Paralabral Cyst of the Hip Causing Deep Vein Thrombosis Treated with Arthroscopic Decompression and Labral Repair.

In the setting of femoroacetabular impingement of the hip joint, paralabral cysts are well-documented sequelae. These cysts are typically associated with labral tears caused by CAM and/or pincer-type bony lesions. Synovial fluid extravasation through a tear in the labrum, similar to a popliteus cyst, leads to formation of a capsular-based cyst that is usually self-limiting. Few documented cases of these cysts causing compression of nearby neurovascular structures exist. There are several studies documenting arthroscopic decompression of these cysts, but none reporting compression of the femoral vein by a paralabral cyst resulting in deep vein thrombosis. We present the case of a large anterior paralabral cyst causing compression of the right femoral vein in a patient presenting with deep vein thrombosis and hip pain. Treatment consisted of arthroscopic decompression, followed by definitive aspiration by interventional radiology after labral repair and bipolar hip osteoplasty. The purpose of this case report was to document this rare presentation and offer learning points from our experience.

Workers' Compensation: The Burden on Healthcare Resource Utilization After Foot and Ankle Surgery.

INTRODUCTION: The purpose of this study is to investigate the amount of healthcare resources dedicated to patients with WC after common foot or ankle procedures compared with a procedure-matched control group. METHODS: A retrospective review was performed of patients with WC and without WC undergoing foot and ankle procedures. Measures of healthcare burden included clinical communications, documents, prescriptions, office visits, and days to return to work and clinic discharge. RESULTS: Collectively, 142 patients met the inclusion criteria. Patients with workers' compensation had increased office communication encounters (P < 0.001), processed documents (P < 0.001), medication prescriptions (P < 0.001), number of office visits (P < 0.001), number of days until return to work (P < 0.001), and days until final disposition from clinic (P < 0.001). Patients with workers' compensation were more likely to have postoperative complications (OR 2.1; 95% CI, 1.0 to 4.3; P = 0.04), secondary surgeries (OR 8.2; 95% CI, 2.3 to 29.4; P < 0.001), and new complaints during the perioperative period (OR 1.9; 95% CI, 0.9 to 4.0; P = 0.07) but were less likely to cancel appointments (OR 0.41; 95% CI, 0.19 to 0.86; P = 0.02). DISCUSSION: When undergoing common foot and ankle orthopaedic procedures, patients with WC demonstrated increased healthcare utilization of resources. This included more office staff work burden dedicated to patients with WC for longer amounts of time, effectively doubling the effort of a non-WC cohort.

A Case Report of Bilateral Lipoma Arborescens: An Unusual Consideration for Knee Pain.

Introduction: Lipoma arborescens (LAs) is a benign, intra-articular proliferation of fat cells in villous projections, creating a tree-like pattern on magnetic resonance imaging (MRI). The suprapatellar pouch is usually affected, and symptoms are typically gradual in nature, and patients may report painless swelling of the knee. Only ten cases of bilateral LA have been reported in the literature so far. Early recognition of this disease process and treatment may help to prevent prolonged symptoms and delays in care. Case Report: A 49-year-old female with bilateral knee pain and intermittent swelling for over 20 years presented to our clinic with complaints of bilateral knee pain and swelling. She had previous steroid injection but no relief. After MRI was obtained concerning for LA, a surgical discussion was had with the patient about arthroscopic removal. She elected to proceed with surgery and underwent arthroscopic debridement of both knees. At her follow-up at 6 months for the right knee and 2 months for the left knee, she had a significant improvement in pain and quality of life. Conclusion: LA of the knee is a rare condition, particularly bilateral, and in this patient, the diagnosis was missed for many years, and her definitive treatment was delayed. In her case, arthroscopic debridement of her bilateral LA proved to be a viable treatment option which significantly improved the patient's quality of life and function.

A Survey Analysis of Patient Understanding and Preferences for Podiatrists Versus Foot and Ankle Orthopaedic Surgeons.

BACKGROUND: Recent studies suggest poorer outcomes and higher costs associated with patients treated by podiatrists, yet no studies have evaluated patient perception and preference for foot and ankle providers. This study aims to determine patient perception of training for podiatrists compared to orthopaedic surgeons and patient preference for type of provider seen. METHODS: A 20-question survey was administered to new patients seeing either a podiatrist or foot and ankle orthopaedic surgeon. Questions pertained to demographics, patient knowledge of their provider, perception of training requirements, number of years in professional training, and differences in surgical volume during training. Patients were asked their preference for a particular type of foot and ankle provider, and whether they perceived a difference in surgical skillset or a provider's ability to manage different pathology. RESULTS: In all, 147 podiatry and 115 orthopaedic patients were included in the study. Demographics were similar between groups. Both groups believed orthopedists required more years of education and surgical training. In all, 61.5% of orthopaedic patients believed that orthopedists performed more foot and ankle surgeries and were more skilled as compared to podiatrists, while only about a third of podiatry patients believed this to be true (68.7% vs 38.6%; P < .001). Most patients believed orthopedists were more skilled in treating fractures. In all, 48.7% of orthopaedic patients preferred seeing an orthopedist compared to only 3.5% of podiatry patients. CONCLUSIONS: Our study demonstrates that patients are knowledgeable about the type of foot and ankle provider they are seeing. Most patients believe orthopaedic surgeons require more years of education and surgical training compared to podiatrists and believe they are more skilled in fracture-related surgery. Fewer podiatry patients expressed a preference for an orthopaedic surgeon. Providers must play an active role in discussing their training background prior to treating foot and ankle patients, especially in the setting of fracture-related pathology. CLINICAL RELEVANCE: This study demonstrates that most patients seeking care from a podiatrist or foot and ankle orthopaedic surgeon are relatively knowledgeable about the type of provider they are seeing; however, there are some differences. Most patients understand that orthopaedic surgeons require more years of education and surgical training and also believe orthopaedic surgeons are more skilled in fracture work and taking care of arthritic conditions. In general, podiatry patients have less preference for seeing an orthopaedic surgeon; however, many of these patients are seeking care for wounds and infections. With expanding roles and scope of practice among podiatry providers, it is important that providers become more active in explaining their training background and qualifications when treating foot and ankle conditions. LEVELS OF EVIDENCE: Level II: Prospective.

Erratum to 'Left Profunda Femoral Artery Pseudoaneurysm After Revision Total Hip Arthroplasty' [Arthroplasty Today 6 (2020) 906-910].

[This corrects the article DOI: 10.1016/j.artd.2020.09.004.].

Progression of Intracranial Hemorrhage After Chemical Prophylaxis Using Low-Molecular-Weight Heparin in Patients With Traumatic Brain Injury.

INTRODUCTION: Chemical prophylaxis using low-molecular-weight heparin (LMWH) is considered a standard of care for venous thromboembolism in trauma patients. Our center performs a head computed tomography (CT) scan 24 hours after initiation with prophylactic LMWH in the setting of a known traumatic brain injury (TBI). The purpose was to determine the overall incidence of ICH progression after chemoprophylaxis in patients with a TBI. METHODS: This retrospective study was performed at a Level I trauma center, from 1/1/2014 to 12/31/2017. Study patients were drawn from the institution's trauma registry based on Abbreviated Injury Score codes. RESULTS: 778 patients met all inclusion criteria after initial chart review. The proportion of patients with an observed radiographic progression of intracranial hemorrhage after LMWH was 5.8%. 3.1% of patients had a change in clinical management. Observed radiographic progression after LMWH prophylaxis and the presence of SDH on initial CT, the bilateral absence of pupillary response in the emergency department, and a diagnosis of dementia were found to have statistically significant correlation with bleed progression after LMWH was initiated. CONCLUSION: Over a 4-year period, the use of CT to evaluate for radiographic progression of traumatic intracranial hemorrhage 24 hours after receiving LMWH resulted in a change in clinical management for 3.1% of patients. The odds of intracranial hemorrhage progression were approximately 6.5× greater in patients with subdural hemorrhage on initial CT, 3.1× greater in patients with lack of bilateral pupillary response in ED, and 4.2× greater in patients who had been diagnosed with dementia.

Evaluating Tourniquet Efficacy Comparing Exsanguination Techniques for the Upper Extremity.

Tourniquets have been used in the medical setting for centuries and have become the gold standard when preparing patients for surgery, particularly in orthopaedic surgery. Upper extremity tourniquet use improves intraoperative visibility and identification of anatomy. It also decreases blood loss intraoperatively and improves the safety of orthopaedic procedures. Despite the widespread use of tourniquets and differing methods of limb exsanguination, little research has been done quantifying its efficacy. The purpose of this study was to compare gravity exsanguination to Esmarch exsanguination of the upper extremity prior to tourniquet inflation in a large patient sample. A plethysmographic method based on water displacement served as a surrogate for the blood volume exsanguinated. Control measurements of water displacement were obtained from both upper extremities without tourniquet inflation. Water displacement was then measured with both gravity and Esmarch exsanguination techniques. Gender, handedness, height, weight, body mass index, and age were recorded for volunteers and used as covariates. Change in mean water displacement from control (un-exsanguinated) arm and gravity alone measurement was 37.2 ml. Change in mean water displacement between control arm and mean Esmarch measurement was 56.3 ml. Exsanguination using Esmarch compared to gravity alone resulted in a 51.2% increase in blood removal. Only age had a significant interaction effect for the Esmarch method. Analysis revealed that age accounted for 21.4% of all variance in blood exsanguinated using the Esmarch method when compared to the control group. The Esmarch technique was more efficacious for all demographics measured, but most efficacious in subjects who were older than 40 years. This data reaffirms that gravity exsanguination is more efficacious than no tourniquet use at all, and that the Esmarch technique is more efficacious than gravity. To our knowledge, this study is the most robust of its kind to critically and objectively compare upper extremity exsanguination methods and overall tourniquet use by age and supports the common practice of Esmarch exsanguination in orthopaedic extremity surgery.

18-Year Operative Incidence and Cost Analysis of the Treatment of Adult Acquired Flatfoot Deformity.

BACKGROUND: Adult acquired flatfoot (AAFD) is commonly treated by foot and ankle surgeons. Despite how commonly this disease presents, its incidence and economic impact have yet to be defined. We hypothesized that the operative incidence of AAFD and its economic burden would increase over the time period 1996 to 2014. METHODS: The South Carolina database was queried for data from acute care and ambulatory surgery centers. Bivariate descriptive statistics were used to analyze the data. Operative incidence was calculated and demographics and medical comorbidities of patients who progressed to operative intervention were analyzed. Costs associated with operative care episodes were calculated to determine the economic burden. RESULTS: A total of 1299 patients underwent AAFD corrective surgery between 1996 and 2014. Patients who underwent surgery for AAFD were most likely to be white, female, and in their fourth, fifth, and sixth decade of life. Operative incidence for AAFD rose from 0.26 per 100 000 covered lives in 1996 to 3.04 in 2014. The total health care costs associated with patients who underwent surgery for AAFD increased from $57 395.33 in 1996 to $6 859 723.60 in 2014. CONCLUSIONS: This data demonstrate that patients most commonly undergoing operative intervention for AAFD were white, female, and in their fourth, fifth, or sixth decade of life. There has been a significant increase in operative incidence, which may help direct attention to further exploration of outcome data in these patient populations, associated treatment costs, and preventative treatment options. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Left Profunda Femoral Artery Pseudoaneurysm After Revision Total Hip Arthroplasty.

We present a case report of an 84-year-old male who presented with a profunda femoris artery (PFA) pseudoaneurysm 8 years after the index revision total hip arthroplasty procedure. Failure of revision hardware and subsequent migration of implants led to damage of the PFA and pseudoaneurysm formation. The patient was hemodynamically unstable on presentation and required emergent endovascular intervention. Once medically stabilized, the patient underwent extensive debridement of the aneurysm and hematoma bed and broken hardware was removed to prevent further complications. At 6-month follow-up, the patient was able to mobilize independently and had returned to all prior levels of activities of daily living. We discuss the vascular anatomy of the hip, the paucity of literature on PFA pseudoaneurysm, as well as the likely etiology of total hip arthroplasty failures.

A Case Report of Giant Cell Tumor in the Thumb Distal Phalanx.

INTRODUCTION: The following report describes a rare case of giant cell tumor (GCT) of the bone that presented in the distal phalanx of the thumb. GCT of the bone is a relatively rare, and typically benign condition that presents most frequently in the metaphysis of long bones in women age 30-50 years old. There are only three other instances in the literature describing GCT of the bone presenting in the distal phalanx of the thumb. Although rare, delayed or missed diagnosis can be very debilitating to the patient. CASE REPORT: A 28-year-old male laborer who is right hand dominant and works with his hands for a living presented to the emergency department (ED) with swelling and pain at the distal aspect of his left thumb with no known injury. The patient was seen 4 weeks previously and was treated for cellulitis of the hand with antibiotics. At that time, no radiographs were taken. Despite this treatment, the patient reported increased swelling and pain over the next 2 weeks. He then sought treatment in the ED where a hand surgeon was consulted and radiographs were obtained that displayed a lytic, disruptive, and mildly expansile lesion of the distal phalanx of the first finger concerning for sarcoma. The risks and benefits of surgery were discussed with the patient and surgical intervention was planned. CONCLUSION: Due to how rarely this condition presents clinically, the patient was initially misdiagnosed and definitive treatment was delayed. Although rare, this is an important diagnosis to consider in patients presenting similarly. The patient ultimately received adequate treatment, but the delay in diagnosis in combination with the locally aggressive nature of this tumor could have led to extensive surgical intervention with impairment in hand function. As a laborer whose income relies on daily use of his hands a delayed diagnosis; in this case could have had a catastrophic impact.