Total shoulder arthroplasty for proximal humerus fracture is associated with increased hospital charges despite a shorter length of stay.

BACKGROUND: Operation choice is a complex decision in the surgical management of proximal humerus fractures. Recently, there has been an increase in the use of total shoulder arthroplasty (TSA) for complex fracture patterns. HYPOTHESIS: Patients with proximal humerus fractures who receive TSA are more likely to have higher hospital charges and a prolonged length of stay relative to patients receiving hemiarthroplasty (HA), open reduction with internal fixation (ORIF) or closed reduction with internal fixation (CRIF). MATERIALS AND METHODS: A statewide electronic database was used to identify 13,316 hospital admissions from 2000-2011 were a proximal humerus fracture was surgically managed in an effort to determine the effect of operation choice on cost and length of stay. A univariate analysis was preformed to examine overall trends in surgical management. Additionally, a periodic, multivariate logistic regression analysis was used to determine how operation choice affected the odds of a high cost hospital stay or a prolonged length of stay after controlling for age, comorbidity burden, gender, and insurance type. RESULTS: After controlling for confounding factors, patients receiving total shoulder arthroplasty (TSA) were 2.25 times more likely to have high total hospital charges than patients receiving HA and 3.21 times more likely than patients receiving ORIF. Additionally, TSA was found to be a significant negative predictor of prolonged length of stay (pLOS). HA, ORIF and CRIF did not significantly predict pLOS. DISCUSSION: The use of TSA for acute proximal humerus fractures is associated with increased hospital costs despite a shorter length of stay when compared to other operative choices. As reverse total shoulder arthroplasty becomes more popular for treatment of this injury, it is important that functional outcomes be interpreted in the context of relative cost trade-offs. LEVEL OF EVIDENCE: Level IV.

Transcriptome analysis reveals coordinated spatiotemporal regulation of hemoglobin and nitrate reductase in response to nitrate in maize roots.

Given the importance of nitrogen for plant growth and the environmental costs of intense fertilization, an understanding of the molecular mechanisms underlying the root adaptation to nitrogen fluctuations is a primary goal for the development of biotechnological tools for sustainable agriculture. This research aimed to identify the molecular factors involved in the response of maize roots to nitrate. cDNA-amplified fragment length polymorphism was exploited for comprehensive transcript profiling of maize (Zea mays) seedling roots grown with varied nitrate availabilities; 336 primer combinations were tested and 661 differentially regulated transcripts were identified. The expression of selected genes was studied in depth through quantitative real-time polymerase chain reaction and in situ hybridization. Over 50% of the genes identified responded to prolonged nitrate starvation and a few were identified as putatively involved in the early nitrate signaling mechanisms. Real-time results and in situ localization analyses demonstrated co-regulated transcriptional patterns in root epidermal cells for genes putatively involved in nitric oxide synthesis/scavenging. Our findings, in addition to strengthening already known mechanisms, revealed the existence of a new complex signaling framework in which brassinosteroids (BRI1), the module MKK2-MAPK6 and the fine regulation of nitric oxide homeostasis via the co-expression of synthetic (nitrate reductase) and scavenging (hemoglobin) components may play key functions in maize responses to nitrate.

Foot compartment syndrome.

FCS is a recognized clinical entity that has few consistent clinical signs except tense swelling. A high degree of clinical suspicion is necessary to provide appropriate treatment. Invasive direct pressure monitoring is needed to diagnose FCS. High-energy injuries are known to cause FCS, but individual risk factors, such as prolonged venous occlusion and blood dyscrasias, are causative factors.

Operative treatment of the difficult stage 2 adult acquired flatfoot deformity.

In the flexible pes planovalgus deformity of stage 2 posterior tibial tendon dysfunction, osteotomies appear to have a significant role in operative management by restoring more normal biomechanics, allowing tendon transfers to function successfully. The options when considering osteotomies for stage 2 disease include lateral column lengthening, medial displacement calcaneal osteotomy, and combined double osteotomy technique. The tight Achilles tendon should be lengthened as well. Lateral column lengthening has been used extensively for treatment of flexible flatfeet. It has been shown clinically and radiographically to address all 3 components of the pes planovalgus deformity present in stage 2 posterior tibial tendon dysfunction. Lateral column lengthening is used in combination with a medial soft tissue rebalancing procedure. The mechanism of action is still speculative but clearly is not owing to tensioning of the plantar fascia as previously thought. Despite the excellent correction of foot posture obtained by use of lateral column lengthening for adult acquired flatfoot, many clinicians have reservations about its use because of reported secondary increases in the calcaneocuboid joint pressures. This increase in pressure has been shown to occur experimentally, increasing the potential risk of calcaneocuboid joint arthrosis. This experimental evidence is supported by Phillips' study of the original Evans procedure, which resulted in a 65% incidence of calcaneocuboid joint arthrosis at 13-year follow-up. Mosier-LaClair et al reported a 14% incidence of calcaneocuboid joint arthritis at 5-year follow-up after double osteotomy for stage 2 posterior tibial tendon dysfunction. This incidence has not been proved true in the remainder of the literature surrounding this procedure and its use for flexible flatfoot. To address the concern regarding potential calcaneocuboid arthrosis secondary to lateral column lengthening, calcaneocuboid joint distraction arthrodesis has been explored as an alternative technique. The results show good initial correction, but the follow-up is extremely limited, and one study reported loss of correction over time. Longer follow-up is needed to determine whether or not this technique would provide the lasting correction seen with the Evans procedure. Calcaneocuboid joint lengthening arthrodesis does result in some limitation of adjacent hindfoot motion. Although this limitation is significantly less compared with talonavicular and subtalar joint fusion, this procedure may result in increased local pressures and arthrosis of the midfoot or hindfoot. For the above-mentioned reasons, longer follow-up studies are needed to determine whether calcaneocuboid joint distraction arthrodesis would prove to be a reliable and safe alternative for lateral column lengthening in the treatment of adult acquired flatfoot. Medial displacement calcaneal osteotomy has been used for correction of the pes planovalgus foot in posterior tibial tendon dysfunction. It has been used extensively for the surgical treatment of flexible flatfoot throughout the literature. Medial displacement osteotomy, in combination with flexor digitorum longus tendon transfer, can address all 3 components of adult acquired flatfoot. It does not recreate the medial longitudinal arch in all patients, however. Although the mechanism of action of medial displacement calcaneal osteotomy is unknown, it has been proved that it is not through the tightening of the plantar fascia in a windlass effect as previously thought. In contrast to lateral column lengthening, however, medial displacement calcaneal osteotomy does address the deforming valgus force of the Achilles tendon. Functionally transferring the insertion of the Achilles tendon medially removes a constant valgus-deforming force. The osteotomy can then act as a double tendon transfer with the flexor digitorum longus tendon to aid in foot inversion. For stage 2 posterior tibial tendon insufficiency, the authors favor the combination double osteotomy technique with a flexor digitorum longus tendon-to-medial cuneiform tendon transfer, débridement or removal of the posterior tibial tendon, and percutaneous heel cord lengthening. Early results were positive at 1.5 years after surgery with respect to maintenance of correction and functional improvement with no evidence of calcaneocuboid arthrosis. More recently, the intermediate 5-year follow-up has been assessed for this combination of procedures, and similar results were found. There was a high rate of patient satisfaction and functional improvement, and surgical correction of the flatfoot deformity was maintained and compared favorably with the contralateral normal foot. Although the intermediate follow-up found a 14% incidence of calcaneocuboid arthrosis, 50% of these patients had preoperative evidence of calcaneocuboid joint arthritis. (ABSTRACT TRUNCATED)

Intermediate follow-up on the double osteotomy and tendon transfer procedure for stage II posterior tibial tendon insufficiency.

26 patients with 28 pes planovalgus feet secondary to Johnson stage 2 posterior tibial tendon insufficiency were treated with flexor digitorum longus tendon transfer, lateral column lengthening, medial displacement calcaneal osteotomy, and heel cord lengthening. The mean patient age at surgery was 48.5 years. The AOFAS ankle-hindfoot scale was applied postoperatively to assess clinical outcome. Preoperative and postoperative standing radiographs of the foot and ankle were analyzed to determine radiographic correction of the pes planovalgus deformities. The mean follow-up to date is 5 years. The mean ankle-hindfoot score was 90 postoperatively. The medial cuneiform to fifth metatarsal distance improved from -0.2 mm preoperatively to 7.6 mm postoperatively. Similarly, the talonavicular distance improved from 19.4 mm preoperatively to 10.9 postoperatively. There were no nonunions. Four feet (14%) displayed radiographic signs of calcaneocuboid arthritis at follow-up. Only one was symptomatic requiring calcaneocuboid joint fusion. The double osteotomy technique provides symptomatic relief and lasting correction of the pes planovalgus deformity associated with stage 2 posterior tibial tendon insufficiency at intermediate follow-up. It has a high patient satisfaction based on the AOFAS ankle-hindfoot scale and radiographic measurements demonstrate maintenance of correction of the adult acquired flatfoot.

Where there's hope.

A young patient's account of her preoperative and postoperative experiences is recalled.

Modified lapidus procedure for the treatment of hypermobile hallux valgus.

The intermediate outcome of patients who underwent a modified Lapidus procedure for the treatment of hallux valgus secondary to a hypermobile first ray was evaluated with an outcome tool to determine if their pain and functional status were improved. We evaluated 31 feet in 26 patients who underwent a modified Lapidus procedure. All working patients (100%) returned to full-time work. Six patients were retired and one was unemployed prior to surgery. There was an average of eight months until sports or unlimited activities were performed, and an average 16 weeks until conventional shoes could be worn. All patients but one (96%) were satisfied with the surgery and knowing their results would have the surgery again. Postoperative pain relief satisfaction was totally satisfied in 19 patients, satisfied with reservations in six patients, and not satisfied in one patient. Postoperative appearance satisfaction was totally satisfied in 21 patients and satisfied with reservations in five patients. Postoperative joint motion was no noticeable stiffness in 22 patients, noticeable stiffness but not bothersome in three patients, and stiffness that impairs activity in one patient (two feet). In the radiographic measurements, there was an average improvement of 10 degrees in the hallux valgus angle, 10 degrees in the intermetatarsal angle, two degrees in the lateral metatarsal-floor angle and two grades in the sesamoid position. Complications experienced were five recurrent deformities, two metatarsalgias, and one deep vein thrombosis. One of the five recurrences became symptomatic and required a revision.

Medial impingement syndrome of the anterior tibiotalar fascicle of the deltoid ligament on the talus.

Eleven patients with medial impingement syndrome of the anterior tibio-talar fascicle (ATTF) of the deltoid ligament on the talus were identified. Six sustained inversion injuries, one talus and four ankle fractures. The mean preoperative Ankle-Hindfoot Scale (AHS) was 56 and the postoperative was 87. Surgical debridement of the ATTF was performed. A thickened ATTF and localized synovitis were seen. Talar osteophytes were removed in 8 patients. Mean follow up 4 years. Nine patients had good to excellent results and all patients returned to work.

Plantarflexion torque following reconstruction of Achilles tendinosis or rupture with flexor hallucis longus augmentation.

Nine patients treated surgically for Achilles tendon rupture (7 patients) or tendinosis (2 patients) with primary repair or debridement and augmentation with the flexor hallucis longus muscle-tendon unit were evaluated at a mean of 19 months postoperative. Subjective evaluation revealed a high level of satisfaction. All patients returned to work and only two patients reported limitation in their recreational activities. The mean post-operative AOFAS Ankle-Hindfoot Score was 90 points. Four patients reported mild occasional pain and one patient complained of moderate daily pain. Motion assessment showed a 20% increase in the hallux MTP dorsiflexion compared to the non-operative side (p = 0.045). No difference in ankle motion was noted. Cybex II+ dynamic evaluation of plantarflexion peak torque was complete on both extremities. The torque deficit on the reconstructed extremity was 20% (p = 0.01) at 120 degrees per second and 26% (p = 0.003) at 30 degrees per second. There is no significant difference between the torque deficit recorded for patients with Achilles rupture and those with Achilles tendinosis. A trend toward improved torque production with longer follow up was observed.

Osteoid osteoma of the lateral talar process presenting as a chronic sprained ankle.

Pathologic conditions of the lateral talar process may be difficult to diagnose using physical examination and roentgenographs. A computed tomography scan of the hindfoot is often useful to define lesions of the lateral process. We report a case of osteoid osteoma of the lateral talar process that defied diagnosis for 4 years. The patient had an antecedent history of an inversion injury, which had been treated as a chronically painful sprained ankle without resolution of symptoms. The tumor was ultimately identified on a computed tomography scan, best seen on a coronal section through the talus. The patient had complete relief of pain after excisional biopsy of the tumor.

Triple arthrodesis in adults using rigid internal fixation: an assessment of outcome.

The intermediate outcome of patients who underwent a triple arthrodesis for the treatment of adult foot disorders was evaluated with an outcome tool to determine if their pain and functional status were improved. We evaluated 63 feet in 57 patients who underwent a triple arthrodesis using rigid internal fixation for the treatment of hindfoot deformities associated with symptomatic arthrosis. Twenty-four men and thirty-three women, with an average age of 54 years, were evaluated. The average follow-up was 30 months. Multiple diagnoses contributed to hindfoot deformities with secondary arthrosis. Iliac crest bone graft was used in 56 of 63 cases (89%). Percutaneous heel cord lengthening was done in 53 of 63 cases (84%). Twenty-four of the thirty patients (80%) returned to work. Twenty-five patients were retired and two were unemployed before surgery. All patients except two (97%) were satisfied with the surgery and would have the surgery again. The average American Orthopaedic Foot and Ankle Society Ankle-Hindfoot preoperative score was 28 points, and the average postoperative score was 81 points (P < 0.0001). In the radiographic measurements, there was an average improvement of 12 degrees in the lateral talometatarsal angle, 7 degrees in the lateral talocalcaneal angle, and 10 degrees in the AP talometatarsal angle (P < 0.0001). Complications experienced included two varus malunions, two valgus malunions, two nonunions, two deep vein thromboses, one distal fibula stress fracture, and one wound infection. Of the 26 feet in 22 patients with mortise views available, 10 feet (38%) had evidence of ankle arthrosis and 19 feet (73%) had some degree of talar tilt postoperatively.

Excrescent lesion: a diagnosis of lateral talar exostosis in chronically symptomatic sprained ankles.

The excrescent lesion is a symptomatic anterolateral exostosis at the insertion of the anterior talofibular ligament. It is found in patients with chronic ankle pain after inversion injuries. It is most reliably diagnosed by computed tomography scan, but physical examination and oblique radiographs are suggestive in most cases. A technique for surgical excision and, in some cases, repair of the anterior talofibular ligament is described. Five patients having a history of inversion sprains of the ankle, without significant symptomatic improvement for a mean of 21 months after the injury, were evaluated. None had significant instability in the ankle or subtalar joints, clinically or with stress radiographs. The diagnosis of excrescent lesion was confirmed with computed tomography scan in all five patients. Each underwent excision of the exostosis. Removal of the exostosis produced laxity of the anterior talofibular ligament in four of the patients and required an additional modified Broström procedure to tighten the anterior talofibular ligament. Clinical results were evaluated at a mean of 33 months postoperatively, using the Ankle-Hindfoot scale from the American Orthopaedic Foot and Ankle Society. The three patients without pending claims for Workers' Compensation or related litigation all had excellent results (mean score, 93 points). Two patients with active legal claims had fair and poor results (mean score, 53 points).

Posterior tibial tendon insufficiency: diagnosis and treatment.

Posterior tibial tendon insufficiency is the most common cause of acquired adult flatfoot deformity. Although the exact etiology of the disorder is still unknown, the condition has been classified, on the basis of clinical and radiographic findings, into four stages. In stage I, there is no notable clinical deformity; patients usually present with pain along the course of the tendon and evidence of local inflammatory changes. Stage II is characterized by a dynamic deformity of the hindfoot. Stage III involves a fixed deformity of the hindfoot and typically also a fixed forefoot supination deformity but no obvious evidence of ankle abnormality. In stage IV, ankle involvement is secondary to long-standing fixed hindfoot deformities. The initial treatment of patients in any stage should be nonoperative, with immobilization, a nonsteroidal anti-inflammatory drug, and perhaps an orthotic device. Corticosteroid injections continue to be controversial. When nonoperative management fails, the treatment options consist of soft-tissue procedures alone or in combination with osteotomy or arthrodesis. Stage I insufficiency is generally treated with debridement and tenosynovectomy. Soft-tissue transfer does not appear to correct the underlying deformity in stage II disease; however, there is growing interest in joint-sparing operations that attempt to compensate for the underlying deformities with osteotomies or arthrodeses, supplemented with dynamic transfers to replace the insufficient posterior tibial tendon. Subtalar, double, or triple arthrodesis is the procedure of choice for stage III disease, frequently in conjunction with heel-cord lengthening. Tibiocalcaneal arthrodesis or pantalar arthrodesis is most commonly used to treat stage IV disease.

Clinical outcome of arthrodesis of the ankle using rigid internal fixation with cancellous screws.

Thirty consecutive patients underwent arthrodesis of the ankle using rigid internal fixation with cancellous screws between 1992 and 1996. One patient died of causes unrelated to the surgery before bony union. Primary fusion occurred in 27 of the remaining 29 patients (93%). The average time to primary union was 9 weeks. Two patients developed a delayed union and were treated with an additional bone-grafting procedure. Ultimately, each of the 29 patients went on to fusion. Use of tobacco during the postoperative period had no apparent effect on the rate of fusion or time to fusion. Twenty-five patients were available for clinical evaluation at an average of 24 months after surgery. Subjective evaluation using questionnaires revealed a high level of satisfaction. All patients stated that they would undergo the procedure again. The mean postoperative score on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale was 81 points, compared with 48 points preoperatively (of a possible 100). Constant pain was the reason given by all patients for seeking treatment. After the arthrodesis, pain was reported as absent in 13 and occasional in 12 patients. All patients noted less pain in the hindfoot after fusion of the ankle. Active litigation and Workers' Compensation claims during the perioperative period had a significant negative effect on scores on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale and seemed to decrease patients' perceived ability to return to work.

Osteotomy for malunion of a talar neck fracture: a case report.

A malunion of the talar neck after a Hawkins type II fracture/dislocation of the talar neck occurred in a 34-year-old man after nonoperative treatment. Rigid varus deformity of the forefoot was a source of severe pain and disability in this patient. We describe our surgical technique for osteotomy of the talar neck with insertion of a tricortical iliac crest bone graft to correct the deformity. At follow-up (56 months), the patient had consistent relief of pain and was employed at his preinjury job doing heavy labor. The score on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale improved from 11 points, preoperatively, to 85 points, postoperatively. Radiographs showed maintenance in the position of the osteotomy and no evidence of avascular necrosis in the talar body. Evidence of arthrosis of the talonavicular joint was apparent radiographically, but the patient did not complain of symptoms referable to this area.

Pathoanatomy and etiology of posterior tibial tendon dysfunction.

Posterior tibial tendon dysfunction is a cause of painful acquired flatfoot in adults. It is associated with progressive collapse of the medial longitudinal arch, hindfoot valgus, and forefoot abduction deformities. The clinical manifestations and surgical treatment have been well documented in the literature. Epidemiologic studies have not shown any clear predisposing factors to the disease. Numerous etiologies have been proposed to explain the clinical evidence of tendon degeneration found at the time of surgery including trauma, anatomic, mechanical inflammatory, and ischemic factors. Although previously thought to be secondary to an inflammatory process resulting in acute and chronic tendinitis, more recent histopathologic evidence has revealed a degenerative tendinosis with a nonspecific reparative response to tissue injury characterized by mucinous degeneration, fibroblast hypercellularity, chondroid metaplasia, and neovascularization. These pathologic changes result in marked disruption in collagen bundle structure and orientation. This may compromise the tendon and predispose it to rupture under physiologic loads. However, it cannot be determined whether these changes precede or postdate posterior tibial tendon dysfunction. It seems that there are many contributing factors to the etiology of posterior tibial tendon dysfunction all culminating in a common disease process with resulting tendon degeneration and an insufficient repair response.

Great toe neuroarthropathy: a report of two cases.

Two cases of diabetic neuroarthropathy of the great toe are presented. The differential diagnosis is emphasized, and the literature regarding this unusual site for symptomatic disease is reviewed.