Normal Values for Distal Tibiofibular Syndesmotic Space With and Without Subject-Driven External Rotation Stress

BACKGROUND

The diagnosis and treatment of distal tibiofibular syndesmosis (DTFS) injury can be challenging, especially in cases of subtle instability that may be masked on 2-dimensional conventional radiographs. Weightbearing computed tomography (WBCT) has recently emerged as a useful diagnostic tool allowing direct assessment of distal tibiofibular area widening. The purpose of the current study was to examine and report normal threshold values for DTFS area measurements in a cohort of healthy volunteers, assessing the ankles in natural weightbearing position and under subject-driven external rotation stress.

METHODS

In this prospective study, we enrolled 25 healthy volunteers without a history of DTFS injury or high ankle sprain, previous foot and ankle surgery, or current ankle pain. Subjects with any prior ankle injuries were excluded. Study participants underwent bilateral standing nonstress and external rotation stress WBCT scans. The DTFS area (mm2) was semiautomatically quantified on axial-plane WBCT images 1 cm proximal to the apex of the talar dome using validated software. Syndesmosis area values were compared between "unstressed" and "stressed" ankles, as well as left and right ankles. Statistical analysis was performed using independent t tests/Wilcoxon analysis with statistical significance defined as P <.05.

RESULTS

The study cohort consisted of 50 ankles in 25 patients (12 males, 48%) with a mean age of 28.7 ± 9.3 years. In the unstressed ankle, the mean pooled DTFS area was determined to be 103.8 + 20.8 mm2. The mean syndesmosis area of unstressed left ankles (104.2 + 19.5 mm2) was similar to unstressed right ankles (109.2 + 17.2 mm2) in the cohort (P = .117). With external rotation stress, the DTFS area of left ankles (mean difference -0.304 mm2, CI -12.1 to 11.5; P = .082), right ankles (mean difference -5.5 mm2, CI 16.7-5.7; P = .132), and all ankles (mean difference -2.9 mm2, CI -10.8 to 5.1; P = .324) remained similar.

CONCLUSION

This study presents normal values and range for DTFS area calculation. In uninjured ankles with expected intact ligaments, subject-driven external rotation stress did not result in significant widening of the DTFS space as imaged on with WBCT.

LEVEL OF EVIDENCE

Level II, cross-sectional study.

Decreased Peritalar Subluxation in Progressive Collapsing Foot Deformity with Ankle Valgus Tilting

Background

Middle facet subluxation (MFS) has been established as an early indicator of peritalar subluxation. However, when progressive collapsing foot deformity (PCFD) affects the ankle leading to a valgus talar tilt (Class E), structures and anatomic relationships distal to the ankle joint may be affected. Therefore, this study aimed to assess radiographic parameters of peritalar subluxation in patients with PCFD who either did or did not have a valgus ankle. Our hypothesis was that these parameters would differ in Class E patients, upsetting their capability to quantify deformity.

Methods

We performed a prospective comparative study utilizing weight-bearing computed tomography (WBCT) images of 21 feet with PCFD and with valgus of the ankle and 64 with flexible PCFD without ankle involvement. Parameters including MFS, the medial cuneiform-to-floor distance, the forefoot arch angle, the talonavicular coverage angle, the hindfoot moment arm (HMA), the foot-ankle offset (FAO), and the talar tilt angle (TTA) were measured and compared. Variables that influence the presence of ankle valgus and overall alignment were assessed by multivariable regression models.

Results

Patients with PCFD and ankle valgus demonstrated a higher mean HMA (20.79 mm [95% confidence interval (CI), 17.56 to 24.02 mm] versus 8.94 mm [95% CI, 7.09 to 10.79 mm]), FAO (14.89% [95% CI, 12.51% to 17.26%] versus 6.32% [95% CI, 4.96% to 7.68%]) and TTA (95% CI, 17.10° [14.75° to 19.46°] versus 2.30° [95% CI, 0.94° to 3.65°]) and lower mean MFS (21.84% [95% CI, 15.04% to 28.63%] versus 38.45% [95% CI, 34.55% to 42.34%]) compared with the group without ankle valgus (p < 0.0001 for all). The FAO was influenced by MFS in the group without ankle valgus (p <0.0001) but not in the group with ankle valgus (p = 0.9161). FAO values of ≥12.14% were a strong predictor (79.2%) of ankle valgus deformity.

Conclusions

Subluxation of the middle facet was not as severe and did not influence the overall alignment in patients with PCFD who had valgus of the ankle (Class E). These findings suggest a distal peritalar reduction in the presence of a proximal deformity, making MFS an imprecise disease parameter in this scenario. An FAO value of ≥12.14% was a strong indicator of ankle deformity in patients with PCFD.

Level of Evidence

Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Total Hip Arthroplasty: Direct Anterior Approach Versus Posterior Approach in the First Year of Practice

Background

The direct anterior approach (DAA) for total hip arthroplasty (THA) has been popularized as a less invasive technique, however outcomes within the first year of practice after fellowship have not been investigated. The primary aim was to determine differences in complications and outcomes between DAA and posterior approach (PA) in the first year of practice. The secondary aim was to determine if there was a learning curve factor in DAA and PA after fellowship training.

Methods

THA cases performed by two surgeons during their first year of practice were reviewed. Overall, 181 THAs (91 DAA, 90 PA) in 168 patients, were performed. Intraoperative differences (blood loss, operative time), hospital stay, complications, reoperations, and revisions were compared.

Results

Overall surgical complications were similar between DAA and PA (11% vs. 9%, p=0.64), but complication profiles were different: dislocation (1% vs. 4%, p=0.17), intraoperative femoral fracture (2% vs. 1%, p=0.32), postoperative periprosthetic fractures (2% vs. 3%, p=0.64). neuropraxia (3% vs. 0%, p=0.08). There was no difference in rate of reoperation (1% vs. 3%, p=0.31). There was a difference in rate of revision at final follow-up (0% vs. 6%, p=0.02). DAA consisted of longer operative time (111 vs. 99 minutes; p<0.001), however was only significant in the first 50 cases (p<0.001), while the subsequent cases were similar (p=0.31). There was no difference in the first 50 cases compared to the subsequent cases for either approach regarding blood loss, complications, reoperations, or revisions.

Conclusion

DAA and PA for THA performed within the first year of practice exhibit similarly low complication rates, but complication profiles are different. In our series, PA did demonstrate a higher risk of revision at final follow-up. A learning curve is not unique to the DAA. Both DAA and PA THA exhibited a learning curve in the first 50 cases performed at the start of a surgeon's practice. Level of Evidence: III.

The Role of Anterior Ankle Arthroscopy in the Management of Ankle Arthritis: Literature Review, Patient Evaluation, Goals of Treatment and Technique

The current body of literature regarding anterior ankle arthroscopic debridement for anterior ankle impingement (AAI) cases with ankle osteoarthritis (OA) has significant limitations. The reported poor outcomes lack the necessary rigor in patient selection, preoperative evaluations and in most reports, the use of a systematic operative approach. Furthermore, the lack of postoperative evaluation by authors using physical examination and radiologic studies to determine the etiology of ongoing pain leaves open the possibility that treatment of impingement was incomplete. For these reasons, it would be inappropriate to conclude that anterior arthroscopic debridement has no role in the treatment of ankle OA. Critical analysis of some studies provides encouragement that this can be a useful intermediate treatment of appropriately selected patients with AAI and ankle OA. The level of required detail in the physical examination and radiologic evaluation is much greater than for more straight-forward cases of soft tissue impingement or simple osteophyte impingement in otherwise healthy joints. The success of the treatment requires a systematic approach to the evaluation and performance of the procedure, which is perhaps why results in the literature have been suboptimal in most series. Future studies should apply this rigorous approach to patient selection, procedure performance, and postoperative analysis to best clarify which patients can be best served with this procedure as part of the various intermediate treatment options for ankle OA.

Thrombolytic Use in Management of Frostbite Injuries: Eight Year Retrospective Review at a Single Institution

Frostbite injuries are uncommon, understudied, and lack standardized treatment protocols. Although thrombolytics are commonly used, their efficacy remains controversial. Herein, we report the results of a retrospective review of frostbite treatment practices at a single institution. The impact of thrombolytics on outcomes was evaluated. Medical records of frostbite patients admitted between January 2010 and April 2018 were reviewed. Demographics, injury details, treatment, and outcomes were collected. Descriptive statistics were obtained. A case-control analysis comparing patients who received tissue plasminogen activator (tPA) with those who did not was performed. A total of 102 patients were included. The mean age was 43 ± 17.7; 82.4% were male. About 13% of patients were presented with first-degree, 54% with second-degree, 29% with third-degree, and 5% with fourth-degree frostbite. Toes (69%), fingers (53%), and feet (43%) were most commonly affected. Thirteen patients had angiograms. Twelve patients received tPA: three systemic tPA and nine catheter-directed tPA. Overall, 32 patients (31%) required surgery and 27 (26.5%) patients required amputation with an average of 6.5 digits amputated. Digit salvage rate based on angiography was 84.7%. Length of stay (P = .046), number of operations (P = .037), and need for surgery (P = .030) were significantly lower for patients who received thrombolytics. Two patients had bleeding complications but did not require intervention or interruption of therapy. Despite its small sample size, our study suggests benefits from thrombolytic therapy. Prospective, well designed, and multi-institutional studies are warranted to establish evidence-based treatment guidelines for the management of frostbite injuries.

In Situ Straightening of a Bent Tibiofemoral Intramedullary Nail: Case Report and Review of the Literature

Background: Intramedullary nailing is considered the gold standard for the surgical management of diaphyseal long bone fractures of the lower extremity. A rare complication following intramedullary nailing of a femur or tibia fracture is periprosthetic fracture following secondary trauma with deformation of the nail itself. We present a case of a 51-year-old male with a long history of prior left knee arthrodesis with a tibiofemoral nail who sustained a work injury resulting in a proximal tibia fracture and bent tibiofemoral nail. Clinically, he presented with significant varus and procurvatum limb deformity and a six-centimeter limb length discrepancy. The patient was successfully managed with in situ straightening of the tibiofemoral nail under a general anesthetic with return to work three months following manipulation. Level of Evidence: IV.

Preoperative Opioid Usage, Male Sex, and Preexisting Knee Osteoarthritis Impacts Opioid Refills After Isolated Arthroscopic Meniscectomy: A Population-Based Study

PURPOSE

To identify risk factors for opioid consumption after arthroscopic meniscectomy using a large national database.

METHODS

Patients undergoing primary arthroscopic meniscectomy from 2007 to 2016 were retrospectively accessed from the Humana database. Patients were categorized as those who filled opioid prescriptions within 3 months (OU), within 1 month (A-OU), between 1 and 3 months (C-OU), and never filled opioid prescriptions (N-OU) before surgery. Rates of opioid use were evaluated preoperatively and longitudinally tracked for each cohort. Prolonged opioid use was defined as continued opioid prescription filling at ≥3 months after surgery. Multiple logistic regression analysis was used to identify factors associated with opioid refills at 12 months after surgery.

RESULTS

There were 88,120 patients (53.7% female) who underwent arthroscopic meniscectomy, of whom 46.1% (n = 39,078) were N-OU. About a quarter (25.3%) of patients continued filling opioid prescriptions at 1 year postoperatively. In addition, opioid fill rate at 1 year was significantly greater in the OU group compared with the N-OU group with a relative risk of 2.89 (40.7% vs 14.1%; 95% confidence interval 2.81-2.98; P < .0001). Multiple logistic regression model identified C-OU (odds ratio 3.67; 95% confidence interval 3.53-3.82; P < .0001) as the strongest predictor of opioid use at 12 months postoperatively. Furthermore, male sex, A-OU, knee osteoarthritis, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, fibromyalgia, anxiety or depression, alcohol use disorder, and tobacco use (P < .02 for all) had significantly increased odds of opioid use at 12 months postoperatively. However, patients <40 years (P < .0001) had significantly decreased odds of opioid use 12 months postoperatively.

CONCLUSIONS

Preoperative opioid filling is a significant risk factor for opioid use at 12 months postoperatively. Male sex, preexisting knee osteoarthritis, and diagnosis of anxiety or depression were independent risk factors for opioid use 12 months following arthroscopic meniscectomy.

LEVEL OF EVIDENCE

Level-III, Retrospective Cohort Study.

Editorial Commentary: How to Reduce Postoperative Shoulder Pain in Your Practice-Stick to Instability and Opioid-Naive Patients

Preoperative opioid use independently predicts persistent postoperative use after most surgical procedures, and surgery on the shoulder (and labrum specifically) is no exception. Thoughtful preoperative counseling of patients regarding the risks of continued postoperative opioid use, dangers of long-term narcotic use, expectations for postoperative pain control, and potential negative effect on postoperative outcomes is time-consuming and not easy. It is important to note that we have yet to determine whether preoperative opioid users can be restored to an opioid-naive state regarding the associated superior patient-reported outcomes observed postoperatively. Indications for surgery are important predictors of outcomes as well-athletes we treat for shoulder instability do not often present with pain unless associated with an acute instability event. Therefore, postoperative pain and opioid use are not commonly concerns if the indication for surgery is not pain related. The same cannot be said for SLAP tears.

Complete spinal cord injury following computed tomography-guided biopsy of the thoracic spine: A case report

Computed tomography–guided spine biopsy is a routine procedure in diagnosing vertebral infection or tumor. Following a thoracic intervertebral disc biopsy for presumed osteodiscitis, a patient immediately presented with flaccid paralysis and loss of temperature and pinprick sensation below biopsy level, followed rapidly by complete sensation loss. There was no evidence of direct injury during the biopsy, and emergent post-biopsy magnetic resonance imaging revealed no cord signal abnormality or compression. Later magnetic resonance imaging demonstrated corresponding-level cord edema, presumed secondary to transient cord ischemia during the procedures. Despite frequent utility, authors recommend caution in utilization of computed tomography–guided spine biopsy.

Sarcopenia is associated with increased mortality but not complications following resection and reconstruction of sarcoma of the extremities

BACKGROUND AND OBJECTIVES

Evidence regarding the impact of sarcopenia on operative outcomes in patients with sarcoma is lacking. We evaluated the relationship between sarcopenia and postoperative complications or mortality among patients undergoing tumor excision and reconstruction. ​ METHODS: We retrospectively reviewed 145 patients treated with tumor excision and limb reconstruction for sarcoma of the extremities. Sarcopenia was defined as psoas index (PI) < 5.45 cm² /m² for men and <3.85 cm² /m² for women from preoperative axial CT. Regression analyses were used to assess the association between postoperative complications or mortality with PI, age, gender, race, body mass index, tumor histology, grade, depth, location, size, and neoadjuvant/adjuvant therapy.

RESULTS

There were 101 soft tissue tumors and 44 primary bone tumors. Sarcopenia was present in 38 patients (26%). Sarcopenic patients were older (median age: 72 vs 59 years, P = .0010) and had larger tumors (86.5%, >5 cm vs 77.7%, P = .023). Seventy-three patients experienced complications (51%) and 18 patients died within 1 year. Sarcopenia and metastatic disease were associated with increased 12-month mortality (hazard ratio [HR] = 6.68, P < .001; HR: 8.51, P < .001, respectively) but not complications (HR 1.45, P = .155, odds ratio, 1.32, P = .426, respectively).

CONCLUSIONS

Sarcopenia and metastatic disease were independently associated with postoperative mortality but no complications following surgery.

Impact of a Standardized Multimodal Analgesia Protocol on Opioid Prescriptions After Common Arthroscopic Procedures

Background:

Excessive prescription of opioids has become a national problem. Providers must attempt to decrease the amount of opioids prescribed while still providing patients with adequate pain relief after surgery.

Hypothesis:

Implementing a standardized multimodal analgesic protocol will decrease the amount of opioids prescribed at the time of surgery as well as the total amount of opioids dispensed postoperatively.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patients who had undergone meniscectomy, rotator cuff repair (RCR), or anterior cruciate ligament (ACL) reconstruction at our institution were identified by Current Procedural Terminology code 12 months prior to and 6 months after the initiation of a standardized multimodal postoperative pain protocol. Records were reviewed to extract demographic data, amount of opioids prescribed at the time of surgery, amount and frequency of opioid refills, and call-ins regarding pain medication or its side effects. A Wilcoxon rank-sum test was used to evaluate differences in opioid prescriptions between pre- and postprotocol, and significance was set to P < .05.

Results:

The mean amount of opioids prescribed at the time of surgery decreased from 63.5 to 22.3 pills (P < .0001) for meniscectomy, from 73.3 to 39.7 (P < .0001) for ACL reconstruction, and from 75.6 to 39.8 (P < .0001) for RCR. The percentage of patients receiving a refill of opioids during the postoperative period also decreased for all groups: from 13% to 4% (P = .0051) for meniscectomy, 29.2% to 11.4% (P = .0005) for ACL reconstruction, and 47.3% to 24.4% (P < .0001) for RCR. There was no significant difference in patient calls regarding pain medication or its side effects.

Conclusion:

Institution of a standardized multimodal analgesia protocol significantly decreased the amount of opioids dispensed after common arthroscopic procedures. This reduction in the amount of opioids given on the day of surgery did not result in an increased demand for refills. Our study also demonstrated that 20 opioid pills were adequate for patients undergoing meniscectomy and 40 pills were adequate for ACL reconstruction and RCR in the majority of cases. This protocol serves as a way for providers to decrease the amount of opioids dispensed after surgery while providing patients with alternatives for pain relief.

Does Patient Positioning and Portal Placement for Arthroscopic Subtalar Arthrodesis Matter?

Category:

Arthroscopy

Introduction/Purpose:

Arthroscopic subtalar joint arthrodesis was first described over two decades ago. The procedure was originally performed with the patient in the lateral decubitus or supine position using anterolateral and posterolateral portals based on the fibula. More recently, several authors have advocated for prone positioning utilizing posteromedial and posterolateral portals. Proponents of the prone position cite improved intra-articular visualization with limited need for traction and more thorough preparation of the posterior facet. Multiple studies have compared arthroscopic to open subtalar arthrodesis and demonstrated similar fusion rates, lower morbidity, and a high level of patient satisfaction with the arthroscopic procedure. To our knowledge, this is the first study investigating how patient positioning and portal placement affects outcomes and morbidity for the arthroscopic procedure.

Methods:

A systematic review was performed according to PRISMA guidelines utilizing PubMed and Embase. All original studies with reported complication rates for arthroscopic subtalar arthrodesis were included. Two independent reviewers collected patient demographic data, operative positioning, complications, and outcomes including time to fusion and American Orthopaedic Foot and Ankle Society (AOFAS) scores. Patients were placed into the prone group if they were positioned prone with posterior portals or the lateral group if they underwent lateral portal placement. The rate of complications related to portal placement, nonunion rate, rate of painful hardware, and rate of revision were also recorded. The proportions of patients with specific complications in each group were determined and transformed using the Freeman-Tukey double-arcsine method to stabilize variances. Heterogeneity across studies was present as determined using the Q and I2 statistics or likelihood ratio test. Inverse-variance weighted random-effects models were used to evaluate the pooled estimates using R software.

Results:

A total of 484 feet in 468 patients with a mean follow-up of 36.1 months were included for analysis. Thirteen studies examined patients in the prone position (n=302) and seven articles looked at lateral portals (n=182). Mean AOFAS scores improved from 46.3 to 81.6 following surgery. Fusion was seen in 95.8% of feet at a mean of 10.9 weeks. The total complication rate was similar (p=0.620) between the prone (18.2%) and lateral (17.6%) groups. There was no difference observed in the rate of complications secondary to portal placement (p=0.919), rate of painful hardware (p=0.534), and revision rate (p=0.400) between the two groups. The prone group sustained 20 nonunions (6.6%) which was significantly more than the 2 nonunions (1.1%) found in the lateral group (p=0.039).

Conclusion:

Arthroscopic subtalar arthrodesis is an effective treatment option for subtalar joint pathology. We found a higher rate of nonunion when the patient is positioned prone and the arthroscopic portals are placed posteriorly. There was no difference in the rate of nerve/tendon injury, painful hardware, and revision surgery. AOFAS scores were improved regardless of portal placement. Limitations of our study include the variability in fusion hardware and use of bone graft for fusion augmentation between studies. We also were unable to account for surgeon experience, operative volume, and comfort level with the procedure. Further large scale prospective studies are warranted.

Patterns of Complex Carpal Injuries in the Hand from Fireworks

Purpose To describe the various patterns of complex carpal and metacarpal fracture dislocations observed in a consecutive series of firework injuries and the operative management performed. Materials and Methods We performed a retrospective study of seven consecutive patients (six males; mean age = 22 ± 13, range, 8-39 years) who presented to a level I trauma center with firework injuries to the hand between July 2014 and January 2016. Results All injuries were sustained while a lighted firework was held in the hand. The mean length of hospital stay was 13.9 ± 13.8 (range, 4-46) days with an average of 3 ± 2.6 (range, 1-7) surgeries required for both bony and soft tissue reconstruction. Three patterns of injury were seen: type I-no carpal involvement; type II-carpometacarpal joint (CMCJ) dislocations and isolated carpal dislocations; type III-CMCJ dislocations with axial carpal dissociation. One patient had a type I injury, three had a type II injury, and three had a type III injury. Of patients with a type III injury, two of the three had simultaneous axial-radial and axial-ulnar involvement as well as a midcarpal dissociation with divergent dissociation of the carpus and metacarpals. Conclusion The severity of carpal injuries resulting from fireworks is highly variable but is likely to follow predictable patterns due to the position of the hand and the location of the firework prior to explosion. Surgical reconstruction can be challenging, but adequate outcomes with a functional hand can be achieved through a systematic approach. Type of Study/Level of Evidence Therapeutic level IV.