Arthroscopic treatment of posterior glenohumeral joint subluxation resulting from brachial plexus birth palsy.

The purpose of this study is to assess the ability of arthroscopic anterior capsular release, subscapularis tenotomy, and glenohumeral manipulation to reduce glenohumeral joint subluxation resulting from brachial plexus birth palsy. Twenty-two children with a mean age of 3.9 years (range, 1.6-8.3 years) underwent preoperative magnetic resonance imaging, arthroscopic surgery with or without tendon transfers, and postoperative imaging in their spica cast. In the uninvolved shoulders, the mean percentage of the humeral head anterior to the middle of the glenoid fossa (PHHA) was 45.2% +/- 4.8% and the mean glenoid version was -7% +/- 3%. In the involved shoulders, preoperatively, the mean PHHA was 15.6% +/- 13.5% and the mean glenoid version was -37 degrees +/- 15 degrees . Postoperatively, the mean PHHA corrected to 46.9% +/- 11.2% and the mean glenoid version improved to -8 degrees +/- 8 degrees . There was a significant improvement in the mean PHHA (P \u3c .001) and mean glenoid version (P \u3c .001) that approached the values of the uninvolved shoulder. Arthroscopic capsular release and subscapularis tenotomy were successful in obtaining reduction of glenohumeral joint subluxation in all patients. The maintenance of reduction requires continued follow-up over time

Midterm Survivorship and Complications of the Cadence Total Ankle Arthroplasty

Category: Ankle Arthritis; Ankle Introduction/Purpose: The Cadence total ankle arthroplasty (TAA) system first entered clinical use in 2016. Short-term outcomes with a minimum of two-year follow-up time have demonstrated survivorship between 93.7% and 100% with improvements in patient-reported outcomes measures, coronal alignment, and range of motion1–4. The purpose of this study is to report the midterm survivorship and complications of Cadence TAA patients with a minimum of 4.5-year radiographic follow-up. Methods: A retrospective chart review was conducted to identify a total of 22 TAA patients with the Cadence implant and a minimum follow-up time of 4.5-years. Patient age, sex, body mass index, diabetes mellitus status, rheumatoid arthritis status, smoking status, laterality, and diagnosis for TAA were collected from patient chart reviews. Preoperative FAAM-ADL subscore, FAAM-Sport subscore, and VAS pain scores and the postoperative scores at the last follow-up visit was also collected. 13 out of 22 patients had preoperative FAAM-VAS scores available while 10 out of 22 patients had postoperative FAAM-VAS scores available. Postoperative complications in the form of wound-related issues and those requiring reoperation or revision were noted, with revision defined as removal or exchange of metal component. 5-view radiographs obtained preoperatively and at the last follow-up visit were used to measure coronal alignment, range of motion, evidence of subsidence or loosening, and osteolysis as previously described1. Results: 3 out of 22 patients required a revision surgery, 1 for loosening of tibial component and 2 for infection. 4 out of 22 patients underwent a reoperation, 2 for gutter debridement due to impingement or heterotopic ossification, 1 for periprosthetic medial malleolar fracture, and 1 for removal of painful medial malleolar screws. The average FAAM-ADL, FAAM-Sport, and VAS pain scores improved from 50.6, 26.5, and 59.9 to 69.5, 35.5, and 23.6, respectively. The coronal alignment angle decreased from 5.96 degrees from neutral to 2.31 degrees. The average dorsiflexion and plantarflexion angles were 14.74 and 17.18 degrees, respectively, for an average range of motion of 31.9 degrees. 3 out of 22 patients had evidence of osteolysis while no patients had evidence of loosening or subsidence. Conclusion: The midterm survivorship of Cadence TAA system in 22 patients was 86.4%. Excluding the two cases of infection which are typically not attributed to implant performance, the survivorship was 95.4%. The reasons for reoperation included impingement, heterotopic ossification, periprosthetic fracture, and removal of painful hardware. The average FAAM-ADL, FAAM- Sport, VAS pain scores and coronal alignment improved. Analysis of longer follow-up time in greater patient cohorts is necessary for clearer understanding of this fixed-bearing implant’s performance

The Influence of Wait Time on Patient Satisfaction in the Orthopedic Clinic

Introduction: Patient satisfaction is of increasing importance in the delivery of quality healthcare and may influence provider reimbursement. The purpose of this study is to examine how patient wait time relates to their level of satisfaction and likelihood to recommend an orthopedic clinic to others. Methods: A retrospective analysis was performed on standardized new patient survey data collected at a single orthopedic clinic from June 2011 through October 2014. Results: A total of 3125 and 3151 responses were collected for satisfaction and likelihood to recommend the practice. The mean wait time was 27.3 ± 11.3 minutes. The likelihood of obtaining an “excellent” (odds ratio [OR]: 0.86, P = .01081) or “excellent/very good” (OR: 0.82, P = .0199) satisfaction demonstrated significant correlation with wait time in 15-minute intervals. The likelihood of obtaining an “agree” (OR: 0.9, P = .10575) and “strongly agree/agree” (OR: 0.85, P = .139) response to recommend the practice demonstrated no correlation during the same interval. Conclusion: Minimizing wait times in the orthopedic clinic may improve patient satisfaction but may not affect their likelihood of recommending the practice to others

Development of a Predictive Model for the Outcome of Nonsurgical Treatment of Insertional Achilles Tendinosis

Category: Hindfoot Introduction/Purpose: Insertional Achilles tendinosis (IAT) is less responsive to nonsurgical treatment than midstubstance disease. The purpose of this study was to develop a predictive model for the treatment outcomes of patients with IAT. Objectives were to discriminate between predictive and non-predictive presenting parameters with respect to the outcome of nonsurgical treatment, to develop a predictive model using these parameters which assigns individual patients a likelihood of failing nonsurgical treatment based on their respective risk profiles, and to validate this model. Methods: Following IRB-approval, patients with Achilles tendinosis were identified using ICD-9 code 726.71. The authors reviewed medical records and included all 664 patients with IAT who underwent at least 3 months of nonsurgical treatment. Exclusion criteria included midstubstance or bilateral disease, skeletal immaturity, or previous hindfoot surgery. Parameters collected included presenting age, gender, body mass index, presence of diabetes mellitus or rheumatoid arthritis, tobacco use, workman’s compensation status, previous corticosteroid injection, ankle range of motion, visual analogue pain score, Foot and Ankle Ability Measure score, presenting SF-12 score, presence of Haglund’s exostosis, insertional enthesophyte or intrasubstance calcification. Univariate analysis was used to describe the study population. A multivariate logistic regression was developed and pruned using Akaike information criterion. The final model was used to predict an individual’s likelihood of undergoing surgery for IAT and the model was validated using bootstrapping analysis. Results: The study sample was 53% female, had a mean age of 53.7 years (SD 14.7 years), and 80% were overweight or obese. Duration of symptoms at presentation averaged 10.4 months (range, 0 to 348 months, SD 28 months). 1 in 12 patients failed nonsurgical treatment. Final predictors of outcome were presenting visual analog scale >4 (OR 1.13, 95% CI 1.01 -1.26, p=0.02), limited ankle range of motion (OR 0.33, 95% CI 0.19-0.58, p < 0.01), previous corticosteroid injection (OR 2.33, 95% CI 1.06-5.10, p=0.04), and Achilles insertion enthesophyte (OR 2.21, 95% CI 1.38-3.54, p < 0.01). The model assigned a risk of failure ranging from 5% for one predictor to 55% for 4 predictors. For this model, the area underneath the curve was 0.7. Conclusion: These data indicate that patients with IAT can be risk-stratified according to presenting data. A validated model for risk stratifying patients with IAT did not exist prior to this study. Such a model has potential utility in clinical care and when planning and interpreting the outcomes of clinical trials. Strengths of this study were its breadth of included parameters and its large sample size. Weaknesses were its retrospective nature and lack of a defined nonoperative treatment protocol. While encouraging, these findings require prospective validation prior to clinical or investigational use

Content Relevance of the Foot and Ankle Ability Measure in Patients with Achilles Tendon Diseases

Category: Sports Introduction/Purpose: The Foot and Ankle Ability Measure (FAAM) is a widely used evaluative, region-specific patient reported outcome measure. Its construct validity, test-retest reliability, and responsiveness are reasonably well supported in patients with a variety of lower extremity musculoskeletal conditions. However, since its development, the FAAM’s content relevance has never been subject to patient assessment. Therefore, this study was designed to assess the content relevance of the FAAM among patients with Achilles tendon diseases. Methods: IRB-approved, prospective, observational study of patients with Achilles tendon diseases. Subjects gave informed consent to complete a standard FAAM and a FAAM content relevance questionnaire. For each item of the relevance questionnaire, the standard FAAM’s visual analogue scale was replaced by a categorical scale asking subjects to rank the individual item as 1-Not Relevant, 2-Somewhat Relevant, or 3-Very Relevant to their lower extremity condition. The same was asked regarding both the entire ADL and Sports subscales, respectively. Descriptive statistics (mean, standard deviation) were calculated using pooled individual question scores and then 95% confidence intervals were constructed. Any individual item or subscale with a mean score above 2.0 was considered to have substantial content relevance. Floor and ceiling effects were deemed to have been present if 20% or more of patients gave all items of a subscale either the lowest or highest possible scores, respectively. Results: There were 59 respondents with mean age of 52.6 years (range, 28 to 79 years). Mean time from presentation to content relevance assessment was 19.6 weeks (range, 1 to 100 weeks). There were 39 (66%) surgical patients and 20 (34%) nonsurgical patients. Diagnoses included 28 (47%) rupture, 18 (31%) tendinosis, and 13 (22%) paratenonitis. 10 (17%) were pre- treatment and 49 (83%) post-treatment. For each individual item and subscale, the mean relevance was above 2.0 indicating substantial relevance. The 95% confidence interval crossed below this threshold for only one item, ‘Personal Care’ (mean 2.02, 95% CI 1.79 to 2.24). No floor effects were detected. Ceiling effects were apparent for only the Sports subscale (n=25,42.4%). Conclusion: These findings demonstrate that the FAAM has substantial item and subscale-level content relevance in patients with Achilles tendon diseases. Future work should aim to provide additional psychometric data specific to patients with Achilles tendon diseases in order to allow more precise use of the FAAM in this specific patient population

Results of Augmented Half-Thickness Tibialis Anterior Tendon Segment Transposition, a Novel Technique for Tibialis Anterior Tendon Reconstruction

Category: Ankle Introduction/Purpose: Tibialis anterior tendon (TAT) rupture causes substantial morbidity. Nearly 200 surgical cases have been reported in the literature since 1905 wherein primary repair was not achieved approximately 40% of the time due to post- debridement tendon defect size. The present study describes the clinical outcomes of augmented, half-thickness TAT segment transposition, a novel reconstruction technique for managing post-debridement TAT defect. The purpose was to assess this technique as an alternative to tendon transfer and allograft tendon interposition. Methods: IRB-approved, retrospective electronic medical record review of patients with attritional distal TAT rupture. In all cases, the post-debridement tendon defect prohibited primary repair or reinsertion and was managed by distal transposition of a half-thickness TAT segment to span the defect. This graft was secured with a six core suture end-to-end anastomosis. Then, this repair was augmented with human acellular dermal matrix allograft (Graftjacket®, Wright Medical Technology, Memphis, TN). A total of five patients were treated with this technique. One patient died of unrelated causes remote from surgery and one was lost to follow up. Three patients with a minimum one year follow up were included. Outcomes were assessed via observed range of motion, clinical motor power assessment, ability to heel walk 15 feet, visual analog scale pain score, Foot and Ankle Ability Measure score, postoperative complications, and patient satisfaction at one year. Outcomes data were analyzed using descriptive statistics. Results: The mean age was 68 years (range, 59 to 73 years). Two patients were female. Mean interval between injury and surgery was 59.3 days (range, 15 to 146 days). All patients regained symmetrical range of motion, medical research council grade 5 motor power and the ability to heel walk. Mean pain scores improved from 4.6 (range, 2.5 to 8.5) preoperatively to 0.7 (range, 0 to 2) postoperatively. Mean FAAM scores increased from 30.6 (range, 23.8 to 43.8) preoperatively to 78.7 (range, 72.6 to 97.6) postoperatively. No postoperative complications occurred. At one year, one patient was satisfied and two were very satisfied with their outcome. Conclusion: Although constrained by a small sample size, the present findings appear to indicate that this technique produces short term clinical results comparable to those described for other techniques for TAT reconstruction. Future work should assess if these results are reproducible and long lasting. Additionally, the relative value of saving donor site morbidity or the cost of allograft tendon in comparison to the added cost of the Graftjacket should be determine

Comparison of Intraoperative Radiation Exposure Between Minimally Invasive Chevron Akin (MICA) and Open Procedures for Hallux Valgus Correction

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The minimally-invasive Chevron-Akin (MICA) procedure for hallux valgus correction is an increasingly popular technique that has yielded comparable radiographic and clinical outcomes to open procedures3–5. Intraoperative radiation dosages for certain foot and ankle surgeries have been reported relative to the international occupational radioprotection thresholds6. In particular, the mean intraoperative radiation exposure during the MIS Scarf osteotomy has been reported to be 14-times greater than open osteotomy7. However, no study to date has reported on the intraoperative radiation exposure during MICA procedures in relation to that of open procedures. Methods: This is a retrospective comparative study from a single institution. Patients underwent a MICA (n=25) or open (n=40) hallux valgus correction by a single foot and ankle fellowship trained surgeon. To account for the learning curve8, the number of intraoperative fluoroscopy shots for the first 50 consecutive MICA procedures were analyzed, and the first 25 procedures were excluded. Four data points were retrieved from the mini C-arm, including 1) number of fluoroscopy shots taken; 2) total fluoroscopy time (s); 3) total radiation dose (mGy); and 4) total dose area product (DAP; mGy*cm 2 ). Preoperative and postoperative radiographs were referenced to measure the hallux valgus (HVA) and intermetatarsal angles (IMA) as previously described.9 Categorical variables were compared using the chi-square test, and continuous variables were compared using Student’s t-test or the Mann-Whitney U test. Analysis of variance was used to determine the statistical significance of differences in the fluoroscopy data between groups. Results: The average total dose absorbed (4.00 vs. 1.34 mGy, p< 0.001), total fluoroscopy time (226 vs. 48.5 s, p< 0.001), and number of fluoroscopy shots (125 vs. 22.3, p< 0.001) were 2.9, 4.6, and 5.6 times greater in the MICA versus the open group, respectively. The total DAP (4.22 vs. 2.56 mGy*cm 2 , p=0.175) was 1.6 times greater in the MICA group but the difference was not statistically significant. The mean preoperative and postoperative HVA and IMA were greater in the MICA cohort compared to the open cohort. However, there was no statistical difference in change in HVA (MICA -17.43 vs. Open -20.05, p=0.125) or IMA (MICA -8.08 vs. open -9.31, p=0.11) between the two cohorts, with each resulting in normal postoperative angles. Conclusion: In this single surgeon series, the MICA procedure demonstrated significantly greater dose absorbed, total fluoroscopy time, and number of fluoroscopy shots compared to the open procedure. The extent of radiation exposure to the surgeon and the patient in relation to the radioprotection thresholds must be closely monitored to specify the health risks involved with this procedure