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Biomedical subjects

Christopher W DiGiovanni

Publications and source records attributed to Christopher W DiGiovanni.

16 recordsLinked to original sources
PubMed2006

Tibial nonunion.

Nonunions of the tibia represent challenging orthopedic problems, which require the surgeon to analyze numerous factors and choose an appropriate treatment. Tibial nonunion treatment requires establishing its existence and cause. The treatment algorithm necessitates consideration of a wide variety of factors: the location of the nonunion, the presence or absence of infection, and any angular or rotational deformity. Given advances in implant design and biologic agents, a wide variety of management options exist for the treatment of tibial nonunions. This article reviews surgical treatments for tibial nonunions.

Fracture Fixation↗
PubMed2006

Tibial malunion.

Tibial malunion, a fracture healed in a position that affects the mechanical function of the limb, can be difficult to assess and to correct surgically. Precise definition of malunion has yet to be determined, and the limits of deformity which are associated with arthritic change also remain imprecise. Surgical intervention is therefore primarily indicated in symptomatic patients or those with relatively severe deformity. The several described techniques for correction of tibial malunion can achieve excellent results, although the surgery is not without substantial risk and recovery time. These issues should be discussed at length with patients before surgery.

Fracture Fixation↗
PubMed2004

Fractures of the navicular.

Generally, large or significantly displaced intra-articular navicular fractures are treated best by surgical intervention. Open reduction and internal fixation of these injuries allow anatomic restoration of adjacent joint surfaces and preservation of length and stability along the medial column of the foot; intervention must not disrupt the already tenuous blood Supply of the tarsal navicular because of the associated risks of avascular necrosis and nonunion. The unique morphology and vital role of the navicular as a cornerstone of the talonavicular joint require every effort to maintain the congruity and motion of this joint to avoid later fusion. The likelihood for successful reduction decreases with increasing grades of injury. The naviculo-cuneiform joint, alternatively, requires stability for proper foot function and can be fused, if necessary, to improve fixation or enhance vascularity to the navicular. External fixation, bone grafting (often and early), and limited peritarsal fusion also have evolved into useful aids, under certain circumstances, to facilitate the goals of navicular fracture management. Early postoperative range of motion, prolonged protected weight bearing, and aggressive patient counseling as to the severity and long-term implications of these injuries also are paramount to success. Caution also must be exercised in managing navicular dislocations because of the potential long-term complications of redislocation or painful flatfoot deformity if alignment is not maintained. Navicular fracture care remains a challenge to the orthopedic surgeon; successful surgical intervention continues to hinge upon a careful balance between an operative exposure that is limited enough to avoid further devascularization but extensive enough to permit anatomic reduction and rigid internal fixation.

Arthrodesis↗
PubMed2004

A survey of orthopedic surgeons regarding DVT prophylaxis in foot and ankle trauma surgery.

This study hypothesized that thromboembolism in patients with foot and ankle trauma is higher than currently recognized, and that prophylaxis varies among surgeons. A questionnaire sent to members of two orthopedic specialty societies surveyed the use of thromboembolic prophylaxis over 1 year. Most did not use preoperative prophylaxis. Postoperatively, 44% of surgeons used prophylaxis, most commonly sequential compression devices and low molecular weight heparin. This survey suggests that thromboembolic prophylaxis is used by < 50% of surgeons treating foot and ankle trauma. The reported cases of thromboembolism in this study underline the need for a prospective investigation.

Ankle Injuries↗
PubMed2004

Use of emergency room external fixator in provisional reduction of posterior malleolar fractures.

Closed reduction is an important initial step in managing ankle fractures. Although the majority of ankle fractures can be managed with closed reduction, the posterior malleolar fracture is often unstable. Posterior malleolar fractures may result in persistent posterior ankle dislocation with compromise of the soft tissue surrounding the joint. Persistent dislocation is best treated with urgent open reduction and fixation to protect the cartilage and surrounding soft tissues and to allow for ease of reduction at the time of surgery. We describe a technique for placing an emergency room external fixator for provisional reduction of the unstable posterior malleolar fracture. This technique allows for early reduction of unstable posterior malleolar fractures and avoids the need for urgent operative reduction.

Adult↗
PubMed2003

Anatomic study of the gastrocnemius-soleus junction and its relationship to the sural nerve.

BACKGROUND: Gastrocnemius recession is performed for equinus contracture of the ankle and as an adjunct treatment for various foot pathologies. Successful release relies on many factors, including a thorough knowledge of the anatomy of the gastrocnemius-soleus junction and its relationship to the sural nerve which may be vulnerable to iatrogenic injury. Neither the average width of the tendon at the gastrocnemius-soleus junction, the anatomy of the sural nerve with respect to the gastrocnemius-soleus junction, nor appropriate landmarks for accurate incision placement at this level to avoid undesirable vertical extension, however, have yet to be acceptably defined. METHODS: Fourteen fresh-frozen cadavers were dissected and the width of the tendon at the gastrocnemius-soleus junction, the distance of the sural nerve from the lateral border of the tendon at this level, the length of the fibula, and the distance from the distal tip of the fibula to the gastrocnemius-soleus junction were measured. RESULTS: The average width of the gastrocnemius-soleus complex at the junction was 58 mm (range, 44-69 mm), the average distance of the sural nerve from the lateral border of the gastrocnemius-soleus complex at the level of the gastrocnemius-soleus junction was 12 mm (range, 7-17 mm), the average percentage of this distance as compared to the entire width of gastrocnemius-soleus junction was 20% (range, 13%-27%), and the ratio of the distance of the gastrocnemius-soleus junction from the distal tip of the fibula divided by the length of the fibula was 0.5 (range, 0.5-0.6). CONCLUSION: These results provide some guidelines as to the approximate size of the gastrocnemius-soleus complex at the site of gastrocnemius recession along with the location of the sural nerve at the musculotendinous junction. Also, the results indicate that the fibula can serve as a reproducible anatomic landmark to enable localization of the gastrocnemius-soleus junction at the time of gastrocnemius recession.

Cadaver↗
PubMed2003

Endoscopic gastrocnemius recession: evaluation in a cadaver model.

The purpose of this study was to describe a new method of gastrocnemius recession using an endoscopic approach and to determine the accuracy of incision placement during gastrocnemius recession. Fifteen fresh-frozen cadaveric limbs underwent an endoscopic gastrocnemius recession utilizing a two-portal technique. All limbs were anatomically dissected after the procedure and each was examined for injury to the sural nerve. The ability to visualize the sural nerve intraoperatively, improvement in ankle dorsiflexion, time requirement for the procedure, incision size, and appropriateness of placement to facilitate recession were recorded for each specimen. An average of 83% of the gastrocnemius aponeurosis was transected in all 15 cadavers. After modifications of the technique, the final eight cadavers were noted to have had the entire (100%) gastrocnemius aponeurosis transected. Sural nerve injury occurred in one specimen (7%) in which the aponeurosis and the sural nerve were not well visualized. The sural nerve was definitively visualized during the procedure in 5 of 15 specimens (33%). No Achilles tendon injury was noted in any specimen. There was a mean improvement in ankle dorsiflexion of 20 degrees (range, 10 degrees-30 degrees) during full knee extension. The average length of time to perform the procedure was 20 minutes (range, 10-35 minutes). The average medial and lateral incision lengths used in the two-portal technique were 18 mm (range, 14-22 mm) and 17 mm (range, 12-19 mm), respectively, and the average distance from the midpoint of the medial incision to the level of the gastrocnemius-soleus junction was 26 mm (range, 5-60 mm). These results indicate that a complete gastrocnemius aponeurosis transection may be obtained utilizing a modified endoscopic gastrocnemius recession, but visualization of the sural nerve is poor with possible risk of iatrogenic nerve injury.

Cadaver↗
PubMed2003

Flexor hallucis longus transfer for repair of chronic achilles tendinopathy.

BACKGROUND: The flexor hallucis longus (FHL) tendon has been used to augment the repairs for chronic Achilles tendinopathy. Two common methods of FHL harvesting include a single incision (posterior) technique and a double incision (posterior and medial utility) technique. This cadaver study was designed to measure and compare the lengths of FHL tendon obtainable for reconstruction with each technique. METHODS: Fourteen fresh-frozen cadaver lower limbs were utilized for FHL harvest. The tendon was first exposed through the single posterior-medial incision approach adjacent to the Achilles. A second medial utility midfoot incision was then made and the FHL was marked at the level of Henry's knot with a suture, to approximate the level of potential harvest via a two-incision technique. The FHL was then harvested and delivered into the posterior wound. Single incision technique graft length was then measured from the tip of the calcaneal tuber to the level of transection. The remaining in situ tendon was then also measured between its level of transection and the more distal suture placed at Henry's knot. These two lengths were then combined to determine the total potential tendon graft length obtainable using a double incision technique. RESULTS: The average length of the FHL tendon harvested through the single posterior incision technique measured 5.16 cm (range, 3.4-6.9 cm, SD = 1.29). The average total tendon graft length available using the double incision technique measured 8.09 cm (range, 5.1-11.1 cm, SD = 1.63). The difference between the lengths obtained from these two techniques was significant (p < .001). CONCLUSIONS: These results demonstrate approximate FHL graft lengths obtainable by using either a single or double incision harvest technique and show that a significantly longer graft can be obtained using a double incision technique. Further data need to be obtained, however, to support whether the extra surgery and graft length obtained from a double incision technique are of any benefit in improving the ultimate functional outcome of these repairs.

Achilles Tendon↗
PubMed2003

Patient compliance in avoiding wrong-site surgery.

BACKGROUND: Wrong-site orthopaedic surgery is an uncommon, devastating, and preventable complication. The sole responsibility for avoiding this inadvertent event has historically been placed on physicians, nurses, and ancillary health-care personnel. Very little attention has been focused on the role of the patient. The successful outcome of any surgical or medical intervention requires an interactive doctor-patient relationship. The hypothesis of this study was that a substantial number of patients who undergo elective orthopaedic surgery do not comply with instructions designed specifically to prevent wrong-site surgery. METHODS: We prospectively evaluated the frequency with which 100 consecutive patients in a private foot-and-ankle practice followed the explicit preoperative instruction, before they underwent elective orthopaedic surgery, to mark "NO" on the extremity that was not to be operated on. Full compliance was defined as a mark on the correct extremity consistent with the instructions. Partial compliance was defined as a mark that was different from that requested by the specific preoperative instructions, and noncompliance was defined as the absence of any mark. Specific demographic and surgical factors were recorded from medical charts and compared between compliant and noncompliant patients. RESULTS: Fifty-nine of the 100 patients marked the extremity correctly, thirty-seven made no mark, and four were considered partially compliant. Of the ten patients with a Workers' Compensation claim, seven were noncompliant compared with thirty (33%) of the ninety patients who had not made a Workers' Compensation claim (p = 0.023). Patients who had had a previous related surgical procedure also had a significantly higher rate of noncompliance (51%; nineteen of thirty-seven) compared with those with no previous surgery (29%; eighteen of sixty-three; p = 0.023). CONCLUSIONS: A surprisingly high number of patients do not comply with explicit preoperative instructions created specifically to prevent wrong-site surgery. This behavior suggests that patients expect the system to "take care of everything," despite solicitation of their active participation to avoid such adverse events. Although physicians and related health-care personnel certainly have the greatest responsibility to provide the highest possible quality of care, patients undergoing surgery must be encouraged to take a more active role in their health care in order to optimize outcome and minimize risk.

Adolescent↗
PubMed2002

Differences in bone-cement porosity by vacuum mixing, centrifugation, and hand mixing.

The mean pore size and percent porosity of vacuum-mixed cement were compared with centrifuged cement and cement hand mixed by skilled specialized operating room technicians. Centrifuged cement samples had the smallest mean pore size when compared with vacuum-mixed specimens. The mean pore size for the hand-mixed specimens was intermediate and not significantly different from the other 2 mixing techniques. Results were reversed, however, for mean percent porosity. Centrifuged cement had the highest percent porosity; vacuum-mixed cement, the lowest; and hand-mixed cement, intermediate. The porosity of vacuum-mixed Simplex P (Howmedica, Rutherford, NJ) bone-cement was similar from the initial to the remnant cement extruded from the cement gun. There was no reduced cement porosity with vacuum mixing or centrifugation as anticipated. Reversion to hand mixing by highly skilled technicians could result in a significant cost savings without negative effects on cement porosity.

Bone Cements↗
PubMed2002

Isolated gastrocnemius tightness.

BACKGROUND: Contracture of the gastrocnemius-soleus complex has well-documented deleterious effects on lower-limb function in spastic or neurologically impaired individuals. There is scarce literature, however, on the existence of isolated gastrocnemius contracture or its impact in otherwise normal patients. We hypothesized that an inability to dorsiflex the ankle due to equinus contracture leads to increased pain in the forefoot and/or midfoot and therefore a population with such pain will have less maximum ankle dorsiflexion than controls. We further postulated that the difference would be present whether the knee was extended or flexed. METHODS: This investigation was a prospective comparison of maximal ankle dorsiflexion, as a proxy for gastrocnemius tension, in response to a load applied to the undersurface of the foot in two healthy age, weight, and sex-matched groups. The patient group comprised thirty-four consecutive patients with a diagnosis of metatarsalgia or related midfoot and/or forefoot symptoms. The control group consisted of thirty-four individuals without foot or ankle symptoms. The participants were clinically examined for gastrocnemius and soleus contracture and were subsequently assessed for tightness with use of a specially designed electrogoniometer. Measurements were made both with the knee extended (the gastrocnemius under tension) and with the knee flexed (the gastrocnemius relaxed). RESULTS: With the knee fully extended, the average maximal ankle dorsiflexion was 4.5 degrees in the patient group and 13.1 degrees in the control group (p < 0.001). With the knee flexed 90 degrees, the average was 17.9 degrees in the patient group and 22.3 degrees in the control population (p = 0.09). When gastrocnemius contracture was defined as dorsiflexion of < or = 5 degrees during knee extension, it was identified in 65% of the patients compared with 24% of the control population. However, when gastrocnemius contracture was defined as dorsiflexion of < or = 10 degrees, it was present in 88% and 44%, respectively. When gastrocnemius-soleus contracture was defined as dorsiflexion of < or = 10 degrees with the knee in 90 degrees of flexion, it was identified in 29% of the patient group and 15% of the control group. CONCLUSIONS: On the average, patients with forefoot and/or midfoot symptoms had less maximum ankle dorsiflexion with the knee extended than did a control population without foot or ankle symptoms. When the knee was flexed 90 degrees to relax the gastrocnemius, this difference was no longer present. CLINICAL RELEVANCE: These findings support the existence of isolated gastrocnemius contracture in the development of forefoot and/or midfoot pathology in otherwise healthy people. These data may have implications for preventative and therapeutic care of patients with chronic foot problems.

Adult↗