Joseph A. Gil

Treatment of Osteomyelitis in Charcot Foot with Single-Stage Resection of Infection, Correction of Deformity, and Maintenance with Ring Fixation

Background: There is both increased interest and awareness in diabetes-associated Charcot foot arthropathy. The number of affected patients will likely increase as the incidence of both diabetes and morbid obesity increases. Many experts now favor surgical correction of the deformity rather than longitudinal management with accommodative bracing. In patients with open wounds and exposed bone and/or chronic osteomyelitis, it is controversial whether resolution of the bony infection should be achieved before attempting surgical correction of the acquired deformity. Methods: During a 78-month period, 178 patients underwent surgical correction of deformity with diabetes-associated Charcot foot or ankle arthropathy by a single surgeon. Seventy-three had evidence of osteomyelitis at the time of surgery. There were 41 males and 32 females. Their average age was 57.9 (range, 31 to 76) years, and body mass index was 36.9 (range, 21.8 to 60.9). The clinical diagnosis of osteomyelitis was made by (a) an open wound overlying the deformity with exposed bone and chronic drainage; (b) a history of biopsy-diagnosed osteomyelitis that was not currently draining, but had clinical and pathologic evidence of abnormal bone in the region of the previous infection; or (c) a history of previous wound overlying bony deformity with abnormal bone observed at the time of surgery. Surgery involved radical resection of the clinically infected bone, combined with acute correction of the deformity to a plantigrade foot. Parenteral culture-specific antibiotic therapy was administered and monitored by an infectious disease comanagement service. A three-level preconstructed static circular external fixator was applied to maintain the surgically obtained correction. Results: Sixty-eight of 71 patients (95.7%) achieved limb salvage and were able to ambulate with commercially available therapeutic footwear. One patient died shortly after removal of the external fixator from unrelated causes. Three patients required amputation. Resolution of infection and wound closure was achieved in five patients following a second surgical debridement. Two noninfected wounds were resolved with local soft tissue flaps. Two patients have persistent noninfected wounds that have been resistant to wound care therapy. Discussion: A plantigrade noninfected foot can be achieved in patients with infected diabetic Charcot foot deformity with single-stage radical resection of osteomyelitis, correction of the deformity, maintenance of the correction with static external fixation, and culture-specific antibiotic therapy. Level of Evidence: IV, Retrospective Case Series

Cost Comparison Limb Salvage Versus Amputation in Diabetic Patients With Charcot Foot

Background: The negative impact on health-related quality of life in patients with Charcot foot has prompted operative correction of the acquired deformity. Comparative effectiveness financial models are being introduced to provide valuable information to assist clinical decision making. Methods: Seventy-six patients with Charcot foot underwent operative correction with the use of circular external fixation. Thirty-eight (50%) had osteomyelitis. A control group was created from 17 diabetic patients who successfully underwent transtibial amputation and prosthetic fitting during the same period. Cost of care during the 12 months following surgery was derived from inpatient hospitalization, placement in a rehabilitation unit or skilled nursing facility, home health care including parenteral antibiotic therapy, physical therapy, and purchase of prosthetic devices or footwear. Results: Fifty-three of the patients with limb salvage (69.7%) did not require inpatient rehabilitation. Their average cost of care was

Variability in Surgical Case Volume of Orthopaedic Surgery Residents: 2007 to 2013.

56,712. Fourteen of the patients with amputation (82.4%) required inpatient rehabilitation, with an average cost of

Orthopedic Manifestations of Ochronosis: Pathophysiology, Presentation, Diagnosis, and Management

49,251. Conclusions: Many surgeons now favor operative correction of Charcot foot deformity. This investigation provides preliminary data on the relative cost of transtibial amputation and prosthetic limb fitting compared with limb salvage. The use of comparative effectiveness models such as this simple attempt may provide valuable information in planning resource allocation for similar complex groups of patients. Level of Evidence: Level III, economic and decision analysis.

Epidemiology of lower extremity injuries presenting to the emergency room in the United States: Snow skiing vs. snowboarding

Introduction: Variability in orthopaedic surgery training is an important issue facing trainees. We examined orthopaedic surgery case logs for subspecialty case volume during residency training and assessed trends and variability in case volume over time. We hypothesized that there is variability in training in all subspecialties encountered in orthopaedic surgery resident training and that the volume of cases in each subspecialty has increased over time.Methods: Annual surgical case logs of the Accreditation Council for Graduate Medical Education from 2007 to 2013 for orthopaedic surgery residency were assessed for variability and case volume trends.Results: The average total adult cases logged per graduating resident in 2007 was 1,952, which increased to 2,291 in 2013, representing a 17.4% increase (P = 0.00041). The gap in case volume between residents in the 10th and 90th percentiles for case exposure decreased from 2007 to 2013 (P = 0.0268), although the 10th percentile group still logged significantly fewer procedures compared with the 90th percentile group in 2013 (P = 0.0159).Conclusions: Although case volume is not the sole determinant of surgical skill and further study is needed to investigate the effects of training experience, this variability in surgical volume may affect the knowledge, skill, and practice patterns of surgeons.

Resident Exposure to Peripheral Nerve Surgical Procedures During Residency Training

Ochronotic arthropathy occurs in patients with alkaptonuria, manifesting first in the intervertebral discs of the lumbar spine, with subsequent degeneration most often observed in the knee, hip, and shoulder joints. Efforts at treatment are targeted at minimizing the damaging effects of the underlying metabolic disorder on the articular cartilage. Vitamin E and N-acetyl cysteine are potential therapies because of their scavenging of free radicals and consequent limitation of oxidative damage to joint tissue. Arthroscopy has been found to be an effective diagnostic tool in cases of suspected ochronosis. Arthroplasty performed in patients with ochronotic arthropathy suggests that the procedure is effective in the alleviation of joint pain and the improvement of mobility. Perioperative management of these patients may require more careful consideration pertinent to the associated comorbidities of this disorder.

Hypersensitivity to Orthopedic Implants: A Review of the Literature

PURPOSE To quantify and compare the incidence of lower extremity injuries in skiers and snowboarders who present to emergency rooms in the United States. METHODS Cross-sectional study of lower extremity injuries in skiers and snowboarders that were evaluated in emergency rooms in the United States. The National Electric Injury Surveillance System (NEISS) database was queried from January 1st, 2014 and December 31st, 2014 and the reported cases of lower extremity injuries in skiers and snowboarders were examined. RESULTS An estimated total of 13,381 snow skiing and 6061 snowboarding lower extremity injuries presented to the emergency department in 2014 representing a national incidence of 42 injuries per 1,000,000 person-years for skiers and 19 injuries for snowboarders. The most common region of the lower extremity that was injured was the knee for skiers (47%) and the lower trunk (e.g. pelvis, hip, lumbar spine) for snowboarders (34%). The incidence of injuries in the pediatric and young adult population in skiers (62 per 1,000,000 person-years) and snowboarders (40 per 1,000,000 person-years) was significantly higher than the incidence of these injuries in adult population (35 and 12 per 1,000,000 person-years respectively) (P<0.01). The incidence of these injuries was significantly higher in males compared to females in both skiing (46 per 1,000,000 person-years vs. 38 per 1,000,000 person-years, P<0.01) and snowboarding (30 per 1,000,000 person-years vs. 9 per 1,000,000 person-years, P <0.01). The rate of injuries from 2010 to 2014 for skiers remained stable while snowboarding injuries down trended approaching significance. CONCLUSION The incidence of lower extremity injuries in skiers was higher than that of snowboarders in 2014, with the 0-19year old age group and males being those most likely to sustain an injury. The most common region of the lower extremity that was injured was the knee for skiers and the lower trunk (e.g. pelvis, hip, lumbar spine) for snowboarders. Physicians and consumers alike should be aware of this data when considering participation in these sports as well as strategies for injury prevention.

Current Concepts in the Diagnosis and Management of Traumatic, Anterior Glenohumeral Subluxations

Background Variability in case exposures has been identified for orthopaedic surgery residents. It is not known if this variability exists for peripheral nerve procedures. Objective The objective of this study was to assess ACGME case log data for graduating orthopaedic surgery, plastic surgery, general surgery, and neurological surgery residents for peripheral nerve surgical procedures and to evaluate intraspecialty and interspecialty variability in case volume. Methods Surgical case logs from 2009 to 2014 for the 4 specialties were compared for peripheral nerve surgery experience. Peripheral nerve case volume between specialties was performed utilizing a paired t test, 95% confidence intervals were calculated, and linear regression was calculated to assess the trends. Results The average number of peripheral nerve procedures performed per graduating resident was 54.2 for orthopaedic surgery residents, 62.8 for independent plastic surgery residents, 84.6 for integrated plastic surgery residents, 22.4 for neurological surgery residents, and 0.4 for surgery residents. Intraspecialty comparison of the 10th and 90th percentile peripheral nerve case volume in 2012 revealed remarkable variability in training. There was a 3.9-fold difference within orthopaedic surgery, a 5.0-fold difference within independent plastic surgery residents, an 8.8-fold difference for residents from integrated plastic surgery programs, and a 7.0-fold difference within the neurological surgery group. Conclusions There is interspecialty and intraspecialty variability in peripheral nerve surgery volume for orthopaedic, plastic, neurological, and general surgery residents. Caseload is not the sole determinant of training quality as mentorship, didactics, case breadth, and complexity play an important role in training.

Variability in United States Allopathic Medical School Tuition

Awareness of rare etiologies for implant failure is becoming increasingly important. In addition to the overall increase in joint arthroplasties, revision surgeries are projected to increase dramatically in the coming years, with volume increasing up to seven-fold between 2005 and 2030. The literature regarding the relationship between metal allergy and implant failure is controversial. It has proven difficult to determine whether sensitization is a cause or a consequence of implant failure. Testing patients with functional implants is not a clinically useful approach, as the rate of hypersensitivity is higher in implant recipients than in the general population, regardless of the status of the implant. As a result of the ineffectiveness of preoperative patch testing for predicting adverse outcomes, as well as the high cost of implementing such patch testing as standard procedure, most orthopedists and dermatologists agree that an alternative prosthesis should only be considered for patients with a history of allergy to a metal in the standard implant. In patients with a failed implant requiring revision surgery, hypersensitivity to an implant component should be considered in the differential diagnosis. Because a metal allergy to implant components is currently not commonly considered in the differential for joint failure in the orthopedic literature, there should be improved communication and collaboration between orthopedists and dermatologists when evaluating joint replacement patients with a presentation suggestive of allergy.

The Relationship Between Knee Arthroplasty and Foot Loading

Traumatic anterior glenohumeral subluxations comprise the majority of glenohumeral instability events and are endemic in young athletes. Unlike the definitive complete dislocation event, subluxation events may often be more subtle in presentation and, therefore, may be overlooked by clinicians. Glenohumeral subluxation events are associated with a high rate of labral tears as well as humeral head defects. While less is known of the natural history of these injuries, young athletes are at risk for recurrent instability events if not properly diagnosed and treated. While reports of surgical treatment outcomes isolated to subluxation events are limited, arthroscopic and open Bankart repair have been shown to result in excellent outcomes. The purpose of this paper is to review the etiology and pathoanatomy of traumatic anterior glenohumeral subluxations as well as to review the appropriate evaluation and management of patients with this injury.