Eva Lehtonen

The surgical anatomy of the dorsal scapular nerve: a triple-tendon transfer perspective

BACKGROUNDnIatrogenic or traumatic injury to the spinal accessory nerve is a rare but debilitating injury. An effective treatment, known as the Eden-Lange modification triple-tendon transfer procedure, involves the transfer of the rhomboid major (RM), rhomboid minor (Rm), and levator scapulae (LS). Careful detachment of their insertions is necessary to avoid injury of the dorsal scapular nerve (DSN). This study evaluated the surgical anatomy and safety of the DSN relative to this procedure.nnnMETHODSnThe study used 12 cadavers (22 shoulders). The RM, Rm, and LS were detached from their insertions, and the DSN was dissected. Measurements were taken to evaluate the anatomy of each relative to the triple-tendon transfer procedure. Additional measurements were taken to identify danger zones for DSN injury, regarding detachment of RM, Rm, and LS from their respective insertions.nnnRESULTSnMeasurements of the 22 shoulders included in the study showed wide variation in anatomy. The minimum distance between the scapula and the DSN at the vertebral scapular border was 0.7u2009cm, suggesting that care and precision are needed to perform this technique. The region where the DSN crosses the superior border of the Rm was shown to be the greatest danger zone of this technique, with a mean distance to the scapula of 1.61u2009±u20090.53u2009cm CONCLUSIONS: This study provides insight into the surgical anatomy of the DSN relative to a rare but successful procedure used to treat trapezius paralysis. The results of this study can inform the surgeon regarding potential anatomic considerations when performing the triple-tendon transfer.

Incidence of Venous Thromboembolism in Orthopaedic Foot and Ankle Surgeries

Category: Other Introduction/Purpose: Venous thromboembolism (VTE) is a rare but potentially lethal complication following orthopaedic foot and ankle surgery. Surgeons continue to debate the types of patients and procedures in which it is appropriate to use chemical thromboprophylaxis. A recent meta-analysis concluded that patients at high risk for VTE after foot and ankle surgery should receive prophylaxis, but there remains a paucity of data to elucidate which demographic or comorbidity variables are most strongly associated with development of VTE. The incidence of VTE after orthopaedic foot and ankle surgery stratified by specific procedure has yet to be examined. The purpose of this study is to report the incidence of and identify risk factors for VTE in a large sample of patients receiving orthopaedic foot and ankle surgery. Methods: In this study, we retrospectively analyzed prospectively-collected data from the National Surgical Quality Improvement Program (NSQIP) 2006 to 2015 data files. The incidence of VTE was calculated for 30 specific orthopaedic foot and ankle surgeries and for four broad types of foot and ankle surgery. A total of 23,212 patients were identified and grouped by current procedures terminology (CPT) codes. Demographic, comorbidity, and complication variables were analyzed to determine associations with development of VTE. Pearson’s chi-squared test was used to compare categorical variables and Student t test was used to compare continuous variables. P-values of p<0.05 were considered statistically significant. Multivariable modelling was not possible due to the very low number of VTE cases relative to non-VTE cases. Results: The mean age at the time of surgery was 52.7±17.8 years. VTE events were documented 142 times in our sample, yielding an overall sample VTE incidence of 0.6%. The types of procedures with the highest frequency of VTE were ankle fractures (105/15,302 cases, 0.7%), foot pathologies (28/5,466, 0.6%), and arthroscopy (2/398, 0.5%). Female sex, increasing age, obesity level, inpatient status, and non-elective surgery were all significantly associated with VTE events. Postoperative pneumonia was significantly associated with VTE development. Patients who developed a VTE stayed at the hospital after surgery significantly longer than patients without VTE (6.2 vs. 3.1 days). Patients who developed VTE also had significantly higher estimated probability of morbidity (8.0% vs. 6.0%) and mortality (2.0% vs. 1.0%) when compared to patients without VTE. Conclusion: The present study confirms that VTE events after foot and ankle procedures are rare. The data presented suggest that female sex, increasing age, higher BMI, inpatient status, and non-elective procedures are associated with increased risk for VTE after orthopaedic foot and ankle surgery. Prospective, randomized, controlled trials are necessary to definitively determine the efficacy of chemoprophylaxis and to develop evidence-based clinical practice guidelines to minimize VTE after foot and ankle procedures.

Postoperative Tourniquet Pain in Patients Undergoing Foot and Ankle Surgery

Category: Other Introduction/Purpose: The tourniquet is commonly used in orthopedic surgeries on the upper and lower extremities to reduce blood loss, improve visualization, and expedite the surgical procedure. However, tourniquets have been associated with multiple local and systemic complications, including postoperative pain. Guidelines vary regarding ideal tourniquet pressure and duration, while the practice of fixed, high tourniquet pressures remains common. The relationship between tourniquet pressure, duration, and postoperative pain has been studied in various orthopaedic procedures, but these relationships remain unknown in foot and ankle surgery. The purpose of this study was to assess for correlation between excessive tourniquet pressure and duration and the increased incidence of tourniquet pain in foot and ankle surgery patients. Methods: Retrospective chart review was performed for 132 adult patients who underwent foot and ankle surgery with concomitant use of intraoperative tourniquet at a single institution between August and December of 2015. Patients with history of daily opioid use of 30 or more morphine oral equivalents for greater than 30 days, patients who underwent foot and ankle surgery without regional nerve block, patients deemed to have failed regional nerve block, and patients who underwent foot and ankle surgery without tourniquet use were excluded. Patient’s baseline systolic blood pressure, tourniquet pressure and duration, tourniquet deflation time, tourniquet reinflation pressure and duration, intraoperative blood pressure and heart rate changes, intra-operative opioid consumption, PACU pain scores, PACU opioid consumption, and PACU length of stay were collected. Statistical correlation between tourniquet pressure and duration and postoperative pain scores, pain location, narcotic use, and length of stay in PACU was assessed using linear regression in SPSS. Results: Average age of patients was 47.6 years (Range: 16 - 79). Tourniquet pressure was 280 mmHg in 90.6% of patients (Range: 250-300 mmHg). Only 3.8% percent of patients had tourniquet pressures 100-150 mmHg above systolic blood pressure. Mean tourniquet time was 106.2 ± 40.1 min. Tourniquet time showed significant positive correlation with morphine equivalents used in the perioperative period (N = 121; r = 0.406; p < 0.001). Long tourniquet times (= 90 minutes) were associated with greater intraoperative opioid use than short tourniquet times (= 90 minutes) (19 mg ± 22 mg vs. 5 mg ± 11.6 mg; p <0.001). Tourniquet duration and PACU length of stay had a positive association (R2 = 0.4). Conclusion: The majority of cases of foot and ankle surgery at our institution did not adhere to current tourniquet use guidelines, which recommend tourniquet pressure between 100 and 150 mmHg above patient’s systolic blood pressure. Prolonged tourniquet times at high pressures not based on limb occlusion pressure, as observed in our study, lead to increased pain and opioid use and prolonged time in PACU. Basing tourniquet pressures on limb occlusion pressures could likely improve the safety margin of tourniquets, however randomized studies need to be completed to confirm this.

Postoperative infection in foot & ankle surgery: does the season matter?

Category: Other Introduction/Purpose: Surgical site infections (SSI) are infections of the incision site, organ, or space at or near the surgical incision within 30 days of the procedure or within 90 days for prosthetic implants. Being the most common nosocomial infection, SSI’s are a burden to the healthcare system as they increase costs, duration of stay, antimicrobial resistance, morbidity, and mortality. While there is limited evidence in the orthopaedic literature suggesting that the incidence of SSI increases during the summer months, this association has not been examined in the setting of foot and ankle surgery. The purpose of this study was to determine whether seasonal variation plays a role in developing SSI’s after orthopaedic foot and ankle surgery. Methods: Data from the National Surgical Quality Improvement Program (NSQIP) years 2011-2015 were used in this study. The pooled and individual incidences of superficial incisional SSI, deep SSI, and organ space SSI were calculated and stratified by quarter of admission. The quarters of admission represent the various seasons (1=winter, 2=spring, 3=summer, 4=fall). Differences in the incidence of SSI as well as various demographic, comorbidity, and complication variables were evaluated using ANOVA for continuous variables and Pearson’s Chi-Square for categorical variables. Results: A total of 17,939 patients were identified. After pooling the superficial, deep, and organ space infections, the overall SSI rate was highest in the summer months (July-September, 3rd quarter) at 2.68% as compared to 2.20%, 2.33%, and 2.14% in the other respective quarters (p=0.338). There was a total of 218 cases of superficial incisional SSI. The summer months had the highest incidence of superficial SSI at 1.38% compared to 1.14%, 1.13%, and 1.21% for 1st, 2nd, and 4th quarters, respectively (p=0.677). There were 145 cases of deep incisional SSI. The third quarter again had the highest rate at 1.02% compared to 0.72%, 0.93%, and 0.60% for 1st, 2nd, and 4th quarter respectively (p=0.105). Conclusion: Our results show that superficial incisional SSI, deep incisional SSI, and open wound infections have increased likelihood during the summer months in the setting of orthopaedic foot and ankle surgery. Some studies have associated the increased temperature and humidity during the summer months with increased rates of infections and our results show similar trends. Additional evidence with larger sample sizes is needed to determine which specific procedures are at highest risk of infection during the summer months.

Hemi vs. Total joint arthroplasty for hallux rigidus: a systematic review and a Meta-analysis

Category: Midfoot/Forefoot Introduction/Purpose: Advanced-stage arthritis of the first metatarsophalangeal joint (MTPJ), or “Hallux Rigidus” (HR) is a common forefoot pathology. When surgery is indicated, arthroplasty is an alternative to arthrodesis, which aims to preserve MTPJ dorsiflexion. Since it is unclear whether total-toe or hemi-toe devices are preferred implants in MTPJ arthroplasty, we completed a systematic review of the literature and did a meta analysis to test which type of implants clinically outperform in hallux rigidus. Methods: A systematic review of MTPJ arthroplasty was performed using Pubmed, EMBASE, SCOPUS, and Cochrane library for the years 2000 to 2017. Data was extracted from articles containing both preoperative and postoperative endpoints for either hemi or total MTPJ arthroplasty cases. To be eligible for inclusion, studies must have had a mean follow-up window of at least 24 months and standard deviation of outcome. Total eleven studies were included for review, seven studies with hemi replacement and six studies with total arthroplasty. Pooled mean values were calculated, and a forest plot was created comparing pre-and post-operative American Orthopedic Foot and Ankle Score (AOFAS), visual analogue scale (VAS), and range of motion (ROM) results for both hemi-toe and total-toe arthroplasty. Statistical analysis was performed using SPSS. Results: Mean postoperative AOFAS scores in patients undergoing hemiarthroplasty improved by 50.7 points (95%CI: 48.5, 52.8), which was higher than the mean postoperative AOFAS improvement of 40.6 points (95%CI: 38.5, 42.8) seen in total-toe patients. Mean postoperative VAS improvement in hemiarthroplasty was 6.05 points (95%CI: 5.92, 6.18), which was comparable to the mean VAS improvement of 6.29 points (95%CI: 6.02, 6.55) seen in total arthroplasty. Mean postoperative MTPJ ROM improved by 43.0 degrees (95%CI: 39.3, 46.6) in hemi-toe patients, which exceeded the mean ROM improvement of 32.5 degrees (95%CI: 29.9, 35.1) found in total-toe cases. A meta-analysis of the data revealed non-significant statistical trends for AOFAS and ROM in favor of hemiarthroplasty. Conclusion: Hemi-surface implants in MTPJ arthroplasty may improve postoperative AOFAS and ROM results to a greater extent than total-toe devices. High-quality randomized controlled studies are needed to confirm long-term surgical outcomes in these patients.

A Comparative Analysis of Risk and Cost-effectiveness of Outpatient versus Inpatient Hindfoot Fusion

Category: Hindfoot Introduction/Purpose: Hindfoot fusion procedures are increasingly being performed in the outpatient setting. However, the cost-effectiveness of hindfoot fusion procedures compared with risk and benefit have not been clearly investigated. The primary objective of this study was to investigate the cost-effectiveness of outpatient versus inpatient hindfoot arthrodesis. Secondary objectives were to compare patient characteristics and short-term complications of patients in each cohort. Methods: This was a retrospective review of all patients who underwent inpatient and outpatient hindfoot fusion procedures at a single institution from 2013-2017. Data collected for each patient included demographic information, operative variables, comorbidities, complications, and any subsequent emergency department visits, readmissions or reoperations. Cost data was collected for each inpatient or outpatient encounter, as well as any subsequent encounters related to the index procedure. Results: Of 151 total hindfoot procedures performed over the study period, 37 were inpatient and 114 were performed in the outpatient setting. There were 3 more readmissions, 22 more ED visits, and 0 more reoperations after outpatient surgery vs inpatient surgery. The average total cost for an outpatient hindfoot fusion procedure was significantly lower than the average total cost for inpatient hindfoot fusion, without a significant increase in complication rate. We are currently in the process of performing the total cost analysis, and will have the completed cost and risk/benefit information within the next two weeks. Conclusion: Outpatient hindfoot fusion surgery may be more cost-effective when compared to inpatient fusion surgery without a significant increase in complications, ED visits, or readmissions.

Tendências no tratamento cirúrgico das fraturas do colo do fêmur em idosos

ABSTRACT Objective To analyze recent demographic and medical billing trends in treatment of femoral neck fracture of American elderly patients. Methods The American College of Surgeons National Surgical Quality Improvement Program database was analyzed from 2006 to 2015, for patients aged 65 years and older, using the Current Procedural Terminology codes 27130, 27125, 27235, and 27236. Patient demographics, postoperative complications, and frequency of codes were compared and analyzed over time. Our sample had 17,122 elderly patients, in that, 70% were female, mean age of 80.1 years (standard deviation±6.6 years). Results The number of cases increased, but age, gender, body mass index, rates of diabetes and smoking did not change over time. Open reduction internal fixation was the most commonly billed code, with 9,169 patients (53.6%), followed by hemiarthroplasty with 5,861 (34.2%) patients. Combined estimated probability of morbidity was 9.8% (standard deviation±5.2%), and did not change significantly over time. Postoperative complication rates were similar between treatments. Conclusion Demographics and morbidity rates in femoral neck fractures of elderly patients did not change significantly from 2006 to 2015. Open reduction internal fixation was the most common treatment followed by hemiarthroplasty.

A Case Report of Revision Total Knee Arthroplasty After 17 Years: All Grown Up, What Happens When Implants Mature?

The number of total knee arthroplasties (TKAs) being performed annually is steadily rising. Recommendations for clinical follow-up guidelines following these arthroplasties is controversial, with no strict guidelines for long-term follow up. Although a few case series exist which identify a minority of patients who require revision TKA for aseptic loosening or pain more than 15 years after index surgery, no published studies have yet described these patients or the pathology present at the time of surgery in detail. We present the case of a patient who underwent revision TKA for pain and instability that developed 17 years after index surgery. Postoperative pathology revealed foreign body giant cell reaction of the tissue surrounding the previous implant. This case of revision after more than 17 years attempts to improve our understanding of long-term reactions to implants and highlights the necessity of long-term follow up in patients with TKA. It is one of the longest follow-ups of TKA reporting long-term anatomic changes at the bone cement interphase and around the implant.

A Case of a Second Intermetatarsal Space Gouty Tophus with a Presentation Similar to a Morton’s Neuroma

Non-infectious soft tissue lesions of the foot and ankle are relatively rare clinically. These include benign and malignant neoplasms, as well as non-neoplastic or pseudotumoral lesions such as ganglionic, synovial and epidermoid cysts, intermetatarsal and adventitious bursitis, inflammatory lesions like gouty tophi and rheumatoid nodules, Morton’s neuroma, and granuloma annulare. A 48-year-old male with a history of medically treated tophaceous gout presented with left foot neuropathic pain and paresthesia, in the setting of a well-circumscribed soft tissue lesion of the second intermetatarsal space, suspected to be a Morton’s neuroma. Magnetic resonance imaging (MRI) showed a 4.1 x 2.7 x 2.6 cm heterogeneous soft tissue mass containing multiple cystic areas. Excisional biopsy was performed and histologic examination revealed well-circumscribed nodules of amorphous material containing needle-shaped clefts, rimmed by histiocytes, and multinucleated giant cells consistent with a gouty tophus. This is the first case reported in the literature of an intermetatarsal gouty tophus causing neuropathic pain and paresthesia. While Morton’s neuroma is the most common cause of this presentation, this case illustrates that other pseudotumoral lesions, such as a gouty tophus, may present similarly, and should be considered in the differential diagnosis. While most cases of tophaceous gout can be adequately treated with urate-lowering therapy, surgery may be indicated for tophi that do not resolve with medical treatment based upon symptom severity, compression of nearby structures, and functional impairment.