Publications by Year: 2020

Arthrofibrosis is a common, but often overlooked, condition that imparts significant morbidity following injuries and surgery to the foot and ankle. The most common etiologies are related to soft tissue trauma with subsequent fibrotic and contractile scar tissue formation within the ligaments and capsule of the ankle. This leads to pain, alterations in gait, and ankle dysfunction. Initial treatment often includes extensive physical therapy, however, if severe enough surgical options exist. Although the literature regarding ankle arthrofibrosis is scarce, this review article provides a greater understanding of the pathogenesis of arthrofibrosis and describes the current and future therapeutic options to treat fibrotic joints. Level of Evidence: Level V, expert opinion.

BACKGROUND: Spinal calcium pyrophosphate deposition disease (CPPD) is uncommon, and often resembles more common spine pathologies causing pain and neural compression. Here, we present two unusual cases of CPPD of the cervical and thoracolumbar spines.

CASE DESCRIPTION: Case 1: A 71-year old female smoker presented with a large epidural mass causing rapidly progressive cervical myelopathy with weakness in the upper and lower extremities.Case 2: A 66-year-old morbidly obese male presented with chronic back pain for several years associated with progressively worsening radicular pain in his left lower extremity.

OUTCOME: The first case is an example of tumoral CPPD involving the facet joint and expanding into the epidural space. The second case was an example of CPPD involving a thoracolumbar facet cyst, resulting in unilateral radiculopathy. Both patients were treated surgically and had significant improvement in symptoms post-operatively.

CONCLUSIONS: CPPD in the spine is an uncommon diagnosis but should be considered in the differential diagnosis of patients presenting with back pain and associated neurological symptoms. Accurate diagnosis of spinal CPPD is important in that it will guide postoperative management with anti-inflammatory medications and reduce risk of recurrence.

BACKGROUND: Phrenic nerve palsy is a rare complication of cervical spine surgery. There are no previously reported cases of unilateral diaphragmatic paralysis following posterior cervical spine surgery. Here, we present a case of a 69 year-old Caucasian male with severe cervical stenosis with myelopathy who underwent posterior spinal instrumentation and fusion (PSIF) from C2 to T2, with laminectomies at C3-C7.

OUTCOME: The patient developed respiratory distress post-operatively and was found to have an elevated hemidiaphragm secondary to phrenic nerve palsy. He was treated with respiratory support, with significant improvement in dyspnea. He was also noted to have a left C5 palsy affecting his deltoid function and proximal upper extremity sensation which gradually improved.

CONCLUSIONS: This is the first reported case of unilateral diaphragmatic paralysis causing dyspnea due to phrenic nerve palsy following cervical spine surgery. This rare complication should be kept in mind when assessing any patient with respiratory distress following cervical spine surgery.

BACKGROUND: Survival following a diagnosis of osteosarcoma is correlated strongly with response to chemotherapy. Mineralization changes seen on radiographs have been hypothesized to correlate with chemotherapy response, however, this has never been analyzed using modern techniques.

METHODS: Retrospective review of radiographs obtained before and after neoadjuvant chemotherapy was performed for 31 patients with high-grade, conventional osteosarcoma. Pre-chemotherapy (PreC) images and post-chemotherapy (PostC) images were co-registered. Tumor luminance measurements were normalized based on the non-tumor bone and then the relative change in tumor mineralization were measured.

RESULTS: Mean luminance values for pre-chemotherapy non-tumor-affected bone and tumor were 0.63±0.12 and 0.65±0.12, respectively. Mean values for PostC non-tumor-affected bone were 0.59±0.14 and 0.64±0.10, respectively. Once normalized, osteosarcoma mineralization change showed a statistically significant moderate correlation-Pearson correlation coefficient (ρ) of 0.36 (P=0.038)-with the tumor necrosis value.

CONCLUSIONS: Moderate, positive correlation was found between osteosarcoma mineralization change during chemotherapy and chemotherapy response. Further work is required to determine if these findings are prognostic by identifying best practice for image analysis and repeating this work with prospectively acquired digital radiographs using uniform technique and phantom normalization.

Background: The optimal treatment of human bites to the dorsal metacarpophalangeal region (ie, "fight bite") in the absence of gross purulence is controversial. Few studies have compared the outcomes of operative debridement with expectant wound care and oral antibiotics. Methods: We performed a retrospective chart review of all patients evaluated at a Level 1 trauma center over a 10-year period. We compared demographic and clinical characteristics of patients across treatment and outcome groups using the Fisher exact test. Logistic regression models were used to describe the relationships between the outcome and treatment variables. Results: We identified 115 patients with a mean age of 29 years. The mean follow-up was 51.8 days. Seventy-two (63%) patients were treated with antibiotics only. Thirty-two (28%) patients were treated with irrigation in the emergency department (ED) and expectant wound care. Eleven (9%) patients were treated with irrigation and debridement in the operating room. No demographic variables were found to correlate with the treatment selected. A 12% complication rate (major and minor) was observed. After adjusting for duration of follow-up and days to presentation, neither the treatment rendered nor the antibiotics selected influenced the rate of complications. Time to presentation >24 hours was the only variable associated with higher complication rate (P = .003). Conclusions: Not all fight bites require operative intervention. Irrigation in the ED with expectant wound care and oral antibiotics can be sufficient for patients presenting within 24 hours of injury in the absence of gross purulence.

Background. Utilization of physician rating websites continues to expand. There is limited information on how these websites function and influence patient perception and physicians' practices. No study to our knowledge has investigated online ratings and comments of orthopaedic foot and ankle surgeons. We identified factors impacting online ratings and comments for this subset of surgeons. Methods. 210 orthopaedic foot and ankle surgeons were selected from the American Orthopaedic Foot and Ankle Society (AOFAS) website. Demographic information, ratings, and comments were reviewed on the 3 most visited public domain physician ratings websites: HealthGrades.com , Vitals.com, and Ratemds.com. Content differences between positive and negative comments were evaluated. Results. The mean review rating of 4.03 ± 0.57 out of 5 stars. 84% of the total number of ratings were either 1 star (17%) or 5 stars (67%). Most positive comments related to outcome, physician personality, and communication, whereas most negative comments related to outcome, bedside manner, and waiting time. χ2 Analyses revealed statistically significant proportions of positive comments pertaining to surgeon-dependent factors (eg, physician personality, knowledge, skills) and negative comments concerning surgeon-independent factors (eg, waiting time, logistics). Conclusion. This study examined online ratings and written comments of orthopaedic foot and ankle surgeons. Surgeons had a generally favorable rating and were likely to have positive comments. Patients were likely to write positive comments about surgeon personality and communication, and negative comments pertaining to bedside manner and waiting time. Knowledge and management of online content may allow surgeons to improve patient satisfaction and online ratings. Level of Evidence: Level IV.

BACKGROUND: Fibroadipose vascular anomaly (FAVA) is a recently-defined vascular malformation often involving the extremities and presenting in childhood. Patients may present to orthopaedic surgeons with pain, swelling, joint contractures, and leg length discrepancy. There is no established therapy or treatment paradigm. We report on outcomes following surgical excision for patients with this condition.

METHODS: Between 2007 and 2016, all 35 patients that underwent excision of lower-extremity FAVA were retrospectively reviewed using a combination of medical records, radiologic findings, and telemedicine reviews.

RESULTS: Mean age at initial presentation was 12.3±6.8 years. Mean follow-up from time of definitive diagnosis at our institution was 66 months (range: 12 to 161 mo). Mean follow-up after surgery was 35 months (range: 6 to 138 mo). Females were affected more than males (71% vs. 29%). The most common location of FAVA was in the calf (49%), followed by the thigh (40%). The most commonly involved muscle was gastrocnemius (29%), followed by the quadriceps (26%). At latest follow-up after surgery, there was an improvement in the proportion of patients with pain at rest (63% vs. 29%), pain with activity (100% vs. 60%), as well as analgesia use (94% vs. 37%). Fourteen patients (40%) had symptomatic residual disease or recurrence of FAVA requiring further treatment. Six patients (17%) required further surgery and 6 (17%) required further interventional radiologic procedures. Three patients (9%) required eventual amputation for intractable pain and loss of function. Lesions with direct nerve involvement were associated with persistent neuropathic symptoms at latest follow-up (P=0.002) as well as symptomatic residual disease and/or recurrence requiring further treatment (P=0.01). Seventeen patients (49%) had 19 preoperative joint contractures. Eighteen of the 19 contractures (95%) had sustained improvement at latest follow-up.

CONCLUSIONS: In carefully selected patients, surgical excision of FAVA results in improvement of symptoms. However, symptomatic residual disease and/or recurrence are not uncommon. Direct nerve involvement is associated with a worse outcome.

LEVEL OF EVIDENCE: Level IV-case series.

BACKGROUND: Radiographs are the most commonly available diagnostic imaging modalities used to evaluate orthopaedic conditions. In addition to suspected findings based on the initial indication to obtain radiographic images, incidental findings may be observed as well, some of which may have notable medical and legal ramifications. This study evaluates the number of incidental findings reported from orthopaedic radiographs ordered in an academic orthopaedic multispecialty group over 1 year.

METHODS: A retrospective review was conducted of 13,948 eligible radiographs recorded at our institution over a 12-month period. Reports were categorized based on examination type. Incidental findings were categorized as having concern for possible malignancy versus likely benign conditions. The possibly malignant findings were then further subdivided into either bone or lung malignancies. The benign findings were subcategorized by etiology and anatomic location.

RESULTS: Thirteen thousand nine hundred forty-eight radiographs were evaluated, and 289 (2.07%) incidental findings were identified. The three study categories with the highest prevalence of incidental findings were spine (3.96%), leg length alignment (3.94%), and pelvic and hip (2.81%) radiographs. The three most common types of incidental findings identified were for possible malignancy or metastases in bone (30.1%), benign bone disease (24.9%), and gastrointestinal conditions (6.57%). Follow-up was recommended for 122 (42.2%) incidental findings.

DISCUSSION: This study describes the prevalence of incidental findings on orthopaedic radiographs in adults. Axial radiographs such as of the spine and pelvis are more likely to report an incidental finding as opposed to appendicular radiographs of distal extremities. The exception is leg alignment radiographs that include the entire lower extremity and pelvis and image a larger area of the body. Nearly one-third of incidental findings were suspicious for possible malignancy or metastases. Additional diagnostic workup with focused imaging is often recommended. This information is useful to orthopaedic surgeons who read their own radiographs (without formal radiologist interpretation) to increase awareness of common, concerning incidental findings that may be missed and warrant additional follow-up.

LEVEL OF EVIDENCE: Level III.

Background. Syndesmotic disruption occurs in 20% of ankle fractures and requires anatomical reduction and stabilization to maximize outcomes. Although screw breakage is often asymptomatic, the breakage location can be unpredictable and result in painful bony erosion. The purpose of this investigation is to report early clinical and radiographic outcomes of patients who underwent syndesmotic fixation using a novel metal screw designed with a controlled break point. Methods. We performed a retrospective review of all patients who underwent syndesmotic fixation utilizing the R3lease Tissue Stabilization System (Paragon 28, Denver, CO) over a 12-month period. Demographic and screw-specific data were obtained. Postoperative radiographs were reviewed, and radiographic parameters were measured. Screw loosening or breakage was documented. Results. 18 patients (24 screws) met inclusion criteria. The mean follow-up was 11.7 months (range = 6.0-14.7 months). 5/24 screws (21%) fractured at the break point. No screw fractured at another location, nor did any fracture prior to resumption of weight bearing; 19 screws did not fracture, with 8/19 intact screws (42.1%) demonstrating loosening. There was no evidence of syndesmotic diastasis or mortise malalignment on final follow-up. No screws required removal during the study period. Conclusion. This study provides the first clinical data on a novel screw introduced specifically for syndesmotic fixation. At short-term follow up, there were no complications and the R3lease screw provided adequate fixation to allow healing and prevent diastasis. Although initial results are favorable, longer-term follow-up with data on cost comparisons and rates of hardware removal are needed to determine cost-effectiveness relative to similar implants.Level of Evidence: Level IV: Retrospective case series.

INTRODUCTION: A common criticism of the peer-review process is the often disparate nature of reviewer recommendations when a decision is rendered which belies the supposed uniformity of the process. The purpose of this investigation was to examine level of agreement between reviewers for Foot & Ankle International (FAI) and analyze variables which may have influenced agreement in order to better understand the peer-review process.

METHODS: Approval to conduct this investigation was obtained from the Executive Board and Editor in Chief of FAI. All manuscripts submitted to FAI during the calendar year 2016 which underwent formal peer-review were included in the analysis. For each reviewed manuscript, demographic data was collected regarding specific reviewer and manuscript characteristics in a de-identified manner.

RESULTS: 442 manuscripts underwent formal blinded peer-review by two independent reviewers during the study period. Only 199 manuscripts (45%) had a decision rendered in which both reviewers agreed on the same initial recommendation. There were no differences in demographic characteristics between the group of reviewers who agreed as compared to those who disagreed on the initial round of peer review. A similar number of indexed peer-reviewed publications between reviewers correlated with increased levels of agreement.

CONCLUSIONS: During the study period, there was 45% initial agreement between reviewers for FAI when assessing the same manuscript. Aside from research productivity, no other reviewer-specific variables examined in this investigation were found to correlate with agreement. Specific recommendations and changes may be considered to increase the efficiency and effectiveness of the peer-review process.