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PURPOSE: Dorsal wrist ganglions are treated commonly with aspiration, or open or arthroscopic excision in operating room (OR) or procedure room (PR) settings. As it remains unclear which treatment strategy is most cost-effective in yielding cyst resolution, our purpose was to perform a formal cost-minimization analysis from the societal perspective in this context. METHODS: A microsimulation decision analytic model evaluating 5 treatment strategies for dorsal wrist ganglions was developed, ending in either resolution or a single failed open revision surgical excision. Strategies included immediate open excision in the OR, immediate open excision in the PR, immediate arthroscopic excision in the OR, or 1 or 2 aspirations before each of the surgical options. Recurrence and complications rates were pooled from the literature for each treatment type. One-way sensitivity and threshold analyses were performed. RESULTS: The most cost-minimal strategy was 2 aspiration attempts before open surgical excision in the PR setting ($1,603 ± 1,595 per resolved case), followed by 2 aspirations before open excision in the OR ($1,969 ± 2,165 per resolved case). Immediate arthroscopic excision was the costliest strategy ($6,539 ± 264 per resolved case). Single aspiration preoperatively was more cost-minimal than any form of immediate surgery ($2,918 ± 306 and $4,188 ± 306 per resolved case performed in the PR and OR, respectively). CONCLUSIONS: From the societal perspective, performing 2 aspirations before surgical excision in the PR setting was the most cost-minimal treatment strategy, although in reference to surgeons who do not perform this procedure in the PR setting, open excision in the OR was nearly as cost-effective. As patient preferences may preclude routinely performing 2 aspirations, performing at least 1 aspiration before surgical excision improves the cost-effectiveness of dorsal wrist ganglions treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic Decision Analysis II.
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Cistos Glanglionares , Punho , Humanos , Punho/cirurgia , Artroscopia/métodos , Resultado do Tratamento , Cistos Glanglionares/cirurgia , Custos e Análise de CustoRESUMO
BACKGROUND: Antegrade humeral intramedullary nails are an effective fixation method for certain proximal humeral fractures and humeral shaft fractures. However, owing to potential rotator cuff damage during nail insertion, shoulder pain remains a common postoperative complaint. The purpose of this study was to provide quantitative data characterizing the anatomic and radiographic location of the rotator interval (RI) for an antegrade humeral intramedullary nail using a mini-deltopectoral approach. METHODS: Six consecutive fresh-frozen intact cadaveric specimens (mean age, 69 ± 12.8 years) were obtained for our study. Demographic data were collected on each specimen. A mini-deltopectoral approach was used, followed by placement of a guidewire in the RI. Quantitative anatomic relationships were calculated using a fractional carbon fiber digital caliper. Radiographic measurements were performed by 2 orthopedic residents and 1 practicing fellowship-trained orthopedic surgeon. In addition to re-measurement of similar anatomic relationships on radiographs, the ratio of the distance from the lateral humeral edge to the starting point relative to the width of the humeral head on the anteroposterior (AP) view was calculated. Similarly, on the lateral view, the ratio of the distance from the anterior humeral edge to the starting point relative to the humeral head width was calculated. RESULTS: In all cases, the described approach allowed for preservation of the biceps tendon and access to the RI for guidewire insertion, with no subsequent rotator cuff or humeral articular cartilage damage identified following nail insertion. The ratio of the distance from the lateral humeral edge to the starting point relative to the humeral head width on the AP view was 0.4 ± 0.0. The ratio of the distance from the anterior humeral edge to the starting point relative to the humeral head width on the lateral view was 0.3 ± 0.0. CONCLUSION: This study demonstrates the clinical feasibility of a mini-deltopectoral approach and shows that the ideal starting point through the RI radiographically lies along the medial aspect of the lateral third of the humeral head on the AP view and along the posterior aspect of the anterior third of the humeral head on the lateral view.
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Fixação Intramedular de Fraturas , Fraturas do Úmero , Idoso , Idoso de 80 Anos ou mais , Pinos Ortopédicos , Cadáver , Humanos , Pessoa de Meia-Idade , Manguito Rotador/diagnóstico por imagem , Manguito Rotador/cirurgia , Fraturas do OmbroRESUMO
BACKGROUND: Total elbow arthroplasty (TEA) and open reduction-internal fixation (ORIF) are 2 viable surgical treatment options for acute, intra-articular distal humeral fractures in elderly patients. Whereas recent systematic reviews and randomized trials have suggested that TEA and ORIF result in similar functional outcome scores, no previous study has assessed the comparative cost-effectiveness between TEA and distal humeral ORIF in this specific demographic. METHODS: A Markov model was created with the highest-level data available from the literature depicting transitioning health states based on treatment strategies. To populate the quality-of-life data points in the model lacking in the literature, a survey was conducted of patients at 2 referral institutions who underwent TEA or ORIF for acute, intra-articular distal humeral fractures via the European Quality of Life, 5 Domains (EQ-5D) questionnaire at least 2 years postoperatively. Cost data from 2016 for each strategy were used to calculate the comparative cost-effectiveness of TEA versus ORIF. RESULTS: For patients aged 65 years, the total cost of TEA was $19,407 compared with $20,669 for ORIF. The effectiveness of TEA and ORIF was 8.17 and 7.72, respectively. Overall, the incremental cost-effectiveness ratio of TEA ($2375.76/quality-adjusted life-year) was favored more than ORIF ($2677.26/quality-adjusted life-year). CONCLUSION: These findings suggest TEA is a slightly more cost-effective procedure than ORIF for most elderly patients who sustain acute, intra-articular distal humeral fractures. Still, the unique limitations, complications, and revision rates for each strategy must be carefully weighed for each patient when making a decision.
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Artroplastia de Substituição do Cotovelo/economia , Fixação Interna de Fraturas/economia , Fraturas do Úmero/cirurgia , Redução Aberta/economia , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Deep fungal infection localized to the foot is not common, and when it occurs it often affects immunocompromised individuals. In this report, we describe the case of an adult diabetic patient who suffered with with Blastomycosis infection of the flexor digitorum longus and peroneal tendon sheaths. The condition was treated with systemic antifungal therapy and surgical debridement.
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Articulação do Tornozelo , Antifúngicos/uso terapêutico , Blastomyces , Blastomicose/cirurgia , Doenças Ósseas Infecciosas/cirurgia , Tenossinovite/cirurgia , Abscesso/diagnóstico , Abscesso/tratamento farmacológico , Abscesso/cirurgia , Tornozelo , Articulação do Tornozelo/microbiologia , Articulação do Tornozelo/cirurgia , Blastomicose/complicações , Blastomicose/diagnóstico , Blastomicose/tratamento farmacológico , Doenças Ósseas Infecciosas/complicações , Doenças Ósseas Infecciosas/diagnóstico , Doenças Ósseas Infecciosas/tratamento farmacológico , Desbridamento , Diabetes Mellitus Tipo 1/complicações , Pé , Humanos , Tenossinovite/complicações , Tenossinovite/diagnóstico , Tenossinovite/tratamento farmacológico , Irrigação TerapêuticaRESUMO
PURPOSE: The purpose of this study was to compare suture anchor placement in the acetabular rim between straight and curved drill guides regarding angle and distance of the suture anchor tip from the articular cartilage during labral refixation. METHODS: A total of 14 fresh-frozen cadaveric hips underwent arthroscopic labral incision from the 12 to 3 o'clock positions and subsequent repair with either a curved drill guide or a straight drill guide. These hips were then compared by computed tomographic imaging analysis by measuring the angle of suture anchor insertion and the distance of the tip of the suture anchor to the articular cartilage at the 1 o'clock, 2 o'clock, and 3 o'clock positions. RESULTS: The curved suture anchor (CSA) guide significantly increased the insertion angle (P = .009) and distance from the articular cartilage to anchor (P = .003) at the 1 o'clock position on the acetabulum. The angle of insertion at the 2 and 3 o'clock positions was greater for the CSA guide compared with the straight suture anchor (SSA) guide but did not reach statistical significance. CONCLUSIONS: A CSA guide was shown to be significantly more effective in increasing the angle of insertion of suture anchors and increased the distance of the suture anchor tip to the articular cartilage surface at the 1 o'clock position but not at the 2 or 3 o'clock position. CLINICAL RELEVANCE: The use of SSA guides can be difficult because of the osseous morphologic characteristics of the acetabular rim, leading to placement of the suture anchor away from the acetabular rim and therefore resulting in a nonanatomical refixation of the acetabular labrum. The use of a curved guide, flexible drill, and flexible suture anchor inserter may provide more precise placement of suture anchors in the acetabular rim.
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Acetábulo , Artroscopia/métodos , Cartilagem Articular , Osteotomia/instrumentação , Âncoras de Sutura , Tomografia Computadorizada por Raios X/métodos , Acetábulo/diagnóstico por imagem , Acetábulo/cirurgia , Idoso , Idoso de 80 Anos ou mais , Cadáver , Cartilagem Articular/diagnóstico por imagem , Cartilagem Articular/cirurgia , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Osteotomia/métodosRESUMO
Osteochondral lesions of the talus (OLTs) are a difficult pathologic entity to treat. They require a strong plan. Lesion size, location, chronicity, and characteristics such as displacement and the presence of subchondral cysts help dictate the appropriate treatment required to achieve a satisfactory result. In general, operative treatment is reserved for patients with displaced OLTs or for patients who have failed nonoperative treatment for 3 to 6 months. Operative treatments can be broken down into cartilage repair, replacement, and regenerative strategies. There are many promising treatment options, and research is needed to elucidate which are superior to minimize the morbidity from OLTs.
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Background: Phalanx fractures are common, and plate fixation can be used to treat difficult fractures. Major complications have been reported in up to 64% of phalanx fractures treated with plate fixation, with stiffness being the most common. Low-profile anatomic plates (LPAP) have been designed to decrease soft tissue irritation and postoperative stiffness. The objective of this study was to determine whether the use of LPAP has decreased complications in plate fixation of phalanx fractures. Methods: A retrospective chart review was performed of patients with phalanx fractures treated with open reduction and internal fixation (ORIF) using LPAP at a single institution from January 1, 2010, to January 25, 2018. Twenty-three patients with 23 phalanx fractures treated with LPAP were included. The primary outcome was the presence of a complication. Results: Of the 23 patients, 12 patients (52.2%) had a postoperative complication. Nine patients (39.1%) required return to the operating room, with 7 (30.4%) returning for removal of hardware and tenolysis/capsulotomy. Two patients (8.7%) had superficial infections, one requiring irrigation and debridement. The other infection resolved clinically after 2 courses of oral antibiotics, with the fracture going on to nonunion. One patient had delayed wound healing treated prophylactically with cephalexin; although the wound healed, the patient developed a boutonniere deformity requiring surgery. There were 2 malunions (8.7%), one requiring revision surgery and the other electing for nonoperative management. All but one fracture progressed to union. Conclusions: ORIF with LPAP consistently achieves fracture union for phalanx fractures, but it does not appear that LPAP reduce the high complication rate.
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Fixação Interna de Fraturas , Fraturas Ósseas , Placas Ósseas , Fraturas Ósseas/cirurgia , Humanos , Redução Aberta , Estudos RetrospectivosRESUMO
High complication rates have been reported using conventional plating systems to treat metacarpal fractures. This study investigated complication rates in metacarpal fractures treated with low-profile anatomic plates. A retrospective chart review was performed of patients with metacarpal fractures who were treated with open reduction and internal fixation using low-profile anatomic plates at a single institution from January 2010 to February 2017. Patients with concomitant tendon injury, open fractures, prior same metacarpal fracture, or thumb metacarpal fracture were excluded. A total of 79 patients with 110 metacarpal fractures were included. The primary outcome was the presence of a complication, defined as superficial or deep infection, delayed wound healing, delayed union, nonunion, major or minor extensor lag or stiffness 90 days postoperatively, or return to the operating room. Eleven fractures (10%) had 1 or more complications. Complications included 6 fractures (5%) with major extensor lag or stiffness, 4 fractures (4%) with minor extensor lag or stiffness, 1 fracture (1%) with delayed radiographic union that did not require operative intervention, and 1 fracture (1%) with return to the operating room for removal of hardware. In this retrospective study, treatment of metacarpal fractures with low-profile plate fixation resulted in a 10% overall complication rate and a 1% reoperation rate; this rate is significantly less than reported in previous literature prior to the widespread use of low-profile plates. This study suggests treatment of patients with metacarpal fractures using low-profile plating systems provides a reliable solution with acceptable complication rates. [Orthopedics. 2021;44(1):e91-e94.].
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Placas Ósseas , Fixação Interna de Fraturas/efeitos adversos , Fraturas Ósseas/cirurgia , Traumatismos da Mão/cirurgia , Ossos Metacarpais/lesões , Adolescente , Adulto , Idoso , Feminino , Fixação Interna de Fraturas/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Reoperação , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: The purpose of this study was to investigate the impact of diabetes on complications after open trigger finger release compared with a cohort matched for age, sex, race, and body mass index class. METHODS: A retrospective chart review was performed of diabetic patients who underwent trigger finger release at an academic institution within the past 10 years. Exclusion criteria included rheumatoid arthritis, malignancy, human immunodeficiency virus/acquired immunodeficiency syndrome, connective tissue disorders, or systemic steroid use. These patients were then matched by age, sex, race, and body mass index class to nondiabetic patients who underwent trigger finger release during the same period. One hundred thirty-seven patients met inclusion criteria and were matched with controls. Complications included superficial or deep infection, delayed wound healing, limited range of motion at 6 weeks, pain requiring medication at 6 weeks, and return to the operating room. RESULTS: In adjusted analyses, diabetic patients had a significantly higher rate of all-cause complication following trigger finger release compared with matched nondiabetic controls at an odds ratio of 2.1. Diabetic patients also had a significantly higher rate of limitation in postoperative range of motion compared to the controls with an odds ratio of 2.4. CONCLUSION: This retrospective case-control study identified that diabetic patients undergoing trigger finger release are at increased risk of all-cause postoperative complications and, specifically, range of motion limitation when compared with similar patients without diabetes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.
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Complicações do Diabetes/cirurgia , Complicações Pós-Operatórias/epidemiologia , Dedo em Gatilho/cirurgia , Idoso , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: A dorsal wrist-spanning plate (DWSP) can be affixed to the second or third metacarpal, depending on the morphology of the distal radial fracture (DRF) and on surgeon preference, but comparative biomechanical analyses between these methods are limited. This biomechanical study compared fixation to the second metacarpal versus the third metacarpal as measured by lunate facet fragment displacement in a cadaveric model of an axially loaded intra-articular DRF. The construct rigidity with the addition of an intrafragmentary lunate facet locking screw was also evaluated. METHODS: A sample size of 14 cadaveric matched pairs was calculated to achieve 81.7% power. The 28 limbs were randomized to DWSP fixation to the second metacarpal (Group 1) or third metacarpal (Group 2); each wrist underwent an osteotomy simulating an unstable intra-articular DRF. Limbs were tested at axial loads of 50, 100, 150, 200, 250, and 300 N. Lunate facet displacement from the metaphyseal fragment at each load was measured with use of differential variable reluctance transducers. After initial testing, a locking screw was placed through the plate into the lunate facet fragment in the third metacarpal group (Group 3). Displacement measurements were repeated for all loads. Paired 2-tailed t tests with Bonferroni correction (significance, p < 0.008) were performed to assess differences in fragment stability between groups. RESULTS: The average fracture displacement at 300 N was 0.8 mm in Group 1, 0.4 mm in Group 2, and 0.2 mm in Group 3. Plating to the third metacarpal more effectively resisted displacement compared with the second metacarpal at all axial loads (p < 0.008). The addition of a lunate facet screw further stiffened the construct at loads of ≥200 N (p < 0.008). CONCLUSIONS: Plate fixation to the third metacarpal with an intrafragmentary screw was the most biomechanically favorable construct, although other factors may favor an alternative distal fixation site. Mean displacement of the lunate facet fragment at 300 N was <1 mm in all groups. CLINICAL RELEVANCE: The present study demonstrated that a DWSP affixed to the third metacarpal with an intrafragmentary screw provides the most effective stabilization of the lunate facet fragment in intra-articular DRFs. This study validates the use of intrafragmentary screws to increase stability in DWSP fixation.
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Placas Ósseas , Parafusos Ósseos , Fraturas Intra-Articulares/cirurgia , Osso Semilunar/cirurgia , Ossos Metacarpais/cirurgia , Fraturas do Rádio/cirurgia , Adulto , Idoso , Cadáver , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Amplitude de Movimento Articular , Suporte de Carga , Articulação do PunhoRESUMO
Background: Unstable intra-articular proximal interphalangeal (PIP) joint fracture-dislocations present a difficult problem that requires congruous joint reduction and stable internal fixation or distraction. Though fractures with limited articular involvement may be treated successfully with less invasive procedures, fracture-dislocations with a volar shear component may benefit from joint reduction with subchondral support for maintenance of stability. The purpose of this article is to describe a volar transverse plate and screw technique and report the short-term postoperative results. Methods: Seventeen patients with volar shear PIP dorsal fracture-dislocations were treated with transverse plate and screw constructs at an average of 21 days (range, 2-52) after injury. Information on postoperative stability, range of motion at PIP and distal interphalangeal (DIP) joints, and radiographic outcomes and complications were retrospectively collected. Results: At a mean of 7.3 months post-operation (range, 1.5-24), there were no recurrent dislocations and an average PIP arc of 77.4° and DIP arc of 61.5°. Sixteen of 17 patients had radiographically concentric joints, with 1 patient showing slight radiographic dorsal subluxation not apparent clinically. Two of 17 patients (11.8%) had revision surgery for tenolysis and removal of hardware to improve range of motion at 4 and 9 months post-operation. Conclusions: In the setting of PIP dorsal fracture-dislocations with volar shear component >40% of the articular surface, the Seatbelt procedure allows for concentric joint and articular surface reduction with subchondral support for maintenance of stability. This volar transverse plating technique allows for highly functional range of motion without PIP dorsal subluxation clinically in the setting of comminution and delayed presentation.
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Traumatismos dos Dedos , Luxações Articulares , Adulto , Feminino , Traumatismos dos Dedos/diagnóstico por imagem , Traumatismos dos Dedos/cirurgia , Articulações dos Dedos/diagnóstico por imagem , Articulações dos Dedos/cirurgia , Fixação Interna de Fraturas , Humanos , Luxações Articulares/diagnóstico por imagem , Luxações Articulares/cirurgia , Masculino , Estudos RetrospectivosRESUMO
Background: The distal radius is commonly used as a bone graft donor site for surgery in the hand and wrist. The aim of this study was to evaluate the volume and relative density of cancellous bone in the distal radius. Methods: Thirty-four consecutive computed tomographic scans of the wrist in 33 patients without distal radius pathology were included. For each subject, 6 spherical regions of interest (ROIs) were identified within the distal radius. In each ROI, volumetric measurements and mean Hounsfield unit (HFU) values were recorded by 2 observers using a 3-dimensional imaging reconstruction software. Results: Compared with proximal bone, distal bone had larger volume (0.82 vs 0.27 cm3) and greater relative density (178 vs 152 HFU) on average. Among the 6 ROIs, the distal-central region had the largest average volume (1.20 cm3) and the distal-ulnar ROI had the greatest average relative density (193 HFU). Conclusion: Based on these results, we recommend performing cancellous autograft harvest relatively distal and ulnar within the distal radius.
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Fraturas Ósseas , Fraturas não Consolidadas , Rádio (Anatomia)/cirurgia , Osso Escafoide , Feminino , Humanos , Masculino , Rádio (Anatomia)/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Transplantes , Articulação do Punho/diagnóstico por imagem , Articulação do Punho/cirurgiaRESUMO
BACKGROUND: An increased rate of complications has been demonstrated with increasing hemoglobin A1c value for a variety of orthopedic procedures, including arthroplasty and spine surgery. The authors investigated the effects of elevated hemoglobin A1c value on postoperative complications at the time of carpal tunnel release. METHODS: This retrospective, cohort study evaluated all diabetic patients with a preoperative hemoglobin A1c value within 90 days of primary, open carpal tunnel release at a single academic institution within the past 10 years. Binary hemoglobin A1c thresholds were tested for association with outcomes of superficial or deep infection, delayed wound healing, and persistent symptoms using chi-square analysis. Multivariable models with adjustment for baseline and operative factors were then constructed. Odds ratios and 95 percent confidence intervals were displayed. RESULTS: Hemoglobin A1c value greater than or equal to 7.8 percent was most strongly associated with an increased risk of all-cause wound healing complications (p = 0.049) at an odds ratio of 4.2 (95 percent CI, 1.0 to 17.7) in adjusted analyses. Six patients (4 percent) experienced delayed wound healing and five patients (4 percent) developed a superficial infection. Six patients (4 percent) reported persistent carpal tunnel syndrome symptoms. CONCLUSIONS: Diabetic patients undergoing open, primary carpal tunnel release with a hemoglobin A1c value of 7.8 percent or higher had a higher rate of postoperative wound complications compared to diabetic patients with improved preoperative glucose control. Diabetics with poor glycemic control should be counseled that their risk of postoperative complication is higher. Further work is needed to determine whether delaying surgery to optimize glucose control could result in a reduction of wound healing complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.
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Síndrome do Túnel Carpal/sangue , Síndrome do Túnel Carpal/cirurgia , Complicações do Diabetes/sangue , Hemoglobinas Glicadas/análise , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Síndrome do Túnel Carpal/complicações , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Ortopédicos , Período Pré-Operatório , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/epidemiologia , CicatrizaçãoRESUMO
There are several forefoot conditions that can result in metatarsal head pain. Various points of the gait cycle can predispose the metatarsal heads to pain based on intrinsic and extrinsic imbalances. Metatarsalgia can further be classified according to primary, secondary, or iatrogenic etiologies. Within these groups, conservative management is the first line of treatment and can often obviate surgical intervention. Depending on the cause of pain, proper shoewear, orthoses, and inserts coupled with targeted physical therapy can alleviate most symptoms of metatarsalgia and lesser toe deformities.
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Tratamento Conservador/métodos , Deformidades do Pé/terapia , Metatarsalgia/terapia , Humanos , Ossos do Metatarso/fisiopatologia , Metatarsalgia/etiologia , Dedos do Pé/anormalidadesRESUMO
BACKGROUND: Particulated juvenile cartilage allograft transplantation (PJCAT) is a novel treatment option for osteochondral lesions of the talus (OLTs). It is typically employed as a salvage procedure after initial debridement and microfracture has failed as it is theorized to deliver viable hyaline cartilage. We hypothesized that PJCAT would be a safe and effective treatment option for OLTs. METHODS: This is a retrospective case-control study of patients who underwent PJCAT for the treatment of OLTs at a single academic institution. Failure of the procedure was defined as no change or worsening of symptoms and/or the need for a subsequent cartilage restoration procedure. Variables recorded included preoperative magnetic resonance imaging (MRI) area and volume, intraoperative size, etiology, lesion location, sex, age, body mass index (BMI), history of prior surgery, American Orthopaedic Foot & Ankle Society score, and foot and ankle outcome score. Fifteen patients completed a minimum of 12 months of follow-up (mean, 34.6 months). RESULTS: The failure rate of PJCAT in this series was 40% (6/15). Preoperative MRI area and intraoperative OLT size along with male sex were predictive of failure ( P < .05). Age, BMI, etiology, technique (open vs arthroscopic), history of prior surgery, and location of lesion were not predictors of failure in this limited series ( P > .05). Patients with lesions greater than 125 mm2 area had a significant increased risk of clinical failure ( P < .05). Functional outcome scores were significantly better at final follow-up in the patients who had undergone successful treatment vs those who did not. CONCLUSION: These findings demonstrate the association of preoperative MRI lesion area, intraoperative lesion size, and male sex as risk factors for failure of PJCAT setting of an already difficult to treat pathology. LEVEL OF EVIDENCE: Level IV, retrospective case series.
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Fraturas do Tornozelo/cirurgia , Transplante Ósseo/métodos , Cartilagem Articular/patologia , Cartilagem Articular/cirurgia , Tálus/cirurgia , Centros Médicos Acadêmicos , Adolescente , Adulto , Fatores Etários , Aloenxertos , Fraturas do Tornozelo/diagnóstico por imagem , Fraturas do Tornozelo/patologia , Cartilagem Articular/diagnóstico por imagem , Estudos de Casos e Controles , Feminino , Seguimentos , Humanos , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Procedimentos Ortopédicos/métodos , Recuperação de Função Fisiológica , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Tálus/diagnóstico por imagem , Tálus/lesões , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: The advancement of 3D printing technology has allowed for the use of custom-designed implants for difficult-to-treat foot and ankle pathologies. This study reports on the radiographic and functional outcomes of a case series of patients treated with patient-specific 3D-printed titanium implants. METHODS: Fifteen consecutive patients treated with custom-designed 3D-printed implant cages for severe bone loss, deformity correction, and/or arthrodesis procedures were included in this study. A minimum of 1 year of clinical and radiographic follow-up was required. No patients were lost to follow-up. Patients completed a visual analog scale for pain, the Foot and Ankle Ability Measure Activities of Daily Living score, and the American Orthopaedic Foot & Ankle Society Score outcomes questionnaires preoperatively and at most recent follow-up. All patients had postoperative radiographs and computed tomography (CT) scans to assess bony incorporation. The mean age was 53.3 years (range, 22-74 years) with a mean follow-up of 22 months (range, 12-48 months) for these 15 patients. RESULTS: Radiographic fusion verified by CT scan occurred in 13 of 15 patients. There was significant improvement in pain and all functional outcome score measures. All patients who went on to fusion were satisfied with their surgery. There were 2 failures, consisting of 1 infection and 1 nonunion, with an overall clinical success rate of 87%. CONCLUSION: These patients demonstrated the successful use of patient-specific 3D-printed titanium implants to treat complex large bony defects, deformities, and arthrodesis procedures. These implants offer surgeons a novel and promising approach to treat both lower extremity pain and deformity that is not always available with current techniques. LEVEL OF EVIDENCE: Level IV, retrospective case series.
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Articulação do Tornozelo/cirurgia , Traumatismos do Pé/cirurgia , Pé/cirurgia , Impressão Tridimensional , Próteses e Implantes , Titânio , Adulto , Idoso , Articulação do Tornozelo/diagnóstico por imagem , Artrodese , Feminino , Seguimentos , Pé/diagnóstico por imagem , Traumatismos do Pé/diagnóstico por imagem , Fraturas não Consolidadas/cirurgia , Humanos , Prótese Articular , Salvamento de Membro/instrumentação , Salvamento de Membro/métodos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , RadiografiaRESUMO
BACKGROUND: The proposed benefit of total ankle replacement (TAR) over ankle fusion is preserved ankle motion, thus we hypothesized that an increase in range of motion (ROM) is positively correlated with validated patient-reported outcome measures (PROMs) in individuals receiving TAR. METHODS: Patients undergoing TAR at a single academic medical center between 2007 and 2013 were evaluated in this study. In addition to a minimum of 2-year follow-up, complete preoperative and postoperative outcome measures for the Foot and Ankle Disability Index (FADI), Short Musculoskeletal Function Assessment (SMFA) Bother and Function Indices, Visual Analog Scale (VAS), and 36-Item Short Form Health Survey (SF-36) were requisite for inclusion. Standardized weightbearing maximum dorsiflexion and plantarflexion sagittal radiographs were obtained and previously described ankle and foot measurements were performed to determine ankle ROM. RESULTS: Eighty-eight patients met inclusion criteria (33 INBONE, 18 Salto-Talaris, 37 STAR). Mean time to final ROM radiographs was 43.8 months (range 24-89 months). All aforementioned PROMs improved between preoperative evaluation and most recent follow-up ( P < .01). Final ankle ROM was significantly correlated with postoperative FADI, SF-36 Mental Component Summary (MCS), SMFA Bother and Function Indices, and VAS. Additionally, dorsiflexion was positively associated with FADI, SF-36 MCS, and SMFA Function ( P < .05) but plantarflexion had no such influence on outcomes. No differences were identified with subset stratification by prosthesis type, fixed versus mobile-bearing design or etiology. CONCLUSION: In this TAR cohort with prospectively collected outcomes data, radiographic sagittal plane ankle motion was positively correlated with multiple PROMs. Disease-specific and generic health-related quality of life PROMs demonstrated improvement postoperatively in all domains when evaluating final total range of motion. Patients who undergo TAR for end-stage osteoarthritis with improvement in ROM demonstrate a direct correlation with improved patient-centric metrics and outcome scores. LEVELS OF EVIDENCE: Level III: Retrospective comparative study.
Assuntos
Artroplastia de Substituição do Tornozelo/métodos , Osteoartrite/cirurgia , Medidas de Resultados Relatados pelo Paciente , Qualidade de Vida , Amplitude de Movimento Articular/fisiologia , Centros Médicos Acadêmicos , Idoso , Articulação do Tornozelo/diagnóstico por imagem , Articulação do Tornozelo/cirurgia , Artroplastia de Substituição do Tornozelo/efeitos adversos , Estudos de Coortes , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Osteoartrite/diagnóstico por imagem , Medição da Dor , Radiografia/métodos , Estudos RetrospectivosRESUMO
OBJECTIVES: To describe a midshaft forearm fracture pattern that places the ulnar nerve at risk in the pediatric population and provide 7 clinical case examples describing the injury pattern and treatment methods. DESIGN: Retrospective observational case series, review of literature, cadaver dissection, and treatment recommendations. SETTING: Multi-institutional, Southeast United States. PATIENTS: Seven pediatric patients (5 male and 2 female) with mean age of 8.7 years (range, 3-14) who sustained a significantly displaced closed, or grade I open, middle to distal one-third both-bone forearm fracture with subsequent ulnar nerve dysfunction. INTERVENTIONS: Manual reduction and casting of both-bone forearm shaft fractures, operative debridement, fracture fixation, nerve exploration, neurolysis, nerve repair, and nerve grafting. MAIN OUTCOME MEASUREMENTS: Radiographic fracture union, clinical ulnar nerve motor and sensory function testing, along with selective electric nerve testing and advanced imaging were monitored throughout follow-up postinjury. RESULTS: Five of 7 patients underwent surgical treatment and 2 others were treated with conservative measures. The ulnar nerve was entrapped within the fracture site of one patient with an open fracture along with partial nerve transection, and 4 patients were found to have the nerve encased in hypertrophic scar tissue or bony callus upon surgical exploration at 3-12 months postinjury. CONCLUSIONS: The ulnar nerve lies in a precarious position in the middle to distal one-third forearm and is bound by anatomic constraints that place the nerve at risk of injury. This article offers a treatment algorithm that includes conservative treatment, acute exploration, early exploration (≤3 months), and late exploration (>3 months). LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Redução Aberta/métodos , Traumatismos dos Nervos Periféricos/etiologia , Fraturas do Rádio/cirurgia , Fraturas da Ulna/cirurgia , Nervo Ulnar/lesões , Adolescente , Adulto , Cadáver , Criança , Pré-Escolar , Tratamento Conservador/métodos , Dissecação , Feminino , Seguimentos , Traumatismos do Antebraço/complicações , Traumatismos do Antebraço/cirurgia , Consolidação da Fratura/fisiologia , Humanos , Escala de Gravidade do Ferimento , Masculino , Pediatria , Traumatismos dos Nervos Periféricos/fisiopatologia , Traumatismos dos Nervos Periféricos/cirurgia , Guias de Prática Clínica como Assunto , Fraturas do Rádio/diagnóstico por imagem , Fraturas do Rádio/reabilitação , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento , Fraturas da Ulna/diagnóstico por imagem , Fraturas da Ulna/reabilitaçãoRESUMO
The development of tendinitis and tendinopathy is often multifactorial and the result of both intrinsic and extrinsic factors. Intrinsic factors include anatomic factors, age-related factors, and systemic factors, whereas extrinsic factors include mechanical overload and improper form and equipment. Although tendinitis and tendinopathy are often incorrectly used interchangeably, they are in 2 distinct pathologies. Due to their chronicity and high prevalence in tendons about the ankle, including the Achilles tendon, the posterior tibialis tendon, and the peroneal tendons, tendinitis and tendinopathies cause significant morbidity and are important pathologies for physicians to recognize.
Assuntos
Tendinopatia/diagnóstico , Tendinopatia/etiologia , Pé , HumanosRESUMO
BACKGROUND: The purpose of this study was to assess the radiographic progression of subtalar and talonavicular degenerative joint disease in a series of patients who had undergone TAA (total ankle arthroplasty) with minimum follow-up of 5 years. METHODS: TAA patient radiographs from a single institution were analyzed for peritalar arthritic changes by extrapolating the modified Kellgren Lawrence (KL) grades of the knee to the subtalar and talonavicular joints. Patients were included if they had a minimum of 5 years of follow-up. Patients who had undergone prior arthrodesis of the talonavicular or subtalar joints were excluded. A total of 140 patients with average follow-up of 6.5 years (range, 5.0-8.9 years) were included. RESULTS: Overall, 27% of patients advanced 1 KL grade at the subtalar joint and 31% of patients increased 1 KL grade at the talonavicular joint. Furthermore, 60% and 66% of patients showed no progression in the subtalar and talonavicular joints, respectively. Two patients progressed greater than 2 KL subtalar arthritis grades and only 2 patients with talonavicular arthritis progressed to the same extent. Sixteen patients went on to require a subtalar arthrodesis compared to 2 requiring a talonavicular fusion ( P < .05). CONCLUSION: This study suggests a moderate but nominal radiographic increase in adjacent subtalar and talonavicular arthritis over a minimum of 5 years after TAA. Future studies require a comparative control group of ankle fusion, but these data may suggest the motion preserved with an arthroplasty diminishes the stresses and compensatory motion incurred during tibiotalar arthrodesis. LEVEL OF EVIDENCE: Level IV, retrospective case series.