Paul G. Talusan

Distinguishing Lyme From Septic Knee Monoarthritis in Lyme Disease–Endemic Areas

OBJECTIVE: Because Lyme and septic arthritis may present similarly, we sought to identify children with knee monoarthritis at low risk for septic arthritis who may not require arthrocentesis. METHODS: We performed a retrospective study of children with knee monoarthritis presenting to 1 of 2 pediatric centers, both located in Lyme disease–endemic areas. Septic arthritis was defined by a positive result on synovial fluid culture or synovial fluid pleocytosis with a positive blood culture result. Lyme arthritis was defined as a positive Lyme serologic result or physician-documented erythema migrans rash. All other children were considered to have other inflammatory arthritis. A clinical prediction model was derived by using recursive partitioning to identify children at low risk for septic arthritis, and the model was then externally validated. RESULTS: We identified 673 patients with knee monoarthritis; 19 (3%) had septic arthritis, 341 (51%) had Lyme arthritis, and 313 (46%) had other inflammatory arthritis. The following predictors of knee septic arthritis were identified: peripheral blood absolute neutrophil count ≥10 × 103 cells per mm3 and an erythrocyte sedimentation rate ≥40 mm/hour. In the validation population, no child with a absolute neutrophil count <10 × 103 cells per mm3 and an erythrocyte sedimentation rate <40 mm/hour had septic arthritis (sensitivity: 6 of 6 [100%], 95% confidence interval [CI]: 54–100; specificity: 87 of 160 [54%], 95% CI: 46–62). Overall, none of the 19 children with septic arthritis were classified as low risk (10%, 95% CI: 0–17). CONCLUSIONS: Laboratory criteria can be used to identify children with knee monoarthritis at low risk for septic arthritis who may not require diagnostic arthrocentesis.

Freiberg's infraction: diagnosis and treatment.

Freiberg’s infraction is a condition of cartilage degeneration of the lesser metatarsal heads. Adolescent females are the “textbook” patients but both males and females may present with this condition later in life. The second and third metatarsals are the most commonly affected, while involvement of the fourth and fifth is rare. The incidence is higher in females than in males. The pathophysiology is unknown, but studies suggest a combination of vascular compromise, genetic predisposition, and altered biomechanics. Diagnosis is made clinically and imaging is used to confirm. Early in the process, radiographs are normal however bone scans may demonstrate a photopenic center with a hyperactive collar and magnetic resonance imaging can reveal hypointensity of the metatarsal head. As Freiberg’s infraction progresses, radiographs show a flattened and fragmented metatarsal head. Nonoperative treatment is based on decreasing foot pressure and unloading the affected metatarsal. Spontaneous healing with remodeling may occur in early stages of the disease. Operative options are dorsal closing wedge osteotomies, osteochondral transplant, and resection arthroplasty. Currently, we do not understand this disease sufficiently to prevent its occurrence. Outcomes of nonoperative and operative management are good to excellent and most patients are able to return to previous activity. Levels of Evidence: Therapeutic, Level IV

Driving Reaction Times in Patients With Foot and Ankle Pathology Before and After Image-Guided Injection Pain Relief Without Improved Function

Background: Foot and ankle pathology is common in the driving population. Local anesthetic steroid injections are frequent ambulatory treatments. Brake reaction time (BRT) has validated importance in motor vehicle safety. There are no prior studies examining the effect of foot and ankle pathology and injection treatment on the safe operation of motor vehicles. We studied BRT in patients with foot and ankle musculoskeletal disease before and after image-guided injection treatment. Methods: A total of 37 participants were enrolled. Image-guided injections of local anesthetic and steroid were placed into the pathological anatomical location of the right or left foot and ankles. A driving reaction timer was used to measure BRTs before and after injection. Patients suffering right “driving” and left “nondriving” pathology as well as a healthy control group were studied. Results: All patients reported >90% pain relief postinjection. All injections were confirmed to be accurate by imaging. Post hoc Bonferonni analysis demonstrated significant difference between the healthy group and the right-sided injection group (P = .008). Mean BRT for healthy controls was 0.57 ± 0.11 s. Patients suffering right foot and ankle disease displayed surprisingly high BRTs (0.80 ± 0.23 s preinjection and 0.78 ± 0.16 s postinjection, P > .99). Left nondriving foot and ankle pathology presented a driving hazard as well (BRT of 0.75 ± 0.12 s preinjection and 0.77 ± 0.12 s postinjection, P > .99). Injections relieved pain but did not significantly alter BRT (P > .99 for all). Conclusion: Patients suffering chronic foot and ankle pathology involving either the driving or nondriving side have impaired BRTs. This preexisting driving impairment has not previously been reported and exceeds recommended cutoff safety values in the United States. Despite symptom improvement, there was no statistically significant change in BRT following image-guided injection in either foot and ankle. Levels of Evidence: Therapeutic, Level II: Prospective Comparative Study

Anterior Ankle Impingement: Diagnosis and Treatment

Anterior ankle impingement is a common clinical condition characterized by chronic anterior ankle pain that is exacerbated on dorsiflexion. Additional symptoms include instability; limited ankle motion; and pain with squatting, sprinting, stair climbing, and hill climbing. Diagnosis is typically confirmed with plain radiographs. Nonsurgical management includes physical therapy, strengthening exercises, activity modification, bracing, and anti-inflammatory medication. Although arthroscopic treatment is sufficient in some patients, most require an open approach to address related pathology. We advocate aggressive range of motion as well as weight bearing postoperatively. Further study is needed to confirm current understanding of anterior ankle impingement and to better define treatment options and prevention strategies.

Venous Thromboembolic Prophylaxis in Foot and Ankle Surgery: A Review of Current Literature and Practice

Venous thromboembolism (VTE) is a well-known and feared complication following foot and ankle surgery, as it is a source of morbidity and mortality in the perioperative phase. The most recent CHEST guidelines recommended against the use of chemoprophylaxis and the majority of the literature has found a low incidence of VTE following foot and ankle surgery. Some authors prefer screening patients for risk factors and recommend the use of chemoprophylaxis on a case-by-case basis. Interestingly, studies that found high incidence of VTE were unable to determine a statistically significant difference between the prophylaxis and placebo groups. Major limitations of retrospective reviews is they are only able to study symptomatic VTE because no routine screening is typically performed. In a survey study, up to 98% of foot and ankle surgeons responded that they use prophylaxis in high-risk patients. Despite evidence-based recommendations, a significant number of foot and ankle surgeons are routinely using some form of VTE prophylaxis without taking risk factors into account. Levels of Evidence: Clinical, Level IV: Review Article

Fifth Toe Deformities Overlapping and Underlapping Toe

Overlapping fifth toe is thought to be a congenital deformity characterized by the proximal phalanx dorsally subluxating and adducting on the fifth metatarsophalangeal joint. Overlapping fifth toes may present as asymptomatic figments of parental concern, but not infrequently this deformity may be painful and disabling in both the pediatric and adult population. Pediatric overlapping fifth toe often corrects with normal ambulation and physicians only need to intervene if symptomatic deformity persists. Nonoperative optimization with strapping, splinting, and shoe modification would be reasonable first-line treatments. Surgical intervention including osteoclysis, percutaneous tenotomy, capsulotomy, syndacilization, tissue rearrangements, tendon transfers, phalangectomy, and toe amputation are indicated only after optimization of less invasive measures. Underlapping fifth toe (or “curly” toe) deformity is also felt to be congenital. In most cases, underlapping fifth toes are noticed by parents and family members early in infancy. The proximal phalanx in underlapping toes is typically in varus at the metatarsophalangeal joint with flexion. It is not uncommon for a rotational malalignment to be present (supination/pronation) as judged by the nailbeds. Similar to overlapping toes, pediatric underlappers commonly correct with reassurance and benign neglect up to age 6. Intervention is warranted in the setting of persistent pain and footwear difficulty. Accommodative shoes, absorbing cushions, and functional modification are the mainstays of nonoperative management. Operative intervention may consist of osteoclysis, percutaneous flexor tenotomy, capsulotomy, tissue rearrangements, tendon transfers, removal of symptomatic spurs, osteotomies, and amputation. After exhaustive review of the published literature, it is clear that fifth toe deformities (whether overlapping or underlapping) have not been extensively studied. No gold standard approach exists in treatment. Prospective research using larger numbers of patients with detailed outcome metrics are needed. Surgeons should carefully tailor surgical intervention to patient specific pathology. Levels of Evidence: Expert Opinion, Level V

Effects of Fatigue on Driving Safety: A Comparison of Brake Reaction Times in Night Float and Postcall Physicians in Training

BACKGROUND Concerns about duty hour and resident safety have fostered discussion about postshift fatigue and driving impairment. OBJECTIVE We assessed how converting to a night float schedule for overnight coverage affected driving safety for trainees. METHODS Brake reaction times were measured for internal medicine and orthopaedic surgery resident volunteers after a traditional 28-hour call shift and after a night float shift. We conducted matched paired t tests of preshift and postshift reaction time means. Participants also completed the Epworth Sleepiness Scale pre- and postshift. RESULTS From June to July 2013, we enrolled 58 interns and residents (28 orthopaedic surgery, 30 internal medicine). We included 24 (41%) trainees on night float rotations and 34 (59%) trainees on traditional 28-hour call shifts. For all residents on night float rotations, there was no significant difference pre- and postshift. An increase in reaction times was noted among trainees on 28-hour call rotations. This included no effect on reaction times for internal medicine trainees pre- and postshift, and an increase in reaction times for orthopaedic trainees. For both night float and traditional call groups, there were significant increases in the Epworth Sleepiness Scale. CONCLUSIONS Trainees on traditional 28-hour call rotations had significantly worse postshift brake reaction times, whereas trainees on night float rotations had no difference. Orthopaedic trainees had significant differences in brake reaction times after a traditional call shift.

Fibular lengthening using distraction osteogenesis for the treatment of fibular malunion: a case report.

The importance of fibular reduction in the treatment of ankle fractures has been well described. The lateral malleolus is an important structure that contributes to ankle stability by maintaining the talus in proper anatomical position. Shortening and rotational malunion of the fibula can result after operative or nonoperative treatment. The resulting lateral talar tilt often results in chronic pain, swelling, and instability. Failure to adequately treat the deformity often leads to degenerative arthritis. Many techniques have been described to restore fibular alignment, including osteotomies with or without bone graft and internal or external fixation. In this case report, we describe a novel technique using a uniplanar external fixator and distraction osteogenesis to correct a fibular malunion.

Treatment of cleft foot deformity with a suture-button construct in the pediatric foot: A case report

Ectrodactyly, ectodermal dysplasia, and clefting syndrome (EEC) is a rare autosomal dominant congenital condition. It is characterized by its “lobster-claw” cleft hand and foot deformities (ectrodactyly) in addition to clefting of the lip and palate and defects in the hair, teeth, nails, sweat glands. The incidence is estimated at 1:90 000 births when both hands and feet are involved and 1:150000 with isolated foot deformities. Cleft feet dysplasia is characterized by a spectrum of complete or partial loss of the central metatarsals and phalanges, often with present first and fifth rays lending to the lobster-claw appearance. Syndactyly of any present central digits is also common. Variations of the cleft feet syndromes have been classified both clinically and radiographically. Mild deformities are often observed if asymptomatic, and if symptomatic they are treated with accommodative shoe wear or orthoses that help distribute the load on the foot during gait. However, more severe cosmetic and functional deformities have been corrected operatively with a variety of procedures. The goal of any invasive treatment is a painless and biomechanically functional foot that can accommodate regular shoes. This is a report of a case of pediatric cleft foot corrected using a suture-button to reconstruct the intermetatarsal ligament.

Effect of McGlamry Elevator Placement on the Plantar Plate Origin: A Radiographic and Anatomic Assessment

Category: Lesser Toes Introduction/Purpose: Lesser metatarsal phalangeal (MTP) joint plantar plate tears have been implicated in a variety of lesser toe pathologies, and plantar plate repair (PPR) through a dorsal approach has become increasingly popular as a treatment of lesser toe deformities and lesser MTP instability. With the aid of a McGlamry elevator, releasing the collateral ligaments and micro-suture passing techniques, the plantar plate is repaired under direct visualization. While this approach is seen as a reliable alternative, the consequence of this technique on local MTP joint anatomy is not yet well understood. The purpose of this study is to describe the proximal plantar plate attachment and to quantify the amount of soft tissue disruption of the lesser toe MTP joint anatomy with insertion of a McGlamry elevator. Methods: Fresh frozen human cadaveric feet were dissected, and the proximal plantar plate attachment of the second, third, and fourth toe MTP joints (n=6) were examined, focusing on the relationship of structures connecting the distal metatarsal shaft and head to the plantar plate. The accessory collateral ligament insertions and proximal plantar plate attachments were measured using digital calipers. Next, the second, third, and fourth rays (n=12) of separate fresh frozen cadaveric specimens were isolated. An 11mm McGlamry elevator was then inserted in standard surgical fashion in both a more shallow (limited exposure) and deeper (greater exposure) position. Using mini C-arm fluoroscopy, radiographs were taken in both positions, and the depth of insertion along the metatarsal was measured. Results: The proximal plantar plate attachment to the metatarsal is most robust just proximal to the lateral articular margin and this attachment extends an average of 10.42mm (SD= 2.71mm) proximally along the metatarsal neck and shaft. In addition there are stout proximal plantar plate attachments at the bilateral insertion sites of the accessory collateral ligament (ACL) which are thick and broad with an average insertion length of 9.01mm (SD=1.35mm). Insertion of a McGlamry elevator resulted in stripping of the distal plantar soft tissues over an average of 21.58% of the total metatarsal length (SD=4.43%) for shallow placement and 34.87% (SD=4.40%) for deep placement with a significant difference of 7.96% between the two positions (p<.00001). Conclusion: Current techniques of plantar plate repair through a dorsal approach require releasing collateral ligaments and proximal stripping of the plantar plate from the metatarsal for adequate visualization. We suggest that this significantly destabilizes the metatarsal from the plantar plate as it strips approximately the distal most one third of the metatarsal including all major proximal plantar plate attachments to the metatarsal. As surgical techniques continue to evolve and improve, surgeons should consider avoiding the placement of a McGlamry elevator as this can destabilize the proximal attachment of the plantar plate to the metatarsal.