Axial Plane Rotation of the Talus in Progressive Collapsing Foot Deformity: A Weightbearing Computed Tomography Analysis.

BACKGROUND: Progressive collapsing foot deformity (PCFD) is recognized as a 3-dimensional deformity centered around the talus. Previous studies have described some features of talar motion in the ankle mortise in PCFD, such as sagging in the sagittal plane or valgus tilt in the coronal plane. However, axial plane alignment of the talus in the ankle mortise in PCFD has not been investigated extensively. The purpose of this study was to examine this axial plane alignment of PCFD vs controls using weightbearing computed tomography (WBCT) images and to determine if talar rotation in the axial plane is associated with increased abduction deformity, as well as to assess the medial ankle joint space narrowing in PCFD that may be associated with axial plane talar rotation. METHODS: Multiplanar reconstructed WBCT images of 79 patients with PCFD and 35 control patients (39 scans) were retrospectively analyzed. The PCFD group was divided into 2 subgroups depending on preoperative talonavicular coverage angle (TNC): moderate abduction (TNC 20-40 degrees, n=57) and severe abduction (TNC >40 degrees, n=22). Using the transmalleolar (TM) axis as a reference, the axial alignment of the talus (TM-Tal), calcaneus (TM-Calc), and second metatarsal (TM-2MT) were calculated. Difference between TM-Tal and TM-Calc was calculated to examine talocalcaneal subluxation. A second method to assess talar rotation within the mortise utilized an angle between the lateral malleolus and the talus (LM-Tal) in the axial slices of WBCT. In addition, the prevalence of medial tibiotalar joint space narrowing was assessed. These parameters were compared between the control and PCFD groups, and between moderate and severe abduction groups. RESULTS: The talus was significantly more internally rotated with respect to the ankle TM axis and the lateral malleolus in PCFD patients compared to controls, and in the severe abduction group compared with the moderate abduction group, using both measurement methods. Axial calcaneal orientation did not differ between groups. There was significantly greater axial talocalcaneal subluxation in the PCFD group, and this was also greater in the severe abduction group. The prevalence of medial joint space narrowing was higher in PCFD patients. CONCLUSION: Our findings suggest that talar malrotation in the axial plane should be considered an underlying feature of abduction deformity in PCFD. The malrotation occurs in both the talonavicular and ankle joints. This rotational deformity should be corrected at the time of reconstructive surgery, especially in cases of severe abduction deformity. In addition, medial ankle joint narrowing was observed in PCFD patients, with a higher prevalence of medial ankle joint narrowing in those with severe abduction. LEVEL OF EVIDENCE: Level III, case-control study.

The Outcome of Hip Arthroscopy in the Setting of Lumbar Spine Disease Is Beneficial, Yet Limited: A Systematic Review of Existing Evidence.

PURPOSE: To compare hip arthroscopy outcomes in femoroacetabular impingement (FAI) patients with concurrent symptomatic lumbar spine disease to the outcomes of arthroscopic FAI patients without spine disease. METHODS: A systematic review was performed according to PRISMA guidelines via PubMed, Cochrane, Embase, and Google Scholar databases. Studies were valid for inclusion if they had an average follow-up ≥12 months and compared patient-reported outcome measures (PROMs) in hip arthroscopy patients with and without concurrent spinal disease. Data collected included study characteristics, patient demographics, follow-up intervals, surgical indications, spinal pathology, PROMs, and reoperation rates. RESULTS: Twelve studies were included in this systematic review. 3,107 patients who underwent hip arthroscopy were evaluated: 1,056 with coexisting lumbar spine disease (spine cohort) and 2,051 control subjects without spine disease (control cohort). The average follow-up period was 24 months. Across included studies, there were 35 instances wherein postoperative PROM scores reported by each cohort were compared. In all 35 instances, the spine cohort reported inferior postoperative PROM scores with the difference being significant (P < .05) on 23 PROMs. Collectively, 23 cases were available contrasting the proportion of each cohort to achieve the minimal clinically important difference (MCID). In 22 (95.65%) of these cases, the spine cohort achieved the MCID at a lower rate than the control cohort. There were 14 PROMs, wherein intragroup analyses were reported that compared the preoperative and postoperative score reported by the spine cohort. On all 14 PROMs, the spine cohort reported significant (P < .05) improvement after arthroscopic intervention. CONCLUSION: FAI patients with coexisting lumbar spine pathology experience significant improvement from baseline state after arthroscopic intervention. However, the postoperative outcomes reported are inferior, and the improvement from arthroscopy was limited when compared to surgical control subjects with FAI and normal spinal anatomy. LEVEL OF EVIDENCE: Level IV: systematic review of Level II, III, and IV studies.

Clinical Outcomes of Revision Surgery Using a Dorsal Approach After Failed Primary Interdigital Neuroma Excision.

BACKGROUND: Revision neurectomy may be approached with either a dorsal or a plantar incision. Although a plantar approach is more commonly described, few studies have investigated outcomes following a dorsal revision neuroma excision. In this study, we performed a case series on a group of patients who underwent revision neuroma excision through a dorsal approach and reported complications and outcomes using validated patient-reported outcome measures (PROMs). METHODS: This retrospective case series included 10 patients who underwent a dorsal-approach revision neuroma excision and had preoperative and minimum 1-year postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores. Complications including neuroma recurrence and continued unresolved pain were obtained from the electronic medical record. Preoperative and postoperative PROMIS scores were compared to assess improvement in PROMs. RESULTS: There were significant improvements in the PROMIS pain interference (P = .026), pain intensity (P = .008), and global physical health (P = .017) domains. One patient experienced recurrence of their neuroma 4 years after surgery. CONCLUSION: This case series provides preliminary data indicating that revision neurectomy using a dorsal approach leads to satisfactory outcomes in pain-related PROMs. Further research with comparative study designs is necessary to determine if one approach is superior to the other. LEVELS OF EVIDENCE: Level IV: Retrospective.

The predictive value of self-reported allergies for reoperation after index hip arthroscopy.

The purpose of this study is to compare the rate of reoperation after index hip arthroscopy for symptomatic femoroacetabular impingement in patients with, and without, at least one self-reported allergy. Data were collected prospectively in 1468 patients whose records were retrospectively reviewed. After the application of inclusion and exclusion criteria, two cohorts were formed: (i) a study cohort (n = 261) composed of patients with a self-reported allergy and (ii) a control cohort. (n = 666). The allergy cohort had a significantly larger [P < 0.001] reoperation rate (24.1% [63/261]) compared to the control cohort (9.6% [64/66]). Univariate analysis (UVA) and multivariate analysis (MVA) were then performed to better understand the implications of allergy status on the arthroscopic outcome. On UVA the presence of an allergy increased the odds of reoperation after index hip arthroscopy by 2.99 [OR (95% CI): 2.99 (2.04, 4.39); P < 0.001] and for each additional allergy a patient reported, their odds of subsequent surgery increased by 1.27 per allergy [OR (95% CI): 1.27 (1.15, 1.39); P < 0.001]. However, on the MVA, allergy status was not an independent risk factor for reoperation. These findings suggest that allergy status is associated with a higher reoperation rate, however, allergy status alone cannot prognosticate the risk of subsequent surgery. Therefore, allergy status and its association with future surgery after hip arthroscopy should be considered in the context of multiple patient-specific factors that influence the surgical outcome. An understanding of this association enables patient-centered care and will strengthen the physician-patient relationship.

Outcomes of Emergency Gastrointestinal Surgery Done on Post-Cardiac Surgery Patients-Analysis From a Tertiary Care Center.

INTRODUCTION: Abdominal complications following cardiac surgery have high mortality rates. This study analyzes the outcomes of patients who have undergone emergency general surgery (EGS) procedures after cardiothoracic surgery (CTS) at the same hospitalization. MATERIALS AND METHODS: This was a retrospective analysis of all patients who underwent emergent abdominal surgery after CTS surgery between 2010-2018. The CTS procedures included coronary artery bypass graft (CABG), valve replacement, cardiac transplant, aortic replacement, ventricular assist device, and pericardial procedures. The records were reviewed to obtain demographics, frequency distribution of EGS procedures, complications, outcomes, and the risk factors of mortality. RESULTS: Of 4826 patients who had CTS, 57 (1.2%) underwent EGS procedures during the period of 2010-2018. This cohort of patients had 113 CTS and 85 EGS procedures during the same hospitalization. The mean age was 62 years, and 49% were elderly (40% were females). CABG with or without valve replacement was the most common surgery (28%). After surgical consultation for "acute abdomen" in the post-CTS phase, the three most common findings on exploratory laparotomy were bowel perforation (23%), massive free fluid leading to abdominal compartment syndrome (19%), and acute cholecystitis (16%). Respiratory failure (46%), acute kidney injury (32%), and multiple organ dysfunction (18%) were the most common hospital-acquired complications. Regarding dispositions, 47% were discharged to an acute rehabilitation center, 10% were discharged to a sub-acute rehabilitation center, and a similar proportion of patients went home (10%). On multivariable logistic regression analysis with backward elimination, age (OR=1.10, 95% CI: 1.02-1.18) and serum proteins (OR=0.99, 95% CI: 0.98-0.998) were independently associated with the odds of mortality after EGS in the immediate CTS phase. CONCLUSIONS: Respiratory failure is the most common complication of EGS immediately after CTS. The older the patient and the lower the serum proteins, the higher the odds of mortality in patients who undergo EGS after ETS.