Sameer Naranje

Proximal Oblique Sliding Closing Wedge Osteotomy for Hallux Valgus

Background: The proximal oblique sliding closing wedge osteotomy (POSCOW) technique was developed to address moderate to severe hallux valgus deformity. We present a retrospective multicenter study to analyze the midterm radiological and clinical outcomes of patients treated with this type of proximal osteotomy fixed with plates. Materials and Methods: One hundred and forty-four patients (187 feet) were operated on between May 2005 and June 2010 in 2 separate centers. Inclusion criteria were symptomatic moderate to severe incongruent hallux valgus deformity, no significant restriction in the first metatarsophalangeal joint movement, none to minimal degenerative changes in the first metatarsophalangeal or the tarsometatarsal joints, and no hypermobility. The median age was 60 years. The preoperative hallux valgus angle (HV) was 35.6 degrees, intermetatarsal angle (IM) was 15.3 degrees, AOFAS score was 53 points. The median follow-up was 35 months (range, 12-73). A POSCOW osteotomy was performed in all patients and fixed with plates. We recorded the satisfaction rate, postoperative clinical and radiological results, and complications. Results: The patient satisfaction rate was 87%. The mean postoperative HV angle was 12.3 degrees, IM angle 4.8 degrees, AOFAS score 89 points. The mean decrease in the first metatarsal length was 2.2 mm (range, 0-8). Twelve feet (6.4%) with recurrence of the deformity required revision surgeries. Removal of complete or partial hardware was needed in 23 feet (12.3%) for symptomatic hardware. Five feet (2.6%) developed hallux varus but only 2 required surgery. Transfer metatarsalgia was noted in 9 feet (4.8%). Conclusions: The POSCOW osteotomy was an effective and reliable method for relieving pain and improving function. A learning curve was present, as most of the complications happened in the initial cases. To our knowledge, this is the largest reported series of proximal closing wedge osteotomy for hallux valgus deformities. Level of Evidence: Level IV, case series.

Use of Collagen Conduits in Management of Painful Neuromas of the Foot and Ankle

Background: Painful neuromas of the foot and ankle frequently pose a treatment dilemma due to persistent pain or recurrence after resection. The purpose of this survey was to evaluate the clinical and functional outcomes in patients in which collagen nerve conduits were used as an adjunct to the resection of a painful neuroma. Our prior experience with vein conduits for this purpose suggested that we might have similar success with the use of these devices. Materials and Methods: Chart reviews and telephone surveys were performed on patients operated by the senior surgeon (JSG) at our medical center from June 2006 to June 2011. A total of 50 patients underwent excision of painful single or multiple neuromas with the end of the resected nerve sutured into the collagen conduit. Each patient preoperatively was asked to describe the amount of pain he or she was experiencing on a scale from 1 to 10, with 10 indicating the most severe pain. In the telephone interview conducted during this study, the same question was asked of each patient following revision. Patient ages ranged from 16 to 77 years, with a mean of 54 years. In all, 30 right and 20 left sides were operated, and 1 patient had bilateral involvement. Mean follow-up was 36 months (6-55 months). There were a total of 69 nerves that underwent conduit procedures. Results: Of 69 nerve conduit constructs, 30 (43%) were painless at final outcome, 23 (33%) had pain scores of 1 to 4, 6 (9%) had pain scores of 5 to 7, and 10 (15%) had severe symptoms with pain scores of 8 to 10. Satisfactory outcomes in which patients stated that they were significantly improved with the procedure and now functional occurred in 59/69 (85%). In all, 24 (48%) patients were completely symptom free, 13 (26%) had a pain score of 1 to 4, 6 (12%) had scores of 5 to 7, and 10 (15%) had severe pain with scores of 8 to 10. Three patients had superficial infections (stitch abscesses): 2 resolved with oral antibiotics and 1 resolved spontaneously. Three patients developed complex regional pain syndrome. One patient responded to a dorsal column stimulator and 2 responded to sympathetic blocks. No other complications were reported. Conclusion: Collagen conduits were safe and generally successful adjuncts to simple excision in the management of painful neuromas of the foot and ankle. Level of Evidence: Level IV, retrospective case series.

Gastrocnemius recession for recalcitrant plantar fasciitis in overweight and obese patients

BACKGROUND Plantar fasciitis is a common foot pathology that is typically treated non-operatively. However, a minority of patients fail non-operative management, develop chronic symptoms, and request a surgical option. Gastrocnemius recession has recently been shown to be effective for the treatment of chronic plantar fasciitis. The purpose of this paper is to present evidence that gastrocnemius recession is safe and effective in the subset of chronic plantar fasciitis patients who are overweight and obese. METHODS We retrospectively reviewed 18 cases (17 patients) of chronic plantar fasciitis in overweight or obese patients who underwent gastrocnemius recession (mean age=46years, mean body mass index=34.7kg/m2, mean follow-up=20months). Data was gathered regarding pre-operative and post-operative pain (visual analog scale, 0-10), Foot Function Index score, and complications. RESULTS Mean Foot Function Index score improved from 66.4 (range, 32.3-97.7) preoperatively to 26.5 (range, 0-89.4) postoperatively (p<0.01). Mean pain score improved from 8.3 (range, 5-10) preoperatively to 2.4 (range, 0-7) at final follow-up (p<0.01). CONCLUSIONS Gastrocnemius recession improved foot function and pain symptoms in overweight and obese patients with chronic plantar fasciitis.

Tibiotalocalcaneal Arthrodesis With Intramedullary Fibular Strut Graft With Adjuvant Hardware Fixation

ABSTRACT Tibiotalocalcaneal arthrodesis (TTCA) is a well‐established operative procedure for different severe pathologic conditions of the ankle and hindfoot joints. We present our results with a modified technique of TTCA using an intramedullary fibular strut graft in a series of complex cases of patients treated for multiple etiologies shown to have improved union rates. The technique involves inserting the fibular strut graft intramedullary after joint preparation and the use of either a Taylor spatial frame or plate and screws for definitive fixation. We reviewed the records of 16 patients who had undergone TTCA with this technique at our hospital from September 2013 to April 2015. Sixteen patients (10 males [62.5%] and 6 females [37.5%]) were included in the present study. These patients had complex cases and multiple risk factors, including diabetes, smoking, poor bone stock, and a history of previous surgeries. The mean follow‐up time was 9.1 (range 9 to 18) months. Thirteen patients (81.2%) subsequently achieved union. The mean visual analog scale scores at the final follow‐up examination had improved from 6.9 to 1.2. We suggest that our technique of TTCA with intramedullary fibular strut graft with fixation is a reasonable option to salvage complex cases with risk factors for operative complications.

ROLE OF BONE GRAFTS AND BONE GRAFT SUBSTITUTES IN ISOLATED SUBTALAR JOINT ARTHRODESIS

ABSTRACT Objectives: The purpose of this study was to compare union rates for isolated subtalar arthrodesis with and without the use of bone grafts or bone graft substitutes. Methods: We retrospectively reviewed 135 subtalar fusions with a mean follow-up of 18 ± 14 months. The standard approach was used for all surgeries. Graft materials included b-tricalcium phosphate, demineralized bone matrix, iliac crest autograft and allograft, and allograft cancellous chips. Successful subtalar fusion was determined clinically and radiographically. Results: There was an 88% (37/42) union rate without graft use and an 83% (78/93) union rate with bone graft use. Odds ratio of union for graft versus no graft was 0.703 (95% CI, 0.237-2.08). The average time to union in the graft group was 3 ± 0.73 months and 3 ± 0.86 in the non-graft group, with no statistically significant difference detected (p = 0.56). Conclusion: Graft use did not improve union rates for subtalar arthrodesis. Level of Evidence IV, Case Series.

Staple Versus Suture Closure for Ankle Fracture Fixation: Retrospective Chart Review for Safety and Outcomes

INTRODUCTION/AIM Recent comparisons of suture versus metal staple skin closure on the rates of wound complications in orthopaedic surgeries have yielded conflicting results. Several studies have since started to approach this question based on anatomic location, comparing suture versus staple closure in total hip and knee arthroplasty and acetabulum fracture surgery. Ankle fractures are one of the most commonly treated fractures by orthopaedic surgeons with unique challenges to skin closure due to the lack of subcutaneous support. However, to date there are no studies comparing superficial skin closure methods specifically in ankle surgery. The objective of this study was to evaluate the safety of staple versus suture closure for open fixation of acute traumatic ankle fractures. METHODS The medical records of patients treated at one institution by a single surgeon with open surgical fixation of an acute traumatic ankle fracture between 2011 and 2017 were retrospectively reviewed. Patients with less than 6 months of follow-up, polytrauma patients, diabetic patients, and patients with more than 3 medical comorbidities were excluded. Skin closure technique was determined by the presence or absence of metallic staples on postoperative imaging. Demographic variables, surgical characteristics, and postoperative outcomes up to one year were compared between patients who received superficial skin closure using staple versus suture techniques. Statistical analysis was performed using chi-squared tests and Fishers exact tests, with p=0.05 used to denote statistical significance. RESULTS This study included 94 patients aged 18 to 75: two groups of 47 patients (Staple group and Suture group) that were demographically similar at baseline. Overweight and obese patients constituted the majority of the sample, 34% and 46% of patients, respectively. Current tobacco use was reported by 45% of patients. Fractures tended to be right-sided (63%), low energy (64%), and closed (98%), and the most common fracture types were bimalleolar (30%), lateral malleolar (24%), and pilon (19%) fractures. Ten patients (10.6%) developed local wound related complications within 4 months postoperatively, including five incidences of wound dehiscence, four superficial wound infections, and one deep infection. Eight patients (8.5%) required revision surgery due to wound related complications. There was no difference in the incidence of surgical site infections (p=0.361), local wound related complications (p=0.316), or revision surgeries (p=0.267) between wound closure techniques. Suture group patients required more staff in the operating room compared with staple group patients (p=0.001). CONCLUSION These results suggest that staples are a safe alternative to sutures for superficial skin closure in healthy, non-diabetic patients following open surgical fixation of acute traumatic ankle fractures. However, this retrospective, single-institution study was limited by the low number of available patients relative to the rare outcomes of interest. Larger, prospective studies are needed to validate the accuracy and generalizability of these results.

Associations between season and surgical site infections in orthopaedic foot and ankle surgery

BACKGROUND Surgical site infections (SSI) in orthopaedic surgery are common nosocomial complications that contribute significantly to patient morbidity and increased healthcare costs. While past studies support an increase in the incidence of SSI during the summer months in orthopaedic spine surgery and joint arthroplasty, there has not been any study examining the association between season and SSI in the setting of orthopaedic foot and ankle surgery. METHODS A retrospective analysis of data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2011-2015 was conducted. 17,939 patients who received at least one of 218 CPT codes specific to orthopaedic foot and ankle surgery were identfied from the NSQIP database. Descriptive statistics of patient demographics, comorbidities, and complications were stratified by quarter of admission. RESULTS Of the 17,939 patients, there were 4995 in the 1st quarter (27.8%), 4078 in the 2nd quarter (22.7%), 4333 in the 3rd quarter (24.2%), and 4533 in the 4th quarter (25.3%). The overall rate of surgical complications was 2.3%. The highest incidence of surgical complications was during the summer at 2.7% and the lowest was during the fall at 2.1% (p=0.338). The summer months also demonstrated the highest incidence of medical complications at 5.9% (p=0.524). There were significantly more women undergoing surgery in the winter and summer months (p=0.028). CONCLUSION The surgical site infection rate in the setting of orthopaedic foot and ankle surgery was higher, although not significantly, in the summer months. LEVEL OF EVIDENCE Level III retrospective.

Marijuana use and mortality following orthopedic surgical procedures

ABSTRACT Background: The association between marijuana use and surgical procedures is a matter of increasing societal relevance that has not been well studied in the literature. The primary aim of this study is to evaluate the relationship between marijuana use and in-hospital mortality, as well as to assess associated comorbidities in patients undergoing commonly billed orthopedic surgeries. Methods: The National Inpatient Sample (NIS) database from 2010 to 2014 was used to determine the odds ratios for the associations between marijuana use and in-hospital mortality, heart failure (HF), stroke, and cardiac disease (CD) in patients undergoing 5 common orthopedic procedures: total hip (THA), total knee (TKA), and total shoulder (TSA) arthroplasties, spinal fusion, and traumatic femur fracture fixation. Results: Of 9,561,963 patients who underwent one of the 5 selected procedures in the 4-year period, 26,416 (0.28%) were identified with a diagnosis of marijuana use disorder. In hip and knee arthroplasty patients, marijuana use was associated with decreased odds of mortality compared with no marijuana use (P < .0001) and increased odds of HF (P = .018), stroke (P = .0068), and CD (P = .0123). Traumatic femur fixation patients had the highest prevalence of marijuana use (0.70%), which was associated with decreased odds of mortality (P = .0483), HF (P = .0076), and CD (P = .0003). For spinal fusions, marijuana use was associated with increased odds of stroke (P < .0001) and CD (P < .0001). Marijuana use in patients undergoing total shoulder arthroplasty was associated with decreased odds of mortality (P < .001) and stroke (P < .001). Conclusions: In this study, marijuana use was associated with decreased mortality in patients undergoing THA, TKA, TSA, and traumatic femur fixation, although the significance of these findings remains unclear. More research is needed to provide insight into these associations in a growing surgical population.

Cadaveric study of the infrapatellar branch of the saphenous nerve: Can damage be prevented in total knee arthroplasty?

Background The infrapatellar branch of the saphenous nerve (IPBSN) is a purely sensory nerve innervating the anteromedial aspect of the knee and anteroinferior knee joint capsule. Total knee arthroplasty (TKA) is commonly used to treat end-stage arthritis, but the IPBSN is often injured and results in numbness around the anteromedial knee. The aim of this cadaveric study was to describe the course and variability of the IPBSN and to assess whether it is possible to preserve during a standard midline surgical approach in TKA. Methods Ten fresh-frozen cadaver legs were dissected using a midline approach to the knee. Skin and subcutaneous flap were reflected to expose both the saphenous nerve and its branches. The branches of the IPBSN were identified, and their vertical distances above the tibial tuberosity (TB) were recorded: TB to inferior branch, to middle branch, and to superior branch. Results There were 10 left-sided specimens (6 female, 4 male) with a mean age of 79.9 ± 9.8 years. 8 (80%) specimens had 2 branches of IPBSN while 2 (20%) specimens had 3 branches. The average distance from TB to the inferior branch was 16.8 ± 8.3 mm (3.0-28.0); middle branch, 24.0 ± 1.4 mm (23.0-24.9); and superior, 45.9 ± 7.7 mm (32.0-54.5). Conclusion Our cadaveric study found no consistent way to preserve the IPBSN using a standard midline approach in TKA. It is important to provide proper patient education on this complication, and surgeons should be aware of approximate locations and variations of IPBSN while performing other knee procedures.

A systematic review and meta-analysis of complications in conversion arthroplasty methods for failed intertrochanteric fracture fixation

Background Conversion arthroplasty for failed primary fixation of intertrochanteric fractures can be achieved using various methods, including cemented total hip arthroplasty, uncemented total hip arthroplasty, hybrid total hip arthroplasty, and hemiarthroplasty. Complication rates vary between each conversion method. The purpose of this paper is to examine the effect of conversion method on total conversion complication rates. Methods We performed a meta-analysis of five studies with sufficient data for analysis. We created a null hypothesis stating that the expected distribution of complications across conversion methods would reflect the distribution of conversion method used for failed primary fixation. Using a z test, we compared proportions of the expected distribution of complications to the observed distribution of complications. Results A total of 138 cases of conversion arthroplasty with 49 complications were available for analysis. The mean age was 73 (range, 32-96) years. 19 males and 48 females were included, with one study not including patient gender. The mean time from primary fixation failure to conversion was 11 months, and the mean duration of conversion surgery was 132 min. Expected and observed complication rate distributions were as follows: cemented total hip arthroplasty, 6.5% versus 4.1% (p = 0.79); uncemented total hip arthroplasty, 77.5% versus 81.6% (p = 0.69); hybrid total hip arthroplasty, 2.9% versus 2.0% (p = 1); and hemiarthroplasty, 13% versus 12.2% (p = 1). Conclusions Our findings suggest that the method of conversion arthroplasty following failed primary intertrochanteric femur fracture fixation does not influence complication rate.