surface can lead to posterior subluxation of the talus. Smaller fragments may also lead to talar instability. Because the posterior inferior tibiofibular ligament inserts on the posterior malleolus, fractures to this region of the tibia will render the ligament incompetent. Repair of the syndesmotic complex can be accomplished via syndesmotic screw fixation or reduction and fixation of the posterior malleolus fragment. Both in vitro and in vivo studies have shown, however, that reconstruction of the posterior malleolus provides equal or greater syndesmotic stability, as well as a more anatomic reconstruction of the tibial incisura, than does screw fixation. In this article, we review the pathophysiology, etiology, and diagnosis of posterior malleolus fractures, and provide a brief overview of the surgical technique for reduction and fixation of the posterior malleolar fragment.

    • Keywords:
    • ankle injury

    • ankle fracture

    • posterior malleolus fracture

    • syndesmotic injury

    • open reduction and internal fixation

    • posteroloateral approach

    • Subspecialty:
    • Trauma

Regional Anesthesia for Wrist and Hand Surgery

Regional anesthesia techniques can be used for primary surgical anesthesia and postoperative analgesia, particularly for patients with a history of sensitivity or poor response to general anesthesia and opioid-based analgesia. The use of high-resolution ultrasound for the localization of peripheral nerves and guidance of local anesthetic injection has some reported advantages over more traditional techniques, specifically in the realm of efficiency and challenging clinical situations. Available evidence, however, does not entirely support the abandonment of other techniques. Continuous peripheral nerve catheters are being used to extend the duration of regional analgesia in selected patients and procedures. Intravenous regional anesthesia continues to combine simplicity and reliability for many hand and wrist procedures of appropriate duration. Allocating resources to maximize parallel, rather than serial, anesthetic care provides the best opportunity for regional anesthesia to improve the efficient functioning of the operating and recovery rooms.

    • Keywords:
    • regional anesthesia

    • brachial plexus block

    • supraclavicular block

    • infraclavicular block

    • axillary block

    • interscalene block

    • peripheral nerve block

    • continuous peripheral nerve catheter

    • ultasound guidance

    • nerve stimulation

    • intravenous regional anesthesia

    • Bier block

    • Subspecialty:
    • Hand and Wrist

The Management of Spinosacropelvic Tumors

Curative treatment for many primary tumors of the sacrum requires oncologic sacrectomy. This is an extensive surgical procedure that often involves the lower lumbar spine and ilia and the deliberate sacrifice of neurologic function. Oncologic resections of sacral tumors are challenging because of their proximity to critical vascular, visceral, and neurologic structures, which makes it difficult to obtain a wide margin of resection. The proper resection of large tumors in this area may require a disruption of spinopelvic continuity. The types of tumor most commonly requiring sacrectomy are chordoma, chondrosarcoma, osteosarcoma, malignant peripheral nerve sheath tumors, extradural myxopapillary ependymoma, and recurrent rectal carcinoma without evidence of distant metastases. The magnitude of the surgical procedure for sacrectomy is such that it is generally done only with curative intent, which requires a wide or R0 margin of resection for removal of the entire tumor as a single specimen, without any margins of the specimen showing microscopic evidence of tumor cells. This article describes the factors that merit a consideration of oncologic sacrectomy and the execution of this surgical procedure. Less radical procedures are done for aggressive benign tumors, such as giant-cell tumor and osteoblastoma, or for the treatment of infection. The techniques described in this chapter may be adapted to intralesional resections when indicated.

    • Keywords:
    • sacrectomy

    • cancer

    • primary sacral tumor

    • chordoma

    • chondrosarcoma

    • osteosarcoma

    • giant cell tumor

    • spinopelvic continuity

    • hemicorporectomy

    • Subspecialty:
    • Spine

    • Musculoskeletal Oncology

Update on the Management of Trochanteric Fractures of the Hip

The trochanteric area of the femur is the region of the femoral metaphysis between the base of the femoral neck and the most distal level of the lesser trochanter. In elderly persons, this area of the femur, also variously called the extracapsular or pertrochanteric region of the femur, is typically affected by osteoporosis, reducing its structural strength, and in persons older than 65 years is subject to a high incidence of fracture. It is estimated that 238,000 hip fractures occur annually in the United States, and this figure could increase to 512,000 hip fractures per year by the year 2040. Trochanteric fractures represent more than half of these hip fractures, and in the geriatric population are among the most common injuries encountered by orthopaedic surgeons. This article reviews the pathophysiology and clinical presentation of trochanteric proximal femur fractures, and is intended to supplement and extend our previously published OKOJ article, "Trochanteric Proximal Femur Fractures."

    • Keywords:
    • trochanteric fracture

    • greater trochanter

    • lesser trochanter

    • pertrochanteric fracture

    • intertrochanteric fracture

    • proximal femur fracture

    • sliding hip screw

    • dynamic hip screw cephalomedullary nail

    • variable angle plate

    • arthroplasty

    • hemiarthroplasty

    • total hip arthroplasty

    • Subspecialty:
    • Trauma

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