Category: Ankle, Arthroscopy, Hindfoot, Sports Introduction/Purpose: Posterior ankle/hindfoot arthroscopy (PAHA) is an established surgical option for treating pathologies, of posterior ankle and subtalar joints, which otherwise would require open incisions. Arthroscopic procedures are less invasive, provide magnified visualization and allow earlier rehabilitation and return to activity. Many studies have reported outcomes after PAHA, however only two studies have reported complications in larger cohorts. Although posterior ankle impingement (PAI) is a common indication for PAHA, it is a non-specific diagnosis. The aims of our study are 1) to report the complications after posterior ankle arthroscopy. 2) Delineate the structures involved in PAI into zones based on arthroscopic findings including bone impingement from the talus or tibia, soft tissue impingement from the PITFL, PTFL, inter-malleolar ligament, posterior deep deltoid ligament and synovitis. Methods: We reviewed the chart for demographic details, diagnosis, arthroscopic findings, and complications in a consecutive series of 250 PAHA in 237 patients (94 males,143 females, mean age 34.3 years) who had surgery between 2008 and 2016 and excluded those who had Haglund excision. The indications were PAI (95 ankles), subtalar arthritis/coalition/nonunion(21/12/5), flexor hallucis longus (FHL) stenosis/tenosynovitis/contracture(22/9/5), osteochondral lesions(14), and others(14)(Table 1A). There were 67 ankles with PAI and at least one other coexisting condition. For patients with PAI, we catalogued the specific anatomic etiologies of impingement. To investigate a priori factors predictive of neurological complication after PAHA, unadjusted and multivariable regression techniques were utilized. Sparse events sensitivity analysis was tested by fitting models with Firth log-likelihood approach; penalizing estimates for first-order bias correction and stability of regression coefficients. To control for clustering of outcomes across surgeons (n=3), estimates were assessed by fitting the primary log-binomial model with generalized estimating equation. Results: Complications: sensory nerves (10) (5 tibial/branches, 5 sural), portals (4) (painful/nodular (1), draining>1week (3)). Achilles pain (1) DVT (1). Nerve symptoms after 6 months (3) had; transection of the sural nerve (1), sural neurolysis (1) or tarsal tunnel release (1). (Table 1B) In unadjusted analysis, advancing age (OR: 1.04; p=0.029) and accessory portal (OR: 15.64; p<0.001) were associated with neurological complication. In multivariable regression models controlled for confounders, accessory posterolateral portal usage (OR:12.37; 95% CI: 3.11-49.27; p<0.001) was the most significant driver for neurological complication after PAHA. No significant correlation exists between neurological complications and surgical duration, surgeon, tourniquet time, BMI, FHL release. There were 162 ankles treated for PAI +/- associated conditions. PAI etiologies were grouped into: posterior, posteromedial, posterolateral, subtalar, and combined zones. Conclusion: This study supports the safety of posterior ankle/hindfoot arthroscopy for the treatment of numerous pathologies with an overall complication rate of 6.4% (16/250). There were no infections, motor nerve or vascular injuries. Complications included sensory nerve symptoms in 10 patients (4%), of which three (1.2%) did not improve and required further treatment. One patient developed DVT which required further treatment. The common pathologies of impingement were able to be grouped into zones that can correlate with physical examination (Table 1C). The ability to visualize the structures with the arthroscope provides greater magnification, detail and precision in the treatment.
Lateral unicompartmental knee arthroplasty (UKA) is an excellent option to alleviate disability and restore function in patients with lateral compartment knee osteoarthritis (OA). The purpose of the present study was to determine the survivorship and long-term outcomes in both younger/middle-aged and older patients with lateral compartment OA following non-robotically-assisted, fixed-bearing lateral UKA and to determine if an acceptable symptom state can be achieved.All patients were managed with fixed-bearing lateral UKA by a single surgeon utilizing a lateral parapatellar approach without robotic assistance. The primary outcome variables were the Knee injury and Osteoarthritis Outcome Score (KOOS) Activities of Daily Living (ADL) and Sport subscale scores. In addition, the other KOOS subscores, the Lysholm score, the achievement of the Patient Acceptable Symptom State (PASS), and the Veterans RAND (VR-12) Physical Component Summary score (PCS) and Mental Component Summary score (MCS) were collected. Failure was defined as conversion to total knee arthroplasty (TKA). Patients were divided into 2 cohorts: younger/middle-aged patients (<60 years of age) and older patients (≥60 years of age).A cohort of 256 patients underwent medial (n = 193) or lateral (n = 63) UKA. Sixty-one patients met the inclusion criteria. At mean of 10 years (range, 4 to 17 years) of follow-up, there were no significant differences between the groups in terms of any patient-reported outcome measures (p > 0.05). The percentage of patients in whom PASS was achieved on the KOOS ADL and Sport subscores was 82% and 88%, respectively, in the younger cohort and 80% and 80%, respectively, in the older cohort. The mean survival estimate of the prothesis was 15.3 years (95% confidence interval [CI], 14.5 to 16.2 years) for the entire cohort. The estimated rate of implant survival in the younger cohort was 100% at 5 and 10 years, and the estimated rate of implant survival in the older cohort was 98% at 5 years and 96% at 10 years.Lateral fixed-bearing, non-robotic UKA for the treatment of isolated lateral compartment OA resulted in >80% of patients reaching an acceptable symptom state in terms of both activities of daily living and sporting activities. UKA provides an excellent option that provides longevity with high PASS rates and return to activities with a low risk of complications and failure.Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
Category: Ankle, Basic Sciences/Biologics Introduction/Purpose: Until recently, many regional anesthetic blocks were performed without the assistance of ultrasound, relying on methods such as anatomical landmarks and nerve stimulation. The use of ultrasound for peripheral nerve blocks has proven extremely useful for improving the efficacy of many regional anesthetic techniques. There remain a few nerve blocks which have lagged in employing the assistance of ultrasound consistently, one of which is the ankle block. This block is commonly utilized for either surgical anesthesia or post-operative analgesia for a variety of foot and ankle procedures. In this study, we compared the accuracy of traditional landmark technique with an ultrasound guided approach for ankle block by assessing the spread of injectate (dye) along the posterior tibial nerve (PTN) in cadaver models. Methods: Ten below-knee cadaver specimens were used for this study. Five were randomly chosen to undergo landmark guided PTN blocks, and five were selected for ultrasound-guided PTN blocks. The landmark technique was performed by identifying the medial malleolus and Achilles tendon and inserting the needle (4 cm long, 21G Braun® Stimuplex) at the midpoint of the two structures, aiming toward the medial malleolus and advancing until bone was contacted. 2 cc of blue acrylic dye was injected at this location. The ultrasound technique was performed with a linear probe identifying the medial malleolus and the PTN. The needle was advanced in-plane with a posterior to anterior trajectory until the tip of the needle was adjacent to the nerve. 2 cc of blue acrylic dye was injected surrounding the nerve. The extremities were then dissected to determine which nerves had been coated with dye. Results: 100% of the ultrasound guided blocks resulted in completely stained PTN with dye. In the landmark group, only 40% of the landmark technique blocks resulted in completely stained PTN with dye. Of the nerves not stained with dye, 2 were noted to have had dye injected posterior to the nerve and 1 was noted to have had dye injected into the flexor digitorum longus tendon. Conclusion: The base of evidence has dramatically increased in recent years in support of the use of ultrasound in regional anesthesia. This study substantiates the superiority of ultrasound guidance for ankle block by demonstrating a 100% success rate amongst the ultrasound guided group.
Background Pathologic conditions of the sesamoids can be a source of disabling pain for patients, particularly during toe-off. Some underlying causes include osteonecrosis, inflammation, arthritis, and fracture. Nonoperative treatment is the initial standard of care, and has demonstrated satisfactory outcomes overall; however, operative management may be indicated in cases of pain refractory to conservative management. Sesamoidectomy is an uncommon procedure with risk of potential complications, but may be warranted in select cases of failed nonoperative treatment. Methods A retrospective chart review was conducted at one institution from 2009 to 2018. Twelve patients diagnosed with fibular sesamoiditis were treated with sesamoidectomy. Baseline patient demographics as well as postoperative outcomes were recorded. Results All 12 patients underwent fibular sesamoidectomy using the plantar approach following which their symptom (pain) resolved. Average follow-up for this cohort was 35 months. Of the sample, two patients experienced transient neuritis, one patient developed a superficial infection, and one had painful postoperative scarring. Hallux varus deformity was not observed in any patients. Conclusion Fibular sesamoidectomy may be a safe, viable procedure for patients with sesamoiditis who fail conservative measures.
Background Surgical approach is known as a risk factor that influences cup malposition while performing total hip arthroplasty (THA). However, no study has been conducted comparing cup positioning between the supine direct anterior (DA) and supine direct lateral (DL) THA approaches. Questions/Purposes (1) Is there a difference in acetabular cup positioning between supine DA and supine DL THA approaches? (2) Are there differences in complications based on acetabular cup positioning between the two approaches? Methods From 2012 to 2014, 186 patients who underwent primary THAs using DA approach were matched with 186 patients using DL approach by body mass index, age, and gender. Cup anteversion and abduction angles were measured from standing anteroposterior pelvis radiographs by two blinded observers. The Lewinnek safe zone was used as the standard for cup positioning. Cup anteversion, abduction angles, and complications were recorded and compared. Results Cup anteversion was on average 3° higher in the DA approach compared to the DL approach. The abduction angle for the DA approach was equivalent to the DL approach both averaging 46° to 47°. There were more DA hips outside of the safe zone (10%) for anteversion than DL (3%) hips. There were no differences in complications between DA and DL approaches. Conclusion There is a tendency to antevert the acetabular cup when performing THAs using the DA approach, and one must be mindful of this when implanting the acetabular component.
Retained bullets in joint spaces have been shown to cause both mechanical and chemical damage to the joint surfaces, leading to the risk of arthritis if untreated.A case of arthroscopic treatment for a gunshot to the shoulder with a retained bullet embedded in the glenoid is presented. The patient presented with multiple gunshots to his back and extremities, including gunshot to the left leg with popliteal vein injury, gunshot to the back with lumbar level laminar fractures and acute spinal cord injury, and gunshot to the left shoulder with a retained bullet in the posterior superior glenoid.Shoulder arthroscopy can be successfully employed to retrieve larger embedded bullet or foreign body with the help of tools such as laparoscopic graspers. Even with significant glenoid bone defect, the stability of the shoulder joint does not get compromised if the bone defects are located posterosuperiorly.
The use of posterior ankle and hindfoot arthroscopy (PAHA) has been expanding over time. Many new indications have been reported in the literature. The primary objective of this study was to report the rate of PAHA complication in a large cohort of patients and describe their potential associations with demographical and surgical variables.In this IRB-approved retrospective comparative study, patients who underwent posterior ankle and/or hindfoot arthroscopy in a single institution from December 2009 to July 2016 were studied. Three fellowship-trained orthopaedic foot and ankle surgeon performed all surgeries. Demographic data, diagnosis, tourniquet use, associated procedures, and complications were recorded. To investigate a priori factors predictive of neurologic complication after PAHA, univariate and multivariable logistic regression was utilized. Where appropriate, sparse events sensitivity analysis was tested by fitting models with Firth log-likelihood approach.A total of 232 subjects with 251 surgeries were selected. Indications were posterior ankle impingement (37%), flexor hallux longus disorders (14%), subtalar arthritis (8%), and osteochondral lesions (6%). Complications were observed in 6.8% (17/251) of procedures. Neural sensory lesions were noted in 10 patients (3.98%), and wound complications in 4 ankles (1.59%). Seven neurologic lesions resolved spontaneously and 3 required further intervention. In a multivariable regression model controlled for confounders, the use of accessory posterolateral portal was the significant driver for neurologic complications (odds ratio [OR] 32.19, 95% CI 3.53-293.50).The complication rate in this cohort that was treated with posterior ankle and/or hindfoot arthroscopy was 6.8%. Most complications were due to neural sensorial injuries (sural 5, medial plantar nerve 4, medial calcaneal nerve 1 ) and 3 required additional operative treatment. The use of an accessory posterolateral portal was significantly associated with neurologic complications. The provided information may assist surgeons in establishing diagnoses, making therapeutic decisions, and instituting surgical strategies for patients that might benefit from a posterior arthroscopic approach.Level III, retrospective comparative study.
Background: Orthopedic surgery is considered among the highly competitive medical specialties to get in as a career in the United States. San Francisco Match (SF Match) is the matching service for orthopedic subspecialty fellowship programs, and the internet is the main source for applicants to obtain program information in the modern era. We aimed to determine and compare the accessibility, content, and accreditation details of the various orthopedic fellowship programs available at the Match website and alternative online resources. Methods: We studied eight subspecialties (Adult Reconstruction, Musculoskeletal Oncology, Foot and Ankle, Pediatric Orthopedics, Shoulder and Elbow, Orthopedic Spine Surgery, Sports Medicine, and Trauma) in a cross-sectional design during August/September 2019 for programs starting in July/August 2021. We registered the available baseline information at the SF Match site under various categories. We tried to reach the program-specific webpage through SF Match hyperlink and categorized our results into successful (direct and indirect) links and unsuccessful links with subcategorization. We also analyzed the information available at sponsoring society, FREIDA (Fellowship and Residency Electronic Interactive Database), and ACGME (Accreditation Council for Graduate Medical Education) websites. Result: We analyzed 465 programs (874 positions) available through the SF Match website. A standardized program description was available for >80% of the programs in each subspecialty. The availability of a successful link for the program-specific webpage ranges from 35% (Pediatric Orthopedics) to 77% (Sports Medicine). Indirect links were almost twice as common as direct links. The success rates through the sponsoring society webpages vary from 3% (Shoulder and Elbow) to 53% (Pediatric Orthopedics). Failure rates after trying both (the Match and Society links) range from 10% (Musculoskeletal Oncology) to 34% (Shoulder and Elbow). FREIDA provides comprehensive information but is limited to accredited programs. ACGME accreditation rate varied from 14.6% (Foot and Ankle) to 98.9% (Sports Medicine). Conclusion: The selection of a subspecialty fellowship program is crucial for most applicants. There are plenty of resources for the orthopedic fellowship programs' online presence after two decades since the first orthopedic fellowship match inception. Match website is the primary resource for the applicants. All parties could be benefited if both the programs and the sponsoring societies offer adequate online information to the Match, leading to ideal fellow-program matches and improved educational experiences. Our study may stand as a reference for future comparison possibly due to post-COVID evolution in the Match process. We recommend that consistent availability of direct functional program website links, point-based program description, and filter/comparison options may further improve online accessibility and quality of the content of the Match website.
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