Lateralizing calcaneal osteotomy performed with a percutaneous burr results in a significantly lower increase in tarsal tunnel pressure.

PURPOSE: Tarsal tunnel syndrome is well documented following lateralizing calcaneal osteotomy to manage varus hindfoot deformity. Traditionally, calcaneal osteotomy is performed with an oscillating saw. No studies have investigated the effect of alternative surgical techniques on postoperative tarsal tunnel pressure. The purpose of this study was to investigate the difference in tarsal tunnel pressures following lateralizing calcaneal osteotomy performed using a high-torque, low-speed "minimally invasive surgery" (MIS) Shannon burr versus an oscillating saw. METHODS: Lateralizing calcaneal osteotomy was performed on 10 below-knee cadaveric specimens. This was conducted on 5 specimens each using an oscillating saw (Saw group) or MIS burr (Burr group). The calcaneal tuberosity was translated 1 cm laterally and transfixed using 2 Kirschner wires. Tarsal tunnel pressure was measured before and after osteotomy via ultrasound-guided percutaneous needle barometer. Mean pre/post-osteotomy pressures were compared between groups. Differences were analyzed using Student's t test. RESULTS: The mean pre-procedure tarsal tunnel pressure was 25.8 ± 5.1 mm Hg in the Saw group and 26.4 ± 4.3 mm Hg in the Burr group (p = 0.85). The mean post-procedure pressure was 63.4 ± 5.1 in the Saw group and 47.8 ± 4.3 in the Burr group (p = 0.01). Change in tarsal tunnel pressure was significantly lower in the Burr group (21.4 ± 4.5) compared to the Saw group (37.6 ± 12.5) (p = 0.03). The increase in tarsal tunnel pressure was 43% lower in the Burr group. CONCLUSION: In this cadaveric study, tarsal tunnel pressure increase after lateralizing calcaneal osteotomy was significantly lower when using a burr versus a saw. This is likely because the increased width ("kerf") of the 3 mm MIS burr, compared to the submillimeter saw blade width, causes calcaneal shortening. Given the smaller increase in tarsal tunnel pressure, using the MIS burr for lateralizing calcaneal osteotomy may decrease the risk of postoperative tarsal tunnel syndrome. Future research in vivo should explore this.

Ultrasound-guided fascial plane blocks for post-breast surgery pain syndrome.

INTRODUCTION: Persistent pain following breast surgery is common and may be challenging to treat. In patients refractory to conservative treatments, ultrasound-guided fascial plane blocks of thoracic nerves can be a useful option. RESULTS: This type of neuro blockade technique provides advantages in terms of safety and efficacy that are convenient for physicians managing refractory and complex cases of post-breast surgery syndrome. CONCLUSION: This technical review aims to present an up-to-date summary of the most common ultrasound-guided fascial plane blocks for chronic pain in post-breast surgery patients, provide a detailed technical description of each intervention, and propose preferred injections based on the anatomical location of the pain.

Neurogenic thoracic outlet syndrome in the overhead and throwing athlete: A narrative review.

Thoracic outlet syndrome is an important cause of shoulder pain and dysfunction due to compression of neurovascular structures as they traverse the thoracic outlet. Symptoms are most commonly due to compression of the brachial plexus called neurogenic thoracic outlet syndrome (nTOS). Throwing athletes are at increased risk of nTOS because of a variety of biomechanical factors. However, because nTOS symptoms are often nonspecific, delayed diagnosis is common. Neurogenic thoracic outlet largely remains a diagnosis of exclusion with advanced imaging ruling out vascular involvement and diagnostic injections gaining favor in helping localize sites of compression. Although rehabilitation alone may improve symptoms in some athletes, many require surgical treatment for long-term relief. This generally entails decompression of the thoracic outlet by some combination of muscle release, brachial plexus neurolysis, and first rib resection. Outcomes tend to be successful in athletes with most achieving resolution of symptoms and return to athletic activity. NTOS is an important cause of shoulder pain and dysfunction in throwing athletes. The history and physical examination should focus on activities that exacerbate symptoms. Treatment of nTOS generally requires surgical intervention and allows throwing athletes to return to sport.

Ultrasound-guided injection of the long head of the biceps tendon sheath with concomitant subacromial bursa injection through the same needlestick.

Sonography and specific shoulder positions allow for injections into both the long head of the biceps tendon sheath (LHBTS) and the subacromial space (SS) with one needlestick. We validated this technique using cadavers. An experienced proceduralist injected latex solution into 12 unembalmed cadaveric shoulders, aiming for the LHBTS and SS, using an ultrasound-guided injection technique that employs a single-needle entry point. An experienced surgeon dissected each specimen and graded latex location as: (1) completely accurate (in both the SS and LHBTS); (2) partially accurate (in either the SS or LHBTS); (3) accurate with overflow (in both locations, but also elsewhere); (4) partially accurate with overflow (in either location, but also somewhere else); or (5) completely inaccurate (no latex in either location). All 12 ultrasound-guided injections using the technique accurately placed latex into both LHBTS and SS (100% accuracy). Latex was also found in adjacent regions after two (17%) injections: one within the shoulder joint and one within the deltoid musculature. This newly described technique allows highly accurate access to the LHBTS and SS with single-needle entry. This technique could become a favored alternative to subjecting patients to two needlesticks and preparing separate injections to address often concomitant pathologies.

Biologics.

Biologics are a growing field that has shown immense promise for the treatment of musculoskeletal conditions both in orthopedic sports medicine and interventional pain management. These procedures utilize injection of supraphysiologic levels of platelets and growth factors to invoke the body's own inflammatory cascade to augment the healing of many bony and soft tissue conditions. While many patients improve with conservative care, there is a need to address the gap between those that improve with rehabilitation alone and those who ultimately require operative management. Orthobiologic procedures have the potential to fill this void. The purpose of this review is to summarize the basic science, evidence for use, and post-injection rehabilitation concepts of platelet-rich plasma (PRP) and mesenchymal stromal cells (MSCs) as they pertain to joints, tendons, ligaments, and the spine.

Exercise-Associated Muscle Cramps in the Tennis Player.

PURPOSE OF REVIEW: Better define the proposed etiologies, risk factors, and treatment plans for exercise-associated muscle cramps in the tennis player. RECENT FINDINGS: While no one theory has been able to fully explain the etiology behind exercise-associated muscle cramping, further classification of acute localized cramping and systemic or recurrent cramping may help guide future treatment and prevention strategies. Neuromuscular fatigue more than electrolyte deficit or dehydration is believed to play a large role in development of exercise-associated muscle cramps. Despite inconclusive evidence at this time, electrolyte deficit may play more of a role in the development of recurrent or systemic muscle cramping in the tennis athlete. More research is needed to better define its conclusive etiology.