Charcot Neuroarthropathy Is Associated With Higher Rates of Phantom Limb After Lower Extremity Amputation.

BACKGROUND: The incidence of phantom limb pain in patients with Charcot neuroarthropathy who undergo major amputation is not well described. The purpose of this study was to determine whether patients with Charcot neuroarthropathy and diabetes who underwent either a below-knee amputation (BKA) or above-knee amputation (AKA) had an increased rate of phantom limb pain compared with those with a diagnosis of diabetes alone. METHODS: Using international classification of disease (ICD) and common procedural terminology (CPT) codes, the TriNetX research database identified 10 239 patients who underwent BKA and 6122 who underwent AKA between 2012 and 2022. Diabetic patients with and without Charcot neuroarthropathy were compared in terms of demographics and relative risk of developing phantom limb pain after AKA or BKA. RESULTS: Age, sex, ethnicity, and race did not significantly differ between groups. Charcot neuroarthropathy was associated with significantly increased risk of phantom limb pain following both BKA (risk ratio [RR]: 1.2, 95% confidence interval [CI]: 1.1-1.3, P < .01) and AKA (RR: 1.6, 95% CI: 1.2-2.3, P < .0068). CONCLUSION: Our results indicate that patients with a coexisting diagnosis of Charcot neuroarthropathy who require BKA or AKA may have an increased risk of developing phantom limb pain. LEVELS OF EVIDENCE: Level III.

Association of Systemic Hormonal Contraceptives With Reconstruction Procedures for Patellar Instability.

Background: Previous research suggests that estrogen plays a role in increased ligamentous laxity observed within the female population. Whereas many studies have sought to evaluate the impact of exogenous estrogen on anterior cruciate ligament injuries, research has not yet explored its impact on the medial patellofemoral ligament. Furthermore, less is known about the role of exogenous progesterone on ligamentous structures. Purpose: To determine whether women prescribed systemic estrogen (ethinyl estradiol) or progesterone (norgestimate or etonogestrel) hormonal contraceptives had an increased risk of undergoing reconstruction surgery for patellar instability compared with women without a prescription for systemic hormonal contraceptives. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The TriNetX Research Network database was queried using International Classification of Disease and Common Procedural Terminology codes for women aged 15 to 26 years who underwent reconstruction procedures for patellar instability between 2012 and 2022. Women were grouped according to whether they had a coded prescription for a systemic hormonal contraceptive containing either ethinyl estradiol or etonogestrel; controls were matched by age, sex, race, and ethnicity. The relative risk (RR) of undergoing reconstruction for patellar instability was determined for each contraceptive. Results: After 1-to-1 propensity score matching, 0.054% (525/980,878) of women prescribed a systemic contraceptive containing ethinyl estradiol underwent reconstruction procedures for patellar instability compared with 0.043% (417/980,878) of controls (RR, 1.3; 95% CI, 1.1-1.4; P = .0004). Likewise, 0.058% (67/116,260) of women prescribed a form of systemic contraceptive containing only etonogestrel underwent reconstruction procedures for patellar instability compared with 0.026% (30/116,260) of controls (RR, 2.2; 95% CI, 1.5-3.4; P = .0002). Conclusion: Female patients prescribed systemic contraceptives containing estrogen or progesterone had an increased rate of reconstruction procedures for patellar instability.

Vancomycin Powder Is Highly Cost-Effective in Total Ankle Arthroplasty.

Prosthetic joint infection (PJI) is a costly and potentially fatal complication in total ankle arthroplasty (TAA). Some surgeons apply topical vancomycin powder to minimize the risk of infection during TAA procedures. The purpose of our study was to determine the cost-effectiveness of using vancomycin powder to prevent PJI following TAA and to propose an economic model that can be applied by foot and ankle surgeons in their decision to incorporate vancomycin powder in practice. Using our institution's records of the cost of 1 g of topical vancomycin powder, we performed a break-even analysis and calculated the absolute risk reduction and number needed to treat for varying costs of vancomycin powder, PJI infection rates, and costs of TAA revision. Costing $3.06 per gram at our institution, vancomycin powder was determined to be cost-effective in TAA if the PJI rate of 3% decreased by an absolute risk reduction of 0.02% (Number Needed to Treat = 5304). Furthermore, our results indicate that vancomycin powder can be highly cost-effective across a wide range of costs, PJI infection rates, and varying costs of TAA revision. The use of vancomycin powder remained cost-effective even when (1) the price of vancomycin powder was as low as $2.50 to as high as $100.00, (2) infection rates ranged from .05 to 3%, and (3) the cost of the TAA revision procedure ranged from $1000 to $10 000.Levels of Evidence: IV.

Venous Thromboembolism Chemoprophylaxis in Knee Arthroscopy: A Break-Even Analysis of Cost.

BACKGROUND: Symptomatic venous thromboembolism (VTE) is a serious and costly complication after knee arthroscopy. There continues to be debate regarding the use of VTE prophylaxis after knee arthroscopy, and minimal research has explored its cost-effectiveness. HYPOTHESIS: Both aspirin and enoxaparin would be cost-effective in preventing symptomatic VTE. STUDY DESIGN: Economic and decision analysis; Level of evidence, 3. METHODS: The literature was searched and the TriNetX research database was queried to determine a range of initial rates of VTE. An open-access retail database was used to determine the mean retail price for aspirin (325 mg) and enoxaparin (30 mg and 40 mg). Our institutional records were used to determine the cost of treating VTE. A "break-even" analysis was then performed to determine the absolute risk reduction necessary to make these drugs cost-effective. This value was then used to calculate the number of patients who would need to be treated (NNT) to prevent a single VTE while still breaking even on cost. RESULTS: The cost of treating VTE was $9407 (US Dollars). Aspirin (325 mg), enoxaparin (30 mg), and enoxaparin (40 mg) were found to cost $1.86, $188.72, and $99.99, respectively. The low, TriNetX, and high rates of VTE were 0.34%, 0.86%, and 10.9%, respectively. Aspirin was cost-effective at all 3 rates if the initial rate decreased by 0.02% (NNT = 5058). Both formulations of enoxaparin were cost-effective at the high initial rate if they decreased by 2.01% (NNT = 50) and 1.06% (NNT = 94), respectively. However, at the low and TriNetX rates, the 2 doses of enoxaparin were not cost-effective because their final break-even rate exceeded the initial VTE rate. CONCLUSION: Aspirin and, in some cases, enoxaparin are cost-effective treatments for VTE prophylaxis after knee arthroscopy.

Cost-Effective Modeling of Thromboembolic Chemoprophylaxis for Total Ankle Arthroplasty.

BACKGROUND: Symptomatic venous thromboembolism (VTE) following total ankle arthroplasty (TAA) can cause substantial morbidity and mortality. To prevent this complication, surgeons often prescribe postoperative chemoprophylaxis. However, much controversy exists regarding the efficacy of chemoprophylaxis because of the limited studies exploring its use. Furthermore, even less is known about its cost-effectiveness. Therefore, this study sought to determine the cost-effectiveness of commonly prescribed chemoprophylactic agents using a break-even analysis economic model. METHODS: The literature was searched, and an online database was used to identify patients who developed a symptomatic VTE after undergoing TAA. Our institutional records were used to estimate the cost of treating a symptomatic VTE, and an online drug database was used to obtain the cost of commonly prescribed chemoprophylactic agents. A break-even analysis was then performed to determine the final break-even rate necessary to make a drug cost-effective. RESULTS: The low and high rates of symptomatic VTE were determined to be 0.46% and 9.8%. From 2011 to 2021, a total of 3455 patients underwent total ankle arthroplasty. Of these patients, 16 developed a postoperative symptomatic VTE (1.01%). Aspirin 81 mg was cost-effective if the initial symptomatic VTE rates decreased by an absolute risk reduction (ARR) of 0.0003% (NNT = 31 357). Aspirin 325 mg was also cost-effective if the initial rates decreased by an ARR 0.02% (NNT = 5807). Likewise, warfarin (5 mg) was cost-effective at all initial rates with an ARR of 0.02% (NNT = 4480). In contrast, enoxaparin (40 mg) and rivaroxaban (20 mg) were only cost-effective at higher initial symptomatic VTE rates with ARRs of 1.48% (NNT = 68) and 5.36% (NNT = 19). Additional analyses demonstrated that enoxaparin (40 mg) and rivaroxaban (20 mg) become cost-effective when costs of treating a symptomatic VTE are higher than our estimates. CONCLUSION: Chemoprophylaxis following TAA can be cost-effective. A tailored approach to VTE prophylaxis with cost-effectiveness in mind may be beneficial to the patient and health system.

Achilles Tendon Ruptures and Repair in Athletes-a Review of Sports-Related Achilles Injuries and Return to Play.

PURPOSE OF REVIEW: Achilles tendon ruptures (ATR) are detrimental to sports performance, and optimal treatment strategy and guidelines on return to play (RTP) remain controversial. This current review investigates the recent literature surrounding nonoperative versus operative management of ATR, clinical outcomes, and operative techniques to allow the athlete a successful return to their respective sport. RECENT FINDINGS: The Achilles tendon (AT) is crucial to the athlete, as it is essential for explosive activities such as running and jumping. Athletes that sustain an ATR play in fewer games and perform at a lower level of play compared to age-matched controls. Recent studies also theorize that ATRs occur due to elongation of the tendon with fatigue failure. Biomechanical studies have focused on comparing modes of fixation under dynamic loading to recreate this mechanism. ATRs can be career-ending injuries. Fortunately, the recent incorporation of early weight-bearing and functional rehabilitation programming for non-operative and operative patients alike proves to be beneficial. Especially for those treated nonoperatively, with the incorporation of functional rehabilitation, the risk of re-rupture among non-operative patients is beginning to approach the historical lower risk of re-rupture observed among patients treated operatively. Despite this progress in decreasing risk of re-rupture particularly among non-operative patients, operative managements are associated with unique benefits that may be of particular interest for athletes and active individuals. Recent studies demonstrate that operative intervention improves strength and functional outcomes with more efficacy compared to nonoperative management with rehabilitation. The current literature supports operative intervention in elite athletes to improve performance and shorten the duration to RTP. However, we acknowledge that surgical intervention does have inherent risks. Ultimately, most if not all young and/or high-level athletes with an ATR benefit from surgical repair, but it is crucial to take a stepwise algorithmic approach and consider other factors, which may lead towards nonoperative intervention. These factors include age, chronicity of injury, gap of ATR, social factors, and medical history amongst others in this review.

Infragluteal Exposure for Resection of Subgluteal Tumors: A Surgical Technique for Accessing the Sciatic Nerve and Notch.

Sciatic nerve impingement via a tumor of or trauma to the proximal subgluteal region creates a considerable surgical challenge that is debated in the literature. The neurosurgery literature favors the infragluteal approach, while in orthopaedics, the transgluteal approach is preferred. The goal of our study was to present an operative technique for the infragluteal approach to the subgluteal region with a step-by-step procedural guide to increase awareness among orthopaedic surgeons of alternative surgical approaches to the sciatic notch. We retrospectively reviewed the case of a 62-year-old female found to have a subgluteal myxoma who underwent the infragluteal approach for tumor excision. We then highlighted the anatomic considerations via cadaveric dissection photographs, artistic renditions, and intra-operative images. Our patient underwent tumor resection and sciatic nerve exploration via the infragluteal approach with a successful outcome. In comparison to other approaches in the literature, the infragluteal approach provides a safer dissection with more options for an extension of the exposure and potentially fewer functional deficits. We conclude that orthopaedic surgeons should strongly consider utilizing this approach to the sciatic notch rather than a transgluteal approach.

Vague neck pain following a gastrointestinal procedure: a rare case presentation of vertebral osteomyelitis and cervical epidural abscess.

INTRODUCTION: Vertebral osteomyelitis (VO), spondylodiscitis, and spinal epidural abscesses (SEA) are infectious and inflammatory processes impacting the spine that cause major morbidity and mortality. They require prolonged hospital stays with expensive treatment regimens. Along with acute management, studies have provided evidence highlighting poor long-term outcomes. VO accounts for ~2% of all osteomyelitis. Recent data have illustrated an increase in incidence to 5.4 per 100,000 person years. The majority of patients that present with SEA and VO typically have some combination of back pain, fevers, and neurological deficits. CASE PRESENTATION: A 55-year-old woman with known history of hypertension and hyperlipidemia, status-post endoscopic repair of a Zenker's Diverticulum 3 weeks prior, presented to our outpatient clinic with a 2-week history of axial cervical spine pain as well as left sided scapular and deltoid pain. Further questioning and exam revealed no neurologic deficits or fever. As pain persisted and she did not respond to treatment, further imaging was performed. She was found to have cervical discitis, osteomyelitis, and a cervical epidural abscess. DISCUSSION: Patients presenting with VO/SEA typically have spine pain with some other associated symptoms of spinal cord compression or fevers, making this a rare presentation. The urgency for discovery because of the need for emergent operative intervention is evident by the documented complications associated with a delay in diagnosis. This case report emphasizes the importance of always keeping VO/SEA on the differential for cervical spine pain even with lack of associated symptoms, in order to optimize patient care.

Perioperative Telephone Encounters Should Be Included in the Relative Value Scale Update Committee Review of Time Spent on Total Hip and Knee Arthroplasty.

BACKGROUND: Providing care for patients undergoing hip and knee arthroplasty requires substantial effort beyond the actual replacement surgery to ensure a safe, clinical, and economically effective outcome. Recently, the Centers for Medicare and Medicaid Services has stated that the procedural codes for total hip (THA) and total knee arthroplasty (TKA) are potentially misvalued and has asked for a review by the Relative Value Scale Update Committee (RUC). The purpose of this study is to quantify one of the additional work efforts associated with telephone encounters during the perioperative episode of care. METHODS: We retrospectively reviewed all 47,841 telephone calls from patients to our office from 2015 to 2017 in a consecutive series of 3309 patients who underwent TKA and 3651 patients who underwent THA. We recorded reasons for communication, amount of communication, and the caller identity for both 30 days preoperatively and 90 days postoperatively. We then used the RUC Building Block Method to calculate the preservice and postservice work included in a review of the time and intensity of the codes for THA and TKA. RESULTS: The average number of preoperative patient calls per patient was 2.31 for TKA and 2.44 for THA, and the average number of postoperative calls was 5.01 for TKA and 4.00 for THA. The most common reasons for patient calls were perioperative care instructions, medications, medical clearance, paperwork/insurance, and complications. Using the RUC-approved work relative value units (wRVUs) assigned to each telephone encounter, an additional 1.83 wRVUs for perioperative telephone encounters for TKA and 1.61 for THA should be assigned. CONCLUSIONS: Providing patients with appropriate support during the arthroplasty episode of care requires substantial telephonic support, which should be acknowledged. As the RUC considers reviewing the time and intensity spent on perioperative care for patients undergoing THA and TKA, they should consider appropriately documenting the amount of work required for telephone communication.