Intrasubstance Patellar Tendon Repair with the Addition of a Bio-inductive Implant.

Intrasubstance patellar tendon ruptures are an uncommon injury that can have devastating long-term effects for patients. Operative intervention to repair the ruptured tendon is the gold standard treatment for these injuries and can be performed using a variety of techniques. Unlike the more common patellar tendon ruptures at the level of the patella, repairs of intrasubstance ruptures are often challenging because of the poor quality of the remaining tendon fibers. Tendon repair with augmentation via bio-inductive implants has gained popularity in upper extremity literature, as it has demonstrated improved tendon strength and patient outcomes. However, there remains a sparsity of reports regarding tendon augmentation in the lower extremity literature. Here, we describe repair of an intrasubstance patellar tendon rupture using a modified SpeedBridge repair and augmentation with a bio-inductive implant.

Anterior Compartment Neurovascular Bundle Entrapment in a Minimally Displaced Distal Tibial Fracture: A Case Report.

CASE: A 29-year-old woman presented with a low-energy, minimally displaced pilon fracture with progressive pain and paresthesias in the affected foot, ultimately requiring open reduction and internal fixation. Intraoperatively, the deep peroneal nerve and anterior tibial artery and vein were entrapped within the fracture. After freeing the bundle and fixing the fracture, the paresthesias improved and ultimately resolved. CONCLUSION: Injury to the anterior leg compartment neurovascular structures should be considered in low-energy, minimally displaced pilon fractures. In this instance, progressive neurologic symptoms not consistent with the radiographic findings indicated the patient for surgical exploration and fixation.

Heterotopic Ossification After Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autograft: A Case Report.

CASE: A 32-year-old healthy woman tore her right anterior cruciate ligament (ACL) and underwent reconstruction with quadriceps tendon autograft. Twelve weeks postoperatively, she had anterior thigh pain limiting knee flexion and a palpable mass in the anterior thigh. Imaging revealed a calcified mass near the graft site, concerning for heterotopic ossification (HO). After maturation of the heterotopic bone, she underwent debridement and HO removal. CONCLUSION: This is a case of HO at the quadriceps tendon autograft site after ACL reconstruction. When counseling patients, clinicians should be mindful of this possible complication and its treatment.

The Evolution of the Walch Classification for Primary Glenohumeral Arthritis.

Our understanding of the pathology of and treatment for glenohumeral arthritis (GHA) has grown dramatically in the past few decades. Original observations regarding patterns of glenoid erosion, glenoid retroversion, and posterior humeral head subluxation in patients with primary GHA were documented in the 1980s and early 1990s. In the late 1990s, Walch et al proposed what is now the most widely used classification system to describe the characteristic pathology of GHA. Improved understanding of both premorbid and pathologic anatomies, along with advancements in imaging, have steered modifications in this classification system. These changes have improved its reliability and helped to further guide management decisions. The purpose of this article is to review the evolution of the Walch classification, understand the rationale behind the modifications, and discuss potential future developments.

Patient-Reported Outcomes After Multiple-Revision ACL Reconstruction: Good but Not Great.

PURPOSE: To evaluate the patient-reported and objective functional outcomes of patients undergoing multiple-revision anterior cruciate ligament (ACL) reconstruction surgery. The secondary purpose was to determine failure rates and factors associated with failure, with a focus on posterior tibial slope. METHODS: All patients who underwent a repeat revision ACL reconstruction with a single surgeon over a 13-year period were identified. Chart data were obtained, including radiographic findings, operative details and findings, and postoperative examination findings. Failure was defined as subjective instability with evidence of graft incompetence on physical examination and MRI. Patients completed the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC-SKF) and Tegner Activity Level Scale. Patients who had outcomes scores completed a minimum of 2 years postoperatively were included. RESULTS: Fourteen patients were available for follow-up; 12 underwent secondary revision procedures, and 2 underwent tertiary revisions. Three patients (21%) had subsequent failure of the revision graft with mean time to failure of 27 months. Posterior tibial slope was significantly higher in the failures than in the nonfailures (13.3˚; 95% CI 10.1-16.6 versus 10.1˚; 95% CI 6.7-11.4; P = 0.049). Eleven patients completed outcomes measures at a mean of 42 months postoperatively (range 24-79 months). The mean Tegner activity score was 6.3 at follow-up, compared with 8.3 prior to the original ACL injury. The mean IKDC-SKF score was 70 at follow-up. CONCLUSION: Multiple revision ACL reconstruction surgery appears to have reasonable functional outcomes but is associated with a relatively high failure rate. Activity level following repeat revision surgery is diminished compared to the preinjury state, but most patients are able to return to recreational sports. LEVEL OF EVIDENCE: Therapeutic Study, Level IV.

Treatment Outcomes in Septic Arthritis of the Foot and Ankle in People Who Inject Drugs.

BACKGROUND: Although injection drug use (IDU) is a known risk factor for septic arthritis (SA) of the foot and ankle (F&A), disease and hospitalization outcomes are poorly characterized. We evaluated national trends, demographic characteristics, and hospitalization outcomes of SA of the F&A in people who inject drugs vs those who do not. METHODS: Using the Nationwide Inpatient Sample, we identified all patients aged 15-64 with a principal discharge diagnosis of SA of the F&A from 2000 to 2013 and evaluated if they were related or unrelated to IDU. We assessed differences in demographic characteristics and in-hospital outcomes in these groups. RESULTS: From 2000 to 2013, there were an estimated 14,198 hospitalizations for SA of the F&A in the United States, and 11% were associated with IDU (SA-IDU). Compared to SA unrelated to IDU, people with SA-IDU were significantly more likely to be younger, black, and have Medicaid or no insurance. People with SA-IDU were significantly more likely to leave against medical advice (9.7% vs 1.4%, P < .001), have a longer length of stay (9.2 vs 6.8 days, P < .001), and incur increased hospital charges ($58 628 vs $38 876, P = .005). People with SA-IDU were significantly less likely to receive an arthroscopy (1.5% vs 6.5%, P < .001) or arthrotomy (2.2% vs 11.0%, P < .001) of the foot. CONCLUSION: People with SA-IDU of the F&A had suboptimal hospitalization outcomes with greater costs. Recognizing risk factors and proactively addressing potential complications of substance use disorder in the hospital should be prioritized by the orthopedic community. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The challenge of Propionibacterium acnes and revision shoulder arthroplasty: a review of current diagnostic options.

BACKGROUND: Propionibacterium acnes is the most common cause of infection after shoulder arthroplasty. Whereas there are several methods that can aid in the diagnosis of P. acnes infection, there is not a single "gold standard" because of the difficulties inherent in identifying this bacterium. We present an evidence-based discussion of the demographic, clinical, and radiographic predictors of P. acnes infection and review the current options for diagnosis. METHODS: This review was written after a comprehensive analysis of the current literature related to shoulder periprosthetic joint infection and P. acnes identification. RESULTS AND CONCLUSIONS: Of the techniques reviewed, α-defensin had the highest sensitivity in detecting P. acnes infection (63%). C-reactive protein level and erythrocyte sedimentation rate were often normal in cases of infection. Whereas P. acnes can be challenging to successfully diagnose, there are several options that are considered preferable because of their higher sensitivities and specificities. The current gold standard is intraoperative culture, but major advances in molecular techniques may provide future improvements in diagnostic accuracy.

Single-port laparoscopic colorectal surgery shows equivalent or better outcomes to standard laparoscopic surgery: results of a 190-patient, 7-criterion case-match study.

INTRODUCTION: Single-port (SP) surgery has been characterized as having limited applicability regarding procedure, disease, and patient characteristics. There is a question if SP procedures offer disadvantages or advantages to multiport (MP) colorectal surgery. We hypothesize that SP is equivalent to MP and is a safe alternative in the full spectrum of colorectal disease and procedures. METHODS: A case-matched analysis of a prospectively maintained database to compare perioperative outcomes in SP versus MP was performed. Criteria included age, gender, BMI, previous abdominal surgery, previous XRT, disease process, and procedure. 95 exact matches for all 7 criteria were found between 159 SP and 1,617 MP cases. Perioperative outcomes, surgical technique, morbidity, mortality, local recurrence, and 5-year survival were analyzed. RESULTS: There was lower mean EBL in SP but no difference in transfusion requirement. OR time for SP left colectomy was shorter, with a trend to shorter OR times found in all procedures. 99 % SP and 98 % MP had no intra-operative complications. Conversion to open was equivalent (0/1). Mean largest incision was smaller for SP. There were no differences in return of bowel function or length of hospital stay. There were no mortalities. There were no differences in perioperative morbidity, local recurrence, distant metastasis, or overall 5-year survival. CONCLUSIONS: SP is a safe alternative to MP colorectal surgery across the full array of procedures in equivalent patients. This study demonstrates SP has less blood loss, smaller incisions, is quicker in left colectomy, and tends to be quicker across all procedures. Conversion and morbidity rates are equivalent to MP, without compromise in quality of surgical technique. While proper training is essential, concerns regarding the inability to use SP laparoscopic colorectal surgery safely are unfounded in nearly exactly matched patients. These issues will require further study as SP laparoscopic colorectal surgery is practiced more widely.

Phacomatosis pigmentovascularis of cesioflammea type in 7 patients: combination of ocular pigmentation (melanocytosis or melanosis) and nevus flammeus with risk for melanoma.

OBJECTIVE: To describe the features of phacomatosis pigmentovascularis (cesioflammea type). DESIGN: Noninterventional retrospective case series composed of 7 patients. RESULTS: Nevus flammeus combined with ipsilateral ocular melanocytosis or melanosis was seen in all 7 patients. Additional contralateral nevus flammeus was observed in 3 patients. Nevus flammeus (unilateral in 4 patients and bilateral in 3 patients) was distributed in trigeminal nerves V1 (n = 3), V2 (n = 7), and V3 (n = 5). Related findings included diffuse choroidal hemangioma (n = 1) and glaucoma (n = 1), with no patients having brain hemangioma or seizures. Ocular pigmentary abnormalities (unilateral in all 7 patients) included congenital ocular melanocytosis (n = 6) and conjunctival acquired melanosis (n = 1). Pigmentation was sectorial (partial) in 5 patients and complete in 2 patients. Melanocytosis involved the periocular skin in 1 patient, sclera in 2 patients, iris in 2 patients, and choroid in 4 patients. In 3 of 6 patients, melanocytosis was visible in the choroid only on dilated fundus evaluation. Related tumors included choroidal melanoma (n = 3), optic disc melanocytoma (n = 1), and conjunctival melanoma in situ (primary acquired melanosis) (n = 1). Melanoma metastasis developed in 1 patient. CONCLUSIONS: Phacomatosis pigmentovascularis shows features of nevus flammeus and more serious ocular pigmentary abnormalities (uveoscleral melanocytosis and conjunctival melanosis). Melanocytosis may be detected only by dilated ocular fundus examination, as found in 3 of 6 patients. Furthermore, choroidal melanoma can develop from melanocytosis, as noted in 3 of our 6 patients (50%). All patients with nevus flammeus should be examined for phacomatosis pigmentovascularis by an ophthalmologist because ocular melanocytosis and uveal melanoma may remain hidden within the eye.

Iridocorneal endothelial syndrome masquerading as iris melanoma in 71 cases.

OBJECTIVE: To describe the clinical features of iridocorneal endothelial (ICE) syndrome in a group of patients referred because of suspected iris melanoma. METHODS: In a noncomparative case series, we performed medical record review for clinical features of ICE syndrome in 71 patients. RESULTS: At presentation, the median patient age was 54 years. All patients were referred for evaluation of a pigmented iris mass, suspected to be a melanoma. The iris color was blue or green in 51 (72%) and brown in 20 (28%). The mass proved to be a combination of iris stromal atrophy in 41 cases (58%) with exposure or loss of the underlying iris pigment epithelium; ectropion iridis in 24 (34%), imparting a disfigured iris with dark-brown color; iris nodules in 5 (7%); traction elevation with iris distortion from peripheral anterior synechia in 57 (80%); and corectopia in 53 (75%), a feature commonly found with iris melanoma. The mean extent of iris atrophy was 2 clock hours. Ectropion iridis was unidirectional in 10 and multidirectional in 14. Additional features of ICE included corneal endothelial guttata-like changes in 33 (46%), corneal edema in 7 (10%), iris pigment epithelial transillumination defects in 12 (17%), polycoria in 1 (1%), and secondary glaucoma with intraocular pressure higher than 22 mm Hg in 7 (10%). CONCLUSIONS: Iridocorneal endothelial syndrome can simulate iris melanoma. Features more suggestive of ICE syndrome include corneal endothelial guttata-like changes and edema, peripheral anterior synechia, multidirectional ectropion iridis, and iris atrophy.