Monday, June 20, 2011

Impaired Wound-Healing, Local Eczema, and Chronic Inflammation Following Titanium Osteosynthesis in a Nickel and Cobalt-Allergic Patient: A Case Report and Review of the Literature

Peter Thomas, MD1; Manfred Thomas, MD2; Burkhard Summer, PhD1; Karin Dietrich, MD1; Melanie Zauzig3; Erwin Steinhauser, PhD3; Veit Krenn, MD4; Hans Arnholdt, MD5; Michael J. Flaig, MD1 


The Journal of Bone & Joint Surgery, Volume 93, Issue 11


Patients known to develop allergic reactions to nickel (Ni), cobalt (Co), or chromium (Cr) often develop eczema in association with items of daily use such as jewelry, earrings, or watchbands. The overall sensitization rates to these metals may range between 1.1% (chromium) and 13% (nickel) in the general population, with further differences based on age and sex1. Chromium-cobalt alloys and stainless steel are widely used as orthopaedic implants and may release nickel, chromium, or cobalt into the surrounding tissues as a consequence of either wear or corrosion2. Some patients with a metal allergy may develop dermatitis in association with orthopaedic implants, and the prevalence of dermal sensitivity in patients with a joint replacement, particularly a failed implant, is higher than that in the general population3. Metal sensitivity rates to nickel, cobalt, or chromium may be as high as 43% in orthopaedic patients with well-functioning implants and as high as 71% in patients with poorly functioning implants3. In contrast, because of their excellent biocompatibility, titanium (Ti)-based materials are not considered to provoke allergic reactions. Our patient developed eczema and impaired wound-healing following the fixation of an ankle fracture with titanium-based implants. Histological analysis of the tissue around the implant demonstrated inflammation primarily with lymphocytes, and a contact allergy to nickel and cobalt was found in the absence of titanium hyperreactivity, raising the question of a prior unknown nickel exposure as the source of the complications. The patient was informed that data concerning this case would be submitted for publication, and she consented.


Investigation performed at the Department of Dermatology and Allergology, Ludwig-Maximilians-University Munich, Munich; the Department of Precision- and Micro-Engineering/Engineering Physics, Munich University of Applied Sciences, Munich; the Department of Foot Surgery, Hessingpark-Clinic, Augsburg; and the Institute of Pathology, Augsburg, Germany

Monday, June 13, 2011

Total Ankle Replacement in the Varus Ankle

Authors:  Shock, R., Christensen, J., Schuberth, J. (2011). 

Reviewed by:  James Johnston, DPM


This is a retrospective study of patients with more than 5º of ankle varus arthrosis who underwent total ankle replacement before October 2007.  Patient preoperative, immediate postoperative and most recent post operative weight bearing films were evaluated.  The degree of varus deformity was determined by measurement of the long axis of the tibia to a perpendicular axis of the talar dome on AP and mortise views.

Results:
A total of 26 patients with preoperative varus ankle deformity of greater than 5 degrees were reviewed in the study.  Patient ages ranged from 63.85 ± 9.33 years, with 7 females and 19 males.  The average follow up was 16.69 ± 7.26 months.  The average varus deformity was 18.3º ± 6.4º on the AP preoperative radiograph and 16.8º ±6.79º on the mortise projection.  The immediate postoperative radiographs were measured and showed correction of 19º on the AP and 17º on mortise projections.  All corrections where within 1º of postoperative films at follow up. There was a significant change in coronal plane correction of varus deformity on both AP and mortise views indicating either one can be used for preoperative planning.  The sequence of corrective maneuvers for varus deformity was:  Ancillary pedal procedures including but not limited to subtalar arthrodesis, ankle ligament reconstruction and talonavicular arthrodesis.  A standard incisional approach was used followed by a medial deltoid sleeve release, lateral gutter resection, talar deformity reduction, tibial-talar preparation, component insertion and lateral ligament placation.

Conclusions:
At the time of review there has been no standard surgical approach to the varus ankle TAA in foot and ankle literature.  This article demonstrates a stepwise approach to management of the rearfoot deformity and presents a convincing although limited case review for the indication of TAR in the varus ankle.  The article points out that the varus ankle deformity frequently involves ligamentous imbalance with leads to a maladaptive joint.  Previous literature has provided us with the suggestion that moderate to severe (10 º to 20 º) coronal plane deformity of the tibiotalar complex may be a contraindication to TAA.  This article argues that with proper soft tissue balancing and the reestablishment of the plantigrade foot with a neutral ankle mortise, success can be found at least in the intermediate follow up.

Monday, June 6, 2011

Functional Outcomes after Fibula Locking Nail for Fragility Fractures of the Ankle

Aysha Rajeev, MBBS, FRCS1, Shanaka Senevirathna, MRCS2Corresponding Author Informationemail address, Sarkhell Radha, MRCS3, N.S. Kashayap, FRCS4


The aim of the present study was to assess the functional outcome of fragility fractures of the ankle treated with a fibular locking nail. A retrospective review of 24 patients with fragility fractures treated with a fibular locking nail from January 2005 to December 2007 was performed. The fibular nail used in our study was Biomet SST (stainless steel taper) small bone locking nail for the fibula. The Olerud and Molander scale was used to assess the functional outcome at the end of 1 year. The domains of the Olerud and Molander scale are pain, stiffness, swelling, stair climbing, running, jumping, squatting, support, and the activities of daily living. The patients were interviewed by telephone or the questionnaire was send by mail. Of the 24 patients, 2 were men and 22 were women. The left side was affected in 15 patients. The age group ranged from 71 to 91 years (average, 79). Of the fractures, 10 were lateral alveolus, 8 were bimalleolar, and 6 were trimalleolar fractures. All the patients were followed up at 6 weeks, 12 weeks, and after 6 months. The average period to fracture union was 8.7 weeks. No wound breakdown or any deep infections developed. The average Olerud and Molander scale score was 57 (range, 30 to 65). The use of fibular locking nails to treat these difficult fracture are quite crucial to achieve early mobilization and also to maintain a good fracture position. In our study, the use of fibular nails was a very useful and successful method of treating fragility fractures with a very low risk of complications. It also helps to restore function and results in patient satisfaction.
Level of Clinical Evidence4


1 Associate Specialist, Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, United Kingdom
2 Junior Clinical Fellow, Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, United Kingdom
3 Senior Clinical Fellow, Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, United Kingdom
4 Consultant Orthopaedic Surgeon, Trauma and Orthopaedics, Queen Elizabeth Hospital, Gateshead, United Kingdom