Charcot Neuroarthropathy Is Associated With Higher Rates of Phantom Limb After Lower Extremity Amputation.

BACKGROUND: The incidence of phantom limb pain in patients with Charcot neuroarthropathy who undergo major amputation is not well described. The purpose of this study was to determine whether patients with Charcot neuroarthropathy and diabetes who underwent either a below-knee amputation (BKA) or above-knee amputation (AKA) had an increased rate of phantom limb pain compared with those with a diagnosis of diabetes alone. METHODS: Using international classification of disease (ICD) and common procedural terminology (CPT) codes, the TriNetX research database identified 10 239 patients who underwent BKA and 6122 who underwent AKA between 2012 and 2022. Diabetic patients with and without Charcot neuroarthropathy were compared in terms of demographics and relative risk of developing phantom limb pain after AKA or BKA. RESULTS: Age, sex, ethnicity, and race did not significantly differ between groups. Charcot neuroarthropathy was associated with significantly increased risk of phantom limb pain following both BKA (risk ratio [RR]: 1.2, 95% confidence interval [CI]: 1.1-1.3, P < .01) and AKA (RR: 1.6, 95% CI: 1.2-2.3, P < .0068). CONCLUSION: Our results indicate that patients with a coexisting diagnosis of Charcot neuroarthropathy who require BKA or AKA may have an increased risk of developing phantom limb pain. LEVELS OF EVIDENCE: Level III.

Vancomycin Powder Is Highly Cost-Effective in Total Ankle Arthroplasty.

Prosthetic joint infection (PJI) is a costly and potentially fatal complication in total ankle arthroplasty (TAA). Some surgeons apply topical vancomycin powder to minimize the risk of infection during TAA procedures. The purpose of our study was to determine the cost-effectiveness of using vancomycin powder to prevent PJI following TAA and to propose an economic model that can be applied by foot and ankle surgeons in their decision to incorporate vancomycin powder in practice. Using our institution's records of the cost of 1 g of topical vancomycin powder, we performed a break-even analysis and calculated the absolute risk reduction and number needed to treat for varying costs of vancomycin powder, PJI infection rates, and costs of TAA revision. Costing $3.06 per gram at our institution, vancomycin powder was determined to be cost-effective in TAA if the PJI rate of 3% decreased by an absolute risk reduction of 0.02% (Number Needed to Treat = 5304). Furthermore, our results indicate that vancomycin powder can be highly cost-effective across a wide range of costs, PJI infection rates, and varying costs of TAA revision. The use of vancomycin powder remained cost-effective even when (1) the price of vancomycin powder was as low as $2.50 to as high as $100.00, (2) infection rates ranged from .05 to 3%, and (3) the cost of the TAA revision procedure ranged from $1000 to $10 000.Levels of Evidence: IV.

Improving Randomized-Controlled Trials in Foot and Ankle Orthopaedics: The Need to Include Sociodemographic Patient Data.

BACKGROUND: The representation of sociodemographic data within randomized-controlled trials (RCT) regarding foot and ankle surgery is undefined. The purpose of this study was to determine the incidence of sociodemographic data being reported in contemporary foot and ankle RCTs. METHODS: Randomized-controlled trials within the PubMed database from 2016 to 2021 were searched and the full text of 40 articles was reviewed to identify sociodemographic variables reported in the manuscript. Data regarding race, ethnicity, insurance status, income, work status, and education were collected. RESULTS: Race was reported in the results in 4 studies (10.0%), ethnicity in 1 (2.5%), insurance status in 0 (0%), income in 1 (2.5%), work status in 3 (7.5%) and education in 2 (5.0%). In any section other than the results, race was reported in 6 studies (15.0%), ethnicity in 1 (2.5%), insurance status in 3 (7.5%), income in 6 (15.0%), work status in 6 (15.0%), and education in 3 (7.5%). There was no difference in sociodemographic data by journal (P = .212), year of publication (P = .216), or outcome study (P = .604). CONCLUSION: The overall rate of sociodemographic data reported in foot and ankle RCTs is low. There was no difference in the reporting of sociodemographic data between journal, year of publication, or outcome study. LEVEL OF EVIDENCE: Level II.

Achilles Tendon Ruptures and Repair in Athletes-a Review of Sports-Related Achilles Injuries and Return to Play.

PURPOSE OF REVIEW: Achilles tendon ruptures (ATR) are detrimental to sports performance, and optimal treatment strategy and guidelines on return to play (RTP) remain controversial. This current review investigates the recent literature surrounding nonoperative versus operative management of ATR, clinical outcomes, and operative techniques to allow the athlete a successful return to their respective sport. RECENT FINDINGS: The Achilles tendon (AT) is crucial to the athlete, as it is essential for explosive activities such as running and jumping. Athletes that sustain an ATR play in fewer games and perform at a lower level of play compared to age-matched controls. Recent studies also theorize that ATRs occur due to elongation of the tendon with fatigue failure. Biomechanical studies have focused on comparing modes of fixation under dynamic loading to recreate this mechanism. ATRs can be career-ending injuries. Fortunately, the recent incorporation of early weight-bearing and functional rehabilitation programming for non-operative and operative patients alike proves to be beneficial. Especially for those treated nonoperatively, with the incorporation of functional rehabilitation, the risk of re-rupture among non-operative patients is beginning to approach the historical lower risk of re-rupture observed among patients treated operatively. Despite this progress in decreasing risk of re-rupture particularly among non-operative patients, operative managements are associated with unique benefits that may be of particular interest for athletes and active individuals. Recent studies demonstrate that operative intervention improves strength and functional outcomes with more efficacy compared to nonoperative management with rehabilitation. The current literature supports operative intervention in elite athletes to improve performance and shorten the duration to RTP. However, we acknowledge that surgical intervention does have inherent risks. Ultimately, most if not all young and/or high-level athletes with an ATR benefit from surgical repair, but it is crucial to take a stepwise algorithmic approach and consider other factors, which may lead towards nonoperative intervention. These factors include age, chronicity of injury, gap of ATR, social factors, and medical history amongst others in this review.

Neurophysiological Intraoperative Monitoring in Patients with Cochlear Implant Undergoing Posterior Spinal Fusion: A Case Report.

CASE: Transcranial electric stimulation motor-evoked potentials (tcMEPs) are the most sensitive technique in multimodality intraoperative neuromonitoring (IONM) for posterior spinal fusion (PSF). The presence of a cochlear implant (CI) is considered a contraindication to IONM because of theoretical risk of implant device and local tissue damage from voltages induced by tcMEPs. We present the case of a 10-year-old girl with CI who underwent successful PSF with tcMEP and monopolar electrocautery (MoEC) without perioperative complications or CI damage. CONCLUSION: With proper precautions, such as MoEC usage at a minimal voltage, motor-evoked potential monitoring can be safely performed in pediatric patients with CI undergoing PSF.

Implant Selection for Proximal Humerus Fractures.

Proximal humerus fractures (PHF) are a common orthopedic injury; however, their treatment remains largely controversial with evidence supporting a wide array of treatments. Although many injuries can be treated nonoperatively, there has been much debate about surgical management of PHF. A detailed review of the literature was performed relative to operative management options specifically related to implant choices. Although no definitive answers are available regarding best practice, there is literature to guide operative decision-making and implant selection based on both patient- and surgeon-specific factors.

Novel policing techniques decrease gun-violence and the cost to the healthcare system.

The objective was to investigate the effects of novel policing techniques on hospital-observed incidence, healthcare utilization, mortality and costs associated with gun violence, from the perspective of a level-1 trauma center. An eight-year retrospective review evaluating the clinical and financial effects of gunshot wound (GSW) encounters between January 1st, 2010 and December 31st, 2017. Individuals who presented to the emergency department (Level-1 trauma center in Camden, NJ) between January 1, 2010 and December 31, 2017 with GSW (995 encounters) were included; however, patients with incomplete financial or medical record data were excluded (55 encounters). Patients were subdivided into two cohorts: before and after changes in policing tactics (May 1st, 2013). 940 total firearm-related encounters were included in the study. Following the policing changes, the hospital-observed quarterly incidence of GSW encounters decreased by 22% post-policing changes, 44.3 to 34.6 (p = 0.038). Average quarterly days spent in-house for GSW treatment decreased 220.7 to 151.3 (31%) days. Hospital observed mortality increased from 13.5% of presentations to 17.3% of presentations (p = 0.106). Total cost savings associated with the policing change was roughly $254,000 per quarter (p = 0.023). In areas susceptible to high rates of gun violence, similar novel policing tactics could significantly decrease hospital-observed incidence, costs and healthcare utilization demanded by firearm-related injury.

Animal models of rheumatoid pain: experimental systems and insights.

Severe chronic pain is one of the hallmarks and most debilitating manifestations of inflammatory arthritis. It represents a significant problem in the clinical management of patients with common chronic inflammatory joint conditions such as rheumatoid arthritis, psoriatic arthritis and spondyloarthropathies. The functional links between peripheral inflammatory signals and the establishment of the neuroadaptive mechanisms acting in nociceptors and in the central nervous system in the establishment of chronic and neuropathic pain are still poorly understood, representing an area of intense study and translational priority. Several well-established inducible and spontaneous animal models are available to study the onset, progression and chronicization of inflammatory joint disease, and have been instrumental in elucidating its immunopathogenesis. However, quantitative assessment of pain in animal models is technically and conceptually challenging, and it is only in recent years that inflammatory arthritis models have begun to be utilized systematically in experimental pain studies using behavioral and neurophysiological approaches to characterize acute and chronic pain stages. This article aims primarily to provide clinical and experimental rheumatologists with an overview of current animal models of arthritis pain, and to summarize emerging findings, challenges and unanswered questions in the field.