Surgical Management of Chronic Exertional Compartment Syndrome of the Lower Extremity: Outcome Analysis and Return to Sport.

OBJECTIVE: To evaluate patient-reported outcomes and return to sport after open fasciotomy for lower extremity chronic exertional compartment syndrome (CECS). DESIGN: Retrospective case series. SETTING: Foot and ankle specialty service at a large multisite academic medical center. PATIENTS: All patients undergoing lower extremity fasciotomy for CECS from 2009 to 2017 by one surgeon were eligible. Patients that underwent a fasciotomy for trauma, infection, or an acute pathologic process were excluded. Fifty-nine patients that underwent 63 procedures were included. The average age was 26.6 years, and 35 (59%) patients were women. Thirty-seven patients underwent simultaneous bilateral fasciotomies, 4 had staged bilateral fasciotomies, and 18 underwent unilateral fasciotomy. Four-compartment fasciotomy was performed 15 times. INTERVENTIONS: Retrospective email/telephone follow-up. MAIN OUTCOME MEASURES: Return to sports questionnaire, the Foot and Ankle Ability Measure-Sports subscale, and visual analog scale for pain. RESULTS: At a mean follow-up of 58.8 months, significant postoperative improvement was seen in patient-reported outcome scores compared with preoperative scores (P < 0.0001). Overall, 55 (93%) patients were able to return to sport, 42 (76%) returned to the same level of sport, and 13 (24%) returned to a lower level of competition. Bivariate regression analysis demonstrated that a higher preoperative body mass index [odds ratio: 0.829 (95% confidence interval: 0.688, 0.999); P = 0.049] was associated with a lower likelihood of return to sport. CONCLUSIONS: This study demonstrates that lower extremity fasciotomy for CECS results in improvement of patient-reported outcomes and a high rate of return to sport.

Predictors of Improvement After Fasciotomy for Treatment of Chronic Exertional Compartment Syndrome of the Lower Extremity.

BACKGROUND: Previous studies have demonstrated the effectiveness of lower extremity fasciotomies in treating chronic exertional compartment syndrome (CECS). However, not all patients have demonstrated the same level of symptom improvement. HYPOTHESIS: Specific patient variables will lead to enhanced functional improvement after fasciotomy for CECS of the lower extremity. STUDY DESIGN: Case series. LEVEL OF EVIDENCE: Level 4. METHODS: A review of patients undergoing fasciotomy of the lower extremity for treatment of CECS by a single surgeon from 2009 to 2017 was performed. Pre- and postoperative measures of Foot and Ankle Ability Measure-Sports subscale (FAAM-Sports), FAAM-Sports Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) for pain during sporting activities were collected at a minimum of 12 months postoperatively. The primary outcomes of change in FAAM-Sports, FAAM-Sports SANE, and VAS during sporting activities were calculated by taking the difference of post- and preoperative scores. Generalized multiple linear regression analyses was performed to determine independent predictors of functional and pain improvement. RESULTS: A total of 61 patients (58% response rate) who underwent 65 procedures were included in this study, with postoperative outcome measures obtained at mean duration of 57.9 months (range, 12-115 months) after surgery. Patients had a mean ± SD improvement in FAAM-Sports of 40.4 ± 22.3 points (P < 0.001), improvement in FAAM-Sports SANE of 57.3 ± 31.6 points (P < 0.001), and reduction of VAS pain of 56.4 ± 31.8 points (P < 0.001). Multiple linear regression analysis revealed deep posterior compartment involvement, younger age, a history of depression, and male sex to be significant independent predictors of enhanced improvement after fasciotomy. CONCLUSION: Fasciotomy is an effective treatment of CECS, with our study identifying certain patient variables leading to greater functional improvement. CLINICAL RELEVANCE: Male patients, younger patients, patients with depression, and patients with deep posterior compartment involvement may serve to benefit more with fasciotomies for treatment of CECS.

Ankle Arthrodesis Through a Fibular-Sparing Anterior Approach.

BACKGROUND: The open anterior approach to ankle arthrodesis offers a technique that provides several advantages for surgeons, such as easier visualization of the joint for deformity correction and preservation of the malleoli for potential future conversion to total ankle arthroplasty. The purpose of this study was to evaluate clinical, radiographic, and functional outcomes in a large series of patients undergoing open ankle arthrodesis via a fibular-sparing anterior approach. METHODS: A retrospective review was performed of patients undergoing primary ankle arthrodesis with a single fellowship-trained foot and ankle orthopedic surgeon between 2009 and 2017. Patients were excluded if an approach other than anterior was performed. Patient-reported outcome measures (Foot and Ankle Ability Measure-Activities of Daily Living [FAAM-ADL], Short-Form 12 [SF-12], and visual analog scale [VAS] pain) were subsequently collected at a minimum of 24 months (2 years) following index surgery, along with outcome satisfaction and likelihood to repeat surgery. Fusion of the tibiotalar joint at the time of last radiographic follow-up was also assessed. Paired t tests were performed to assess change in pre- to postoperative outcomes, while linear regression analysis was performed to identify any patient factors associated with outcomes. Eighty-one patients, including 31 women and 50 men, with a mean age of 51.5 years and a mean follow-up of 58.9 (range, 24-104) months, were included. RESULTS: Sixty-two patients reported significant improvement in mean FAAM-ADL (P < .0001), SF-12 Physical Composite Scale (P < .0001), and VAS pain (P < .0001), while the SF-12 Mental Composite Scale also improved, though not significantly (P = .2854). Twelve patients (14.8%) experienced complications following their arthrodesis procedure. Seventy-nine patients (97.5%) achieved fusion at their last radiographic follow-up. Multiple linear regression analysis revealed age (B = 0.071 [0.004, 0.128]; P = .0373) to have a positive association with postoperative VAS pain. CONCLUSION: Ankle arthrodesis utilizing a fibular-sparing anterior approach combined with the transarticular screw fixation technique offers surgeons several advantages, along with a low postoperative complication rate, high rate of radiographic evidence of joint fusion, and substantially large improvement in pain and functional levels. LEVEL OF EVIDENCE: Level IV, retrospective case series.

When is it Safe to Drive After Total Ankle Arthroplasty?

BACKGROUND: With the increase in the number of total ankle arthroplasties (TAA), guidelines on when physicians should begin to consider patients' return to driving are valuable. Further, due to sagittal motion strength, the ankle is the most important mover in braking motions over the knee and hip. QUESTIONS/PURPOSES: (1) Does brake-reaction time return to a safe value within 6 weeks of TAA? (2) Are there factors associated with a delay of return of brake-reaction time to safe values after TAA? METHODS: After obtaining institutional review board approval for the study, we prospectively recruited 60 patients undergoing right TAA. A large proportion of the patients undergoing TAA during the period were recruited. Patients who had extensive concomitant surgery, such as triple arthrodesis or tibial osteotomy, were excluded from the study. Patients were between 43 and 83 years old (median, 63 years), and 35 (59%) were men. Brake-reaction time was tested at 6 weeks postoperatively and repeated weekly until patients achieved a passing brake-reaction time. A control group of 20 volunteer participants matched for age and sex who did not have right lower-extremity pathology or pain were used to establish a passing brake-reaction time of 0.850 seconds. Patients were given a novel driver-readiness survey to complete; a score of 10 of 15 points or higher was considered a passing score. The following factors were explored for their association with brake-reaction time: age, American Orthopaedic Foot and Ankle Society (AOFAS)-Hindfoot assessment and VAS for pain via a patient-reported survey, and ankle plantarflexion and dorsiflexion via dedicated weightbearing lateral radiographs made with the ankle in maximum plantarflexion and dorsiflexion. RESULTS: At 6 weeks postoperatively, 92% of patients (54 of 59) achieved a passing brake-reaction time and were considered able to drive safely, and the mean brake-reaction time of the patients with a passing brake-reaction time was 0.626 seconds (± 0.111). At 9 weeks, all patients who completed the study achieved a passing brake-reaction time. Patients with a failed brake-reaction time at 6 weeks had greater median VAS scores for pain (3 [interquartile range 2 to 7] versus 1 [IQR 0 to 3]; p = 0.022) and diminished ankle plantarflexion (14° [± 5°] versus 24° [± 10°]; p = 0.037) compared with those with a passing brake-reaction time at that time point. All five patients with a failed brake-reaction time also had a failing score for the driver-readiness survey. CONCLUSIONS: More than 90% of patients in this series achieved a safe brake-reaction time within 6 weeks of TAA, and those who did not were more likely to have had more pain and a stiffer ankle. Surgeons might counsel patients with persistent pain and stiffness at 6 weeks to delay driving for an additional 3 weeks, since by 9 weeks after TAA, all patients in this series had a brake-reaction time comparable with patients who had not undergone surgery. Future studies might elucidate what key gaps in knowledge remain and determine a practical way to answer these questions. LEVEL OF EVIDENCE: Level II, therapeutic study.

Tenosynovial Giant Cell Tumor in the Midfoot Treated With Femoral Head Allograft Reconstruction.

Tenosynovial giant cell tumor (also known as giant cell tumor of tendon sheath or pigmented villonodular synovitis) is a rare soft tissue tumor that arises from the tenosynovium of a tendon sheath or the synovium of a diarthrodial joint. This disease process occurs infrequently in the foot and ankle but can result in significant bone erosion and destructive changes of affected joints. These cases are challenging to treat, because the tumor most commonly presents in young, active patients and can be associated with extensive bone loss. We review a case of tenosynovial giant cell tumor of tendon sheath of the midfoot, which was treated with mass resection, structural femoral head allograft bone grafting, and internal fixation with dorsal plating. The patient had achieved successful bony fusion and acceptable functional outcomes at the final follow-up visit 40 months postoperatively.

Effect of Arthroscopic Evaluation of Acute Ankle Fractures on PROMIS Intermediate-Term Functional Outcomes.

BACKGROUND: Following open reduction internal fixation (ORIF) of unstable ankle fractures, some patients have persistent pain and poor outcomes. This may be secondary to intra-articular injuries that occur at the time of fracture, which occur in up to 88% of fractures. Ankle arthroscopy at the time of ORIF has been proposed to address these intra-articular injuries. This study compared patient-reported functional outcomes in patients who underwent ankle ORIF with and without ankle arthroscopy. METHODS: An institutional database was used to retrospectively identify 93 patients who underwent ORIF for an unstable ankle fracture with an intact medial malleolus between 2002 and 2013. Forty-two patients had ankle arthroscopy at the time of ORIF and 51 did not. Functional outcomes between groups were compared using Patient Reported Outcomes Measurement Information System (PROMIS) physical function and pain interference computerized adaptive tests at a minimum follow-up of 1 year. Outcomes were also measured with the visual analog scale (VAS) pain score and the Olerud and Molander ankle fracture outcome scale. Average patient follow-up was 67 months (n = 51). RESULTS: PROMIS physical function and pain interference scores were not significantly different between groups (physical function, 57.8 vs. 54.5, P = .23; pain interference, 45.6 vs. 46.9, P = .56). Operative time was increased in the arthroscopy group (74 minutes vs. 59 minutes, P = .027). Overall, 60% (25/42) had chondral lesions of the talus, 7% (3/42) had chondral lesions of the tibial plafond, and 21% (9/42) had loose bodies requiring removal. There was no significant difference in complication rates between groups. CONCLUSION: At intermediate-term follow-up of patients with unstable ankle fractures and intact medial malleoli, functional outcomes were not significantly improved in patients who underwent ankle arthroscopy. However, there were no increased complications attributable to ankle arthroscopy, and average total operative time was increased by only 15 minutes. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Update on Antibiotic Prophylaxis for Genitourinary Procedures in Patients with Artificial Joint Replacement and Artificial Heart Valves.

Infection of artificial joint replacements and heart valves is an uncommon but serious complication encountered anytime after the implantation of these prostheses. It is known that bacteremia can lead to infection of a prosthetic device. However, there is no strong evidence to correlate urologic procedures with the development of periprosthetic joint infection or prosthetic valve endocarditis. Therefore, antibiotic prophylaxis for the prevention of endocarditis is not recommended in patients undergoing urologic procedures. However, guidelines regarding prophylaxis to prevent infection of an artificial joint in the setting of a genitourinary procedure are more varied.

Molecular engineering and measurements to test hypothesized mechanisms in single molecule conductance switching.

Six customized phenylene-ethynylene-based oligomers have been studied for their electronic properties using scanning tunneling microscopy to test hypothesized mechanisms of stochastic conductance switching. Previously suggested mechanisms include functional group reduction, functional group rotation, backbone ring rotation, neighboring molecule interactions, bond fluctuations, and hybridization changes. Here, we test these hypotheses experimentally by varying the molecular designs of the switches; the ability of the molecules to switch via each hypothetical mechanism is selectively engineered into or out of each molecule. We conclude that hybridization changes at the molecule-surface interface are responsible for the switching we observe.