A Review of Perioperative Complications of Outpatient Total Ankle Arthroplasty.

BACKGROUND: Total ankle arthroplasty (TAA) is commonly pursued for patients with painful arthritis. Outpatient TAA are increasingly common and have been shown to decrease costs compared to inpatient surgery. However, there are very few studies examining the safety of outpatient TAA. In this study, we retrospectively reviewed 65 consecutive patients who received outpatient TAA to identify complication rates. METHODS: The medical records of 65 consecutive outpatient TAA from October 2012 to May 2016 with a minimum 6-month follow-up were reviewed. All patients received popliteal and saphenous blocks prior to surgery and were managed with oral pain medication postoperatively. All received a STAR total ankle. Demographics, comorbidities, American Society of Anesthesiologists (ASA) class, and perioperative complications including wound breakdown, infection, revision, and nonrevision surgeries were observed. Mean follow-up was 16.6 ± 9.1 months (range, 6-42 months). RESULTS: There were no readmissions for pain control and 1 patient had a wound infection. The overall complication rate was 15.4%. One ankle (1.5%) had a wound breakdown requiring debridement and flap coverage. This patient thrombosed a popliteal artery stent 1 month postop. The 1 ankle (1.5%) with a wound infection occurred in a patient with diabetes, obesity, hypertension, and rheumatoid arthritis. CONCLUSION: This study demonstrates the safety of outpatient TAA. The combination of regional anesthesia and oral narcotics provided a satisfactory experience with no readmissions for pain control and 1 wound infection. The 1 wound breakdown complication (1.5%) was attributed to arterial occlusion and not outpatient management. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Vertically Oriented Femoral Neck Fractures: A Biomechanical Comparison of 3 Fixation Constructs.

OBJECTIVES: To compare the static and dynamic mechanical properties of a modified crossed cannulated screw (CS) configuration, the inverted triangle (IT) cannulated screw configuration, and a compression hip screw (CHS) with derotation screw in Pauwels type III femoral neck fractures. METHODS: Thirty synthetic femora were divided into 3 groups, and vertical femoral neck osteotomies were made. Ten osteotomized femora were fixed with a CS configuration, 10 were fixed with 3 parallel screws in an IT configuration, and the remaining 10 osteotomized femora were fixed with a CHS construct. All groups were tested using a cyclic (up to 15,000 load cycles) axial loading protocol, and survivors were statically loaded to failure. Cycles to failure, load to failure, and stiffness were calculated. The Kaplan-Meier method was used to estimate survival functions and were compared among fixation methods. The relationship between construct structural properties (maximum load and stiffness) and treatment were assessed using general linear modeling. RESULTS: All CHS fixation constructs survived the 15,000 cycle loading protocol. They endured longer (P = 0.034) than the CS fixation constructs (mean failure 13,332 cycles), but were not different from IT fixation constructs (mean failure 13,592 cycles). Maximum loads to failure for CS (3870 N) and IT (3756 N) fixation constructs were not different, but were less (P < 0.0001) than the maximum loads to failure for the CHS fixation constructs (5654 N). These findings parallel the results of the axial stiffness measurements: CS fixation constructs (663.01 N/mm) were not stiffer than IT fixation constructs (620.0 N/mm), but were less (P = 0.0005) than the axial stiffness of the CHS fixation constructs (1241.86 N/mm). CONCLUSIONS: The biomechanical performance of the CHS fixation method was superior to both the CS fixation method and the IT fixation method using a synthetic femoral model and this test protocol. Biomechanical performance of the latter 2 groups was indistinguishable. We recommend the use of CHS with the derotational screw construct for Pauwels III femoral neck fractures whenever possible.

A Review of Anatomical Placement of Corticosteroid Injections for Uncommon Hand, Wrist, and Elbow Pathologies.

Corticosteroid injections are a common nonsurgical treatment of intersection syndrome, flexor carpi radialis tendonitis, flexor carpi ulnaris tendonitis, and medial epicondylitis. The benefits of corticosteroid injections for these conditions have been well studied and documented in the medical literature. Patients with less common upper extremity complaints usually first present to their primary care provider. A correct anatomical diagnosis will help with early definitive treatment, as the injection must be in the proper location for maximal benefit to the patient. The following review on uncommon upper extremity complaints provides information for a correct diagnosis and treatment plan, followed by a possible injection. This review will hopefully provide high quality care while also cutting health care costs by making the correct diagnosis at the initial presentation. [Full article available at http://rimed.org/rimedicaljournal-2017-03.asp].

Acute plantar midtarsal dislocation with intercuneiform dislocation: Case study, diagnosis and management.

The midtarsal joint, also known as the Chopart or the transverse tarsal joint, is composed of the talonavicular and calcaneocuboid articulations.1 Midtarsal joint dislocations are rare injuries given the strong periarticular ligamentous support.2, 3 Medial, lateral, dorsal, and rarely plantar dislocations have been reported from multiple high-energy mechanisms.4, 5 We describe the case of a 24-year-old male who sustained talonavicular and calcaneocuboid plantar dislocations associated with a middle and lateral intercuneiform dislocation, open proximal 5th metatarsal fracture, 2nd-4th metatarsal base fractures, and lateral cuneiform fracture. The mechanism of injury, diagnosis, management, operative intervention, and follow up are discussed.

High-Pressure Injection to the Great Toe with River Water.

CASE: A 53-year-old male sustained a high-pressure water injection injury to his foot while working in a river. He was taken to the operating room for emergent irrigation and debridement of copious riverbed sediment. Cultures taken from the operating room were positive for multiple anaerobes, fungus and mold and he was treated with appropriate antibiotics. To date, his only residual deficit is a 1 cm area of numbness at the entrance wound. CONCLUSION: High-pressure water injections to the foot are uncommon injuries. These are serious injuries that require emergent antibiotics, tetanus and surgical debridement.

Procedural sedation in the emergency department.

Procedural sedation options in the emergency department now allow for more effective and safer care and facilitate the delivery of orthopaedic care that would otherwise require operating room anesthesia. Traditional sedation agents, such as nitrous oxide, midazolam, fentanyl, and ketamine, have a persistent role. Etomidate and propofol are relatively recent additions that are highly effective. Combination regimens, such as ketamine-midazolam and ketamine-propofol, may be superior because they benefit from synergistic traits. Despite these sedation regimens, use of local blocks in adults continues to be effective, and intranasal delivery in children has emerged as a viable option. Orthopaedic surgeons should be aware of the appropriateness of different sedation regimens and other options for specific clinical scenarios.

Deltoid Compartment Syndrome After Prolonged Lateral Decubitus Positioning: A Case Report.

CASE: A thirty-six-year-old man fell off a ladder and sustained an open fracture of the distal end of the left humerus. He was taken to the operating room for irrigation, debridement, and fixation of the fracture and was placed in the right lateral decubitus position for over seven hours. He subsequently developed right deltoid compartment syndrome, necessitating emergency compartment release. One year later, he had limited function, with a Disabilities of the Arm, Shoulder and Hand score of 81.3 points. CONCLUSION: Deltoid compartment syndrome can occur from operative positioning, with poor long-term outcomes as a result. Expeditious surgery, additional padding, and repeat checks are necessary for at-risk patients.