Anatomical structures at risk in the arthroscopic Broström-Gould procedure: A cadaver study

BACKGROUND

The Broström Gould procedure is the gold standard for repair of lateral ankle ligament injury and ankle instability. This procedure has demonstrated excellent short- and long-term outcomes in the orthopedic literature. Arthroscopic Broström Gould techniques have become increasingly popular among some foot and ankle orthopedic surgeons. Typically, this technique requires standard anteromedial and anterolateral portals along with an accessory lateral working portal. The exact location of this portal is variable within the available described surgical techniques. The objective of this cadaveric study is to establish a standard entry point for and to assess the safety of the accessory lateral portal with respect to nearby anatomical structures.

METHODS

Ten fresh-frozen below-knee cadaver specimens were used. The location of the accessory lateral portal was created 1.5 cm anterior to the distal tip of the fibula. A small vertical incision was made at this point, followed by insertion of a Kirschner wire into the joint. The wire was then gently impacted into the fibula. Superficial dissection was subsequently carried out around the entry point to identify the peroneal tendons, superficial peroneal nerve branches, and sural nerve branches. Structures were marked with colored push pins, and distance was measured between the nearest edge of the Kirschner wire and each of the three anatomic structures listed. Any instances of structural contact or damage were documented.

RESULTS

The average distance from the Kirschner wire to the peroneal tendon was 16.1 (±4.41) mm. The average distance from the wire to the superficial peroneal nerve and sural nerve was 13.11 (±6.79) mm and 12.33 (±4.08) mm, respectively. There were no instances of injury to any of the studied structures. However, there was a notable amount of variability in the proximity of structures in question for each cadaver. A branch of the superficial peroneal nerve was measured as close as 2 mm and as far as 24 mm in separate cadaver specimens.

CONCLUSION

Arthroscopic Broström Gould procedures are a safe and effective method for lateral ankle ligamentous repair but are not without risk. Accessory lateral portal placement is relatively safe but should be meticulously executed to avoid damage to nearby anatomical structures.

Hip external rotation and extension angles for exposure and preparation of the proximal femur in direct anterior total hip arthroplasty: A cadaveric study

INTRODUCTION

The direct anterior approach (DAA) to total hip arthroplasty (THA) has a known learning curve, largely due to difficulty achieving exposure and visualization of the acetabulum and proximal femur for joint preparation. There is paucity of information on limb positioning and the degree of angulation at which the limb is positioned for adequate visualization. This study aimed to identify the mean angles of limb positioning necessary for adequate exposure when using two Mueller retractors for femoral preparation using traditional table.

MATERIALS & METHODS

A surgeon performed a DAA THA on 11 cadaveric hemipelves, exposing the femoral canal with two simple, robust Mueller retractors. The degree of external rotation and extension of the hip was measured.

RESULTS

Of the 11, the mean age was 77.6 years and mean BMI was 27.95. The mean external rotation angle was 56.5 ± 13.5°. The mean extension angle was 19.9 ± 6.6°.

DISCUSSION & CONCLUSION

The key technical step in this study incorporated a second robust Mueller retractor on the posterior aspect of the greater trochanter, providing maximum leverage to deliver the femur and achieve visibility while reducing angles of limb positioning thereby reducing complications, and ultimately lessening the learning curve.

Do Geographic Region, Medicaid Status, and Academic Affiliation Affect Access to Care Among Medicaid and Privately Insured Total Hip Arthroplasty Patients?

BACKGROUND

Medicaid provides health coverage to those beneath the federal poverty line. The literature shows that patients with Medicaid experience barriers to scheduling initial and follow-up visits, although this has not been studied in patients undergoing total hip arthroplasty (THA). The purpose of this study is to assess whether insurance type, geographic location, Medicaid expansion, or academic affiliation affect access to evaluation for THA.

METHODS

The American Academy of Orthopedic Surgeons directory was used to call a total of 100 practices. Five random private and 5 random academic medical facilities were called from each of 5 Medicaid-expanded and 5 non-expanded states representing different US geographic regions. Calls were made by an investigator requesting the earliest available appointment for their fictitious parent to be evaluated for a THA. Half of the calls were made with the investigator reporting private insurance of Blue Cross Blue Shield (BCBS), and half reporting Medicaid. Appointment success rate and average time to appointment were compared. Further comparisons were drawn among Medicaid-expanded vs non-expanded states, geographic regions, and private vs academic affiliation.

RESULTS

Appointments were successful for 99 of 100 (99%) calls made with BCBS, and 72 of 100 (72%) with Medicaid (P < .001). Success rates were significantly higher for BCBS, regardless of academic vs private affiliation. In all geographic regions, appointment success rate was significantly lower with Medicaid than with BCBS (P ≤ .01). Average time to appointment was also significantly longer for Medicaid (26 days) than private (13 days) insurance (P = .020). In the Medicaid group, appointment success rate was significantly greater for academically affiliated practices compared to private practices (84.0% vs 60.0%, respectively; P = .008).

CONCLUSION

Patients with Medicaid seeking consultation for THA experience limits in access to evaluation for THA when compared to patients with private insurance, regardless of geographic region or affiliation of the practice.

Anatomical structures at risk in the arthroscopic Broström-Gould procedure: A cadaver study

BACKGROUND

The Broström Gould procedure is the gold standard for repair of lateral ankle ligament injury and ankle instability. This procedure has demonstrated excellent short- and long-term outcomes in the orthopedic literature. Arthroscopic Broström Gould techniques have become increasingly popular among some foot and ankle orthopedic surgeons. Typically, this technique requires standard anteromedial and anterolateral portals along with an accessory lateral working portal. The exact location of this portal is variable within the available described surgical techniques. The objective of this cadaveric study is to establish a standard entry point for and to assess the safety of the accessory lateral portal with respect to nearby anatomical structures.

METHODS

Ten fresh-frozen below-knee cadaver specimens were used. The location of the accessory lateral portal was created 1.5 cm anterior to the distal tip of the fibula. A small vertical incision was made at this point, followed by insertion of a Kirschner wire into the joint. The wire was then gently impacted into the fibula. Superficial dissection was subsequently carried out around the entry point to identify the peroneal tendons, superficial peroneal nerve branches, and sural nerve branches. Structures were marked with colored push pins, and distance was measured between the nearest edge of the Kirschner wire and each of the three anatomic structures listed. Any instances of structural contact or damage were documented.

RESULTS

The average distance from the Kirschner wire to the peroneal tendon was 16.1 (±4.41) mm. The average distance from the wire to the superficial peroneal nerve and sural nerve was 13.11 (±6.79) mm and 12.33 (±4.08) mm, respectively. There were no instances of injury to any of the studied structures. However, there was a notable amount of variability in the proximity of structures in question for each cadaver. A branch of the superficial peroneal nerve was measured as close as 2 mm and as far as 24 mm in separate cadaver specimens.

CONCLUSION

Arthroscopic Broström Gould procedures are a safe and effective method for lateral ankle ligamentous repair but are not without risk. Accessory lateral portal placement is relatively safe but should be meticulously executed to avoid damage to nearby anatomical structures.

Outcomes of Inpatient Versus Outpatient Elective Foot and Ankle Surgery

Background Complications following orthopedic surgeries are undesirable and costly. A potential method to reduce these costs is to perform traditionally inpatient surgical procedures in the outpatient setting. The purpose of this study is to compare outcomes between inpatient and outpatient settings for elective foot and ankle surgeries using the National Surgical Quality Improvement Program (NSQIP) database. Methods Patients with Current Procedural Terminology (CPT) codes specific to orthopedic foot and ankle surgery were identified from the 2011-2015 American College of Surgeons NSQIP database. Demographics, comorbidities, and complications were compared between patients undergoing inpatient and outpatient procedures. Results Patients receiving inpatient surgery were significantly older and more frequently male. Black patients were significantly more likely to undergo inpatient surgery than outpatient surgery while white patients were significantly more likely to undergo outpatient surgery. Outpatients had a significantly higher mean body mass index (BMI) than inpatients. Smokers were at a significantly greater risk of undergoing inpatient surgery than outpatient surgery. Outpatients had significantly longer operative times, were more likely to receive general anesthesia, had a lower American Society of Anesthesiologists (ASA) class, were more likely to be functionally independent, and were less likely to expire postoperatively. Patients who received surgery as an inpatient were significantly more likely to have comorbidities as compared to outpatients. The overall risk of surgical complications was significant between groups with 8.6% in the inpatient group and 2.0% in the outpatient group. The overall risk of medical complications was 16.9% in the inpatient group and 1.7% in the outpatient group. Similar to the surgical complications, inpatients were significantly more likely to sustain each of the individual medical complications except for stroke/CVA and venous thromboembolism. Conclusions Outpatient management is associated with decreased postoperative complications in select patients. Performing more operations in the outpatient setting in select patients may be beneficial for cost reduction and patient satisfaction.

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.

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.

Impact of time to surgery from injury on postoperative infection and deep vein thrombosis in periprosthetic knee fractures

PURPOSE

Periprosthetic fracture (PPF) is a serious complication that occurs in 0.3%-2.5% of all total knee arthroplasties used to treat end-stage arthritis. To our knowledge, there are no studies in the literature that evaluate the association between time to surgery after PPF and early postoperative infections or deep vein thrombosis (DVT). This study tests our hypothesis that delayed time to surgery increases rates of postoperative infection and DVT after PPF surgery.

METHODS

Our study cohort included patients undergoing PPF surgery in the American College of Surgeons National Surgical Quality Improvement Program database (2006-2015). The patients were dichotomized based on time to surgery: group 1 with time ≤2 days and group 2 with time >2 days. A 2-by-2 contingency table and Fisher's exact test were used to evaluate the association between complications and time to surgery groups, and multivariate logistic regression was used to adjust for demographics and known risk factors.

RESULTS

A total of 263 patients (80% females) with a mean age of 73.9 ± 12.0 years were identified receiving PPF surgery, among which 216 patients were in group 1 and 47 patients in group 2. Complications in group 1 included 3 (1.4%) superficial infections (SI), 1 (0.5%) organ space infection (OSI), 1 (0.5%) wound dehiscence (WD), and 4 (1.9%) deep vein thrombosis (DVT); while complications in group 2 included 1 (2.1%) SI, 1 (2.1%) OSI, 1 (2.1%) DVT, and no WD. No significant difference was detected in postoperative complications between the two groups. However, patients in group 2 were more likely (p = 0.0013) to receive blood transfusions (57.5%) than those in group 1 (32.4%).

CONCLUSION

Our study indicates patients with delayed time to surgery have higher chance to receive blood transfusions, but no significant difference in postoperative complications (SI, OSI, WD, or DVT) between the two groups.

Readmission Following Revision Total Knee Arthroplasty: An Institutional Cohort

Purpose: Total knee arthroplasty (TKA) is the most common joint replacement surgery performed in the United States. Given the aging and increasingly comorbid patient populations undergoing these procedures, complication rates and the need for subsequent hospital readmission are only expected to rise. It is, therefore, crucial to investigate the risk factors leading to readmission in order to improve patient outcomes. The purpose of this study is to identify significant risk factors for readmission following revision TKA procedures.

Methods: Patients undergoing revision TKA were identified at our institution from 2006-2017. The primary outcome was hospital readmission after revision TKA. Patient demographics, comorbidities, and postoperative complications were recorded and compared between readmitted and non-readmitted patients.

Results: Forty-five (26.2%) of the 171 cases were readmitted following revision TKA. The leading diagnoses at readmission varied from arthrofibrosis in 28.9% of patients, implant infection in 22.2% of patients, and implant failure in 20.0% of patients. Male gender was found to be a significant independent variable for readmission. This study also found that 51.1% of all readmitted patients continued to have complaints that required additional hospital readmissions. The average number of total readmissions was 2.1 per readmitted patient.

Conclusion: This study was successful in identifying variables associated with readmission following revision TKA, as well as presenting information regarding the diagnoses associated with readmission. Our data also showed that if a patient was readmitted after revision TKA, it was likely that they would be admitted again. Due to the increasing prevalence and cost of these procedures, further studies are needed to better understand the risk factors and comorbidities leading to readmission in order to improve the perioperative care of these patients.

Risk Factors for Readmission Following Revision Total Hip Arthroplasty in Patients Undergoing Surgery for Noninfective Causes

Introduction

Readmission following revision orthopedic surgery imposes tremendous costs due to the increased length of stay, procedure complexity, and revision surgery. Following revision total hip arthroplasty, as many as one in five patients are readmitted postoperatively. Readmissions cost the federal government $17.4 billion annually. The purpose of this study was to identify risk factors for unplanned readmission following revision total hip arthroplasty.

Methods

This was a retrospective case series review of randomized revision total hip arthroplasties (THA) patients between 2008 and 2018. Exclusions were as follows: outside hospital revisions, staged revisions, revisions for infection, and bilateral revisions. Data were collected by manual chart review. Readmissions were tracked from discharge until the final follow-up.

Results

A total of 61 patients and 85 revision THAs were analyzed. Nineteen patients (31.1%) were readmitted; 31.6% of the readmitted patients had a coronary artery disease compared to 6.5% of non-readmitted patients. Readmission was also associated with obesity, former smokers, and hypertension. Also, the mean duration of follow-up was 26.5 months for readmitted patients as compared to 8.96 for non-readmitted patients.

Conclusion

Obesity, former tobacco use, younger age, coronary artery disease (CAD), and hypertension were associated with readmission. The medical optimization of patients with these risk factors prior to surgery could significantly lower costs relative to revision THA.

A Case Report of Revision Total Knee Arthroplasty After 17 Years: All Grown Up, What Happens When Implants Mature?

The number of total knee arthroplasties (TKAs) being performed annually is steadily rising. Recommendations for clinical follow-up guidelines following these arthroplasties is controversial, with no strict guidelines for long-term follow up. Although a few case series exist which identify a minority of patients who require revision TKA for aseptic loosening or pain more than 15 years after index surgery, no published studies have yet described these patients or the pathology present at the time of surgery in detail. We present the case of a patient who underwent revision TKA for pain and instability that developed 17 years after index surgery. Postoperative pathology revealed foreign body giant cell reaction of the tissue surrounding the previous implant. This case of revision after more than 17 years attempts to improve our understanding of long-term reactions to implants and highlights the necessity of long-term follow up in patients with TKA. It is one of the longest follow-ups of TKA reporting long-term anatomic changes at the bone cement interphase and around the implant.

Total hip arthroplasty for posttraumatic osteoarthritis following acetabular fracture: A systematic review of characteristics, outcomes, and complications

PURPOSE

Posttraumatic arthritis (PTA) may develop years after acetabular fracture, hindering joint function and causing significant chronic musculoskeletal pain. Given the delayed onset of PTA, few studies have assessed outcomes of delayed total hip arthroplasty (THA) in acetabular fracture patients. This study systematically reviewed the literature for outcomes of THA in patients with PTA and prior acetabular fracture.

METHODS

Pubmed, EMBASE, SCOPUS, and Cochrane library were searched for articles containing the keywords "acetabular", "fracture", "arthroplasty", and "post traumatic arthritis" published between 1995 and August 2017. Studies with less than 10 patients, less than 2 years of follow-up, conference abstracts, and non-English language articles were excluded. Data on patient demographics, surgical characteristics, and outcomes of delayed THA, including implant survival, complications, need for revision, and functional scores, was collected from eligible studies.

RESULTS

With 1830 studies were screened and data from 10 studies with 448 patients were included in this review. The median patient age on date of THA was 51.5 years, ranging from 19 to 90 years. The median time from fracture to THA was 37 months, with a range of 27-74 months. Mean follow-up times ranged from 4 to 20 years. The mean Harris hip scores (HHS) improved from 41.5 pre-operatively, to 87.6 post-operatively. The most prevalent postoperative complications were heterotopic ossification (28%-63%), implant loosening (1%-24%), and infection (0%-16%). The minimum 5-year survival of implants ranged from 70% to 100%. Revision rates ranged from 2% to 32%.

CONCLUSION

Despite the difficulties associated with performing THA in patients with PTA from previous acetabular fracture (including soft tissue scarring, existing hardware, and acetabular bone loss) and the relatively high complication rates, THA in patients with PTA following prior acetabular fracture leads to significant improvement in pain and function at 10-year follow-up. Further high quality randomized controlled studies are needed to confirm the outcomes after delayed THA in these patients.

Marijuana use and mortality following orthopedic surgical procedures

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.

Tibiotalocalcaneal Arthrodesis With Intramedullary Fibular Strut Graft With Adjuvant Hardware Fixation

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.

Epidemiology and recent trends of geriatric fractures presenting to the emergency department for United States population from year 2004-2014

OBJECTIVES

Fractures in geriatric age group (over 65 years of age) are an important public health issue and frequent causes of emergency room visits. The purpose of this descriptive epidemiological study was to present the epidemiology of geriatric fractures and their trends in the USA using National Electronic Injury Surveillance System (NEISS) database from year 2004-2014.

METHODS

National Electronic Injury Surveillance System (NEISS) Database was queried for all fracture injuries from 2004 to 2014 for ages 65 years and above. The proportions of fractures based on NEISS national estimates were calculated and their trends using linear regression over last 11 years were studied.

RESULTS

Lower trunk (pelvis, hip and lower spine) fractures were the most common (34% for year 2014) type of fractures in this age group. Upper trunk (upper spine, clavicle and ribs) fractures were the second most common type of fractures (13% for year 2014). Other body parts commonly fractured involved the upper arm and wrist with an average of 7% fractures in both during the study period. About 5% of geriatric fractures pertained to shoulder and upper leg. Although less common, there was also about 2% increase in fractures to face and neck in 2014 as compared to about 3.2% and 1% respectively in 2004. Fractures to other body parts were less common with no major variations during the study period.

CONCLUSIONS

Overall, lower trunk (hip, pelvic and lower spine) fractures were the most common geriatric fractures followed by upper trunk (upper spine, clavicle and rib) fractures. We suggest that there were decreasing trends for incidence of lower trunk, wrist and upper body fractures over the last 11 years (2004-2014). Approximately half of the geriatric fractures presenting to Emergency Department needed hospitalizations.

Radiofrequency Ablation of Osteoid Osteoma with Use of Intraoperative Three-Dimensional Imaging and Surgical Navigation

Introduction

During the performance of radiofrequency ablation of osteoid osteomas, the use of intraoperative cone-beam computed tomography (CT) imaging with surgical navigation lowers radiation exposure while allowing real-time targeting of the nidus.

Step 1 Preoperative Planning

Review all images to confirm a high level of confidence in the radiographic diagnosis.

Step 2 Patient Positioning and Setup

Be sure to position and set up properly.

Step 3 Placement of Tracking Optical Array

Attach the optical array to the target bone.

Step 4 O-Arm Setup Initial CT Imaging for Surgical Navigation and Remote Mouse Registration

Set up the intraoperative CT (O-Arm) machine and acquire the initial images for surgical navigation.

Step 5 CT Data Interpretation and Approach Planning

Analyze the initial images, rotated or positioned as necessary, to allow you to proceed with the planned direction and angle of approach to the nidus.

Step 6 Surgical Navigation Setup

Register the surgical instruments with the surgical navigation unit.

Step 7 Nidus Localization and Kirschner Wire Insertion

Target the nidus and then insert the Kirschner wire into its center.

Step 8 Exchanging Kirschner Wire for a Radiofrequency Probe

Once the accuracy of the Kirschner wire placement is confirmed, exchange it for the radiofrequency probe and perform a CT scan to confirm proper probe placement.

Step 9 Confirmation of RFA Probe Placement

Perform a CT scan to confirm proper placement of the probe within the center of the nidus.

Step 10 Activation of the Radiofrequency Probe and Closure

Perform the radiofrequency treatment to ablate the cells within the nidus.

Results

We conducted a study of three different techniques of radiofrequency ablation.IndicationsContraindicationsPitfalls & Challenges.

Nonaccidental traumatic dislocation of the hip in a 3-year-old child: a report of a rare pediatric injury

Traumatic hip dislocations are rare in children, and reports of these injuries focus primarily on the risk of osteonecrosis of the femoral head as well as the long-term efficacy of treatment. Anatomical characteristics of the hip in young children, such as ligamentous laxity and a pliable acetabulum, can allow hip dislocation with low-energy trauma, but these injuries occur primarily in school-aged children during play activities. We report a hip dislocation in a 3-year-old child with no clear explanation of the mechanism of injury and with multiple unexplained bruises at different stages of healing that led to the diagnosis of nonaccidental trauma (NAT). This case highlights the need to consider NAT in young patients with a traumatic hip dislocation.

Radiation dosimetry of intraoperative cone-beam compared with conventional CT for radiofrequency ablation of osteoid osteoma

BACKGROUND

Radiofrequency (RF) ablation is the standard of care for the surgical treatment of non-spinal osteoid osteoma and has greatly reduced morbidity associated with surgical excision. Precise placement of the RF ablation probe is necessary to avoid incomplete ablation. Limiting radiation exposure is especially advantageous in the pediatric population in whom osteoid osteoma frequently occurs. The aim of this study was to compare the radiation dosimetry and clinical outcomes among patients treated with RF ablation using three different localization techniques.

METHODS

Case-control methods were used to analyze sixty-six cases. Patients were categorized into three treatment groups: (1) intraoperative three-dimensional cone-beam CT (computed tomography) imaging (O-Arm) with surgical navigation (StealthStation S7), (2) intraoperative three-dimensional imaging (O-Arm) only, and (3) radiology suite-based diagnostic CT imaging. Radiation dosimetry and clinical outcome were analyzed with use of the dose-length product and local-relapse-free survival, respectively.

RESULTS

Mean age was nineteen years for the twenty-three patients in group 1, twenty years for the seven patients in group 2, and nineteen years for the thirty-six patients in group 3. Mean follow-up was fifty-three months. The mean radiation dose for groups 1, 2, and 3 was 446.62, 379.78, and 1058.83 mGy-cm, respectively. Significant (p < 0.05) differences in the radiation dose existed between groups 1 and 3 and between groups 2 and 3, whereas no difference was found between groups 1 and 2. Local-remission-free survival at three years for groups 1, 2, and 3 was 84.7% (95% confidence interval [CI], 64.5% to 100%), 100% (95% CI, 100% to 100%), and 90.7% (95% CI, 80.7% to 100%), respectively. Fifty-eight (92%) of the sixty-three followed patients were asymptomatic at the latest follow-up visit.

CONCLUSIONS

RF ablation using intraoperative cone-beam CT imaging, with or without surgical navigation, was associated with a significantly lower radiation dose compared with ablation using a radiology suite-based CT technique. Ablation using each of the three imaging techniques was equally effective in treating osteoid osteomas with a similar risk of relapse.

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.