Jodi F. Hartman

A Practical Approach for the Differential Diagnosis of Chronic Leg Pain in the Athlete

Chronic lower leg pain results from various conditions, most commonly, medial tibial stress syndrome, stress fracture, chronic exertional compartment syndrome, nerve entrapment, and popliteal artery entrapment syndrome. Symptoms associated with these conditions often overlap, making a definitive diagnosis difficult. As a result, an algorithmic approach was created to aid in the evaluation of patients with complaints of lower leg pain and to assist in defining a diagnosis by providing recommended diagnostic studies for each condition. A comprehensive physical examination is imperative to confirm a diagnosis and should begin with an inquiry regarding the location and onset of the patients pain and tenderness. Confirmation of the diagnosis requires performing the appropriate diagnostic studies, including radiographs, bone scans, magnetic resonance imaging, magnetic resonance angiography, compartmental pressure measurements, and arteriograms. Although most conditions causing lower leg pain are treated successfully with nonsurgical management, some syndromes, such as popliteal artery entrapment syndrome, may require surgical intervention. Regardless of the form of treatment, return to activity must be gradual and individualized for each patient to prevent future athletic injury.

Simultaneous bilateral total knee arthroplasties: who decides?

The purpose of the current retrospective review was to compare the results of 1498 patients having 1090 simultaneous bilateral total knee arthroplasties and 958 unilateral total knee arthroplasties in a 3-year period, focusing on perioperative complications, length of hospital stay, and discharge disposition. Gender, age, diagnosis, and weight were similar between the groups. Patients undergoing simultaneous bilateral total knee arthroplasties had statistically significant higher amounts of intraoperative blood loss, with more patients requiring blood transfusion, and a higher average number of units of blood transfused compared with patients undergoing unilateral total knee arthroplasty. Overall, a significantly higher incidence of gastrointestinal complications was reported in patients who had simultaneous bilateral knee arthroplasties compared with patients who had unilateral knee arthroplasty. Comparing age subgroups within the unilateral group revealed significantly higher incidences of pulmonary, neurologic, cardiac, and genitourinary complications among patients 80 years or older versus patients younger than 80 years. Patients having simultaneous bilateral arthroplasties who were 80 years or older had significantly higher incidences of pulmonary, neurologic, and cardiac complications than patients younger than 80 years in that same group. These results suggest that age, not procedure, has a more significant role in the perioperative morbidity of total knee arthroplasty. Based on the results from the current study and previous literature documenting patient preference, patient satisfaction, efficacy, and outcomes comparable with those of patients having unilateral total knee arthroplasty, the authors continue to offer patients the option of simultaneous bilateral total knee arthroplasties.

A 5-year review of management of lower extremity arterial injuries at an urban level I trauma center

BACKGROUND The purpose of this study was to review the management of lower extremity arterial injuries to determine incidence, assess the current management strategy, and evaluate hospital outcome. METHODS This was a retrospective review, including trauma database query, and medical records review set in an urban level I trauma center. Sixty-five patients with 75 lower extremity arterial injuries were admitted between April 2005 and April 2010. The interventions were primary amputation, medical management, vascular surgical intervention, and subsequent amputation. The main outcome measures were age, gender, race, mechanism of injury, type of injury, associated lower extremity injuries, concomitant injuries, Injury Severity Score, Abbreviated Injury Scale, surgical procedures and interventions, limb salvage rate, mortality, length of stay, and discharge disposition. RESULTS During a 5-year period, 65 patients with 75 lower extremity arterial injuries were admitted to the hospital, yielding an incidence of 0.39% among trauma admissions. The study population was comprised primarily of young men, with a mean Injury Severity Score of 15.2 and a mean Abbreviated Injury Scale of 2.7 (moderate to severe injuries). The majority of patients (78.4%) suffered concomitant lower extremity injuries, most frequently bony or venous injuries, whereas 35.4% experienced associated injuries to other body regions. The most common injury mechanism was a gunshot wound (46.7%). Arterial injuries were categorized into 42 penetrating (56.0%) and 33 blunt mechanisms (44.0%). Involved arterial distribution was as follows: 4 common femoral (5.3%), 4 profunda femoris (5.3%), 24 superficial femoral (32.0%), 16 popliteal (21.3%), and 27 tibial (36.0%) arteries. The types of arterial injuries were as follows: 28 occlusion (37.3%), 23 transection (30.7%), 16 laceration (21.3%), and 8 dissection (10.7%). Orthopedic surgeons performed amputations as primary procedures in 3 patients (4.6%). The majority (76.8%) of injuries receiving vascular management underwent surgical intervention, with procedure distribution as follows: 26 bypass (49.1%); 13 primary repair (24.5%); 7 ligation (13.2%); 4 endovascular (7.5%); and 3 isolated thrombectomy (5.7%) procedures. Concomitant venous repair and fasciotomy were performed in 22.4% and 38.2% of cases, respectively. Medication was the primary strategy for 16 arterial injuries (23.2%). Subsequent major amputation was required for 3 patients (4.8%) who initially received vascular management. Three patients (4.6%) died during hospitalization. CONCLUSION The current multidisciplinary team management approach, including use of computed tomographic or conventional angiography and prompt surgical management, resulted in successful outcomes after lower extremity arterial injuries and will continue to be utilized.

A Systematic Review and Meta-Analysis of Diagnostic Screening Criteria for Blunt Cerebrovascular Injuries

BACKGROUND Despite progress in diagnosing and managing blunt cerebrovascular injury (BCVI), controversy remains regarding the appropriate population to screen. A systematic review of published literature was conducted to summarize the overall incidence of BCVI and the various screening criteria used to detect BCVI. A meta-analysis was performed to evaluate which screening criteria may be associated with BCVI. Goals were to confirm inclusion of certain criteria in current screening protocols and possibly eliminate criteria not associated with BCVI. STUDY DESIGN Studies published between January 1995 and April 2011 using digital subtraction angiography or CT angiography as a diagnostic modality and reporting overall BCVI incidence or prevalence of BCVI for specific screening criteria were examined. Screening criteria were analyzed using a random effects model to determine if an association with BCVI was present. RESULTS The incidence range of BCVI was between 0.18% and 2.70% among approximately 122,176 blunt trauma admissions. The meta-analysis encompassed 418 BCVI and 22,568 non-BCVI patients. Of the 9 screening criteria analyzed, cervical spine (odds ratio [OR] 5.45; 95% CI 2.24 to 13.27; p < 0.0001) and thoracic (OR 1.98; 95% CI 1.35 to 2.92; p = 0.001) injuries demonstrated a significant association with BCVI. CONCLUSIONS Patients with cervical spine and thoracic injuries had significantly greater likelihoods of BCVI compared with patients without these injuries. All patients with either injury should be screened for BCVI. Multivariate logistic regression analysis is needed to elucidate the possible impact of the combined presence of screening criteria, but it was not possible in our study due to limitations in data presentation. Standardized reporting of BCVI data is not established and is recommended to permit future collaboration.

Use of autologous bone marrow mononuclear cell implantation therapy as a limb salvage procedure in patients with severe peripheral arterial disease

BACKGROUND Few options other than amputation exist for some patients with peripheral arterial occlusive disease (PAD) and severe anatomical limitations. METHODS This prospective study presents short-term results of dual intramuscular and intra-arterial autologous bone marrow mononuclear cell (BM-MNC) implantation for the treatment of patients with severe PAD in whom amputation was considered the only viable treatment option. Baseline, two-week, and three-month evaluations were conducted. Ankle brachial indices (ABI) were calculated for both the dorsal pedis and the posterior tibial arteries. Rest pain and ulcer healing also were assessed. Success was defined as meeting the following four criteria: improvement in ABI measurements; relief of rest pain; ulcer healing, if applicable; and absence of major limb amputations. Patients not undergoing major limb amputations continued to be monitored for subsequent procedures. RESULTS Nine patients for whom limb amputation was recommended underwent this procedure. The study population was comprised of five females and four males, with a mean age of 61.7 years. Eight (88.9%) patients had rest pain. Seven (77.8%) patients also had diabetes. Non-healing ulcers were present in eight (88.9%) cases. After the procedure, non-significant improvements of 0.12 and 0.08 in ABI were observed for the dorsalis pedis and posterior tibial ankle arteries, respectively. Three (33.3%) major amputations subsequently were performed, including a below-knee amputation 4.1 weeks after the BM-MNC implantation and two above-knee amputations at 5.4 and 11.0 weeks after the procedure. The six (66.7%) patients who did not have major amputations demonstrated improvement in symptom severity three months after the procedure, as evidenced by alleviation of rest pain and improvements by at least one level in Rutherford and Fontaine classifications, and have not required amputations at a mean follow-up of 7.8 months. Complete wound healing was achieved within three months in all patients who had ulcers prior to BM-MNC implantation and for whom amputation was not required. This specific BM-MNC implantation technique was fully successful in three (33.3%) patients, as major amputation was avoided and the other applicable criteria were met. Five (55.6%) additional patients demonstrated success in at least one of the four criteria. CONCLUSIONS With eight (88.9%) of nine patients showing some level of improvement and amputation avoided in six (66.7%) patients, these short-term results indicate the use of BM-MNC implantation as a means of limb salvage therapy for patients with severe PAD shows promise in postponing or avoiding amputation in a patient population currently presented with few alternatives to amputation.

Interpositional Arthroplasty of the First MTP Joint Using a Regenerative Tissue Matrix for the Treatment of Advanced Hallux Rigidus

Background: Treatment options are limited for young and active patients with hallux rigidus of the first metatarsophalangeal (MTP) joint. Soft-tissue interpositional arthroplasty is a promising alternative. Methods: The surgical technique for interpositional arthroplasty utilizing a human acellular dermal regenerative tissue matrix as a spacer is described. A retrospective review of a consecutive series of the first nine patients with Coughlin grade 3 halux rigidus who underwent this procedure is presented. Five patients were female and four were male, with a mean age of 53.3 years, a mean body mass index of 28.6, and a mean duration of symptoms of 3.1 years. Results: The mean length of followup was 12.7 months, with no reported complications or failures. The mean total AOFAS score and pain sub-score were significantly higher at the most recent followup (87.9 and 34.4, respectively) versus preoperatively (63.9 and 17.8, respectively). Conclusions: These excellent early results and lack of complications may be due to the minimal bone resection associated with the procedure. This technique does not require autograft harvesting, is bone-sparing by preserving the plantar plate, and maintains the natural intrinsics of the joint by preserving its associated tendons and the FHB insertion. The sesamoid articulation also is resurfaced. Although further followup is needed, this technique may offer the young and active patient with advanced hallux rigidus an opportunity to maintain an active lifestyle, while retaining the possibility for more surgical options should the condition progress.

A Multicenter Study Involving the Use of a Human Acellular Dermal Regenerative Tissue Matrix for the Treatment of Diabetic Lower Extremity Wounds

This multicenter, retrospective study presents the use of a human acellular dermal regenerative tissue matrix as an alternative treatment for 100 chronic, full-thickness wounds of the lower extremity in 75 diabetic patients. Comorbidities included cardiac disease (86.0%), neuropathy (86.0%), peripheral vascular disease (82.0%), infection (54.0%), obesity (51.0%), and osteomyelitis (37.0%). Wound locations included the foot (86.0%), ankle (8.0%), and lower extremity (6.0%). Mean wound age was 20.4 weeks (1.3-191.4 weeks). University of Texas (UT) wound classifications included 15 (15.0%) 1A, 1 (1.0%) 1B, 1 (1.0%) 1C, 2 (2.0%) 1D, 18 (18.0%) 2A, 8 (8.0%) 2B, 5 (5.0%) 2C, 3 (3.0%) 2D, 3 (3.0%) 3A, 7 (7.0%) 3B, 3 (3.0%) 3C, and 34 (34.0%) 3D. The mean time to matrix incorporation, 100% granulation, and complete healing was 1.5 weeks (0.43-4.4 weeks), 5.1 weeks (0.43-16.7 weeks), and 13.8 weeks (1.7-57.8 weeks), respectively. The overall matrix success rate, as defined by full epithelialization, was 90.0%. One failed wound subsequently healed approximately 7 weeks after matrix reapplication. The healing rate was 91.0%, as 91 of the 100 wounds healed. No statistically significant differences were observed between UT classifications and time to matrix incorporation, 100% granulation, and complete healing. Absence of matrix-related complications and high rates of closure in a wide array of diabetic wounds suggest that this matrix is a viable treatment for complex lower extremity wounds. Lack of any statistically significant differences between UT grades and wound outcome end points lends further support to the universal applicability of this matrix, with successful results in both superficial diabetic wounds and in wounds penetrating to the bone or joint.

An algorithm for the posterior cruciate ligament in total knee arthroplasty.

The fate of the posterior cruciate ligament in primary total knee arthroplasty is controversial. An algorithmic approach is presented that is based on pathologic criteria for evaluating and treating patients with primary total knee arthroplasty that will aid in the posterior cruciate ligament decision-making process, producing more predictable procedures and outcomes. A consecutive series of the first 120 patients (171 knees) who had primary posterior cruciate-retaining arthroplasty and the first 120 patients (180 knees) who had primary posterior-stabilized arthroplasty with a minimum 5-year followup in which the Maxim ® Complete Total Knee System and the algorithmic approach were used were compared. No statistically significant differences in outcome between the groups were observed. Among the patients who had posterior cruciate-retaining arthroplasty, no revisions attributable to aseptic loosening have been reported at an average followup of 6.39 years. The average followup Knee Society total score was 162.16 points, with 91 (54.8%) knees having excellent outcome ratings. No revisions attributable to aseptic loosening have been reported among the patients who had posterior-stabilized arthroplasty at an average followup of 5.98 years. The average followup Knee Society total score was 158.05 points, with excellent outcome ratings reported in 96 (54.9%) knees. The use of a standardized algorithm has streamlined the treatment of patients having primary total knee arthroplasty, consistently providing excellent clinical results when either retaining or sacrificing the posterior cruciate ligament.

Management of Upper Extremity Arterial Injuries at an Urban Level I Trauma Center

Although relatively uncommon, upper extremity arterial injuries are serious and may significantly impact the outcome of the trauma patient. Management of upper extremity arterial injuries at an urban level I trauma center was reviewed to determine incidence, assess the current management strategy, and evaluate hospital outcome. Upper extremity trauma patients with arterial injury who presented between January 2005 and December 2006 were included in this retrospective review. Data collected included age, gender, race, mechanism of injury, type of injury, associated upper extremity injuries, concomitant injuries, injury severity score (ISS), diagnostic modalities employed, surgical procedures and interventions, mortality, length of stay, and discharge disposition. Statistical analysis between blunt and penetrating arterial injuries as well as between proximal and distal arterial injuries also was conducted. During a 2-year period, 28 patients with 30 upper extremity arterial injuries were admitted, yielding an incidence of 0.48%. The study population was comprised primarily of young Caucasian males, with a mean ISS of 9.0. The majority (89.3%) of patients suffered concomitant upper extremity injuries. Twenty-two nerve injuries were identified in 16 (57.1%) patients. The most common injury mechanism was cut by glass (39.3%). Arterial injuries were categorized into 18 (60.0%) penetrating and 12 (40.0%) blunt injuries. Involved artery distribution was as follows: 12 (40.0%) brachial, eight (26.7%) ulnar, seven (23.3%) radial, and three (10.0%) axillary. Over half (56.7%) of the injuries resulted from lacerations. Injuries were managed as follows: 14 (46.7%) primary repairs, eight (26.7%) ligations, six (20.0%) saphenous vein graft bypasses, and two (6.7%) endovascular procedures. Eleven (39.3%) patients required intensive care unit (ICU) admission. The overall mean length of hospitalization for these patients was 7.4 days compared to a mean length of hospitalization of 2.0 days for the 17 (44.7%) patients who did not require ICU admission. The overall limb salvage rate was 96.4% as arterial injuries were successfully repaired in 27 of 28 patients. No patients expired and all were discharged home. Equivalent demographics, mechanisms of injury, surgical management approaches, and successful hospital outcomes were demonstrated between penetrating and blunt injuries as well as between proximal and distal arterial injuries. The current management approach, including use of angiography and prompt surgical management, results in successful outcomes after upper extremity arterial injuries and will continue to be utilized.

A 10-year review of blunt renal artery injuries at an urban level I trauma centre

INTRODUCTION Little consensus exists over the management of high-grade renal injuries, with continued debate over observation versus invasive surgery. Blunt renal artery injury (BRAI) is a high-grade injury that may result in renal dysfunction, hypertension, or failure. MATERIALS AND METHODS Management of BRAI at a level I trauma centre during a decade was retrospectively reviewed to determine incidence, assess management strategy, and evaluate hospital outcomes. Data collected included demographics, injury details, standardised scoring, renal injury grade, haemodynamic stability, diagnostic modalities, medical interventions, mortality, and hospitalisation length. RESULTS Thirty-eight BRAI patients (21 Grade IV and 17 Grade V injuries) were admitted, representing 0.16% of trauma admissions, and consisting primarily of young males. Ultrasonography and CT was performed in 92.1% and 76.3% of patients, respectively. Primary management included exploratory laparotomy in 42.9%, angiography and embolisation in 34.3%, and observation in 22.9%. Six nephrectomies and one revascularisation were performed. The incidence of BRAI and use of angiography are higher than those reported in previous studies. CONCLUSION Over the past decade, increased use of CT as a diagnostic tool for confirming renal injury in haemodynamically stable patients at our institution may have contributed to the increase in BRAI detection. Higher utilisation of angiography has enabled a more conservative approach. In this series, angiography had a success rate of 94.4%. Angiography and embolisation or observation with careful monitoring are viable management options in haemodynamically stable patients with isolated BRAI.