Achilles tendon-splitting approach and double-row suture anchor repair for Haglund syndrome.

BACKGROUND: Haglund syndrom is characterized as a painful posterosuperior deformity of the heel with possible causes as tight Achilles tendon, high-arched foot and tendency to walk on the outside of the heel. Surgical treatment may be recommended in cases where of insufficient response to nonoperative treatment. This study aims to evaluate the clinical and radiographic results of central Achilles tendon splitting and double-row suture anchor technique in the surgical treatment of patients with Haglund syndrome. METHODS: 27 patients with Haglund syndrome who underwent central Achilles tendon splitting and double-row suture anchor were retrospectively evaluated. The results were evaluated by the pre- and post-operative American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and visual analogue scale (VAS). All patients were evaluated radiographically to assess lateral talus-first metatarsal angle (TMTA), Calcaneal pitch angle (CPA), and the Fowler-Philip angle (FPA) preoperatively and postoperatively. RESULTS: The mean preoperative AOFAS score was 47 ± 7 points; at the end of the follow-up period, it increased to 92 ± 4 points (p < 0.001). The mean preoperative VAS score was 9 ± 0.9 points; at the end of the follow-up period, it was 2 ± 0.6 points (p < 0.001). The lateral TMTA (preoperative: 5° ± 2°; follow-up: 4° ± 2°; p < 0.001), CPA (preoperative: 21° ± 5°; follow-up: 20° ± 5°; p = 0.005) and FPA (preoperative: 55° ± 6°; follow-up: 32° ± 3°; p < 0.001) values decreased at the end of the follow-up period. CONCLUSION: In the absence of an improvement to nonoperative treatment methods, central Achilles tendon-splitting approach appears to be an effective and safe treatment option. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Symptom related to Essure® and evolution after removal: Outcomes of retrospective cohort.

INTRODUCTION: The number of requests for Essure removal has grown continually over recent years. The objective is to describe the symptoms reported after Essure sterilization, methods of removal and results. MATERIAL AND METHODS: Retrospective and single-centre cohort (Regional university hospital of Lille, France) was conducted. All women, having consulted from December 2016 to February 2019 for symptoms related to Essure insertion, were included. All the symptoms were noted. A second group was created that included patients who underwent Essure removal to evaluate the benefits of surgery on these symptoms. RESULTS: The study included 98 patients. Most frequent symptoms were musculoskeletal pain (75 %), asthenia (63 %) and pelvic pain (55 %). Fifty-nine patients (60 %) underwent surgery. Surgery appeared beneficial with reduction of symptoms in 60 % of these patients, complete resolution in 33 % and no reduction of symptoms in 7%. Many symptoms were relieved by surgery with an overall decline of 96 % in menorrhagia, 94 % in metrorrhagia and 93 % in dyspareunia. However, other symptoms were not relieved by surgery like 100 % of sleep disorders, 70 % of abdominal pain cases and 57 % of memory impairment cases. CONCLUSION: Symptoms related to Essure insertion are numerous. Although surgery appears beneficial, some adverse effects remain. Therefore, a preoperative aetiologic assessment and information about risk of surgery failure are important.

Normal Preoperative Images Do Not Indicate a Poor Outcome of Surgery for Coccydynia.

STUDY DESIGN: This is a retrospective cohort study. OBJECTIVE: To evaluate the long-term outcomes after surgery for refractory coccygodynia in patients with normal imaging studies compared with patients where imaging shows an anomaly. SUMMARY OF BACKGROUND DATA: Patients with coccydynia who do not respond to conservative treatment will often profit from coccygectomy. Most surgeons employ plain radiographs or magnetic resonance imaging (MRI) in their preoperative work-up. These will often show anomalies, but in some cases they do not. We investigated whether these patients do less well than those with abnormal images. METHODS: We operated on 184 patients with coccydynia during a 7-year period and 171 (93%) responded to follow-up questionnaires after 37 (range: 12-85) months. Images of 33 patients were normal and 138 showed some coccygeal pathology. Surgery was considered to have been unsuccessful when respondents stated at review that they were somewhat better, unchanged, or worse. RESULTS: There were no clinically or statistically significant differences in outcome between the groups. Surgery was unsuccessful in 24% of patients with normal images and in 32% among those with abnormal images. The median pain scores (0-10) during the week before review were two (interquartile range [IQR]: 0-3) and one (IQR: 1-5) in the two groups respectively. Similar proportions in the two groups stated that they would not have consented to surgery if they had known the outcome in advance. CONCLUSION: Patients with severe coccydynia who have not responded to conservative treatment should not be denied surgery only because their radiographs or MRI studies look normal. LEVEL OF EVIDENCE: 4.

Clinical course of pain and disability following primary lumbar discectomy: systematic review and meta-analysis.

PURPOSE: To conduct a meta-analysis to describe clinical course of pain and disability in adult patients post-lumbar discectomy (PROSPERO: CRD42015020806). METHODS: Sensitive topic-based search strategy designed for individual databases was conducted. Patients (> 16 years) following first-time lumbar discectomy for sciatica/radiculopathy with no complications, investigated in inception (point of surgery) prospective cohort studies, were included. Studies including revision surgery or not published in English were excluded. Two reviewers independently searched information sources, assessed eligibility at title/abstract and full-text stages, extracted data, assessed risk of bias (modified QUIPs) and assessed GRADE. Authors were contacted to request raw data where data/variance data were missing. Meta-analyses evaluated outcomes at all available time points using the variance-weighted mean in random-effect meta-analyses. Means and 95% CIs were plotted over time for measurements reported on outcomes of leg pain, back pain and disability. RESULTS: A total of 87 studies (n = 31,034) at risk of bias (49 moderate, 38 high) were included. Clinically relevant improvements immediately following surgery (> MCID) for leg pain (0-10, mean before surgery 7.04, 50 studies, n = 14,910 participants) and disability were identified (0-100, mean before surgery 53.33, 48 studies, n = 15,037). Back pain also improved (0-10, mean before surgery 4.72, 53 studies, n = 14,877). Improvement in all outcomes was maintained (to 7 years). Meta-regression analyses to assess the relationship between outcome data and a priori potential covariates found preoperative back pain and disability predictive for outcome. CONCLUSION: Moderate-level evidence supports clinically relevant immediate improvement in leg pain and disability following lumbar discectomy with accompanying improvements in back pain. These slides can be retrieved under Electronic Supplementary Material.

Peroneus Tertius Syndrome: A Rare Cause of Anterolateral Ankle and Rearfoot Pain.

There is limited literature describing anterolateral ankle or rearfoot pain associated with the peroneus tertius tendon. The purpose of this study is to define peroneus tertius syndrome, in which the peroneus tertius tendon causes catching or locking over the anterolateral ankle or rearfoot with accompanying pain. We present a retrospective case series involving 4 patients diagnosed with peroneus tertius syndrome, discuss symptoms for clinical diagnosis, review radiographic imaging, and outline a minimally invasive operative technique for resection of the symptomatic tendon. Furthermore, we sought to evaluate postoperative outcomes and satisfaction scores after surgical management. All patients experienced resolution of symptoms by the fourth postoperative week. There was a statistically significant improvement in visual analog scale scores (average ± SD, 7.75 ± 0.96 preoperative to 0.75 ± 1.19 postoperative) (p = .002). Overall patient satisfaction was 100%, with improved functional status and no evidence of recurrent symptoms at final follow-up (average 18.88 ± 8.68 months). Our results demonstrate that excision of a symptomatic peroneus tertius provides resolution of symptoms, facilitates a quick return to activity, and has excellent patient outcomes. We suggest that during the evaluation of anterolateral ankle or rearfoot pain, peroneus tertius syndrome be considered as part of the differential diagnosis.

Volumetric Analysis in Autologous Fat Grafting to the Foot.

BACKGROUND: Pedal fat grafting is a safe, minimally invasive approach to treat pedal fat pad atrophy. Prior randomized controlled trials demonstrate that the fat as measured directly under the metatarsal heads disappears between 2 and 6 months after fat grafting, despite patients having relief for 2 years. The authors aim to use magnetic resonance imaging to further assess three-dimensional volume of fat in the foot after autologous fat grafting to help explain the mechanism for improved pain. METHODS: A prospective study was performed using magnetic resonance imaging before and at 6 months after pedal fat grafting to assess changes in the three-dimensional morphology of the fat. RESULTS: Seventeen patients (six men and 11 women) underwent injections with a mean volume of 5.8 cc per foot. At 6 months, patients demonstrated increased tissue thickness (p = 0.008) and volume (p = 0.04). Improvements were seen in pain (p < 0.05) and activity (p < 0.05). Foot pressures and forces were significantly decreased and positively correlated with increased fat pad volume (p < 0.05). CONCLUSIONS: Pedal fat grafting significantly increases metatarsal fat pad volume. The distribution of the fat may contribute to lasting clinical relief in these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Comparison of the French and CARDS classifications for lumbar degenerative spondylolisthesis: reliability and validity.

BACKGROUND: The aim of this study was to compare the reliability and validity of the CARDS and French classification systems for lumbar DS. METHODS: Between May 2013 and December 2016, 158 consecutive patients diagnosed with single-level lumbar DS were included in this study, and all underwent lumbar fusion. All patients underwent long-cassette standing anterioposterior and lateral radiographs of the spine preoperatively and postoperatively. The images were graded according to the CARDS and French classification systems by two orthopedic spinal surgeons and two orthopedic spinal fellows, independently. Clinical outcome measures used were the visual analog scale, Oswestry Disability Index, and the 36-Item Short Form Health Survey. Clinical data were collected before surgery and 1 year after surgery. RESULTS: A total of 146 patients were finally included in this study and followed up for at least 1 year. When grading using the CARDS system, the κ values for inter- and intraobserver reliability were 0.837 and 0.869, respectively, representing perfect agreement. The interobserver κ value for the French classification was 0.693 and the intraobserver κ value was 0.743, both representing substantial agreement. CARDS Type D patients have higher preoperative back pain scores and better improvement after surgery compared with non-Type D patients. Mean back and leg pain was worse in French Type 5 patients, while the most significant improvement was also seen in Type 5 patients after surgery. CONCLUSIONS: Both CARDS and French classification systems have acceptable reliability and validity. The CARDS system is easier to utilize and has better reliability. LEVEL OF EVIDENCE: IV.

10-year results of the Nesovic procedure combined with adductor release for groin pain in 33 competitive athletes.

The authors present a 10-year review of the postoperative bilateral release of the adductor brevis and gracilis muscles combined with a bilateral abdominal myo-fascio-plasty according to Nesovic for groin pain in competitive athletes. We present the 10 years results of 33 patients operated on between April 2002 and May 2006 diagnosed with a "sports hernia". The injury was treated with a bilateral abdominal procedure according to Nesovic combined with a bilateral adductor release after unsuccessful conservative treatment of at least 2 months. There were 32 male patients between 18 and 43 years and one female patient aged 25 years with a mean age of 28.8 at time of surgery. All procedures were bilateral. Patients were seen in the postoperative clinic and a questionnaire was collected after 2 years and 10 years. Within 16 weeks, 30 patients (90,9 %) returned to the same or a higher level of sports activities. 10 years after surgery 31 patients (93,9%) remained free of pain. 1 patient has minor pain after training (VAS 0-1) and only 1 patient still experiences pain (VAS ≥ 5) after heavy work. 13 patients (39,3%) are still performing sports today, and 19 of 20 patients (95%, 57% of total cohort) were pain free to the end of their sporting careers. The bilateral Nesovic procedure with bilateral adductor release has a high success rate for the competitive athlete with chronic groin pain. It also is a procedure that gave most athletes suffering from a certain type of groin pain a solution till the end of their sporting careers.

Hallux valgus correction utilising a modified short scarf osteotomy with a magnesium biodegradable or titanium compression screws - a comparative study of clinical outcomes.

BACKGROUND: Biodegradable implants reduce the likelihood of further surgery for hardware removal and reduce the risks of associated infection and allergy. The purpose of this study is to evaluate the clinical efficacy and determine the comparability of biodegradable magnesium alloy MgYREZr (MAGNEZIX® CS) compression screw fixation compared with standard titanium screw fixation in the surgical treatment of hallux valgus deformity. METHODS: Eleven patients undergoing corrective surgery for hallux valgus utilising biodegradable magnesium screws and a control group of 25 patients undergoing corrective hallux valgus surgery with standard titanium screws were reviewed at a median of 19 months (range 12-30 months). PROM scores (Manchester-Oxford Foot Questionnaire (MOXFQ), Foot and Ankle Outcomes Instrument (FAOI) and the EQ-5D-3 L) were recorded preoperatively and at latest follow-up. RESULTS: The results between the two groups were broadly similar, with the Magnesium and Titanium patients showing similar patterns in the various domains in the MOXFQ, the FAOI and the EQ-5D-3 L. Most patients reported a near full shoe comfort score, and EQ-5D-3 L scores were significantly improved in both patient groups (with most patients reporting a full score). Foot pain and foot function improved irrespective of the scoring systems and patients in both groups demonstrated significantly improved scores following the surgery (p < 0.05). Notably, there were no significant differences when comparing the post-operative scores between the groups for any individual scoring parameter. No impairment to quality of life was recorded. There were no intra or post-operative complications. There were no problems encountered through the use of the bioabsorbable screws. CONCLUSION: Biodegradable magnesium-based compression screws appeared to be safe in this study and are an effective fixation device in the treatment of hallux valgus deformity with clinical outcomes similar to standard titanium screw fixation.

Have the frequency of and reasons for revision total knee arthroplasty changed since 2000? Comparison of two cohorts from the same hospital: 255 cases (2013-2016) and 68 cases (1991-1998).

INTRODUCTION: The number of total knee arthroplasty (TKA) revisions is expected to increase 601% in the United States between 2005 and 2030. This type of information is not available in France, and the last national study on this topic was done in 2000. This led us to perform a comparative study to determine if 1) the frequency of TKA revisions has increased and 2) the reasons for reoperation have changed relative to data gathered in 2000 at a single hospital in France. HYPOTHESIS: The frequency of TKA revision has increased between the two studies, performed 15 years apart. MATERIAL AND METHODS: In this retrospective observational single-center study (January 2013 to December 2016), all patients with a TKA who were reoperated with or without any component change were included. This cohort was compared to our historical cohort defined in 2000 of 68 TKA reoperations between January 1991 and January 1998. The reasons for revision were determined by consulting computerized patient records to find the disease history, clinical examinations, imaging findings, laboratory tests and the surgery report. Cases due to periprosthetic fractures, infection and skin-related complications were excluded in order to be consistent with the indications of the historical cohort. RESULTS: Between 2013 and 2016, 349 TKA revisions were performed, and 255 met the inclusion criteria. Note that the historical cohort had 68 cases. The mean time elapsed between the primary TKA and revision procedure was 5.3 years [34 days to 31 years]. Eight reasons for reoperation were identified. Aseptic loosening (85 cases (33.3%)), stiffness (70 cases (27.5%)), tibiofemoral laxity (39 cases (15.3%)) and patellar complications (34 cases (13.3%)) were the four most common reasons for reoperation. The frequency has changed over time: relative to 2000, the annual frequency increased by a factor of 6.5. The reasons have also changed over time: there was an increase in revisions for aseptic loosening (33.3% vs. 23.5%), stiffness (27.5% vs. 20.6%) and knee joint laxity (15.3% vs. 10.3%). Conversely, there was a reduction in revisions for patellar complications (13.3% vs. 26.5%), unexplained pain (0.4% vs. 8.8%) and patellar clunk syndrome (1.2% vs. 4.4%). DISCUSSION: The number of TKA revisions has increased by a factor of 6.5, with aseptic loosening still being the most common reason. The number of revisions performed for stiffness and knee joint laxity have increased. Fewer revisions are being done for unexplained pain because surgeons are now better able to determine the cause of TKA-related pain. There were fewer patella-related complications because of technical progress. The data generated from our single-center study are consistent with current published data. LEVEL OF EVIDENCE: II, comparative study.

The Effect of Patient Characteristics on 1 to 2-Year and Minimum 5-Year Outcomes After Total Ankle Arthroplasty.

BACKGROUND: Total ankle arthroplasty has shown durable improvements in patient-reported outcomes. However, the impact of common comorbidities and patient factors has not been fully characterized. The purpose of this study was to identify patient comorbidities and characteristics that impact outcomes after total ankle arthroplasty. METHODS: Patients who underwent a total ankle arthroplasty between January 2007 and December 2016 were enrolled into a prospective study at a single academic center. Patients completed outcome measures before the surgical procedure and at the time of follow-up: a visual analog scale (VAS) for pain, the 36-item Short Form Survey (SF-36), and the Short Musculoskeletal Function Assessment (SMFA). Patient and operative factors, along with prevalent preoperative comorbidities, were analyzed for association with preoperative to postoperative changes in 1 to 2-year and minimum 5-year outcomes. Comorbidities that met a significance threshold of p < 0.05 in adjusted analyses were incorporated into multivariable outcome models. RESULTS: A total of 668 patients with a mean 1 to 2-year follow-up (and standard deviation) of 1.6 ± 0.5 years (range, 10 months to 2 years and 2 months) were included. Patients' pain and function significantly improved across all outcomes (p < 0.05). However, depression, staged bilateral ankle arthroplasty, increased length of stay, a prior surgical procedure, increased American Society of Anesthesiologists (ASA) score, and particular implant types were associated with significantly smaller improvements in at least 1 patient-reported outcome after total ankle arthroplasty in the 1 to 2-year follow-up, although the effects were relatively small. At a minimum 5-year follow-up, smoking, depression, implant type, and staged bilateral ankle arthroplasty were associated with worse outcomes, and a prior surgical procedure, a simultaneous bilateral surgical procedure, and obesity were associated with improved outcomes. CONCLUSIONS: Patients who underwent total ankle arthroplasty had significant improvement in patient-reported outcomes, although several factors were associated with a small, but significant, negative impact on improvement, including depression, increased ASA score, current smoking, increased length of stay, a prior surgical procedure, and staged bilateral total ankle arthroplasty. Current smoking, obesity, and depression are potentially modifiable risk factors that could be improved prior to total ankle arthroplasty. Patients with these characteristics should be counseled on their risk of limited improvement in ankle pain and disability after total ankle arthroplasty. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Improvement in Back and Leg Pain and Disability Following Adult Spinal Deformity Surgery: Study of 324 Patients With 2-year Follow-up and the Impact of Surgery on Patient-reported Outcomes.

STUDY DESIGN: A retrospective review of a prospective, multicenter adult spinal deformity (ASD) database. OBJECTIVE: Our objective was to quantify the change in disability reported for patients with radiculopathy as compared with patients with back pain only following ASD realignment surgery. SUMMARY OF BACKGROUND DATA: Studies utilizing patient-reported outcomes (PROs) have shown that ASD patients suffer from significant pain and disability. Although surgical correction has been effective at improving back and leg pain, no studies have investigated the impact of radiculopathy on pain and disability in ASD patients. METHODS: Inclusion criteria were age ≥ 18 years and presence of spinal deformity as defined by coronal Cobb angle ≥ 20°, sagittal vertical axis (SVA) ≥ 5 cm, pelvic tilt (PT) angle ≥ 25°, or thoracic kyphosis (TK) angle ≥ 60°. Demographics and PRO were collected. Patients with radiculopathy were propensity matched with patients with back pain. Preoperative, postoperative, and 2-year follow-up radiographic parameters and PRO were analyzed. RESULTS: Three hundred twenty-four patients met inclusion criteria, and following propensity matching, 90 patients were placed into the radiculopathy and back pain groups. These groups showed no difference in demographic or radiographic parameters. The groups were similar in PRO, with a difference in leg pain as per design. At baseline, leg pain patients had higher disability [Oswestry Disability Index (ODI) and Scoliosis Research Society (SRS)]. Surgical strategies between the two groups showed no differences. Postoperative radiographic parameters showed no difference. Despite a significantly greater decrease in numerical rating scale (NRS) Leg for the leg pain group, postoperatively, these patients remained more disabled than the nonleg group in terms of NRS (back and leg), ODI, and most of the SRS domains. CONCLUSION: ASD patients with radiculopathy exhibit increased pain and disability when compared with patients without leg pain. This increased pain and disability persists after surgical correction in these patients. LEVEL OF EVIDENCE: 3.

Fasciotomy for chronic exertional compartment syndrome of the leg: clinical outcome in a large retrospective cohort.

BACKGROUND: Chronic exertional compartment syndrome (CECS) is an overuse disorder typically affecting an athletic population. CECS is a diagnosis based on history and intracompartmental pressure (ICP) testing. CECS patients can be treated surgically by fasciotomy; however, research on the relationship between ICP and patient symptoms and also between ICP and patient-reported outcome post-fasciotomy is limited. This study aims to (1) assess functional outcome and patient satisfaction post-fasciotomy and (2) identify any potential correlation between ICP and reported levels of pain. METHODS: 138 CECS patients who had ICP measurements and subsequently underwent fasciotomy were identified from our regional service for exercise-induced lower limb extremity pain between January 2000 and March 2017. Clinical outcomes were recorded at the time of ICP testing and in the post-operative follow-up clinic. Pain was reported using a verbal rating scale (VRS) ('low', 'moderate' or 'high') or as a visual analogue score (VAS) 0-10 (0 = least painful, 10 = most painful). Spearman's ranked correlation test was used to calculate correlation between ICP and reported pain. RESULTS: A total of 138 patients were eligible for inclusion in this study (mean age 29.7 ± 9.7 years, 110 M, 28 F) of which 109 patients (VRS n = 61, VAS n = 48) reported pain level at pre- and post-operative stages. Mean pre-operative VAS score was 8.52 ± 0.71, and decreased to 0.77 ± 0.69 post-operatively. An insignificant positive correlation (r = 0.046, two-tailed p = 0.76) was found between VAS pain and ICP. A significant moderate positive correlation (r = 0.497, two-tailed p = 0.01) was found between VRS pain and ICP. CONCLUSION: Fasciotomy significantly reduces pain and increases activity levels in CECS patients. ICP was found to positively correlate with patient-reported pain.

Long-term pain relief at five years after medical, repeat surgical procedures or no management for recurrence of trigeminal neuralgia after microvascular decompression: analysis of a historical cohort.

BACKGROUND: Management strategies for the recurrence of trigeminal neuralgia after microvascular decompression include repeat procedures, medical management or no further therapy. No consensus exists as to which strategy is best for pain relief. The aim of this study was to determine the characteristics of patients with recurrences after microvascular decompression in the cohort, and to compare long-term pain relief between different management strategies. MATERIALS AND METHODS: A historical cohort of patients who underwent microvascular decompression at a neurosurgical institution between 1982-2002, followed up by postal survey at five years, was included. Characteristics of patients who experienced a recurrence were compared to those who were recurrence free, and pain relief was compared between each management strategy. RESULTS: From 169 responders who were included in the study, 28 (16.6%) experienced a recurrence after MVD. No characteristics were significantly different between patients who experienced a recurrence and those who did not. Repeat procedures, including repeat microvascular decompression, partial sensory rhizotomy or radiofrequency thermocoagulation, yielded the highest proportion of pain relief after recurrence (p = 0.031), with 63.6% of patients pain-free at five-years. There was no evidence to suggest that the choice of repeat procedure influenced the likelihood of pain relief after recurrence. No further treatment yielded 57.1% pain-free, whereas medical therapy had the lowest proportion of pain-free patients, at 10.0%. CONCLUSION: A variety of options are available to patients for recurrence of TN after microvascular decompression with repeat procedures yielding the greatest likelihood of long-term pain relief in this historical cohort. The choice of management should consider the mechanism of recurrence, the benefits and risks of each option and the severity of the pain. Regardless of the management strategy selected, careful phenotyping of patients before and after surgery is paramount.

Obesity-Related Foot Pain: Diagnosis and Surgical Planning.

Obese patients are at higher risk for surgical complications and consist of a large portion of podiatric patients. Obese patients are additionally at increased risk of developing specific podiatric conditions, and it is important to be able to identify and appropriately treat these conditions accordingly. Initially, conservative treatment is adequate for a variety of pathologic conditions related to obesity. Occasionally surgical intervention is warranted depending on the severity and lack of response to conservative measures. Arthrodesis-type procedures are often preferable and may be necessary, as opposed to periarticular osteotomy, in obese patients even if the deformity is flexible.

Gender Disparities in Preoperative Resource Use for Wrist Arthroscopy.

BACKGROUND: Although national efforts to minimize gender biases exist, gender differences in surgery persist. This study aims to investigate gender differences in preoperative resource use of patients undergoing wrist arthroscopy for nontraumatic wrist pain. METHODS: Patients who underwent a wrist arthroscopy for nontraumatic pain from 2009 to 2015 were selected from the Truven MarketScan databases. Demographic and preoperative resource use data were recorded. Multivariable regression models were performed to examine the relationship between gender and preoperative resource use and to investigate the cost of these services. RESULTS: A total of 8792 patients, 3805 men and 4987 women, met our inclusion criteria. Women were less likely to use imaging modalities preoperatively (OR, 0.08; 95 percent CI, 0.07 to 1.00; p = 0.02). However, women used more occupational therapy (OR, 1.2; 95 percent CI, 1.1 to 1.3; p = 0.002), nonnarcotic analgesia (OR, 1.2; 95 percent CI, 1.1 to 1.3; p = 0.001), and narcotic analgesia (OR, 1.6; 95 percent CI, 1.5 to 1.8; p < 0.001). Preoperative costs during the 12 months before surgery were similar between genders ($1308 versus $1367, respectively; p = 0.07). However, women accrued more costs from occupational therapy ($130 versus $93; p = 0.003), and nonnarcotic ($65 versus $46; p < 0.001) and narcotic medications ($568 versus $197; p < 0.001). CONCLUSIONS: Significant gender differences exist in the preoperative care for patients undergoing wrist arthroscopy. Men use more imaging, implying more intense preoperative investigation for wrist pain, whereas women use more conservative measures, highlighting possible implicit provider biases in preoperative management and potential gender differences in disease presentation.

Surgical management of lateral epicondylitis combined with ligament insufficiency.

BACKGROUND: Lateral collateral ligament (LCL) insufficiency may occur in patients with chronic lateral epicondylitis (LE). We report on 14 consecutive patients with chronic LE and LCL insufficiency. METHODS: We performed a retrospective review of 14 patients with LE and LCL insufficiency diagnosed between 2006 and 2015. The patients had undergone débridement for LE and ligament reconstruction for LCL insufficiency. The study included 9 men and 5 women with an average age of 53 years (range, 41-69 years). The mean follow-up period was 36 months (range, 24-97 months). We analyzed the pain visual analog scale score; Mayo Elbow Performance Score; Disabilities of the Arm, Shoulder and Hand score; range of motion; and posterolateral rotatory drawer test. We compared histories of steroid injection, trauma, and surgery. RESULTS: The pain visual analog scale score, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder and Hand score were significantly improved postoperatively and improved in all patients. Three patients had mild instability on the stress test at final follow-up. All patients had a history of steroid injection, 2 had a history of trauma, and 3 had a history of surgery. The number of steroid injections and the number of cases receiving steroid injections more than 3 times were significantly higher in patients with LCL insufficiency. CONCLUSIONS: Assessment of stability is important in patients with chronic LE and risk factors such as multiple steroid injections. Simultaneous surgical treatment including open débridement and ligament reconstruction provides satisfactory pain relief and functional improvement in patients with LE and LCL insufficiency.

Is a Unilateral Surgical Approach Effective in Patients with Bilateral Leg Pain with Unilateral Lumbar Disc Herniation? A Prospective Nonrandomized Clinical and Surgical Study.

OBJECTIVE: To examine the surgical results of unilateral lumbar discectomy in patients with bilateral leg pain and discuss short- and long-term outcomes within the limits of lumbar decompression. METHODS: We analyzed 60 patients with unilateral disc herniation who underwent unilateral lumbar discectomy and hemipartial laminectomy between 2014 and 2017. Group 1 (30 patients) had bilateral leg pain and unilateral lumbar disc herniation. Pain lateralization was determined radiologically. Group 2 (30 patients) had unilateral leg pain and unilateral lumbar disc herniation. Pain scores were preoperatively evaluated with visual analog scale (VAS) for both legs and Oswestry Disability Index (ODI) for overall life quality. In both groups, surgery was performed on the ipsilateral side of the herniated disc. Scores were repeated on postoperative day 1 and 1, 3, 6, 12, and 24 months later. VAS score differences for pain lateralization and disc levels were compared in group 1. ODI score differences were compared between both groups. Results were statistically analyzed. RESULTS: VAS score differences were statistically significant at all follow-up time points in patients with ipsilateral and contralateral pain. VAS score differences between L4-L5 and L5-S1 level discopathies were statistically insignificant for all time points in both groups. All postoperative ODI score decreases for all time points were statistically significant (P < 0.001) for both groups, whereas the differences between groups 1 and 2 were statistically insignificant. CONCLUSIONS: Conventional lumbar disc surgery alone is sufficient for the ipsilateral side of radiologically demonstrated disc herniation in patients with bilateral leg pain.

Clinical outcomes of anconeus interposition arthroplasty after radial head resection in native and prosthetic radial heads.

BACKGROUND: Radiocapitellar pathology after traumatic injury to the elbow can be challenging to treat. The anconeus interposition arthroplasty has been proposed to treat radiocapitellar or proximal radioulnar joint dysfunction and pain, or both. This study evaluated whether radial head excision (native or prosthetic), followed by an anconeus interposition arthroplasty, relieves pain and improves subjective and objective elbow function in patients with post-traumatic radiocapitellar pathology. METHODS: A retrospective comparative case series was performed of 50 consecutive patients who underwent a native radial head excision or radial head implant excision, followed by an anconeus interposition arthroplasty. Clinical outcome scores, range of motion, and proximal radius migration were evaluated in patients with at least 2 years of follow-up. RESULTS: Included were 23 patients (11 native and 12 prosthetic radial heads) with a mean age of 41 years. Average follow-up was 38 months. Overall, significant improvement was obtained in the Disabilities of the Arm, Shoulder and Hand and visual analog scale scores. Range of motion significantly improved from preoperatively to postoperatively. Patients with a native radial head excision scored better on the Single Assessment Numeric Evaluation (76.8 vs. 56.3, P = .037) and obtained significantly more flexion postoperatively (141° vs. 123°, P = .016). Mild wrist pain developed in 3 patients, but no further intervention was required. The overall complication rate was 13%, and 5 patients required reoperation. CONCLUSIONS: Anconeus interposition arthroplasty performed after radial head resection in native and prosthetic groups is a viable adjunct in the operative treatment of patients with post-traumatic radiocapitellar pathology. However, whether anconeus interposition arthroplasty alone produced the favorable clinical results of this study was difficult to determine.

Radiographic Local Tumor Control and Pain Palliation of Sarcoma Metastases within the Musculoskeletal System with Percutaneous Thermal Ablation.

PURPOSE: To evaluate the effectiveness of percutaneous image-guided thermal ablation in achieving local tumor control and pain palliation of sarcoma metastases within the musculoskeletal system. MATERIALS AND METHODS: Retrospective review of 64 sarcoma metastases within the musculoskeletal system in 26 women and 15 men (total = 41) treated with ablation between December 2011 and August 2016 was performed. Mean age of the cohort was 42.9 years ± 16.0 years. Two subgroups were treated: oligometastatic disease (n = 13) and widely metastatic disease (n = 51). A variety of sarcoma histologies were treated with average tumor volume of 42.5 cm3 (range 0.1-484.7 cm3). Pain scores were recorded before and 4 weeks after therapy for 59% (38/64) of treated lesions. Follow-up imaging was evaluated for local control and to monitor sites of untreated disease as an internal control. Fifty-eight percent (37/64) were lost to imaging follow-up at varying time points over a year. Complication rate was 5% (3/64; one minor and two major events). RESULTS: One-year local tumor control rates were 70% (19/27) in all patients, 67% (12/18) in the setting of progression of untreated metastases, and 100% (10/10) in the setting of oligometastatic disease. Median pain scores decreased from 8 (interquartile range 5.0-9.0) to 3 (interquartile range 0.1-4.0) 1 month after the procedure (P < 0.001). CONCLUSION: Image-guided percutaneous ablation is an effective option for local tumor control and pain palliation of metastatic sarcomas within the musculoskeletal system. Treatment in the setting of oligometastatic disease offers potential for remission. LEVEL OF EVIDENCE: Level 4, Retrospective Review.