A Modified Technique for the Treatment of Severe Adolescent Hallux Valgus: A Modification of the First Metatarsal Double Osteotomy

Adolescent hallux valgus is a deformity of childhood that is often difficult to treat conservatively because of its progressive nature and surgically because of its high risk of complications. Despite numerous procedures described, there is still little consensus on the best technique available for deformity correction. One of the standard procedures to address severe adult hallux valgus was described by Peterson and Newman in 1993. This procedure involved an excision of the medial eminence, an extra-articular distal closing wedge osteotomy to correct the hallux valgus, and a proximal transverse opening wedge osteotomy to correct the metatarsus primus varus. Although good outcomes have been reported, this approach is not without its own complications, including first metatarsophalangeal joint stiffness, avascular necrosis of the first metatarsal head, and painful pin removal. This paper presents a modification to the first metatarsal double osteotomy surgical technique (used by the principal investigator) to address severe adolescent hallux valgus. This technique avoids the complications associated with the traditional Peterson double osteotomy technique, whereas optimizing patient outcomes.Level of EvidenceLevel IV—Technique paper/case series with no control group. Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence

Intra-operative referencing technique is non-inferior to use of fluoroscopy for acetabular component positioning in anterior hip arthroplasty

Intra-operative fluoroscopy has been shown to improve the accuracy of acetabular component positioning when compared to no fluoroscopy in direct anterior approach (DAA) total hip arthroplasty (THA). Due to logistical reasons, our senior author has been performing DAA THA at one institution without the use of fluoroscopy and has created an intraoperative referencing technique to aid in acetabular component positioning. The purpose of this study is to evaluate the accuracy of acetabular component positioning using fluoroscopy when compared to an intra-operative referencing technique without fluoroscopy. A total of 214 consecutive primary DAA THA were performed by one surgeon at two institutions and were retrospectively reviewed over a 3-year period. Intra-operative fluoroscopy was used with all patients at Institution A (N = 154). At institution B (N = 60), no fluoroscopy was used, and an intra-operative referencing technique was employed to assist in placement of the acetabular component. In the fluoroscopy group, 91% of components met our abduction target, 90% met our anteversion target, and 82.5% simultaneously met both targets. In the non-fluoroscopy group, 98% of components met our abduction target, 92% met our anteversion target, and 90% simultaneously met both targets. There was no difference between groups for placement of the component within both targets simultaneously (p = .171). Use of our intra-operative referencing technique is non-inferior in placing acetabular components within a pre-defined safe zone when compared to use of intraoperative fluoroscopy. The intra-operative reference technique can be a helpful adjunct for ensuring accurate acetabular component positioning while simultaneously reducing cost and limiting radiation exposure

Management of Isolated Lateral Malleolus Fractures

Isolated lateral malleolus fractures represent one of the most common injuries encountered by orthopaedic surgeons. Nevertheless, appropriate diagnosis and management of these injuries are not clearly understood. Ankle stability is maintained by ligamentous and bony anatomy. The deep deltoid ligament is considered the primary stabilizer of the ankle. In the setting of an isolated lateral malleolus fracture, identifying injury to this ligament and associated ankle instability influences management. The most effective methods for assessing tibiotalar instability include stress and weight-bearing radiographs. Clinical examination findings are important but less reliable. Advanced imaging may not be accurate for guiding management. If the ankle is stable, nonsurgical management produces excellent outcomes. In the case that clinical/radiographic findings are indicative of ankle instability, surgical fixation options include lateral or posterolateral plating or intramedullary fixation. Locking plates and small or minifragment fixation are important adjuncts for the surgeon to consider based on individual patient needs

Hypothyroidism Increases 90-Day Complications and Cost Following Primary Total Hip Arthroplasty

Abstract Hypothyroidism is common, and the incidence has been increasing annually in the United States. Abnormalities in thyroid hormone can have several effects on the endocrine, immune, and musculoskeletal systems of the body. The influence of hypothyroidism on outcomes following primary total hip arthroplasty (THA) is not well reported. The authors hypothesized that hypothyroidism was associated with a higher risk of postoperative complications and 90-day costs following primary THA. A retrospective review from 2005 to 2014 was performed using the Medicare Standard Analytical Files from the Pearl Diver database. Utilizing International Classification of Disease 9th revision (ICD-9) codes, the authors identified patients who underwent THA. Patients with a concurrent diagnosis of hypothyroidism were matched by age, gender, and Charlson's comorbidity index (CCI) to a control group. Ninety-day postoperative complications, readmission rates, complications related to implants, and cost of care were compared and assessed following primary THA between matched cohorts. Statistical analysis was performed using the programming language R (University of Auckland) to calculate odds ratios (OR) along with their respective 95% confidence intervals (95% CI), and p- values. A total of 383,898 patients underwent primary THA. Among them, 191,949 patients were diagnosed with hypothyroidism and 191,949 patients without hypothyroidism. Hypothyroidism was associated with greater odds of postoperative complications ( p  < 0.001), 90-day readmission rates ( p  < 0.001), implant related complications ( p   <  0.001), and total global 90-day episode of care cost (U.S. $17,549.96 vs.$16,645.01; p   <  0.001). This study demonstrated an increased risk of postoperative complications (medical or implant related), increased readmission rates, and higher costs among patients with hypothyroidism following primary THA. Surgeons should counsel patients and determine strategies to medically optimize patients to mitigate risk and decrease cost

Trends in Hip Resection Arthroplasty in the Medicare Patient Population from 2005 to 2012

Abstract Hip resection arthroplasty (HRA) is a relatively uncommon, yet viable surgical procedure originally developed by Girdlestone for osteomyelitis of the proximal femur. Currently, HRA is primarily indicated as a salvage procedure after a failed total hip arthroplasty. Despite a continuous rise in the rates of primary and revision hip arthroplasty, there is a lack of published evidence regarding the extent of HRA's current use and its recent trends. We sought to provide an epidemiological description of the recent utilization patterns of HRA in the United States. A level of evidence IV, retrospective case series review of the entire Medicare files between 2005 and 2012 was conducted through the use of current procedural terminology codes and International Classification of Disease ninth edition codes. Linear regressions and chi-square tests were used for analysis. Subgroup analysis was performed by patient age. The total number of HRAs performed between 2005 and 2012 significantly decreased from 4,248 to 3,872 ( p  = 0.025). There was a significant increase in the annual incidence of HRA among patients younger than 65 years ( p  = 0.027; 9% increase) and patients 65 to 69 years old ( p  = 0.007; 22% increase), constituting 43% of the total patients. There was a significant decrease in HRA incidence among patients 80 to 84 years old ( p  = 0.001; 32% decrease) and patients 85 years old and over ( p  = 0.002; 24% decrease). Geographic analysis demonstrated the most HRA procedures were performed in the South, whereas gender focused analysis demonstrated a statistically significant decrease in HRA incidence for females ( p  = 0.003; 6% decrease) and a significant increase in incidence for males ( p  = 0.003; 7% increase). The overall annual incidence of HRA performed in the Medicare patient population has significantly decreased in recent years. However, this conceals an increased incidence among the relatively younger patient population. Potential causes for these opposing trends include changes in rates of revision surgery, alternative indications for surgery, advances in hardware, and surgeon expertise. This was a level of evidence IV, retrospective case series study

Proximal Tibial Reconstruction After Tumor Resection: A Systematic Review of the Literature

The proximal part of the tibia is a common location for primary bone tumors, and many options for reconstruction exist following resection. This anatomic location has a notoriously high complication rate, and each available reconstruction method is associated with unique risks and benefits. The most commonly utilized implants are metallic endoprostheses, osteoarticular allografts, and allograft-prosthesis composites. There is a current lack of data comparing the outcomes of these reconstructive techniques in the literature. A systematic review of peer-reviewed observational studies evaluating outcomes after proximal tibial reconstruction was conducted, including both aggregate and pooled data sets and utilizing a Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) review for quality assessment. Henderson complications, amputation rates, implant survival, and functional outcomes were evaluated. A total of 1,643 patients were identified from 29 studies, including 1,402 patients who underwent reconstruction with metallic endoprostheses, 183 patients who underwent reconstruction with osteoarticular allografts, and 58 patients who underwent with reconstruction with allograft-prosthesis composites. The mean follow-up times were 83.5 months (range, 37.3 to 176 months) for the metallic endoprosthesis group, 109.4 months (range, 49 to 234 months) for the osteoarticular allograft group, and 88.8 months (range, 49 to 128 months) for the allograft-prosthesis composite reconstruction group. The mean patient age per study ranged from 13.5 to 50 years. Patients with metallic endoprostheses had the lowest rates of Henderson Type-1 complications (5.1%; p < 0.001), Type-3 complications (10.3%; p < 0.001), and Type-5 complications (5.8%; p < 0.001), whereas, on aggregate data analysis, patients with an osteoarticular allograft had the lowest rates of Type-2 complications (2.1%; p < 0.001) and patients with an allograft-prosthesis composite had the lowest rates of Type-4 complications (10.2%; p < 0.001). The Musculoskeletal Tumor Society (MSTS) scores were highest in patients with an osteoarticular allograft (26.8 points; p < 0.001). Pooled data analysis showed that patients with a metallic endoprosthesis had the lowest rates of sustaining any Henderson complication (23.1%; p = 0.009) and the highest implant survival rates (92.3%), and patients with an osteoarticular allograft had the lowest implant survival rates at 10 years (60.5%; p = 0.014). Osteoarticular allograft appears to lead to higher rates of Henderson complications and amputation rates when compared with metallic endoprostheses. However, functional outcomes may be higher in patients with osteoarticular allograft. Further work is needed using higher-powered randomized controlled trials to definitively determine the superiority of one reconstructive option over another. In the absence of such high-powered evidence, we encourage individual surgeons to choose reconstructive options based on personal experience and expertise. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence

The association of mental health disease with perioperative outcomes following femoral neck fractures

Mental illness in the United States is a growing problem, leading to significant implications for those effected as well as direct and indirect costs to the health care system. The association between psychiatric comorbidity and increased risk of perioperative adverse events has previously been described following elective orthopedic surgery, however, there is a paucity of literature evaluating the correlation between mental health disease and outcomes in patients in an orthopedic trauma setting. Utilizing data from the US National Hospital Discharge Survey, all patients undergoing surgery for femoral neck fracture were identified between the years 1990 and 2007. The association of depression, anxiety, dementia and schizophrenia on surgical outcomes were then analyzed using univariate regression analysis. A cohort of 2,432,931 patients was identified. All psychiatric comorbidities were associated with a lower rate of routine discharge home following surgery (p < 0.001). Schizophrenia was associated with increased odds of any adverse event (p < 0.001), acute post-operative mechanical complications (p < 0.001) and increased length of stay (p < 0.001). Patients undergoing surgery for femoral neck fracture with comorbid psychiatric illness are at increased risk for non-routine discharge. Schizophrenia is independently associated with an increased risk for post-operative complications. An awareness of these risks should optimize preoperative multidisciplinary patient care planning so as to maximize patient outcome and minimize resource utilization

Hepatitis C is an Independent Risk Factor for Perioperative Complications and Nonroutine Discharge in Patients Treated Surgically for Hip Fractures

To evaluate the relationship between noncirrhotic hepatitis C virus (HCV) infection, perioperative complications, and discharge status in patients undergoing surgical procedures for hip fractures. A retrospective epidemiological study was performed, querying the National Hospital Discharge Survey. Patients were selected using the International Classification of Diseases-9 diagnostic codes for hip fracture and primary procedural codes for open reduction internal fixation, hemiarthroplasty, total hip arthroplasty, or internal fixation. Patients with concurrent cirrhosis, HIV, hepatitis A, B, D, or E were excluded. Pearson χ tests, independent-samples t test, and multivariable binary logistic regression were used for data analysis. Two cohorts surgically treated for a hip fracture were identified and compared. The first cohort included 5377 patients with a concurrent diagnosis of noncirrhotic HCV infection (HCV+) and the second included 4,712,159 patients without a diagnosis of HCV (HCV-). The HCV+ cohort was younger and had fewer medical comorbidities, yet was found to have a longer length of hospital stay, higher rates of nonroutine discharge, and higher rates of complications than the HCV- cohort. Multivariate regression analysis demonstrated that HCV+ is an independent risk factor for perioperative complications and nonroutine discharge. In conclusion, our study demonstrates a negative association between noncirrhotic HCV infection and hip fracture surgery outcomes. Caution and appropriate preparation should be taken when surgically treating hip fractures in HCV+ patients because of higher risk of perioperative complications and nonroutine discharge. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence

The Extensile Lateral Approach to the Calcaneus and the Sural Nerve

Category: Hindfoot Introduction/Purpose: Sural nerve related symptoms following the extensile lateral approach to the calcaneus (ELA) are a known postoperative complication despite awareness of the course the sural nerve. While the main trunk of the sural nerve and its location relative to the ELA have been previously described, the nerve gives rise to lateral calcaneal branches (LCBs) that may be at risk of injury. The relation of the LCBs to the ELA has not been previously reported in the literature. The purpose of this study was to describe the course of the sural nerve and its LCBs in relation to the ELA. Methods: 17 cadaveric foot specimens were dissected, exposing the sural nerve and the LCBs. A line representing the ELA incision was then created. It was noted if the line crossed any of the LCBs, how many branches were crossed, and at what distance they were crossed using the distal tip of the fibula as a reference. Results: The sural nerve was identified in all specimens, and the main trunk was noted to cross the path of the ELA in no specimens. At least one LCB of the sural nerve was identified in all specimens. The mean number of LCBs was 2 (range, 1 – 4). The ELA crossed the path of at least one LCB in 15 specimens (88%). The mean number of LCBs that were crossed by the path of the ELA was 1 (range, 0 – 3) The mean distance from the distal tip of the fibula at which an LCB was encountered along the ELA path was 2.4 cm (+/- 1.2) posterior and 2.6 cm (+/- 1.6) inferior. Conclusion: The ELA traverses the paths of the LCBs in the majority of specimens, potentially accounting for the presence of sural nerve postoperative symptoms despite careful dissection