Short-Term Risk Factors for Subtalar Arthrodesis After Primary Tibiotalar Arthrodesis.

While adjacent joint arthritis is a recognized long-term downside of primary tibiotalar arthrodesis (TTA), few studies have identified risk factors for early subtalar arthrodesis (STA) after TTA. This study aims to identify the risk factors for STA within the first few years following TTA. All patients older than 18 years undergoing TTA between 2008 and 2016 were identified retrospectively. Demographic data and comorbidities were collected alongside prior operative procedures, postoperative complications, and subsequent STA. Pre-and postoperative Kellgren-Lawrence osteoarthritis grade of the subtalar joint and postoperative radiographic alignment were obtained. A total of 240 patients who underwent primary TTA were included in this study with median follow up of 13.8 months. Twenty patients (8.3%) underwent STA after TTA due to symptomatic nonunion of TTA in 13 (65%), progression of symptomatic subtalar osteoarthritis (OA) in 4 (20%), and symptomatic nonunion of primary TTA combined progressively symptomatic subtalar OA in 2 (10%). Preoperative radiographic subtalar OA severity and postoperative radiographic alignment were not correlated with subsequent STA. Diabetes mellitus, Charcot arthropathy, neuropathy, alcohol use, substance use disorder, and psychiatric disease were significantly associated with having a subsequent STA. The most common postoperative contributing factor for subsequent STA following primary TTA was the salvage of symptomatic ankle nonunion rather than subtalar joint disease. Patients considering an ankle fusion should be counseled of the risk of subsequent STA, especially if they have risk factors that include diabetes, Charcot arthropathy, neuropathy, alcohol use, substance use disorder, or psychiatric disease.

Nationwide Analysis of Total Ankle Replacement and Ankle Arthrodesis in Medicare Patients: Trends, Complications, and Cost.

BACKGROUND: Surgical management of end-stage ankle arthritis consists of either ankle arthrodesis (AA) or total ankle replacement (TAR). The purpose of this study was to evaluate utilization trends in TAR and AA and compare cost and complications. METHODS: Medicare patients with the diagnosis of ankle arthritis were reviewed. Patients undergoing surgical intervention were split into AA and TAR groups, which were evaluated for trends as well as postoperative complications, revision rates, and procedure cost. RESULTS: A total of 673 789 patients were identified with ankle arthritis. A total of 19 120 patients underwent AA and 9059 underwent TAR. While rates of AA remained relatively constant, even decreasing, with 2080 performed in 2005 and 1823 performed in 2014, TAR rates nearly quadrupled. Average cost associated with TAR was $12559.12 compared with $6962.99 for AA (P < .001). Overall complication rates were 24.9% in the AA group with a 16.5% revision rate compared with 15.1% and 11.0%, respectively, in the TAR group (P < .001). Patients younger than 65 years had both higher complication and revision rates. DISCUSSION: TAR has become an increasingly popular option for the management of end-stage ankle arthritis. In our study, TAR demonstrated both lower revision and complication rates than AA. However, TAR represents a more expensive treatment option. LEVELS OF EVIDENCE: Level III: Retrospective comparative study.

Unicompartmental knee arthroplasty: A PearlDiver study evaluating complications rates, opioid use and utilization in the Medicare population.

PURPOSE: Despite increased utilization of unicompartmental knee arthroplasty (UKA) for unicompartmental knee osteoarthritis, outcomes in Medicare patients are not well-reported. The purpose of this study is to analyze practice patterns and outcome differences between UKA and TKA in the Medicare population. It is hypothesized that UKA utilization will have increased over the course of the study period and that UKA will be associated with reduced opioid use and lower complication rates compared to TKA. METHODS: Using PearlDiver, the Humana Claims dataset and the Medicare Standard Analytic File (SAF) were analyzed. Patients who underwent UKA and TKA were identified by CPT codes. Postoperative complications were identified by ICD-9/ICD-10 codes. Opioid use was analyzed by the number of days patients were prescribed opioids postoperatively. Survivorship was defined as conversion to TKA. RESULTS: In the Humana dataset, 7,808 UKA and 150,680 TKA patients were identified. 8-year survivorship was 87.7% (95% CI [0.861,0.894]). Postoperative opioid use was significantly higher after TKA (186.1 days) compared to UKA (144.7 days) (p < 0.01, Δ = 41.1, 95% CI = [30.41, 52.39]). In the SAF dataset, 20,592 UKA patients and 110,562 TKA patients were identified. Survivorship was highest in patients > 80 years old and lowest in patients < 70 years old. In both datasets, postoperative complication rates were higher in TKA patients compared to UKA patients in nearly all categories. CONCLUSIONS: UKA represents an increasingly utilized treatment for osteoarthritis in the Medicare population and may be comparatively advantageous to TKA due to reduced opioid use and complication rates after surgery. LEVEL OF EVIDENCE: Level III.

Weightbearing Protocols After Posterolateral Corner Reconstruction: A Systematic Review.

BACKGROUND: Multiligamentous knee injuries with a posterolateral corner injury represent a devastating insult to the knee. PURPOSE: To evaluate multiligamentous knee reconstruction rehabilitation programs and recommend a rehabilitation program based on a review of published outcomes studies. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A MEDLINE (PubMed), OVID, and Embase database search was conducted using the terms "posterolateral corner" and "rehabilitation." All articles obtained were examined to confirm their rehabilitation programs for multiligamentous knee injuries. These injuries included a posterolateral corner injury plus an isolated anterior or posterior cruciate ligament injury or a combined cruciate injury. RESULTS: Ten publications representing 245 patients with multiligamentous knee reconstruction were analyzed. Rehabilitation protocols were divided by weightbearing (WB) status: in 2 studies, patients were non-WB until postoperative 4 weeks (delayed WB; n = 61); 5 studies permitted progressive WB until postoperative 6 weeks (progressive WB; n = 123); and 3 studies allowed WB immediately after surgery (immediate WB; n = 61). No significant difference in outcome scores among the 3 WB groups was found. Arthrofibrosis requiring manipulation under anesthesia was the most common complication (11%) in the delayed WB group, followed by the immediate WB group (3%) and the progressive WB group (0%; P < .01). Overall complication rates were highest in the delayed WB group (44%), followed by the immediate and progressive WB groups (25% and 3%, respectively; P < .00001). The delayed WB group was permitted to return to sport at a mean of 10.5 months from the index procedure; the progressive WB group, at 6.0 months; and the immediate WB group, at 9.0 months (P < .05). CONCLUSION: This review revealed no significant difference in outcome scores when comparing immediate, progressive, and delayed WB protocols. Time to permitted return to sport was not significantly different among the groups, but there existed a trend toward earlier return in the progressive WB group. Patients in the delayed and immediate WB groups experienced a higher overall complication rate. Progressive WB postoperative protocols may decrease the risk of complications without compromising outcomes; however, more research is needed to identify the optimal postoperative rehabilitation protocol, given the significant data heterogeneity currently available in the literature.

Diagnosis and Treatment of Chronic Lateral Ankle Instability: Review of Our Biomechanical Evidence.

Definitive diagnosis and optimal surgical treatment of chronic lateral ankle instability remains controversial. This review distills available biomechanical evidence as it pertains to the clinical assessment, imaging work up, and surgical treatment of lateral ankle instability. Current data suggest that accurate assessment of ligament integrity during physical examination requires the ankle to ideally be held in 16° of plantar flexion when performing the anterior drawer test and 18° of dorsiflexion when performing the talar tilt test, respectively. Stress radiographs are limited by their low sensitivity, and MRI is limited by its static nature. Surgically, both arthroscopic and open repair techniques appear biomechanically equivalent in their ability to restore ankle stability, although sufficient evidence is still lacking for any particular procedure to be considered a superior construct. When performing reconstruction, grafts should be tensioned at 10 N and use of nonabsorbable augmentations lacking viscoelastic creep must factor in the potential for overtensioning. Anatomic lateral ligament surgery provides sufficient biomechanical strength to safely enable immediate postoperative weight bearing if lateral ankle stress is neutralized with a boot. Further research and comparative clinical trials will be necessary to define which of these ever-increasing procedural options actually optimizes patient outcome for chronic lateral ankle instability.

Lariat sign: An MRI finding associated with common peroneal nerve rupture.

Traumatic knee dislocation represents a catastrophic orthopedic injury with potentially devastating vascular and neurologic injuries. We report a case of common peroneal nerve rupture sustained during a knee dislocation with novel radiographic findings that we describe as a lariat sign. At the site of rupture, the distal nerve loops back on itself forming a lasso shape or lariat. This thickened nerve's abnormal course should not be misinterpreted as a vessel.

Gastrocnemius Recession for Metatarsalgia.

Metatarsalgia is a common cause of plantar forefoot pain. Causes of metatarsalgia include foot anatomy, gait mechanics, and foot and ankle deformity. One specific cause, mechanical metatarsalgia, occurs because of gastrocnemius muscle contracture, which overloads the forefoot. Muscular imbalance of the gastrocnemius complex alters gait mechanics, which increases recruitment of the toe extensor musculature, thereby altering forefoot pressure. Patients with concomitant metatarsalgia and gastrocnemius contracture demonstrate ankle equinus and a positive Silfverskiold test. Nonoperative therapeutic modalities are mainstays of treatment. In patients in whom these treatments fail to provide metatarsalgia symptomatic relief, gastrocnemius muscle lengthening is a therapeutic option.

Clinical and Functional Outcomes of the Birmingham Hip Resurfacing System.

This study reported the outcomes of patients treated with the Birmingham Hip Resurfacing System (Smith & Nephew, Memphis, Tennessee) to identify the prevalence of complications and failures. A retrospective review of 202 patients (206 hips) was performed. Outcomes were assessed clinically with Harris Hip Score at 6 and 12 months and then yearly. Subanalysis was performed, with the hips divided according to patient sex and size of the femoral component. Mean patient age was 51±8 years, and mean follow-up was 4±1.6 years. Of the patients, 163 were men (83%) and 35 were women (17%). Postoperative improvement was significant, with preoperative Harris Hip Score of 62.9±10.6 and postoperative Harris Hip Score of 98.6±6.7 (P<.001). There were 9 patients (4%) who had complications. A total of 5 hips (2.4%) underwent revision. At 3 years, mean survival was better for men than for women (99% vs 92%, respectively). Survival was lowest in patients with femoral component diameter of less than 46 mm. According to the authors' results, the Birmingham Hip Resurfacing System resulted in good clinical outcomes at 4 years. Survival and outcomes in women, particularly those with modest bone size, are inferior.