Achilles: Failed Acute Repair.

Acute Achilles tendon ruptures are commonly managed with surgical repair. This particular surgery is prone to rerupture, wound complications, deep vein thrombosis, and sural nerve injuries. In this chapter the authors discuss complications, how to avoid them, and ultimately how to manage complications with your patients.

The Effect of the Strengthen Opioid Misuse Prevention Act on Opiate Prescription Practices Within the Orthopaedic Surgery Department of an Academic Medical Center.

In 2017, the Department of Health and Human Service declared a public health emergency known as the opioid crisis. In North Carolina, the "Strengthen Opioid Misuse Prevention Act of 2017" (STOP Act) went into effect on January 1, 2018, seeking to strengthen oversight over opioid prescriptions. Among other mandates, this legislation limited the duration of the initial prescription to 5 or 7 days. The purpose of this study was to compare narcotic prescription practices within the Department of Orthopaedic Surgery at an academic medical center before and after the enactment of the STOP Act. We hypothesized that there would be a statistically significant decrease in the amount of postoperative opioids prescribed after the STOP Act and that this decrease would be consistent across all types of providers in the Orthopaedic Surgery Department. Methods: Opiate prescriptions data from all orthopaedic surgery providers at our academic institution were collected from January to the end of September in 2017 and from January to the end of September in 2018. After filtering the providers by our study's inclusion and exclusion criteria, we included data from 49 providers in our analysis. We used a paired t-test to compare the prescription data between the two periods. Results: There was a 35% decrease in morphine milligram equivalents prescribed at our institution between 2017 and 2018 (P = 0.0003). This reduction was statistically significant and equaled 27,374 less morphine milligram equivalents prescribed per provider (95% confidence interval 13,226 to 41,523). The average number of opiate prescriptions per provider decreased from 171.5 in 2017 to 161 in 2018 (P = 0.48), although this was not statistically significant. Conclusion: The STOP Act effectively decreased the amount of opiates prescribed within our Orthopaedic Surgery Department. Similar legislation may be effective in other states and at the federal level to decrease narcotic prescriptions and subsequent abuse.

Comparing the Efficiency, Radiation Exposure, and Accuracy Using C-Arm versus O-Arm With 3D Navigation in Placement of Transiliac-Transsacral and Iliosacral Screws: A Cadaveric Study Evaluating an Early Career Surgeon.

OBJECTIVES: To compare the efficiency, radiation exposure to surgeon and patient, and accuracy of C-arm versus O-arm with navigation in the placement of transiliac-transsacral and iliosacral screws by an orthopaedic trauma fellow, for a surgeon early in practice. METHODS: Twelve fresh frozen cadavers were obtained. Preoperative computed tomography scans were reviewed to assess for safe corridors in the S1 and S2 segments. Iliosacral screws were assigned to the S1 segment in dysmorphic pelvises. Screws were randomized to modality and laterality. An orthopaedic trauma fellow placed all screws. Time of procedure and radiation exposure to the cadaver and surgeon were recorded. Three fellowship-trained orthopaedic trauma surgeons rated the safety of each screw on postoperative computed tomography scan. RESULTS: Six normal and 6 dysmorphic pelvises were identified. Eighteen transiliac-transsacral screws and 6 iliosacral screws were distributed evenly between C-arm and O-arm. Average operative duration per screw was significantly shorter using C-arm compared with O-arm (15.7 minutes ± 6.1 vs. 23.7 ± 8.5, P = 0.014). Screw placement with C-arm exposed the surgeon to a significantly greater amount of radiation (3.87 × 10 rads vs. 0.32 × 10, P < 0.001) while O-arm exposed the cadaver to a significantly greater amount of radiation (0.03 vs. 2.76 rads, P < 0.001). Two S2 transiliac-transsacral screws (1 C-arm and 1 O-arm) were categorized as unsafe based on scoring. There was no difference in screw accuracy between modalities. CONCLUSIONS: A difference in accuracy between modalities could not be elucidated, whereas efficiency was improved with utilization of C-arm, with statistical significance. A statistically significant increase in radiation exposure to the surgeon using C-arm was found, which may be clinically significant over a career. The results of this study can be extrapolated to a fellow or surgeon early in practice. The decision between use of these modalities will vary depending on surgeon preference and hospital resources.

Glanzmann's Thrombasthenia Diagnosed following Knee Arthroscopy.

A 41-year-old man with an unremarkable medical history presented with a painful knee after a sports injury. He was diagnosed with a medial meniscal tear. Symptoms did not abate after 6 months of physical therapy, and he underwent arthroscopic partial medial meniscectomy. A week after beginning physical therapy he experienced a knee effusion, decreased ROM, and inability to flex his quadriceps. His knee was aspirated. Blood tests were ordered and his complete blood count, liver functions tests, and INR/PTT were normal. The patient had recurrent effusions requiring three additional joint aspirations. Ten weeks after the initial surgery, the patient underwent a second arthroscopy, during which a hematoma was removed and a synovectomy performed. The patient continued bleeding from the incisions after portals were sutured, and he was admitted to the hospital. A hematologist was consulted and comprehensive platelet aggregation testing revealed previously undiagnosed Glanzmann's thrombasthenia. The patient began treatment with platelet infusions and desmopressin and progressed to a full recovery. Clinical suspicion for surgical patients with unusual repetitive postoperative bleeding should include previously undetected rare bleeding disorders even in adults.