Open ankle fractures in the elderly: predisposing factors and the associated mortality.

The purpose of this study was to investigate the independent effect of open ankle fractures on postoperative mortality and to identify factors leading to open ankle fractures in the elderly population. This is a retrospective case-control study of 1,045 patients aged 65 years and older, with ankle fractures undergoing surgical fixation between 2010 and 2020 at three medical centers (Levels 1-2). A logistic regression analysis was used to identify risk factors for open fractures. Propensity score matching and survival analysis were used to measure the hazard of mortality attributable to open versus closed ankle fractures. There were 128 (12.2%) patients with open ankle fractures. Patients with open ankle fractures were more likely to be older, to be active smokers (OR = 1.7, p = 0.049), and tended to have a higher number of medical comorbidities including hypertension (OR = 2, p = 0.006) and chronic kidney disease (OR = 2.9, p = 0.005). Open ankle fractures were, independently of comorbid conditions and age, associated with higher risk of mortality (HR = 1.7, p = 0.03).

The Influence of Patient Characteristics and Social Determinants of Health on Postoperative Complications Following Achilles Tendon Rupture.

BACKGROUND: The influence of social determinants of health (SDH) on postoperative complications has been investigated in several studies, although correlation with Achilles tendon rupture (ATR) repair remains uninvestigated. SDH encompasses several factors, including insurance status and area-based measurements, including the Area Deprivation Index (ADI) and Social Vulnerability Index (SVI), which ranks neighborhoods by social disadvantage. This study investigated the correlation between patient demographics, SDH, and complications following ATR repair. METHODS: A retrospective cohort study was conducted on 521 patients who presented with acute ATR and met the inclusion criteria, including age ≥18 years, a minimum of 30-day follow-up, and repair within 28 days of rupture. We reviewed patient demographics, time to surgery (TTS), and postoperative complications, including venous thromboembolism (VTE), rerupture, surgical site infection (SSI), wound dehiscence, and sural nerve injury. SDH variables included race, smoking status, insurance status, level of education, ADI, and SVI. Univariate regression tested the correlation between complications and SDH indicators. Significant variables (P < .05) were included in a multivariate regression. RESULTS: Sixty-eight complications occurred in 59 patients (11.3%). Multivariate regression showed that a higher ADI, that is, socially deprived individuals, was associated with lower rates of VTE (OR = 0.41, P = .04). Higher body mass index (BMI) was associated with rerupture (OR = 8.73, P < .01). Male patients had lower rates of wound dehiscence (OR = 0.31, P = .03) and VTE (OR = 0.32, P = .02) compared with women. Longer TTS correlated with sural nerve injuries (OR = 2.23, P < .01) and shorter TTS with reruptures (OR = 0.02, P = .02). CONCLUSION: Some measures of SDH were associated with postoperative complications. Gender also may have an effect, with male sex associated with lower rates of wound dehiscence and VTE. BMI was associated with higher rates of reruptures and overall general complications.

Use of Bio-integrative Screws for Fixation of Lisfranc Instability; Pros and Cons from Surgeons' Point of View in a Cadaver Study.

Objectives: Majority of Lisfranc fracture-dislocations require anatomic reduction and rigid internal fixation to prevent debilitating sequelae. Current methods include solid screws and flexible fixations which have been in use for many years. Biointegrative screw is a newer option that has not yet been thoroughly investigated for its effectiveness for Lisfranc injuries. Methods: The ligaments of the Lisfranc complex were resected in eight lower-leg cadaveric specimens. This was done by eight foot and ankle surgeons individually. Distraction forces were applied from opposite sides at the joint to replicate weight bearing conditions. Three methods of fixation - flexible fixation, metal, and biointegrative screws- were evaluated. The diastasis and area at the level of the ligament were measured at four conditions (replicated injury and each type of fixation) in neutral and distraction conditions using fluoroscopy images. The Wilcoxon test and Kruskal Wallis test were used for comparison. P value <0.05 was considered statistically significant. Results: The diastasis value for the transected ligament scenario (2.47 ± 0.51 mm) was greater than those after all three fixation methods without distraction (2.02 ± 0.5 for flexible fixation, 1.72 ± 0.63 mm for metal screw fixation and 1.67 ± 0.77 mm for biointegrative screw fixation). The transected ligament diastasis was also greater than that for metal screw (1.61 ± 1.31mm) and biointegrative screws (1.69 ± 0.64 mm) with distraction (p<0.001). The area at the level of the ligament showed higher values for transected ligament (32.7 ± 13.08 mm2) than the three fixatives (30.75 ± 7.42 mm2 for flexible fixation, 30.75 ± 17.13 mm2 for metal screw fixation and 29.53 ± 9.15 mm2 for biointegrative screw fixation; p<0.05). Conclusion: Metal screws, flexible fixation and biointegrative screws showed comparable effectiveness intra-op, in the correction of diastasis created as a consequence of Lisfranc injury.

Comparison of Several Combinations of Suture Tape Reinforcement and Suture Button Constructs for Fixation of Unstable Syndesmosis.

INTRODUCTION: The purpose of this study was to arthroscopically evaluate syndesmotic stability after fixation with several combinations of suture buttons (SBs) and suture tape reinforcement in a completely unstable cadaver model. METHODS: Fifteen cadaver above-knee specimens underwent sequential ligament transection and fixation to create six experimental models: (1) intact model, (2) after complete disruption of the syndesmotic ligaments, and after repair with either suture tape reinforcement (3), suture tape reinforcement with a single SB (4), suture tape reinforcement with two diverging SBs (5), or two diverging SBs alone (6). Instability measurements included anterior and posterior tibiofibular spaces measured arthroscopically under 100 N coronal stress, tibiofibular anteroposterior and posteroanterior translation in sagittal plane measured arthroscopically under sagittal stress of 100 N, and anterior tibiofibular space measured directly with a caliper under external rotation torque of 7.5 N·m. Instability measurements taken after each fixation method were compared with the uninjured model and with the complete unstable model using the Wilcoxon signed-rank test. RESULTS: Fixation using a combination of one SB and singular suture tape reinforcement augmentation provided stability similar to the intact stage (coronal anterior space 1.24 versus 1.15, P = 0.887; coronal posterior space 1.63 versus 1.64, P = 0.8421; anteroposterior translation 0.91 versus 0.46, P = 0.003; posteroanterior translation 0.51 versus 0.57, P = 0.051; external rotation anterior tibiofibular space 1.08 versus 0.55, P = 0.069). Moreover, adding a second SB led to further gains in fixation stability. DISCUSSION: This study suggests that although a destabilizing syndesmotic injury that includes the anterior inferior tibiofibular ligament, interosseous ligament, and posterior inferior tibiofibular ligament is not adequately stabilized by either one or two SBs, the addition of a suture tape reinforcement to even one SB restores syndesmotic stability to the preinjury level.

Isolated Intermetatarsal Ligament Release as Primary Operative Management for Morton's Neuroma: Short-term Results.

BACKGROUND: Although the precise pathoetiology of Morton's neuroma remains unclear, chronic nerve entrapment from the overlying intermetatarsal ligament (IML) may play a role. Traditional operative management entails neuroma excision but risks unpredictable formation of stump neuroma. MATERIALS AND METHODS: Medical records were examined for adult patients who failed at least 3 months of conservative treatment for symptomatic and recalcitrant Morton's neuroma and who then underwent isolated IML decompression without neuroma resection. RESULTS: A total of 12 patients underwent isolated IML decompression for Morton's neuroma with an average follow-up of 13.5 months. Visual Analog Pain Scale averaged 6.4 ± 1.8 (4-9) preoperatively and decreased to an average of 2 ± 2.1 (0-7) at final follow-up (P = .002). All patients reported significant improvement. CONCLUSION: Isolated IML release of chronically symptomatic Morton's neuroma shows promising short-term results regarding pain relief, with no demonstrated risk of recurrent neuroma formation, permanent numbness, or postoperative symptom exacerbation. LEVEL OF EVIDENCE: Level IV: Case series.

Diagnosis and Treatment of Syndesmotic Unstable Injuries: Where We Are Now and Where We Are Headed.

Up to 10% of ankle sprains are considered "high ankle" sprains with associated syndesmotic injury. Initial diagnosis of syndesmotic injury is based on physical examination, but further evaluation of the distal tibiofibular joint in the sagittal, coronal, and rotational planes is necessary to determine instability. Imaging modalities including weight-bearing CT and ultrasonography allow a physiologic and dynamic assessment of the syndesmosis. These modalities in turn provide the clinician useful information in two and three dimensions to identify and consequently treat syndesmotic instability, especially when subtle. Because there is notable variability in the shape of the incisura between individuals, contralateral comparison with the uninjured ankle as an optimal internal control is advised. Once syndesmotic instability is identified, surgical treatment is recommended. Several fixation methods have been described, but the foremost aspect is to achieve an anatomic reduction. Identifying any associated injuries and characteristics of the syndesmotic instability will lead to the appropriate treatment that restores the anatomy and stability of the distal tibiofibular joint.

Bone resorption of the greater tuberosity after open reduction and internal fixation of complex proximal humeral fractures: fragment characteristics and intraoperative risk factors.

HYPOTHESIS AND BACKGROUND: In complex proximal humeral fractures, bone resorption of the greater tuberosity is sometimes observed after open reduction and internal fixation (ORIF). However, this has not been well characterized, and risk factors for resorption are not completely understood. We aimed (1) to identify the risk factors associated with bone resorption of the greater tuberosity and (2) to quantify the geometric and bone density characteristics associated with bone resorption using 3-dimensional computed tomography models in complex proximal humeral fractures treated with ORIF. METHODS: We identified a retrospective cohort of 136 patients who underwent ORIF of 3- or 4-part proximal humeral fractures; greater tuberosity resorption developed after ORIF in 30 of these patients. We collected demographic, fracture-related, and surgery-related characteristics and performed multivariable logistic regression analysis to identify factors independently associated with the development of greater tuberosity resorption. Furthermore, we identified 30 age- and sex-matched patients by use of propensity score matching to perform quantitative fragment-specific analysis using 3-dimensional computed tomography models. After the fragment of the greater tuberosity was identified, the number of fragments, the relative fragment volume to the humeral head, and the relative bone density to the coracoid process were calculated. Measurements were compared between matched case-control groups. RESULTS: We found that an unreduced greater tuberosity (odds ratio [OR], 10.9; P < .001), inadequate medial support at the calcar (OR, 15.0; P < .001), and the use of an intramedullary fibular strut (OR, 4.5; P = .018) were independently associated with a higher risk of bone resorption. Quantitative fragment-specific analysis showed that greater tuberosities with a larger number of fragments (5 ± 2 vs. 3 ± 2, P = .021), smaller fragments (9.9% ± 3.8% vs. 18.6% ± 4.7%, P < .001), and fragments with a lower bone density (66.4% ± 14.3% vs. 88.0% ± 18.4%, P = .001) had higher rates of resorption. DISCUSSION AND CONCLUSION: An unreduced greater tuberosity or inadequate medial support increases the risk of greater tuberosity resorption, as do a larger number of fracture fragments, smaller fragments, and lower bone density. Additionally, fibular strut grafting is an independent risk factor for tuberosity resorption. Further study is needed, but alternatives to strut grafting such as femoral head allograft may warrant serious consideration.

Using area and volume measurement via weightbearing CT to detect Lisfranc instability.

Weightbearing CT (WBCT) allows evaluation of the Lisfranc joint under physiologic load. We compared the diagnostic sensitivities of one-dimensional (1D) distance, two-dimensional (2D) area, and three-dimensional (3D) volumetric measurement of the injured Lisfranc joint complex (tarsometatarsal, intertarsal, and intermetatarsal) on WBCT among patients with surgically-confirmed Lisfranc instability. The experimental group comprised of 14 patients having unilateral Lisfranc instability requiring operative fixation who underwent preoperative bilateral foot and ankle WBCT. The control group included 36 patients without foot injury who underwent similar imaging. Measurements performed on WBCT images included: (1) Lisfranc joint (medial cuneiform-base of second metatarsal) area, (2) C1-C2 intercuneiform area, (3) C1-M2 distance, (4) C1-C2 distance, (5) M1-M2 distance, (6) first tarsometatarsal (TMT1) angular alignment, (7) second tarsometatarsal (TMT2) angular alignment, (8) TMT1 dorsal step off distance, and (9) TMT2 dorsal step-off distance. In addition, the volume of the Lisfranc joint in the coronal and axial plane were calculated. Among patients with unilateral Lisfranc instability, all WBCT measurements were increased on the injured side as compared to the contralateral uninjured side (p values: <.001-.008). Volumetric measurements in the coronal and axial plane had a higher sensitivity (92.3%; 91.6%, respectively) and specificity (97.7%; 96.5%, respectively) than 2D and 1D Lisfranc joint measurements, suggesting them to be the most accurate in diagnosing Lisfranc instability. The control group showed no difference in any of the measurements between the two sides. WBCT scan can effectively differentiate between stable and unstable Lisfranc injuries. Lisfranc joint volume measurements demonstrate high sensitivity and specificity, suggesting that this new assessment has high clinical implications for diagnosing subtle Lisfranc instability.

Patient comprehension of hip arthroscopy: an investigation of health literacy.

Several studies have demonstrated that patients have significant impairments in understanding their injury and appropriate course of management in orthopedic surgery. The purpose of this investigation is to determine if patients are able to obtain a fundamental understanding of the requisite care associated with hip arthroscopy. Any patient who elected to have hip arthroscopy was prospectively recruited to participate in the study. All patients were told they would be asked to complete a questionnaire about their surgery and post-operative instructions. The answers to each question of the questionnaire they would receive at the first post-operative visit were verbally given to each patient during the pre-operative visit. They were also given a post-operative instruction sheet on the day of surgery that contained answers to the questionnaire. At the first post-operative visit, all patients were then asked to complete a multiple-choice questionnaire prior to seeing the surgeon. A total of 56 patients (14 males, 42 females) were enrolled. All patients reported they had read the post-operative instruction sheet. The average number of correct answers was 6.5 ± 0.6 (95% CI 6 - 7) out of 11 questions (59% correct response rate ±18% [95% CI 52 - 66%]). Although we made significant pre-operative oral and written efforts to help patients achieve an elementary level of health literacy regarding their forthcoming hip arthroscopy, many patients did not achieve satisfactory comprehension. Even with instruction and information given verbally and physically (via post-operative instruction sheet) patients did not obtain satisfactory comprehension of their surgical procedure. New ways (through video, simplified cartoons or verbal explanations) must be considered in educating patients concerning surgical procedures to increase comprehension and health literacy.

Investigation of the Injury Rate of Female Fitness Competitors.

BACKGROUND: Female fitness competitions are increasing in popularity. Athletes are participating in weight-cutting protocols to help reduce body fat percentage to improve muscle definition and physique. METHODS: The goal of the study was to investigate weight-cutting practices and determine if these practices were associated with increased injury rates. A survey was distributed at a New England fitness competition. RESULTS: Thirty-five female fitness competitors participated in the survey at a single competition. The calculated injury rate for female fitness competitors is 0.18 injuries per 1000 hours of training. Age over 35 (p=0.014) and a history of or current eating disorder (p=0.005) were significant risk factors for sustaining an injury. Menstrual cycle abnormalities were present in 11 of 35 individuals (31.4%). CONCLUSIONS: Female fitness competitor injury rates are low; however, injuries were more common in athletes over age 35 and those with either a history of or a current eating disorder.

Tibial Stress Fracture Following Ankle Arthrodesis.

BACKGROUND: End-stage ankle arthritis is frequently treated with either tibiotalar or tibiotalocalcaneal (TTC) arthrodesis, but the inherent loss of accommodative motion increases mechanical load across the distal tibia. Rarely, patients can go on to develop a stress fracture of the distal tibia without any antecedent traumatic event. The purpose of this study was to determine the incidence of tibial stress fracture after ankle arthrodesis, highlight any related risk factors, and identify the effectiveness of treatment strategies and their healing potential. METHODS: A retrospective chart review was performed at 2 large academic medical centers to identify patients who had undergone ankle arthrodesis and subsequently developed a stress fracture of the tibia. Any patient with a tibial stress fracture before ankle arthrodesis, or with a nontibial stress fracture, was excluded from the study. RESULTS: A total of 15 out of 1046 ankle fusion patients (1.4%) developed a tibial stress fracture at a mean time of 42 ± 82 months (range, 3-300 months) following the index procedure. The index procedure for these 15 patients who went on to subsequently develop stress fractures included isolated ankle arthrodesis (n = 8), ankle arthrodesis after successful subtalar fusion (n = 2), primary TTC arthrodesis (n = 2), and ankle arthrodesis subsequent to successful subtalar fusion with resultant ankle nonunion requiring revision TTC nailing (n = 3). Four patients had undergone fibular osteotomy with subsequent onlay strut fusion, and 5 had undergone complete resection of the lateral malleolus. Stress fracture location was found to be at the level of the fibular osteotomy in 2 patients and at the proximal end of an existing or removed implant in 9. Fourteen of the 15 patients had a nondisplaced stress fracture and were initially treated with immobilization and activity modification. Of these, 3 failed to improve with nonoperative treatment and subsequently underwent operative fixation (intramedullary nail in 2; plate fixation in 1). Only 1 of the 15 patients presented with a displaced fracture and underwent immediate plate fixation. All patients reported pain improvement and were ultimately healed at final follow-up. CONCLUSION: In this case series review, we found a 1.4% incidence of tibial stress fracture after ankle arthrodesis, and both hardware transition points and a fibular resection or osteotomy appear to be risk factors. Operative intervention was required in approximately 25% of this population, but the majority of tibial stress fractures following ankle fusion were successfully treated nonoperatively, and ultimately all healed. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Arthroscopic Assessment of Syndesmotic Instability in the Sagittal Plane in a Cadaveric Model.

BACKGROUND: Syndesmotic instability is multidirectional, occurring in the coronal, sagittal, and rotational planes. Despite the multitude of studies examining such instability in the coronal plane, other studies have highlighted that syndesmotic instability may instead be more evident in the sagittal plane. The aim of this study was to arthroscopically assess the degree of syndesmotic ligamentous injury necessary to precipitate fibular translation in the sagittal plane. METHODS: Twenty-one above-knee cadaveric specimens underwent arthroscopic evaluation of the syndesmosis, first with all syndesmotic and ankle ligaments intact and subsequently with sequential sectioning of the anterior inferior tibiofibular ligament (AITFL), the interosseous ligament (IOL), the posterior inferior tibiofibular ligament (PITFL), and deltoid ligament (DL). In all scenarios, an anterior to posterior (AP) and a posterior to anterior (PA) fibular translation test were performed under a 100-N applied force. AP and PA sagittal plane translation of the distal fibula relative to the fixed tibial incisura was arthroscopically measured. RESULTS: Compared with the intact ligamentous state, there was no difference in sagittal fibular translation when only 1 or 2 ligaments were transected. After transection of all the syndesmotic ligaments (AITFL, IOL, and PITFL) or after partial transection of the syndesmotic ligaments (AITFL, IOL) alongside the DL, fibular translation in the sagittal plane significantly increased as compared with the intact state (P values ranging from .041 to <.001). The optimal cutoff point to distinguish stable from unstable injuries was equal to 2 mm of fibular translation for the total sum of AP and PA translation (sensitivity 77.5%; specificity 88.9%). CONCLUSION: Syndesmotic instability appears in the sagittal plane after injury to all 3 syndesmotic ligaments or after partial syndesmotic injury with concomitant deltoid ligament injury in this cadaveric model. The optimal cutoff point to arthroscopically distinguish stable from unstable injuries was 2 mm of total fibular translation. CLINICAL RELEVANCE: These data can help surgeons arthroscopically distinguish between stable syndesmotic injuries and unstable ones that require syndesmotic stabilization.

Ulnar Styloid Base Fractures Cause Distal Radioulnar Joint Instability in a Cadaveric Model.

BACKGROUND: The deep portion of the distal radioulnar ligaments (DRUL) inserts on the ulnar fovea and is the most important stabilizer of the distal radioulnar joint (DRUJ). Ulnar styloid base fractures that include the ulnar fovea may cause DRUJ instability. METHODS: DRUJ stability in pronosupination was evaluated in 12 fresh-frozen upper extremities (4 female) aged 52 to 68 years (mean: 58.8 years) using a custom fixture, which allowed free rotation of the radius around the fixed ulna. Optical motion capture was used to record rotation of the radius with respect to the ulna. Each specimen was subjected to 3 N m of torque in both supination and pronation under 4 conditions: intact, ulnar styloid osteotomy with disruption of the foveal insertion of the DRUL, ulnar styloid fixation, and DRUL transection. Group differences were compared using a 1-way repeated-measures analysis of variance and Tukey multiple comparison post hoc tests. RESULTS: When compared with the intact condition, both ulnar styloid osteotomy and DRUL transection significantly increased mean pronation (by 9.40° and 15.21°, respectively) and supination (by 9.05° and 17.42°, respectively) of the forearm. Screw fixation only significantly reduced pronation compared with osteotomy (by 2.62°). Screw fixation did not significantly affect supination. CONCLUSIONS: Ulnar styloid fractures that disrupt the fovea cause instability of the DRUJ in pronation and supination under 3 N m of torque in a cadaveric model. Screw fixation of ulnar styloid base fractures achieves anatomic reduction; however, it only partially returns rotational stability acutely to the DRUJ and only during pronation.

Hand and arm pain: A pictorial guide to injections.

This article, with illustrative figures, will help you get to the cause of your patient's pain and guide your administration of corticosteroid injections.

MRI of Native Knee Cartilage Delamination Injuries.

OBJECTIVE: The purpose of this article is to describe the normal imaging appearance of cartilage and the pathophysiologic findings, imaging appearance, and surgical management of cartilage delamination. CONCLUSION: Delamination injuries of knee cartilage signify surgical lesions that can lead to significant morbidity without treatment. These injuries may present with clinical symptoms identical to those associated with meniscal injury, and arthroscopic identification can be difficult, thereby creating a role for imaging diagnosis. A low sensitivity of imaging identification of delamination injury of the knee is reported in the available literature, although vast improvements in MRI of cartilage have since been introduced.

Vertically Oriented Femoral Neck Fractures: A Biomechanical Comparison of 3 Fixation Constructs.

OBJECTIVES: To compare the static and dynamic mechanical properties of a modified crossed cannulated screw (CS) configuration, the inverted triangle (IT) cannulated screw configuration, and a compression hip screw (CHS) with derotation screw in Pauwels type III femoral neck fractures. METHODS: Thirty synthetic femora were divided into 3 groups, and vertical femoral neck osteotomies were made. Ten osteotomized femora were fixed with a CS configuration, 10 were fixed with 3 parallel screws in an IT configuration, and the remaining 10 osteotomized femora were fixed with a CHS construct. All groups were tested using a cyclic (up to 15,000 load cycles) axial loading protocol, and survivors were statically loaded to failure. Cycles to failure, load to failure, and stiffness were calculated. The Kaplan-Meier method was used to estimate survival functions and were compared among fixation methods. The relationship between construct structural properties (maximum load and stiffness) and treatment were assessed using general linear modeling. RESULTS: All CHS fixation constructs survived the 15,000 cycle loading protocol. They endured longer (P = 0.034) than the CS fixation constructs (mean failure 13,332 cycles), but were not different from IT fixation constructs (mean failure 13,592 cycles). Maximum loads to failure for CS (3870 N) and IT (3756 N) fixation constructs were not different, but were less (P < 0.0001) than the maximum loads to failure for the CHS fixation constructs (5654 N). These findings parallel the results of the axial stiffness measurements: CS fixation constructs (663.01 N/mm) were not stiffer than IT fixation constructs (620.0 N/mm), but were less (P = 0.0005) than the axial stiffness of the CHS fixation constructs (1241.86 N/mm). CONCLUSIONS: The biomechanical performance of the CHS fixation method was superior to both the CS fixation method and the IT fixation method using a synthetic femoral model and this test protocol. Biomechanical performance of the latter 2 groups was indistinguishable. We recommend the use of CHS with the derotational screw construct for Pauwels III femoral neck fractures whenever possible.

Hypersensitivity to Orthopedic Implants: A Review of the Literature.

Awareness of rare etiologies for implant failure is becoming increasingly important. In addition to the overall increase in joint arthroplasties, revision surgeries are projected to increase dramatically in the coming years, with volume increasing up to seven-fold between 2005 and 2030. The literature regarding the relationship between metal allergy and implant failure is controversial. It has proven difficult to determine whether sensitization is a cause or a consequence of implant failure. Testing patients with functional implants is not a clinically useful approach, as the rate of hypersensitivity is higher in implant recipients than in the general population, regardless of the status of the implant. As a result of the ineffectiveness of preoperative patch testing for predicting adverse outcomes, as well as the high cost of implementing such patch testing as standard procedure, most orthopedists and dermatologists agree that an alternative prosthesis should only be considered for patients with a history of allergy to a metal in the standard implant. In patients with a failed implant requiring revision surgery, hypersensitivity to an implant component should be considered in the differential diagnosis. Because a metal allergy to implant components is currently not commonly considered in the differential for joint failure in the orthopedic literature, there should be improved communication and collaboration between orthopedists and dermatologists when evaluating joint replacement patients with a presentation suggestive of allergy.

Technique Tip.

Lisfranc injury fixation or arthrodesis typically involves the reduction and fixation of several tarsometatarsal joints with either screws or a plate and screw constructs. A successful fixation or arthrodesis of the Lisfranc joint requires proper screw placement from the medial cuneiform to the base of the second metatarsal. This is typically done free-hand; however, we describe use of an anterior cruciate ligament guide to help maintain reduction and assist with drill trajectory for more accurate screw or suture button construct placement. LEVELS OF EVIDENCE: Level V.

A Review of Anatomical Placement of Corticosteroid Injections for Uncommon Hand, Wrist, and Elbow Pathologies.

Corticosteroid injections are a common nonsurgical treatment of intersection syndrome, flexor carpi radialis tendonitis, flexor carpi ulnaris tendonitis, and medial epicondylitis. The benefits of corticosteroid injections for these conditions have been well studied and documented in the medical literature. Patients with less common upper extremity complaints usually first present to their primary care provider. A correct anatomical diagnosis will help with early definitive treatment, as the injection must be in the proper location for maximal benefit to the patient. The following review on uncommon upper extremity complaints provides information for a correct diagnosis and treatment plan, followed by a possible injection. This review will hopefully provide high quality care while also cutting health care costs by making the correct diagnosis at the initial presentation. [Full article available at http://rimed.org/rimedicaljournal-2017-03.asp].