To Be or Not to Be (A Morton's/Interdigital Neuroma): That Is the Question-A Case Series of Lateral Forefoot Pain Localized to the Proper Digital Nerve of the Fifth Toe.

ABSTRACT: We present 2 cases where the initial history and examination were similar to a Morton's/interdigital neuroma. In both cases, however, diagnostic ultrasound revealed symptomatic snapping of the proper digital nerve of the fifth toe. The anatomy of the proper digital nerve of the fifth toe may predispose it to a snapping phenomenon. Clinical awareness of this atypical cause of forefoot pain can help guide the diagnosis and treatment in those patients with persistent and refractory lateral forefoot pain and paresthesias.

Ultrasound-Guided Fasciotomies of the Deep and Superficial Posterior Leg Compartments for Chronic Exertional Compartment Syndrome: A Cadaveric Investigation.

BACKGROUND: Chronic exertional compartment syndrome (CECS) is a type of leg pain related to elevated intracompartmental pressure with activity in one or more of the four compartments of the leg. Open fasciotomy is the definitive treatment for CECS but has a reported complication rate of up to 15.7% and return to full activity reported up to 16 weeks. Ultrasound-guided (USG) fasciotomy of the anterior and lateral compartments has been translated into clinical practice. OBJECTIVE: To determine the safety and feasibility of a USG fasciotomy of the deep posterior compartment (DPC) and superficial compartment (SPC) of the leg in a fresh-frozen cadaveric model. DESIGN: Prospective, cadaveric laboratory investigation. SETTING: Procedural skills laboratory at an academic institution. CADAVERIC COHORT: Ten fresh-frozen cadaveric knee-ankle-foot specimens from five female and five male donors aged 58 to 93 years (mean 77.4 years) with body mass indexes of 18.1 to 33.5 kg/m2 (mean 25.1 kg/m2 ). METHODS OR INTERVENTIONS: One experienced operator performed 10 USG DPC and SPC fasciotomies. A clinical anatomist performed dissections of each. MAIN OUTCOME MEASURES: Achievement of target length and continuity of release was recorded. Target lengths of 10 cm for the superficial posterior compartment (SPC) and 15 cm for the deep posterior compartment (DPC) were established based on previous studies. Tendinous and neurovascular structures were assessed for damage. RESULTS: No tendon or neurovascular injuries were observed. In the SPC, target length was achieved in 90% and continuous release was observed in 80%. In the DPC, target length was achieved in 60% and continuity observed in 30%. CONCLUSIONS: These findings suggest that SPC USG fasciotomies using the technique described in this study are feasible, may be safe, and warrant further translational research; however, DPC USG fasciotomies are more challenging and require more technical refinement prior to clinical translation.

Pre-operative patella alta does not affect midterm clinical outcomes and survivorship of patellofemoral arthroplasty.

PURPOSE: The purpose of this study was to evaluate the effect of preoperative patella alta on clinical outcomes, survivorship, and complication and reoperation rates on patellofemoral arthroplasty (PFA). METHODS: All patients who underwent PFA for isolated patellofemoral arthritis by a single surgeon at our institution were identified. Preoperative radiographs were measured by two independent observers for patellar height using the Caton Deschamps (CD), Insall-Salvati (IS), and Blackburne-Peele (BP) methods. Patients were classified as either "patella alta" or "non-patella alta" for all three measurement methods. Clinical scores including KSS Pain, KSS Function, and Tegner Activity Scores were collected pre- and post-operatively. Failure was defined as conversion to total knee arthroplasty (TKA). Clinical outcomes and survivorship were compared between patients with "patella alta" and "non-patella alta" height measurements. RESULTS: There were 119 patients with 153 knees (86% female) included in the study with a mean age of 55.8 years. Outcome scores improved from pre-operative to post-operative for both patella alta and non-patella alta patients for Tegner, KSS pain and KSS function scores. The mean change in Tegner scores for patella alta and non-patella alta patients were not significantly different for CD (p = 0.24), IS (p = 0.25) or BP measurements (p = 0.39). The mean change in KSS pain scores between groups were not significantly different for CD (p = 0.33) or IS measurements (p = 0.22), but was improved more significantly in patella alta patients vs non-patella alta patients (21.2 and 14.4; p = 0.02) for BP measurement. The mean change in KSS function scores between groups was not significantly different for CD (p = 0.61) IS (p = 0.90) or BP measurements (p = 0.79). The overall survivorship from conversion to total knee arthroplasty (TKA) was 94.1% at a mean follow-up time of 5.0 (SD 2.6) years. There were no significant differences in survivorship from TKA between patella alta and non-patella alta groups (CD: p = 0.72, IS: p = 0.63, BP: p = 0.66). CONCLUSIONS: This study suggests that there are no significant differences in clinical outcome scores or survivorship from TKA between patella alta and non-patella alta patients who underwent onlay design PFA. Both patella alta and non-patella alta patients demonstrated excellent improvement in outcome scores from pre-operative to post-operative. LEVEL OF EVIDENCE: IV.

Smoking, unemployment, female sex, obesity, and medication use yield worse outcomes in patellofemoral arthroplasty.

PURPOSE: The purpose of this study was to identify effects of psychosocial and demographic factors on patellofemoral arthroplasty (PFA) outcomes. METHODS: Patients who underwent PFA by a single surgeon between 2002 and 2013 (min. 2 year follow-up) were included. Knee Society scores (KSS), UCLA, and Tegner Scores were prospectively collected in a designated arthroplasty registry. Patient records were retrospectively reviewed and univariate and multivariate statistical analyses were performed to assess the effect of psychosocial factors and demographic variables including patient sex, BMI, smoking and medication use, psychiatric history, and employment status on improvement between pre- and post-operative scores. RESULTS: Seventy-four knees in 55 patients (88% female) with a mean age of 51.8 (SD 8.8) and mean follow-up of 46.5 (SD 26.9) months were included. Patients showed significant improvement in all functional outcomes (p < 0.001). Mean improvement in KSS-F scores and median improvement in Tegner scores was greater in males compared to females (37.8 vs 16.1, p = 0.007; 3.0 vs 2.0, p = 0.07, respectively). Smokers showed less improvement in KSS-P compared to non-smokers (17.2 vs 30.0, p = 0.028). Retired or employed patients had a greater mean improvement in KSS-F and median improvement in Tegner Scores compared to those were unemployed or on work disability (p = 0.022, p = 0.01). Patients who reported using opioids and/or anti-depressants pre-operatively showed less improvement in UCLA scores (p = 0.006). Obese patients showed less improvement in both KSS-F and Tegner score compared to non-obese patients (p = 0.009, p = 0.004). CONCLUSION: Psychosocial factors influence the degree of improvement following PFA. Although patients showed overall improvement compared to their baseline scores, obese patients, smokers, unemployed/work disabled, and pre-operative use of opioids and/or anti-depressants were risk factors for decreased improvement… The consideration of psychosocial variables are clinically important when assessing a patient's candidacy for PFA and improve pre-operative patient selection and counselling. LEVEL OF EVIDENCE: Level IV.

Systematic Review of Medial Patellofemoral Ligament Reconstruction Techniques: Comparison of Patellar Bone Socket and Cortical Surface Fixation Techniques.

PURPOSE: To compare patellar bone socket and cortical surface fixation techniques for isolated medial patellofemoral ligament (MPFL) reconstruction and determine whether there was a difference in (1) complication rates, including fracture of the patella; (2) redislocation rates; or (3) patient-reported outcomes. METHODS: A literature search was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included patients who underwent isolated MPFL reconstruction for recurrent patellar instability. Patients with confirmed concomitant or prior ipsilateral knee procedures, multiligament injury, or less than 3 months of follow-up were excluded. Risk-of-bias assessment was performed using the Methodological Index for Non-randomized Studies (MINORS) system. Studies were classified by surgical technique (patellar bone socket group [group S] vs cortical fixation group [group F]), and complications, redislocations, and patient-reported outcomes were collected. RESULTS: A total of 29 studies yielded 981 patients with MPFL reconstruction for inclusion. Of the patients, 620 underwent a patellar bone socket technique and 361 underwent a cortical fixation technique. Patients ranged in age from 11 to 68 years. Patellar fracture rates ranged from 0% to 17% in group S and were 0% in all group F studies. Mean Kujala scores ranged from 83.5 to 93.6 in group S and from 84.4 to 94.5 in group F. Mean Lysholm scores ranged from 84.6 to 91.7 in group S and from 83.5 to 95 in group F. Redislocation rates ranged from 0% to 21% in group S and from 0% to 13% in group F. Although heterogeneous in nature, complication rates ranged from 0% to 28% in group S and from 0% to 4% in group F. CONCLUSIONS: MPFL reconstruction techniques with patellar bone sockets showed a larger range of complication rates than cortical fixation techniques, although overall, complications remained uncommon. Clinically, the bone socket group had comparable postoperative redislocation rates and patient outcomes to the group treated with cortical fixation techniques. LEVEL OF EVIDENCE: Level IV, systematic review of Level I through IV studies.

Outcomes of Patellofemoral Arthroplasty Based on Radiographic Severity.

BACKGROUND: Patellofemoral arthroplasty (PFA) is increasingly performed for symptomatic patellofemoral arthritis. The purpose of this study was to evaluate the outcomes of PFA based on preoperative radiographic severity of patellofemoral arthritis. METHODS: All patients who underwent PFA for isolated patellofemoral arthritis between 2002 and 2013 and had undergone preoperative magnetic resonance imaging were identified. Radiographic severity of patellofemoral arthritis was classified according to the Iwano classification system. Groups were divided between mild (grade 0-I) and moderate to severe (grade II-IV) patellofemoral arthritis. Clinical outcomes were evaluated using the Knee Society scores (KSS), University of California at Los Angeles (UCLA) and Tegner scores. RESULTS: Seventy-five knees in 55 patients met inclusion criteria. Mean age was 51 years (range, 36 to 81), and mean follow-up was 3 years (range, 2 to 10). All patients had grade IV patellofemoral chondromalacia and/or significant subchondral cyst formation and edema on magnetic resonance imaging. On plain radiographs, there were no patients with Iwano grade 0, 21 grade I, 15 grade II, 21 grade III, and 18 grade IV patellofemoral arthritis. There was significantly more improvement in KSS pain (P = .046), KSS function (P = .02), University of California at Los Angeles (UCLA) (P = .046) and Tegner (P = .008) scores in the Iwano grade II-IV group vs the Iwano grade I group. Patient-reported pain quality improved significantly more following PFA in the grade II-IV group (P = .04). CONCLUSION: Patients with evidence of mild patellofemoral arthritis on plain radiographs demonstrated less improvement in pain and function after PFA than those with more advanced patellofemoral arthritis. Caution should be used when considering PFA for patients with minimal radiographic evidence of patellofemoral arthritis.

Sideline Ethical Dilemmas.

A team physician is covering a local high-school football game. The All-State starting running back injures his shoulder. "David Doe" is in obvious pain. His arm and shoulder are weak, and he is unable to actively raise his arm above 90°. When his pads are removed, there is a noticeable deformity of the acromioclavicular joint. It is the third quarter of the final game of the playoffs, and the winner goes on to the state championship game. David is a college prospect, and there are many collegiate scouts in the stands. David wants to go back into the game, and David's father, who is the offensive coordinator for the team, says he will take the responsibility for sending David back in. The orthopaedic surgeon on the sideline does not return David to the game and, in spite of this, the team wins. After the game, a reporter for the local newspaper approaches the team physician for information on David's injury and prognosis. David does not keep his follow-up appointment in the orthopaedic surgeon's office, but shows up to practice with a note from another physician saying he is able to play.

A review of occupational knee disorders.

INTRODUCTION: Lower extremity knee disorders, like other cumulative disorders of the body, build up over time through cumulative exposures. 2006 data from the U.S. Bureau of Labor Statistics reveal that cumulative knee disorders account for 65% of lower extremity musculoskeletal disorders and 5% of total body musculoskeletal disorders. METHODS: The objective of the literature review was to find papers on work-related musculoskeletal disorders (WMSDs) common to the knee region. From these, symptoms of the disorders, affected industries, and potential risk factors were assessed. RESULTS: A review of the literature divulges that knee disorders primarily consist of bursitis, meniscal lesions or tears, and osteoarthritis. Though kneeling and squatting are considered to be two of the primary risk factors correlated to these knee disorders, 12 other risk factors should also be contemplated. These 14 contributing risk factors include both occupational (extrinsic) and personal (intrinsic) variables that affect the labor industries. Example industries include mining, construction, manufacturing, and custodial services where knee bending postural activities exist as a commonality. CONCLUSION: The understanding of the types of knee disorders, the affected occupations, and the job related risk factors will allow ergonomic practitioners and researchers to create and adjust work environments for the detection and lessening of knee work-related musculoskeletal risk. Further studies need to be conducted to (1) justify the presence of risk from certain risk factors and (2) enhance the understanding of risk factor dose-response levels and their temporal development.

The heart failure clinic: a consensus statement of the Heart Failure Society of America.

BACKGROUND: Outpatient care accounts for a significant proportion of total heart failure (HF) expenditures. This observation, plus an expanding list of treatment options, has led to the development of the disease-specific HF clinic. METHODS AND RESULTS: The goals of the HF clinic are to reduce mortality and rehospitalization rates and improve quality of life for patients with HF through individualized patient care. A variety of staffing configurations can serve to meet these goals. Successful HF clinics require an ongoing commitment of resources, the application of established clinical practice guidelines, an appropriate infrastructure, and a culture of quality assessment. CONCLUSIONS: This consensus statement will identify the components of HF clinics, focusing on systems and procedures most likely to contribute to the consistent application of guidelines and, consequently, optimal patient care. The domains addressed are: disease management, functional assessment, quality of life assessment, medical therapy and drug evaluation, device evaluation, nutritional assessment, follow-up, advance planning, communication, provider education, and quality assessment.