Displacement after Open vs Saw-Based Minimally Invasive Medial Displacement Calcaneal Osteotomy: A Cadaveric Study.

Background: Medial displacement calcaneal osteotomy (MDCO) is routinely used in hindfoot valgus realignment. Minimally invasive surgery (MIS) calcaneal osteotomies have been reported to be as safe and effective compared to open techniques. The aim of this cadaveric study was to compare the amount of medial tuberosity displacement obtained with fine-cut saw-based MIS vs open MDCO techniques. Methods: Eight matched cadaveric specimens had one side randomly assigned to either open or MIS MDCO. The contralateral limb was then assigned to the alternative osteotomy. The amount of medial displacement provided by the osteotomy was measured manually using a flexible metric ruler and radiographically on standardized axial calcaneal radiographs. Results: Manual measurements showed that a mean displacement of the MIS osteotomy was 7.9 mm compared with 8.7 mm for the open technique (P = .36). Radiograph measurement showed a mean displacement of the MIS osteotomy was 7.1 mm compared with 7.4 mm for the open technique (P = .83). No significant difference was found on manual and radiographic measurement of medial displacement between MIS and open MDCO. Conclusion: In a cadaveric model, we found similar magnitude of calcaneal tuberosity displacement using fine-cut saw-based MIS and open techniques for medial displacement calcaneal osteotomies. Level of Evidence: Level V, cadaveric study.

Republication of "Online Patient Resources for Ankle Instability: An Objective Analysis of Available Materials".

Background: The Internet has drastically changed how patients access health-related information. There are several ways the public can access online health-related information such as search engines, blogs, support groups, and webinars. A recent study found that 45% of orthopedic patients searched for information online regarding their injury. Also, 78% believed they had better understanding of their condition after visiting these websites; furthermore, 41% felt the Internet supplied them with questions and concerns to discuss with their physicians. The aim of our study is to evaluate the accuracy, quality, and readability of online available information using the search terms "ankle sprain" and "ankle instability." Methods: Three search engines (Google, Bing, and Yahoo) were used to search for the terms "ankle sprain" and "ankle instability." The first 25 websites from each search were collected. Each website was assessed for quality, accuracy, and readability by 3 orthopedic residents blinded to the search term used. Websites were also evaluated for commercial bias and whether written by physicians or not. Results: Twenty sites were identified using Google, 14 using Bing, and 3 using Yahoo while the remaining 19 appeared in multiple search engines. Sixty-nine percent of the websites (39/56) were written by physicians whereas only 21% (12/56) were associated with commercial bias. The mean quality and accuracy of the websites written above a seventh-grade level was statistically significantly higher than those at or below a seventh-grade level (P = .01). The mean accuracy of websites written by physicians was not statistically different from those not written by physicians (P = .055). Conclusion: The current study highlights the poor quality and accuracy of online information related to ankle sprains, especially those with commercial bias. Furthermore, although websites written by or under supervision of physicians were found to be of superior quality, a majority of sites were found to have an unacceptably high reading level. Level of Evidence: Level IV, case series.

Radiographic Outcomes of Cotton Osteotomy in Treatment of Adult-Acquired Flatfoot Deformity.

BACKGROUND: We investigated the long-term radiographic outcomes of the Cotton osteotomy performed at our institution by the 2 senior authors in conjunction with other reconstruction procedures to correct adult-acquired flatfoot deformity (AAFD). METHODS: We retrospectively studied patients who underwent Cotton osteotomy between 2005 and 2010 with minimum 4-year follow-up. Radiographic assessment was made on weightbearing radiographs taken at 4 different time intervals: preoperative, early (first postoperative full weightbearing), intermediate (between 1 and 4 years postoperatively), and final (over 4 years postoperatively). RESULTS: Nineteen patients were included. Final follow-up was 8.6 ± 2.6 years. The lateral talus-first metatarsal angle improved significantly from preoperative to early radiographs (n = 15; mean change: 30 degrees, 95% CI, 21.6-38.7; P < .0001). A significant loss of correction was observed between intermediate and final radiographs (n = 11; mean change: 17 degrees, 95% CI, 8.1-26.4; P < .0001). Of 14 patients with early radiographs, 8 lost >50% of the correction initially achieved. Medial column height decreased by 3.0 mm (95% CI, 1.80-7.90; P = .35) between early radiographs and final follow-up. DISCUSSION: This is the longest reported radiographic follow-up of the Cotton osteotomy performed to address forefoot varus deformity as part of AAFD. The Cotton osteotomy achieved radiographic correction of the medial longitudinal arch at early follow-up, but approximately half of the patients had lost over 50% of that correction at final follow-up. The lengthened angular shape of the cuneiform did not collapse, implying that further collapse occurred through the medial column joints. LEVEL OF EVIDENCE: Level IV, case series.

Risk Factors for Complications Associated With Minimally Invasive Medial Displacement Calcaneal Osteotomy.

BACKGROUND: Few studies have reported the outcomes following minimally invasive medial displacement calcaneal osteotomy (MDCO) for correction of pes planovalgus deformities. METHODS: Charts were retrospectively reviewed for consecutive patients who underwent minimally invasive MDCO procedures by a single surgeon from 2013 to 2019 with more than 3 months of follow-up. A total of 160 consecutive patients who underwent 189 minimally invasive MDCO procedures were included in the study. Median follow-up was 12 months (interquartile range, 7-25 months). RESULTS: Osteotomy healing complications were present in 7% of cases during the 6-year study period. A 12-month case cluster of osteotomy healing complications was observed. Healing complication rates were 28% during the cluster and 0.7% outside of the cluster. No definitive cause was found for the case cluster, although heat osteonecrosis from the burr was suspected to be involved. Osteotomy healing complications were significantly associated with higher American Society of Anesthesiologists (ASA) classification, female sex, current tobacco use, and higher body mass index (BMI). Healing complications were not associated with osteotomy technique or fixation type. Other complications included wound dehiscence (3%), surgical site infection (2%), transient nerve symptoms (6%), and persistent nerve symptoms (2%). Nerve symptoms were significantly associated with an increased number of concomitant procedures. CONCLUSION: Patients with higher ASA classification, current tobacco use, and higher BMI were at higher risk for osteotomy healing complications after minimally invasive MDCO procedures. Patients were also more likely to develop nerve complications with more extensive surgical procedures. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Load to Failure and Stiffness of Interference Screw vs Pulvertaft Weave for Distal Fixation in Peroneal Allograft Reconstruction.

BACKGROUND: Allograft reconstruction of the peroneal tendons is an option for treatment of major tears of 1 or both peroneal tendons. No consensus on a superior distal fixation method has been reported. The purpose of the study was to compare load to failure and stiffness of a Pulvertaft weave (PTW) through a residual tendon stump to direct-to-bone interference screw (IS) fixation. METHODS: Fifteen pairs of long leg cadaver specimens were used. All grafts were secured proximally to the peroneus brevis myotendinous junction via a PTW technique. Distally, the tendons were either sutured to the peroneus brevis stump via PTW or secured to the base of the fifth metatarsal via IS. Stiffness (slope of force/displacement) was measured for the intact tendon and after reconstruction, and finally each specimen was loaded to failure. RESULTS: Mean load to failure was significantly higher in the PTW group compared with the IS group (373.6 ± 265.5 N vs 150.1 ± 93.1 N; P = .01). The PTW and IS groups had significantly lower stiffness compared with the intact specimens (P < .001). There was no statistical significance in stiffness between the 2 techniques (P = .96). CONCLUSION: The PTW technique yielded higher load to failure in comparison to IS. There was no difference in overall construct stiffness between both techniques. Both constructs demonstrated 19% decrease in stiffness compared to the intact state. CLINICAL RELEVANCE: The PTW and IS constructs were biomechanically similar, and these results suggest that both should be moderately overtensioned to compensate for an inherent decreased initial stiffness.

Orthopaedic Manifestations of Melanoma and Their Management.

Melanoma is an aggressive form of skin cancer associated with significant morbidity and mortality. Although commonly seen in dermatologist clinics, orthopaedic surgeons must be aware of these lesions in various ways. The five common musculoskeletal manifestations of melanoma will be discussed as well as the epidemiology, pathogenesis, diagnosis, staging, treatment, and prognosis of melanoma. With an index of suspicion and awareness of melanoma, a thorough history and detailed physical examination are critical in establishing a diagnosis. An adequately performed biopsy will confirm the diagnosis and assist in determining prognosis. As ambassadors of health for the musculoskeletal system, orthopaedic surgeons may be the first practitioners to encounter a pigmented skin lesion. Acral pigmented lesions should prompt a concern for melanoma with appropriate subsequent steps for management to follow. Finally, it is important for every orthopaedic surgeon to consider disseminated melanoma in the differential diagnosis of a skeletal metastasis, a deep soft-tissue mass, or lymphadenopathy in a patient with a previous history of a melanotic lesion.

Trends in Urgent Care Utilization Following Ankle Fracture Fixation.

BACKGROUND:: The Centers for Medicare and Medicaid services (CMS) have implemented initiatives to improve postdischarge care and reduce unnecessary readmissions. Readmissions within 30 days are frequent and represent an economic burden on both patients and the healthcare system. The aim of this study was to evaluate the frequency and causes for urgent care visits within 30 days of discharge after ankle open reduction and internal fixation (ORIF) and determine factors correlated with such visits. METHODS:: This was a retrospective analysis of prospectively collected data. All patients who underwent ankle ORIF at our institution between July 1, 2016, and June 30, 2017, were included. Patients were identified using Current Procedural Terminology (CPT) codes for ankle ORIF. Patients' demographics including age, sex, race, body mass index, occupation, insurance payer, and comorbidities were documented. RESULTS:: Thirty-five patients (10.51%) had urgent care visits within 30 days of discharge. Patients presented at a mean of 11.8 days after the day of surgery. Sixteen patients (45.71%) had cast/splint-related issues, 7 (20%) presented with pain, and 7 (20%) with increased operative site drainage. Univariate analysis demonstrated a statistically significant association between postoperative urgent care visits and patients with diabetes ( P = .03) or underlying psychiatric disorders ( P = .03). CONCLUSION:: In this population study of patients undergoing ankle fracture surgery, we found that the rate of urgent care visits within 30 days of discharge exceeded the rate of inpatient readmission. Additionally, patients with diabetes and psychiatric disorders were significantly more likely to present to an urgent care facility postoperatively, potentially accounting for increased expenditures of the healthcare system. LEVEL OF EVIDENCE:: Level III, comparative series.

Lateral Subtalar Dislocation with Tarsometatarsal Dislocation: A Case Report of a Rare Injury.

Dislocation of the fourth and fifth tarsometatarsal joints in conjunction with lateral subtalar dislocation is a rare occurrence. Little is known about the mechanism of injury, the appropriate treatment for this condition, and its ultimate prognosis. In this report, we describe this atypical presentation in a middle aged, otherwise healthy male who sustained a trivial twisting injury to the ankle when he slipped and fell on ice. Open reduction and K-wire fixation were necessary to affix the lateral tarsometatarsal and talonavicular joints. At one year postoperatively, he was able to return to his preinjury occupation with mild to moderate pain with prolonged walking. His Foot and Ankle Disability Index and American Orthopaedic Foot and Ankle Society scores were 64 and 65 points, respectively. Surgical intervention resulted in a stable plantigrade foot; however, the patient had early radiographic evidence of posttraumatic arthritis in the midfoot joints at one-year follow-up.

Recent Advances in Egypt for Treatment of Talar Osteochondral Lesions.

Treatment of osteochondral defects (OCLs) of the talus is a challenging orthopedic surgery. Treatment of talar OCLs has evolved through the 3 "R" paradigm: reconstruction, repair, and replacement. This article highlights current state-of-the-art techniques and reviews recent advances in the literature about articular cartilage repair using various novel tissue engineering approaches, including various scaffolds, growth factors, and cell niches; which include chondrocytes and culture-expanded bone marrow-derived mesenchymal stem cells.

Spontaneous heparin-induced thrombocytopenia presenting as bilateral adrenal hemorrhages and pulmonary embolism after total knee arthroplasty.

Heparin-induced thrombocytopenia syndrome is an acquired potentially life-threatening prothrombotic disorder caused by antibodies that recognize complexes of platelet factor 4 bound to heparin or heparin-like molecules. It typically occurs after exposure to unfractionated heparin, to a lesser extent after exposure to low-molecular-weight heparins, and rarely after exposure to fondaparinux. Herein, we report the case of a 48-year-old woman who developed severe thrombocytopenia, bilateral pulmonary embolism, and bilateral adrenal hemorrhages after total knee arthroplasty without evidence of heparin exposure. Antibodies to the heparin-platelet factor 4 complex and serotonin-release assay were positive. Spontaneous heparin-induced thrombocytopenia syndrome should be considered in patients with unexplained thrombocytopenia after knee replacement surgery even without heparin exposure, and a high index of suspicion for adrenal hemorrhage is needed in patients with fever, abdominal pain, and shock.

The use of dual C-arms during fixation of calcaneal fractures: a technique tip.

UNLABELLED: We describe a simple technique using dual C-arms (large and mini C-arm together) for open reduction internal fixation of calcaneal fractures in the lateral decubitus position that (1) decreases the difficulty of obtaining proper intraoperative imaging; (2) limits C-arm movement, which decreases risk of contamination and operative time; and (3) minimizes the drawbacks of each imaging fluoroscopic modality. LEVELS OF EVIDENCE: Level V, Technical tip, Expert opinion.

External fixator kickstands for free soft tissue flap protection: case series and description of technique.

BACKGROUND: Protected elevation represents a critical component of postoperative care, particularly in posteriorly located flaps, to prevent pressure on the flap's vascular pedicle and ensure a successful skin graft. Although several short case series and technique papers have described kickstand placement to prevent heel ulcers as an adjuvant to fixator placement for fracture management, there remains a paucity of reports describing external fixator placement solely for extremity elevation and pressure alleviation in the postoperative care of flap coverage procedures. METHODS: Patients who underwent lower extremity free flap coverage procedures requiring temporary elevation were included. Age, diagnosis, soft tissue procedures performed, type of external fixator placed, duration of frame placement, mode of removal, and complications related to external fixator placement were documented. Patients requiring external fixator placement for fracture management were excluded. RESULTS: Twelve patients with 13 lower limb soft tissue defects were included in our case series. A thin-wire ring external fixator kickstand was applied in 5 limbs while the rest underwent placement of a uniplanar carbon fiber bar type external fixator kickstands. The average time for removal of the frames was 4 weeks. No complications were reported from kickstand placement. CONCLUSION: The use of external fixator kickstands is an effective and safe adjuvant to soft tissue flap procedures for the lower extremity. Our case series is the largest in the literature and first to address the technical considerations for frame placement, positioning, and removal for external fixator kickstands placed solely for flap coverage procedures. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Preventing falls in the operating room: a technique tip for safely tilting the operating table.

BACKGROUND: Many articles have been published to address the topic of in-hospital falls; however, there is considerably less literature that focuses specifically on the topic of falls from the operating room table. The lay press and legal filings contain reports of such incidents, which can result in considerable morbidity, lawsuits, and occasional death. TECHNIQUE: When tilting the operating table, a simple technique for preventing falls is through the use of posts. Posts are regularly used during knee and hip arthroscopy to facilitate valgus positioning or access into the joint. These posts can be positioned below the axilla and at the level of the greater trochanter to supplement patient safety straps when tilting the table. DISCUSSION: Falls that occur during a hospital admission can lead to serious injury and prolonged hospital stays. Furthermore, falls that occur off the operating table are particularly disastrous and in some cases have resulted in death. Our proposed technique is simple and particularly useful for patients with large or small body habitus or when operating procedures necessitate significant tilting of the operating table. LEVELS OF EVIDENCE: Level V.