Neural sheath tumors of the brachial plexus: a multidisciplinary team-based approach.

Peripheral tumors of the brachial plexus, although rare, provide an opportunity for the plastic surgeon to coordinate a multidisciplinary team and achieve excellent outcomes. Most of the case series are reported from the neurosurgical literature. We report on the experience of the Kaiser Permanente Brachial Plexus Clinic over a recent 2-year period. A retrospective review was conducted to examine the medical records, radiographic images, operative reports, and pathologic findings of 13 consecutive patients with peripheral nerve sheath tumors of brachial plexus origin. Of the 10 patients requiring surgical exploration, 90% had significant improvement or resolution of pain, with sensory and motor recovery showing mixed results. Average follow-up consisted of 2 years with occupational therapy beginning shortly after operative intervention. Our results are similar to or better than those published in the literature. The plastic surgeon with subspecialty training can safely and successfully treat tumors of the brachial plexus by implementing a multidisciplinary approach.

Republication of "Open Repair of Acute Achilles Tendon Ruptures: Is the Incidence of Clinically Significant Wound Complications Overestimated?"

Background: Conflicting evidence exists regarding the optimal management of acute Achilles tendon ruptures. Operative repair is thought to afford patients a lower risk of rerupture, albeit at a higher overall risk of wound complications. Methods: A retrospective chart review of 369 consecutive patients undergoing open repair of acute Achilles tendon ruptures performed by a single foot and ankle fellowship-trained orthopedic surgeon was undertaken. Healing was classified as no complications, complications without prolonging treatment, complications requiring prolonged local treatment, and complications requiring operative intervention. A statistical analysis comparing the rates of complications in this cohort to that reported in the literature was conducted. Results: There were a total of 33 (8.94%) wound complications. Compared to the rates reported in the literature, no significant difference was detected (P = .3943; CI 6.24-12.33). However, when the complications not requiring additional treatment or prolonged care were excluded, only 9 wound complications (2.44%) were identified-a significantly lower complication rate than that reported in the literature (P < .0001; CI 1.12-4.58). There were only 2 (0.54%) major complications requiring operative intervention, also a significantly lower rate than in the literature (P < .0001; CI 0.067-1.94). Conclusion: In the past, wound-healing complications have been cited as a concern when treating patients operatively. We found that when solely looking at healing complications prolonging the patients' overall recovery, a significantly lower rate of complications existed compared to that reported in the literature. Level of Evidence: Level IV.

What is the incidence and severity of dysphagia after anterior cervical surgery?

BACKGROUND: Existing studies suggest a relatively high incidence of dysphagia after anterior cervical decompression and fusion (ACDF). The majority of these studies, however, are retrospective in nature and lack a control group. QUESTIONS/PURPOSES: We therefore (1) prospectively determined the incidence and severity of dysphagia after ACDF using lumbar decompression patients as a control group; and (2) determined which factors, if any, are associated with increased postoperative dysphagia. METHODS: Patients undergoing either one- or two-level ACDF (n=38) or posterior lumbar decompression (n=56) were prospectively followed. Baseline patient characteristics were recorded. A dysphagia questionnaire was administered preoperatively and during the 2-week, 6-week, and 12-week postoperative visits. We found no differences in patient age, body mass index, or the preoperative incidence and severity of dysphagia between the cervical and lumbar groups. We compared the incidence and severity of dysphagia between the patients who had cervical and lumbar surgery. RESULTS: Postoperatively, 71% of patients having cervical spine surgery reported dysphagia at 2 weeks followup. This incidence decreased to 8% at 12 weeks followup. The incidence and severity of dysphagia were greater in the cervical group at 2 and 6 weeks followup with a trend toward greater dysphagia at 12 weeks followup. Body mass index, gender, location of surgery, and the number of surgical levels were not related to the risk of developing dysphagia. We observed a correlation between operative time and the severity of postoperative dysphagia. CONCLUSIONS: Dysphagia is common after ACDF. The incidence and severity of postoperative dysphagia decreases over time, although symptoms may persist at least 12 weeks after surgery. LEVEL OF EVIDENCE: Level II, prospective, comparative study. See Guidelines for Authors for a complete description of levels of evidence.

Correlation of Patient-Reported Outcomes With Physical Function After Total Ankle Arthroplasty.

BACKGROUND: Total ankle arthroplasty (TAA) is successful by both subjective patient-reported outcome measures (PROMs) and objective functional improvements of gait. Each is reproducible and valid, but they are entirely distinct methods. This study investigated the correlation between subjective and objective outcomes of TAA. METHODS: Seventy patients underwent gait analysis preoperatively and 1 year after TAA. The 36-Item Short-Form Health Survey (SF-36) and visual analog score (VAS) for pain and American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scores were recorded at each interval. A Student t test, a multivariate regression, and a Pearson correlation coefficient were used to measure the correlation between parameters of gait and PROMs. RESULTS: Patients had statistically significant improvements in gait velocity, total range of motion (ROM), maximum plantarflexion, ankle power, and SF-36 Physical, VAS, and AOFAS scores. The SF-36 Physical score had a moderate positive correlation with preoperative walking speed, step length, and ankle power and postoperative walking speed and ankle power. No correlation between VAS score and function was detected. The AOFAS score had a moderate positive correlation with postoperative walking speed, step length, and ankle power, and improvement in walking speed, cadence, and ankle power. CONCLUSION: Statistically significant correlations were found between numerous preoperative and postoperative comparisons of PROMs and the AOFAS score with the objective biomechanical outcomes of gait. Walking speed and ankle push-off power correlated most with patient perceptions of function and improvement, while pain and ROM did not. Subjective PROMs and objective biomechanical outcomes were complementary in the assessment of surgical outcomes and, combined, helped to address the dilemma of the confounding effect of other lower extremity pathologies on PROMs. LEVEL OF EVIDENCE: Level III, comparative series.

Association of Cavovarus Foot Alignment With Peroneal Tendon Tears.

BACKGROUND: Although it is a widely accepted clinical principle that cavovarus deformity predisposes to peroneal tendon problems, there are limited data to support that assumption. This study tested the hypothesis that cavovarus is associated with peroneal tendon tears and evaluated which radiographic measures correlated with that association. METHODS: A retrospective comparison of radiographic measures of cavovarus in 234 consecutive patients operatively treated for chronically symptomatic peroneal tendon tears was compared to a matched control group. Measures included calcaneal pitch, anteroposterior (AP) talometatarsal and talocalcaneal angles, and talonavicular coverage angle. A novel coordinate system analyzed midfoot and hindfoot components of cavovarus. Analysis of variance was used to compare cohorts, and a Tukey-Kramer test used to analyze 3 subgroups of brevis and longus tears, and concomitant tears. RESULTS: The distribution of tears was 73% peroneus brevis, 8% longus, and 19% both tendons. Compared with controls, the study group, and subgroups, had multiple measures of increased cavovarus, including greater calcaneal pitch (P = .0001), decreased AP talo-first metatarsal angle (P = .0001), and increased talonavicular coverage angle (P = .0001). Elevated medial longitudinal arch, and rotational changes in the radiographic profiles of the hindfoot were found with the coordinate system described by Yokokura. CONCLUSION: This study found a statistically significant association of increased cavovarus deformity with peroneal tendon tears, compared to controls. It documented the relative incidence of tears of peroneus brevis, peroneus longus, and concomitant tears in a large surgical series. It demonstrated which simple radiographic angles and complex coordinate measurements of cavovarus deformity were significantly associated with peroneal tendon tears. LEVEL OF EVIDENCE: Level III, retrospective comparative cohort study.

Peroneal Tendon Pathology: Treatment and Reconstruction of Peroneal Tears and Instability.

Peroneal tendon pathology is becoming an increasingly recognized source of lateral-sided ankle pain. High clinical suspicion, along with judicious physical examination coupled with confirmatory advanced imaging modalities, are necessary to make an accurate diagnosis and aid in guiding treatment. Peroneal pathology encompasses several distinct conditions. Peroneal tendon tears and injuries to the peroneal retinaculum must be identified to guide treatment. Patients with peroneal pathology report high levels of satisfaction after surgical management with most returning to their preinjury level of function. An early and accurate diagnosis, along with treatment tailored to the individual, is necessary to obtain optimal outcomes.

Repair of a high-flow iliac arteriovenous fistula using a thoracic endograft.

Open surgical repair of iliac arteriovenous fistulas is associated with significant morbidity and mortality, making endovascular repair an attractive alternative. This report describes a 39-year-old man who was admitted with two-pillow orthopnea, edema, and fatigue. He had sustained a gunshot wound to the pelvis 13 years previously. Six years after the gunshot wound, he was diagnosed with cardiomegaly and high-output congestive heart failure. A magnetic resonance angiography documented a large pelvic arteriovenous fistula. A diagnostic contrast angiogram confirmed a high-flow fistula between the left distal main internal iliac artery and left common iliac vein. A Gore TAG thoracic endoprosthesis (W. L. Gore and Assoc, Flagstaff, Ariz) was used to repair this large, high-flow internal iliac artery-common iliac vein arteriovenous fistula.

Identification and characterization of a long isoform of human IFT80, IFT80-L.

Intraflagellar transport (IFT) proteins are evolutionarily conserved throughout all ciliated organisms and are essential for the assembly and maintenance of cilia. IFT80, a component of the IFT complex, was linked recently to a human developmental disorder, Jeune asphyxiating thoracic dystrophy. We report here identification and characterization of a human IFT80 long isoform (namely IFT80-L), the carboxyl terminus of which shares the protein sequence of IFT80. Sequence analysis indicates that IFT80-L is likely an evolutionarily merged product of genes IFT80 and TRIM59, a RING finger gene we reported previously. Expression analysis of IFT80-L demonstrates that IFT80-L is ubiquitously expressed in humans. By using the nerve growth factor-induced cell differentiation assays, we reveal that IFT80-L is highly expressed in the rapidly proliferating cells but not in differentiated cells, which withdraw from the cell cycle. Our findings suggest that IFT80-L, like other IFT proteins, plays an important role in cell proliferation and differentiation.

Economic Analysis of Anatomic Plating Versus Tubular Plating for the Treatment of Fibula Fractures.

Ankle fractures are among the most common injuries requiring operative management. Implant choices include one-third tubular plates and anatomically precontoured plates. Although cadaveric studies have not revealed biomechanical differences between various plate constructs, there are substantial cost differences. This study sought to characterize the economic implications of implant choice. A retrospective review was undertaken of 201 consecutive patients with operatively treated OTA type 44B and 44C ankles. A Nationwide Inpatient Sample query was performed to estimate the incidence of ankle fractures requiring fibular plating, and a Monte Carlo simulation was conducted with the estimated at-risk US population for associated plate-specific costs. The authors estimated an annual incidence of operatively treated ankle fractures in the United States of 59,029. The average cost was $90.86 (95% confidence interval, $90.84-$90.87) for a one-third tubular plate vs $746.97 (95% confidence interval, $746.55-$747.39) for an anatomic plate. Across the United States, use of only one-third tubular plating over anatomic plating would result in statistically significant savings of $38,729,517 (95% confidence interval, $38,704,773-$38,754,261; P<.0001). General use of one-third tubular plating instead of anatomic plating whenever possible for fibula fractures could result in cost savings of up to nearly $40 million annually in the United States. Unless clinically justifiable on a per-case basis, or until the advent of studies showing substantial clinical benefit, there currently is no reason for the increased expense from widespread use of anatomic plating for fractures amenable to one-third tubular plating. [Orthopedics. 2018; 41(2):e252-e256.].

Kinematics and Function of Total Ankle Replacements Versus Normal Ankles.

End-stage ankle arthritis produces severe functional disability, quantifiable by gait abnormalities. In all categories of gait parameters, total ankle arthroplasty (TAA) satistically significantly improves function, compared to patients' preoperative function. There are increases in step length, cadence and velocity; in sagittal plane motion of the ankle, as well has hip and knee motion, and in ankle power and moment. These functional gait improvements correspond to clinical improvements of pain relief and satisfaction. Although these improvements fail to reach the functional performance of healthy controls, the improvement over preoperative function is clinically meaningful and statistically significant.

Radiographic Results and Return to Activity After Sesamoidectomy for Fracture.

BACKGROUND: Limited data are available comparing the results of lateral sesamoidectomy and medial sesamoidectomy for the treatment of fractures recalcitrant to nonoperative treatment interventions. The hypothesis of this study was that sesamoidectomy for either lateral or medial sesamoid fractures would not change radiographic alignment of the first ray given the use of identical reconstruction of the plantar plate, intersesamoid ligament, and plantar ligament complex at the time of surgery. METHODS: This retrospective cohort study compared the outcomes of 46 consecutive patients treated with sesamoidectomy (24 lateral, 22 medial). Patient demographics, mechanisms of injury, and outcomes were recorded. Preoperative, postoperative, and changes in both hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured. RESULTS: No statistically significant difference could be detected for age ( P = .577), sex ( P = .134), return to activity ( P = 1.000), likelihood to undergo the procedure again ( P = 1.000), orthotic use postoperatively ( P = 1.000), perioperative complications ( P = .497), duration of symptoms ( P = .711), or length of follow-up ( P = .609). While statistically significant changes in preoperative and postoperative alignment were detected for both medial and lateral sesamoidectomy, these changes were not clinically significant. Patients undergoing medial sesamoidectomy had higher preoperative and postoperative HVA and IMA compared with those undergoing lateral sesamoidectomy. Medial sesamoidectomy patients had a net increase in both HVA and IMA, while patients undergoing lateral sesamoidectomy had a net decrease in both HVA and IMA. CONCLUSION: Although statistically significant changes in both HVA and IMA were detected, these values were too small to be considered clinically significant. Patient outcomes did not differ between the 2 groups, and sesamoidectomy was used with low patient morbidity for both medial and lateral sesamoid fractures that failed to respond to nonoperative modalities. These data suggest that the underlying mechanics of the foot may be different in patients who sustain medial and lateral sesamoid stress injury, suggesting a possible etiologic difference between medial and lateral sesamoid injuries. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Acute Peroneal Injury.

A high clinical suspicion and greater understanding of the anatomy and pathophysiology of lateral ankle injuries have enabled early diagnosis and treatment-improving outcomes of acute peroneal tendon tears. Multiple conditions can be the cause of lateral ankle pain attributed to the peroneal tendons: tenosynovitis, tendinosis, subluxation and dislocation, stenosing tenosynovitis, abnormality related to the os peroneum, as well as tears of the peroneal tendons. It is imperative for the clinician to maintain a high suspicion for peroneal tendon abnormality when evaluating patients with lateral ankle pain.

Economic Burden of Inpatient Admission of Ankle Fractures.

BACKGROUND: Ankle fractures are among the most prevalent traumatic orthopaedic injuries. A large proportion of patients sustaining operative ankle fractures are admitted directly from the emergency department prior to operative management. In the authors' experience, however, many closed ankle injuries may be safely and effectively managed on an outpatient basis. The aim of this study was to characterize the economic impact of routine inpatient admission of ankle fractures. METHODS: A retrospective review of all outpatient ankle fracture surgery performed by a single foot and ankle fellowship-trained surgeon at a tertiary level academic center in 2012 was conducted to identify any patients requiring postoperative inpatient admission. The National Inpatient Sample was queried for operative management of lateral malleolus, bimalleolar, and trimalleolar ankle fractures in 2012 with regard to national estimates of total volume and length of stay by age. The maximum allowable Medicare inpatient facility reimbursements for diagnosis related group 494 and Medicare outpatient facility reimbursements for Current Procedural Terminology codes 27792, 27814, and 27822 were obtained from the Medicare Acute Inpatient Prospective Pricer and the Medicare Outpatient Pricer Code, respectively. Private facility reimbursement rates were estimated at 139% of inpatient Medicare reimbursement and 280% of outpatient reimbursement, as described in the literature. Surgeon and anesthesiologist fees were considered similar between both inpatient and outpatient groups. A unique stochastic decision-tree model was derived from probabilities and associated costs and evaluated using modified Monte Carlo simulation. RESULTS: Of 76 lateral malleolar, bimalleolar, and trimalleolar ankle fracture open reduction internal fixation cases performed in 2012 by the senior author, 9 patients required admission for polytrauma, medical comorbidities, or age. All 67 outpatients were discharged home the day of surgery. In the 2012 national cohort analyzed, 48,044 estimated inpatient admissions occurred postoperatively for closed ankle fractures. The median length of stay was 3 days for each admission and was associated with an estimated facility reimbursement ranging from $12,920 for Medicare reimbursement of lateral malleolus fractures to $18,613 for private reimbursement of trimalleolar fractures. Outpatient facility reimbursements per case were estimated at $4,125 for Medicare patients and $11,459 for private insurance patients. Nationally, annual inpatient admissions accounted for $796,033,050 in reimbursements, while outpatient surgery would have been associated with $419,327,612 for treatment of these same ankle fractures. CONCLUSION: In the authors' experience, closed lateral malleolus, bimalleolar, and trimalleolar fractures were safely and effectively treated on an outpatient basis. Routine perioperative admission of patients sustaining ankle fractures likely results in more than $367 million of excess facility reimbursements annually in the United States. Even if a 25% necessary admission rate were assumed, routine inpatient admission of ankle fractures would result in a $282 million excess economic burden annually in the United States. Although in certain cases, inpatient admission may be necessary, with value-based decision making becoming increasingly the responsibility of the orthopaedic surgeon, understanding the implications of inpatient stays for ankle fracture surgery can ultimately result in cost savings to the US health care system and patients individually. LEVEL OF EVIDENCE: Level III, comparative series.

Rate of Neurologic Injury Following Lateralizing Calcaneal Osteotomy Performed Through a Medial Approach.

BACKGROUND: Calcaneal osteotomies are commonly used to correct varus hindfoot alignment in patients with symptomatic cavovarus deformity. Translational, closing wedge, and Malerba-type osteotomies have been implicated in the development of tarsal tunnel syndrome and neurologic injury to branches of the tibial nerve. The authors hypothesized that there would be minimal clinically important injury to the tibial nerve by performing a translational calcaneal osteotomy from a medial approach. METHODS: All patients undergoing a cavovarus reconstruction by a single surgeon were identified. Patients were included if they underwent a lateralizing calcaneal osteotomy via medial approach. Demographics, operative reports, and clinic notes were reviewed to identify concomitant procedures performed, incidence of postoperative tarsal tunnel syndrome, complications, and preoperative and postoperative nerve examinations. Postoperative radiographs were reviewed for location of the osteotomy relative to the posterior tubercle. RESULTS: Twenty-four patients underwent lateralizing calcaneal osteotomy via a medial approach. Of the osteotomies, 83.3% (20/24) were in the middle third of the calcaneus, with a mean of 11.6-mm translation. No patients developed postoperative tarsal tunnel syndrome or tibial nerve palsy. CONCLUSION: Lateralizing calcaneal osteotomy performed via a medial approach had a clinically negligible incidence of neurologic injury. Adequate translation was achieved to obtain correction of varus hindfoot deformity. The authors believe that there is less direct and less percussive injury to branches of the tibial nerve when performing the osteotomy from medial to lateral. This technique may represent an operative strategy to minimize risk to the tibial nerve and reduce neurologic deficit following cavovarus reconstruction. LEVEL OF EVIDENCE: Level IV, case series.

Role of Total Ankle Arthroplasty in Stiff Ankles.

BACKGROUND: The decision tree for the operative treatment of end-stage ankle arthritis involves either ankle arthrodesis (AA) or total ankle arthroplasty (TAA). Although both have documented success providing diminished pain, improved patient-centered outcomes, and improved objective measures of function, arthroplasty is unique in its ability to preserve motion at the tibiotalar joint. Arthroplasty procedures are normally thought of as a motion-sparing surgery rather than a motion-producing procedure, which may limit its success in patients with stiff ankles. Our hypothesis was that there would be improvements in parameters of gait even in patients with a low degree of preoperative total sagittal range of motion. METHODS: A retrospective review was conducted on patients who underwent total ankle arthroplasty with greater than 1-year follow-up. Seventy-six patients were available who underwent isolated TAA for end-stage ankle arthritis with greater than 1-year follow-up. Patient demographics and preoperative and postoperative gait analyses were evaluated. Using a linear regression model, the effect sizes for the variables of age, gender, BMI, preoperative diagnosis, and preoperative total sagittal range of motion were calculated. Multivariate analysis was used to determine the influence each individual variable had on the many parameters of preoperative gait, postoperative gait, and change in gait after surgery. A post hoc analysis was conducted in which patients were divided into 4 quartiles according to preoperative range of motion. A 1-way analysis of variance (ANOVA) was used to compare improvement in parameters of gait for the 4 subgroups. RESULTS: Although a greater degree of preoperative sagittal range of motion was predictive of greater postoperative sagittal range of motion, patients with limited preoperative range of motion experienced a greater overall improvement in range of motion, and clinically meaningful absolute improvements in range of motion, and other parameters of gait. The post hoc analysis demonstrated that patients in the lowest quartile of preoperative motion had both statistically and clinically significant greater improvements across numerous parameters of gait, although the absolute values were lower than in the patients with higher preoperative ROM. Age, gender, BMI, and preoperative diagnosis did not correlate with changes in parameters of gait after total ankle arthroplasty. CONCLUSION: Preoperative range of motion was predictive of overall postoperative gait function. On one hand, a low preoperative range of motion resulted in a lower absolute postoperative function. On the other hand, patients with stiff ankles preoperatively had a statistically and clinically greater improvement in function as measured by multiple parameters of gait. This suggests that total ankle arthroplasty can offer clinically meaningful improvement in gait function and should be considered for patients with end-stage tibiotalar arthritis even in the setting of limited sagittal range of motion. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Midterm Outcome of the Agility Total Ankle Arthroplasty.

BACKGROUND: Ankle arthritis is a debilitating condition that causes severe functional impairment. While arthrodesis has been the gold standard of surgical treatment for this condition, significant improvements in total ankle arthroplasty have made it a viable alternative. The purpose of this study was to look at the midterm follow-up of the Agility total ankle. METHODS: A retrospective review of prospectively collected data was conducted on 127 consecutive Agility total ankles implanted between 2002 and 2009. Charts were reviewed to collect patient demographics. In addition, coronal alignment, overall arc of motion, tibiotalar component motion, syndesmotic fusion, zones of osteolysis, and subsidence were determined. A Kaplan-Meier survival and linear regression analysis were used to predict implant failure. A multivariate regression analysis was used to assess whether radiographic measures were predictive of patient satisfaction. RESULTS: Ninety (78.2%) of 115 patients retained their primary implant, of which 105 were available for evaluation, with an average follow-up of 9.1 years. Twenty-five had their implant removed. The average score for the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale was 82.4, FAAM sport subscale 55.3, postoperative visual analog scale (VAS) for pain 12.7, and Short Form-12 (SF-12) Health Survey physical component 45.8 and SF-12 mental component 56.1. Average arc of motion across the implant was 22.3 and 6.3 degrees in adjacent joints. Osteolysis most commonly occurred in zones 1 and 6. No statistical differences were found in the rate or location of subsidence. Linear regression analysis demonstrated that age at the time of surgery was predictive of failure ( P = .036). Inflammatory and atraumatic arthritis demonstrated higher likelihoods of revision. No correlation was detected between radiographic parameters and outcomes scores ( P > .05; rho >0.2). A significant reduction in mean VAS pain scores by 67.6% was maintained at an average of 8 years. DISCUSSION: Our results were improved over the nondesigner outcomes published in the current literature. Survivorship approached 80% at 9 years, with Kaplan-Meier 14-year survival calculated at 70.4%. Patients with their original implant were functioning with a high level of satisfaction based on statistically validated outcome scores, which was independent of the radiographic appearance of their implant. Age at the time of surgery and inflammatory/atraumatic arthritis were predictive of failure. LEVEL OF EVIDENCE: Level IV, case series.

Immunoglobulin G Deficiency-Associated Septic Arthritis Identified Following Corticosteroid Injection and Knee Arthroscopy: A Case Report.

CASE: We present the case of a patient who had worsening pain following intra-articular knee corticosteroid injection and who subsequently underwent arthroscopic partial meniscectomy with positive intraoperative cultures for Staphylococcus lugdunensis. He was treated with multiple irrigation and debridements, and subsequent work-up yielded a diagnosis of immunoglobulin G (IgG) deficiency. We believe that it is critical to maintain a high index of suspicion for underlying immune deficiency when faced with atypical presentations of infections or atypical bacteria in otherwise healthy patients. CONCLUSION: Knee arthroscopy for the treatment of meniscal tears is one of the most common procedures performed by orthopaedic surgeons in the United States. Patients with an antibody deficiency may have a limited or reduced immune response when presented with a pathogen foreign to the body. This may place the patient at an increased risk of infection and should be addressed through referral to the appropriate subspecialists when recurrent or atypical infection presents to the orthopaedic surgeon.

The Efficacy of Platelet-Rich Plasma for Incision Healing After Total Ankle Replacement Using the Agility Total Ankle Replacement System.

BACKGROUND: The use of platelet-rich plasma (PRP) to aid in healing of operative incisions has been well documented in the literature. Most studies have been conducted retrospectively with small sample sizes and are conflicting in their outcomes. As such, no consensus exists regarding the utility of PRP for augmenting incisional healing. The Agility total ankle replacement (TAR) poses a significant challenge with respect to incisional healing in the immediate postoperative time frame and was used as a standardized implant in this study. We hypothesized that treating the anterior incision with PRP after Agility TAR would reduce the incidence of incision healing complications. METHODS: A retrospective review of 133 consecutive Agility TAR performed by a single surgeon at a single institution was conducted. Platelet-rich plasma was used to augment incisional closure in 78 patients undergoing TAR. Fifty-five patients had incisional closure without PRP application. Incision healing complications were stratified into patients healing without any complications (none), patients requiring prolonged local wound care (minor), and patients requiring a return to the operation theater to address an incisional complication (major). RESULTS: No statistically significant difference existed between patients treated with PRP incisional augmentation and those without PRP augmentation. Eight patients (10.3%) receiving PRP underwent operative treatment of an incisional complication, whereas 3 patients (5.5%) who had a nonaugmented closure required operative treatment (P = .52). The incidence of minor complications was not statistically significant, with 25 (32.1%) patients receiving PRP and 15 (27.3) patients who had a nonaugmented closure requiring prolonged local treatment (P = .85). CONCLUSIONS: Limited data exist regarding the use of PRP in the augmentation of the closure of operative incisions. We were unable to find a statistically significant reduction in incision-related complications in patients who had their incisions augmented with PRP. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Change in Angular Alignment Is Associated With Early Dysphagia After Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective analysis of a prospective cohort. OBJECTIVE: Change in cervical angular alignment may be associated with dysphagia. SUMMARY OF BACKGROUND DATA: Bony deformities of the cervical spine may be associated with secondary contractures of soft tissues in the neck. Acute surgical deformity correction causes in changes in soft tissue tension in the anterior neck, resulting in dysphagia. METHODS: The study population included patients undergoing 1 and 2 level elective anterior cervical discectomy and fusion for cervical myelopathy or radiculopathy. Preoperative and postoperative radiographs at 2 weeks were measured by a blinded observer for C2-C7 endplate angle, C2-C7 posterior vertebral body length, and occipital condyle plumb line distance on upright lateral radiographs at 2, 6, and 12 weeks postoperatively. Patients were prospectively queried about dysphagia incidence and severity using a numeric rating scale. Multiple linear regression analysis was used to determine the effect of change in radiographic parameters controlling for demographic characteristics. RESULTS: The study population included 25 patients with complete radiographs. The mean change in C2-C7 angle was -0.6 degrees (SD 9), the mean change in C2-C7 length was 1.7 mm (SD 26), the mean change in occipital condyle plumb line distance was 2.3 mm (SD 20).Multiple linear regression analysis was performed including operative time, age, sex, number of levels, and change in radiographic parameters as independent variables and using dysphagia score as the dependent variable. The change in C2-C7 angle and operative time were the only statistically significant predictors of change in dysphagia at 2 and 6 weeks postoperatively. CONCLUSIONS: These results indicate that lordotic change in spinal alignment and longer operative times are associated with increased postoperative dysphagia. Surgeons should counsel patients in whom a large angular correction is expected about the possibility for postoperative dysphagia. Furthermore, future studies on dysphagia incidence should include radiographic alignment as an independent predictor of dysphagia.