A Review of Pediatric Heel Pain.

The objective of this review article is to provide orthopaedic surgeons and general practitioners a reference and guidance for the evaluation and workup of heel pain in pediatric patients. The authors performed a comprehensive literature search to review the etiologies and management of heel pain in patients <18 years of age. Relevant studies in Medline/PubMed and EMBASE were searched from inception to March 3, 2022 using medical subject headings and text words without limitations on language or study type. The initial search utilized the following Boolean operators: (children) AND (heel pain); (pediatric) AND (heel pain). Heel pain in the pediatric population is usually a benign condition. Sever's apophysitis is the most common etiology of heel pain in pediatric patients. Most causes of heel pain in the pediatric population do not require imaging or extensive workup. However, providers must maintain a high index of suspicion for symptoms that could indicate a more severe pathology.

Tibiotalocalcaneal Arthrodesis with Intramedullary Fibular Strut Graft and Adjuvant Hardware Fixation.

Background: In patients with irreparable damage to the articular surfaces of the hindfoot, hindfoot arthrodesis is frequently chosen to provide pain relief and improve activities of daily living. Common etiologies leading to hindfoot arthrodesis procedures include osteonecrosis, failed total ankle arthroplasty, and deformities resulting from Charcot arthropathy or rheumatoid arthritis. Traditionally, this operation utilizes an intramedullary nail to obtain fusion of the tibiotalocalcaneal joint. Although 80% to 90% of patients achieve postoperative union, the remaining 10% to 20% experience nonunion1-3. Factors affecting the rate of nonunion include Charcot neuroarthropathy, use of nonsteroidal anti-inflammatory drugs or methotrexate, osteopenic bone, and smoking4. In the present video article, we describe a tibiotalocalcaneal arthrodesis performed with use of a fibular strut autograft for repeat arthrodesis following failure of primary tibiotalocalcaneal arthrodesis or as a salvage operation in end-stage pathologies of the hindfoot. Our surgical technique yields union rates of approximately 80% and provides surgeons with a viable surgical technique for patients with complex hindfoot pathologies or fusion failure. Description: The patient is placed in the supine position, and a 10-cm curvilinear incision is made including the distal 6 to 8 cm of the fibula. The incision is centered directly lateral on the fibula proximally and transitions to the posterolateral aspect of the fibula distally. As the incision continues distally, it extends inferiorly and anteriorly over the sinus tarsi and toward the base of the 4th metatarsal, using an internervous plane between the superficial peroneal nerve anteriorly and the sural nerve posteriorly. Exposure of the periosteum is carried out through development of full-thickness skin flaps. The periosteum is stripped, and a sagittal saw is used to make a beveled cut on the fibula at a 45° angle, approximately 6 to 8 cm proximal to the ankle. The fibular strut is decorticated, drilled, and stripped of the cartilage on the distal end. Preparation of the tibiotalar and subtalar joints for arthrodesis are completed through the lateral incision. The foot is placed in 0° of dorsiflexion, 5° of external rotation in relation to the tibial crest, and 5° of hindfoot valgus while maintaining a plantigrade foot. This placement can be temporarily maintained with Kirschner wires if needed. Next, the plantar surface overlying the heel pad is incised, and a guidewire is passed through the center of the calcaneus and into the medullary cavity of the tibia. Correct alignment of the guidewire is then confirmed on fluoroscopy. The fibular strut autograft is prepared for insertion while the tibiotalocalcaneal canal is reamed to 1 to 2 mm larger than the graft. The graft is tapped into position, followed by placement of two 6.5-mm cancellous screws to immobilize the joint, taking care to avoid excess contact of the fibular graft with the screws. Alternatives: Alternatives to this procedure include traditional arthrodesis techniques, nonoperative treatment (such as rehabilitation or bracing), or no intervention. Patients with failed primary hindfoot arthrodesis may undergo an additional traditional arthrodesis, but may face an increased risk of complications and failure1,2. Rationale: A recent study1 has shown that the use of a fibular strut autograft for tibiotalocalcaneal arthrodesis produces union rates similar to those seen with the traditional intramedullary nailing technique4,5. These results are important to note, as the presently described technique, which is used as a salvage procedure, produces outcomes that are equivalent to those observed for primary tibiotalocalcaneal arthrodesis with nailing, which is used for the treatment of severe trauma, extensive bone loss, or severe hindfoot pathologies. We recommend using this technique particularly in cases of failed primary tibiotalocalcaneal arthrodesis or in patients with end-stage hindfoot pathologies. The fibular strut autograft is a viable salvage option to decrease daily pain and provide quality improvement in patient activities of daily living. Expected Outcomes: Tibiotalocalcaneal arthrodesis with a fibular strut autograft has been shown to produce a union rate (81.2%) similar to that of the traditional arthrodesis technique with intramedullary nailing (74.4% to 90%). The strut graft provides an osteoinductive environment for healing and increases the post-arthrodesis load tolerance1. Mean visual analog scale pain scores improved from 6.9 preoperatively to 1.2 postoperatively with use of this procedure1. The most common complication was wound dehiscence requiring additional wound care (37.5%); its rate was higher than the rates reported in other studies of tibiotalocalcaneal arthrodesis, possibly because of the small sample size of patients undergoing such a complex procedure for a complex medical issue2,11. Although 7 patients required a reoperation, all ultimately experienced a union and recovered postoperatively. All non-retired patients were all able to return to work1. Important Tips: Place your incision precisely to allow adequate exposure of both the tibiotalar and subtalar joints.Curvilinear incision should begin 6 to 8 cm proximal to, and directly lateral to, the distal end of the fibula. It should continue posterolaterally to the fibula distally and extend inferiorly and anteriorly over the sinus tarsi, toward the base of the 4th metatarsal.Prepare the tibiotalar and subtalar joints this same incision.Decorticate the fibular strut autograft; this plays a key role in obtaining fusion.Harvest the fibula 6 to 8 cm above the ankle joint line. Once the graft is harvested, smooth the edges of the fibula with a burr; this facilitates graft insertion.Finally, when immobilizing the joint, take care to avoid excessive perforation of the graft as this increases the likelihood of fracture. Acronyms and Abbreviations: OR = operating roomIM = intramedullaryCT = computed tomographyTTCA = tibiotalocalcaneal arthrodesisTTC = tibiotalocalcanealK-wire - Kirschner wire.

Achilles Tendon Rupture Repair Using the Mini-Open Approach in a Supine Position.

Background: The mini-open approach with supine patient positioning is a useful technique to consider for acute Achilles rupture repair, ideally performed within 2 weeks from the time of injury. The traditional surgical approach is completed with the patient in the prone position with an extensile midline incision. Here we describe a mini-open approach with supine positioning that utilizes a single incision measuring approximately 3 to 4 cm in length and avoids the pitfalls of prone positioning, which include greater operative time and potential difficult airway management, vision loss, and brachial plexus palsies1. Description: When positioning the patient supine, lower-extremity bolsters are placed beneath the contralateral hip and the operative ankle in order to allow for exaggerated external rotation of the ankle and improved medial visualization. A thigh tourniquet is then applied on the operative side in a standard sterile fashion.After appropriate draping, begin by palpating the tendon rupture site and mark a 3 to 4-cm incision line just medial to the tendon. Sharp dissection through the skin to the level of the paratenon is then performed. Incise the paratenon with a knife, separate the paratenon from the underlying Achilles tendon with a Freer elevator or scissors, subsequently remove any hematoma formation, and cut the paratenon proximally and distally with scissors or a knife. Debride any damaged tendon thoroughly.The steps of the procedure are performed under direct visualization. If the sural nerve is encountered, it is noted and retracted, and extra care is taken to avoid damaging it with instruments or suture.Now that the proximal and distal ends of the Achilles tendon are free, utilize a 4-stranded double Krackow locking stitch with two #2 FiberWires (Arthrex) on both the proximal and the distal stump. The stumps of the ruptured tendon are approximated by tying the free suture ends together with use of a simple surgeon's knot. A running epitendinous repair is performed with use of number-0 Vicryl (Ethicon) suture in a cross-stich weave technique to provide additional strength to the repair. Finally, test the integrity of the repair via an intraoperative Thompson test. The postoperative protocol includes non-weight-bearing with the operative limb in a posterior splint for 2 weeks. At the 2-week follow-up, stitches are removed and the limb is placed in a tall CAM (controlled ankle motion) walker boot with 2 heel wedges measuring 6.35 mm (0.25 inches) apiece. The patient can begin partial weight-bearing with crutches at 2 weeks postoperatively. At 4 weeks postoperatively, 1 heel wedge is removed, and at 6 weeks postoperatively, the second heel wedge is removed. Patients are instructed to begin gentle range-of-motion exercises at 2 weeks, with formal physical therapy scheduled to begin at 6 weeks. Most patients are out of the boot at 8 to 10 weeks postoperatively. Alternatives: Nonoperative treatment of Achilles rupture includes functional bracing or casting with the foot resting in the equinus position and early weight-bearing and rehabilitation. As mentioned earlier, the traditional operative approach with prone positioning is a viable option but is associated with a higher incidence of procedural and anesthesia-related complications, as well as potentially increased cost1. Rationale: Recent studies have shown that a mini-open approach will produce a repair that is comparable with the traditional open approach, while also minimizing the anesthesia and postural complications associated with prone positioning1. Previous studies focusing on supine positioning have generally utilized a larger incision more comparable with that of the traditional prone approach6. Other studies have utilized a minimally invasive approach but require >1 incision and often utilize specialized instrumentation, which may limit the technique to certain facilities7. The technique described in the present article utilizes a single 3 to 4-cm incision that requires no specialized instrumentation, has a minimal learning curve, and can be performed at any facility. Expected Outcomes: McKissack et al. demonstrated that the overall complication rate of the mini-open supine approach (7.7%) was lower than that of the traditional prone approach (9.3%), while the average cost of the prone approach exceeded that of the supine approach by $1,8231. This increased cost, although not significant, may be attributable to longer operating room and post-anesthesia care unit times. Additionally, no patient in either cohort experienced tendon rerupture within the first year after repair, further proving the effectiveness of this technique. We have utilized this mini-open supine technique for acute Achilles ruptures for over 9 years now, with good patient outcomes and satisfaction. Throughout this duration we have not had a single patient experience rerupture of the repaired tendon. In our experience, we find this technique to be effective, with fewer complications than prone positioning. Additionally, this approach may be associated with decreased financial and anesthesia burdens. Important Tips: Always palpate the tendon rupture site to determine the best incision placement.With ruptures close to the tendon insertion site, it can be notoriously difficult to mobilize the distal tendon stump, so extended incisions may be required.Test the integrity of the repair with use of the intraoperative Thompson test.This technique does not utilize any special equipment and thus can be performed at any facility.This supine approach decreases operating room turnover time, anesthesia burden, and complications associated with prone positioning. Acronyms & Abbreviations: AP = anteroposteriorMRI = magnetic resonance imagingUS = ultrasoundDVT = deep vein thrombosisVAS = visual analog scaleNWB = non-weight-bearingCAM = controlled ankle motionPWB = partial weightbearingROM = range of motionPT = physical therapyOR = operating room.

Septic arthritis of the temporomandibular joint: case reports and review of the literature.

BACKGROUND: Septic arthritis of the temporomandibular (TM) joint is rare, but it is associated with high risk for significant morbidity. OBJECTIVE: We reviewed the available literature regarding the presentation, evaluation, treatment, and clinical course of TM joint septic arthritis, focusing on elements relevant to emergency physicians. CASE REPORTS: In the first case, a healthy 6-year-old boy presented with fever and trismus; computed tomography with contrast revealed a TM joint effusion. After empiric intravenous antibiotics, intraoperative arthrocentesis of the TM joint returned 1 mL of flocculent fluid, which was cultured and grew pan-sensitive Streptococcus pyogenes. He was discharged home with amoxicillin/clavulanate and experienced complete resolution of his symptoms. In the second case, more than 3 weeks after extraction of her third molars, an 18-year-old woman presented with facial pain, swelling, and trismus and was found to have a loculated abscess involving the left masseteric and pterygomandibular spaces with extension to the left deep temporal region and the skull base. She experienced a complicated postoperative course and required multiple procedures and intravenous antibiotics for growth of multiple bacteria. More than a month later she underwent TM joint arthrotomy for TM joint septic arthritis, and she was found to have acute osteomyelitis. She continued to require multiple treatment modalities; 20 months after her initial presentation, she underwent left total TM joint arthroplasty for fibrous ankylosis of the TM joint. CONCLUSION: Septic arthritis of the TM joint may be caused by hematogenous spread of distant infection or local spread of deep masticator space infections. Patients may present with TM joint septic arthritis acutely or sub-acutely. Septic arthritis of the TM joint should be considered in the differential diagnosis of patients who present with trismus and pain or fever.