Christopher W. Reb

Selective Early Hospital Discharge Does Not Increase Readmission but Unnecessary Return to the Emergency Department Is Excessive Across Groups After Primary Total Knee Arthroplasty

BACKGROUND There has been much attention paid to the ability to optimize outcomes, limit complications, and reduce costs within the episode of care after total joint arthroplasty. Limiting the duration of postoperative hospitalization as well as reducing emergency department (ED) visits and readmissions are additional considerations in the paradigm of cost containment. Our purpose was to evaluate the safety of early hospital discharge after primary total knee arthroplasty (TKA) and to identify the diagnoses responsible for ED visits and readmissions in the postoperative period. METHODS We investigated risk factors for readmission in 995 patients undergoing primary TKA. We compared 2 groups: length of hospital stay (LOS) ≤2 or ≥3 days. Analysis included LOS, Charlson score, history of DVT, discharge disposition, and postdischarge ED visits. RESULTS Patients who stayed ≤2 postoperative days had a significantly lower mean Charlson score and more likely discharged home. Charlson score and history of DVT were predictive of return events. Patients discharged to home were less likely to have return events. More than half of the patients evaluated in the ED were not readmitted. CONCLUSION Among patients undergoing primary TKA, it is the health of the patient, and not their resultant LOS, that correlates to return events. The ED is overused for complaints that may otherwise be managed as effectively and more cost efficiently in outpatient settings. Cost containment must include unnecessary utilization of the ED.

Diagnosis and Management of Plantar Fasciitis

Plantar fasciitis, a chronic degenerative process that causes medial plantar heel pain, is responsible for approximately 1 million physician visits each year. Individuals with plantar fasciitis experience pain that is most intense during their first few steps of the day or after prolonged standing. The authors provide an overview of the diagnosis and management of a common problem encountered in the primary care setting. Routine imaging is not initially recommended for the evaluation of plantar fasciitis but may be required to rule out other pathologic conditions. Overall, plantar fasciitis carries a good prognosis when patients use a combination of several conservative treatment modalities. Occasionally, referral to a specialist may be necessary.

Driving After Hallux Valgus Surgery

Background: The purpose of the study was to determine when patients can safely return to driving after first metatarsal osteotomy for hallux valgus correction. Methods: After institutional review board approval, 60 patients undergoing right first metatarsal osteotomy for hallux valgus correction surgery were recruited prospectively. Patients’ brake reaction time (BRT) was tested at 6 weeks and repeated until patients achieved a passing BRT. A control group of twenty healthy patients was used to establish as passing BRT. Patients were given a novel driver readiness survey to complete. Results: At 6 weeks, 51 of the 60 patients (85%) had BRT less than 0.85 seconds and were considered safe to drive. At 6 weeks, the passing group average was 0.64 seconds. At the 8 weeks, 59 patients (100%) of those who completed the study achieved a passing BRT. Patients that failed at 6 weeks had statistically greater visual analog scale (VAS) pain score and diminished first metatarsophalangeal (MTP) range of motion (ROM). On the novel driver readiness survey, 8 of the 9 patients (89%) who did not pass disagreed or strongly disagreed with the statement, “Based on what I think my braking reaction time is, I think that I am ready to drive.” Conclusion: Most patients may be informed that they can safely return to driving 8 weeks after right metatarsal osteotomy for hallux valgus correction. Some patients may be eligible to return to driving sooner depending on their VAS, first MTP ROM, and driver readiness survey results. Level of Evidence: Level II, comparative study

Tibialis Anterior Tendon Reconstruction Using Augmented Half-Thickness Tendon Segment Transposition

Tibialis anterior tendon rupture causes substantial morbidity. The present study describes the outcomes of augmented, half-thickness tibialis anterior tendon segment transposition, a novel reconstruction technique. This was an institutional review board–approved retrospective review of 3 patients with surgically treated attritional distal rupture with 1-year follow-up. The postdebridement tendon defect prohibited primary repair and was managed by distal transposition of a half-thickness healthy segment. This repair was augmented with human acellular dermal matrix allograft (Graftjacket, Wright Medical Technology, Memphis, TN). The mean age was 68 years (range, 59-73 years). Mean interval between injury and surgery was 59.3 days (range, 15-146 days). All patients regained symmetrical range of motion, motor power, and the ability to heel walk. Mean pain scores improved from 4.6 (range, 2.5-8.5) preoperatively to 0.7 (range, 0-2) postoperatively. Mean Foot and Ankle Ability Measure scores increased from 30.6 (range, 23.8-43.8) preoperatively to 78.7 (range, 72.6-97.6) postoperatively. No postoperative complications occurred. One patient was satisfied and 2 were very satisfied with their outcome. Although limited, the present findings appear to indicate that this technique produces short-term clinical results comparable to those described for other techniques for tibialis anterior tendon reconstruction. Levels of Evidence: Therapeutic, Level IV

Predicting Failure of Nonoperative Treatment for Insertional Achilles Tendinosis

Nonoperative treatment for midportion Achilles tendinosis is well defined by the literature. Multiple modalities are described for the management of insertional Achilles pathology, but no consensus exists regarding efficacy. Surgical intervention for insertional Achilles tendinosis (IAT) is successful greater than 80% of the time. Our objective was to risk stratify patients who would fail nonsurgical management of IAT and thus benefit progressing to surgery. We reviewed the records of 664 patients with IAT. The cohort was 53% male and 80% obese. Mean age was 53.7 years (standard deviation 14.7 years). Average duration of symptoms was 10.4 months (standard deviation 28 months). Of the parameters collected, 4 were found to correlate with failing nonoperative treatment: visual analog scale, limited ankle range of motion, previous corticosteroid injection, and presence of Achilles tendon enthesophyte. We found that as the number of risk factors increased so did the chance of failing nonoperative treatment. With all 4 parameters, chance of failing conservative treatment was only 55%. Thus, nonoperative management should be exhausted until surgery is the only remaining option. However, the presence of one of the aforementioned risk factors can aid a surgeon in the decision to pursue surgery in the appropriate clinical scenario. Levels of Evidence: Level IV: Retrospective Case series

Clinical Adaptation of the "Tibiofibular Line" for Intraoperative Evaluation of Open Syndesmosis Reduction Accuracy: A Cadaveric Study.

Background: The “tibiofibular line” is a new axial computed tomography parameter for assessing syndesmosis reduction, which references the flat anterolateral surface of the fibula and anterolateral tibial tubercle. These same bony landmarks are easily visualized via a lateral approach to the fibula. This cadaveric study assessed the practical aspects of measuring the tibiofibular line intraoperatively. Methods: Three observers simulated the tibiofibular line using operative rulers in 3 measurement series utilizing 10 cadaveric specimens: intact syndesmosis, syndesmosis reduction, and fixation after application of lateral plate and screws to the fibula, and post syndesmosis reduction and fixation without plate and screws. Results: The majority (78%) of clinical tibiofibular line measurements were within the “normal” range (0-2 mm). However, there was a general trend toward malreduction (>2 mm) across measurement series. Intraobserver variability ranged from poor to excellent (intraclass correlation range, 0.12-0.85, Fleiss kappa range, 0.19-0.40) and interobserver reliability was only generally in the fair range (intraclass correlation range, 0.49-0.61; Fleiss kappa range, 0.19-0.40). Conclusion: Taken as a whole, these findings found that the technique was feasible but clearly indicated that further refinement of this protocol, including the use of computed tomography, would be needed to determine if better control of confounding variables would reveal better observer reliability. Clinical Relevance: The CT-based TFL technique for syndesmosis reduction assessment could not reliably be translated into an intraoperative open technique because of the confounding effects of subjectivity and operator error.

High Prevalence of Obesity and Female Gender Among Patients With Concomitant Tibialis Posterior Tendonitis and Plantar Fasciitis

The link between increased body weight and hindfoot complaints is largely based on correlation to single foot pathology. We retrospectively reviewed 6879 patients with tibialis posterior tendonitis (TPT), plantar fasciitis (PF), or both. Among patients with either TPT or PF, 1 in 11 (9%) had both. We then compared age, gender, and body mass index among these groups. Patients with both diagnoses were neither statistically older nor more obese than patients with single diagnoses. However, they were statistically more female. Given the overall high prevalence of obesity in the study population, we feel these data support the link between obesity and multiple foot pathology. Levels of Evidence: Prognostic, Level IV: Case series

Acute Postoperative Bisphosphonate-Associated Atypical Periprosthetic Femoral Fracture

Periprosthetic bisphosphonate-associated atypical femoral fractures (AFFs) are rare1,2. Recent reports illustrate the need to consider AFF as a cause of hip pain in osteoporotic patients who have been treated with bisphosphonates and have undergone total hip arthroplasty1,3. We report the case of an atraumatic nondisplaced bisphosphonate-associated AFF that manifested three weeks after primary total hip arthroplasty. Retrospective review of the preoperative images showed subtle cortical hypertrophy at the lateral subtrochanteric cortex. By the three-week postoperative visit, the lesion had rapidly progressed to a unicortical fracture. This was treated with immediate femoral revision with a long-stemmed component that achieved fixation distal to the fracture. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A seventy-four-year-old woman with postmenopausal osteoporosis had presented with severe chronic groin pain, reproducible on physical examination of the hip, and radiographic evidence of severe osteoarthritis of the left hip. An intra-articular cortisone injection three months prior to presentation had resulted in short-term pain resolution. The patient had undergone elective total hip arthroplasty, which was performed through a modified Hardinge approach, with use of a cementless proximally fitting tapered stem. Postoperatively, the patient had walked well with a rolling walker during physical therapy sessions, and she had required only intermittent oral opioids for pain control. At the three-week follow-up visit, she reported progressively worsening left thigh pain with weight-bearing. Radiographs demonstrated anterolateral femoral cortical thickening with transverse lucency at the distal third of an otherwise stable femoral prosthesis (Fig. 1). Retrospective review of the preoperative and immediate postoperative radiographs revealed subtle anterolateral subtrochanteric femoral cortical thickening without transverse lucency, which had previously been unrecognized (Figs. 2-A and 2-B). Fig. 1 Three-week postoperative anteroposterior left hip radiograph showing the thickened lateral diaphyseal cortex …

Beaming in Charcot Arthropathy—Intramedullary Fixation for Complicated Reconstructions: A Cadaveric Study

ABSTRACT In the modern treatment of Charcot neuroarthropathy, beam screw fixation is an alternative to plate and screw fixation. Exposure is minimized for implantation, and this technique supports the longitudinal columns of the foot as a rigid load‐sharing construct. A published data review identified a paucity of data regarding metatarsal intramedullary canal morphology relevant to beam screw fixation. The purpose of the present study was to describe metatarsal diaphyseal morphology qualitatively and quantitatively in an effort to provide data that can be used by surgeons when selecting axially based intramedullary fixation. Twenty fresh‐frozen cadaveric below‐the‐knee specimens were obtained. The metatarsals were exposed, cleaned of soft tissue, and axially transected at the point of the narrowest external diameter. Next, a digital caliper was used to measure the size and shape of the diaphysis of the first through fourth metatarsals. The diaphyseal canal shape was categorized as round, oval, triangular, or pear. The widest distance between the endosteal cortical surfaces was measured. Triangular endosteal canals were only found in the first metatarsal, and the remainder of the metatarsal canals were largely round or oval. These data help to approximate the size of fixation needed to achieve maximal screw–endosteal purchase. &NA; Level of Clinical Evidence: 5

Experience with Navigation in Total Ankle Arthroplasty. Is It Worth the Cost

Optimal placement of correctly sized total ankle replacement (TAR) implants is elemental to prolonging the working life. The negative mechanical effects of implant malalignment are well characterized. There is one FDA-approved navigated TAR system with limited but encouraging outcomes data. Therefore, its value can be estimated only based on benefits other than a proven clinical outcomes improvement over conventional systems. These include unique preoperative planning through 3-dimensional templating and virtual surgery and the patient-specific cut guides, which also reduce overall instrumentation needed for the case. To better inform this conversation, well-observed longitudinal outcomes studies are warranted.