Effects of variations in Dwyer calcaneal osteotomy determined by three-dimensional printed patient-specific modeling.

Dwyer (lateral calcaneal closing wedge) osteotomy is commonly used in surgical correction of heel varus deformity. The purpose of this study was to determine the effect of wedge size and angle of osteotomy on deformity correction using preoperative imaging analysis with three-dimensional (3D) printed modeling. Seven patients diagnosed with pes cavovarus deformity who underwent Dwyer calcaneal osteotomy were identified retrospectively. Preoperative computed tomogrphy scans were used to create 3D printed models of the foot. After18 variations of osteotomy and fixation performed for each foot, Harris heel and Saltzman images were obtained. The angle between the tibia-talus axis and calcaneal-tuber axis was measured and compared to pre-osteotomy state. Change in the calcaneal lengths was also analyzed. The average degree correction of deformity per mm of bone resected was 3.8 ± 0.2 degrees in the Harris Heel view and 2.7 ± 0.8 degrees in the Saltzman view. A significant increase in correction was obtained with 10 mm compared with 5 mm wide wedges (P < .001). The difference in correction was not statistically significant between 30 and 45 degree cuts or osteotomy distance from the posterior calcaneal tuberosity, but a 45 degree sagittal angle resulted in less calcaneal shortening compared to 30 degrees (P = .02). A clinically driven method using patient-specific 3D models for determining effects of calcaneal osteotomy variables in correcting hindfoot alignment was developed. In summary, the amount of wedge resected impacts hindfoot alignment more than location and sagittal angle of the cut. Calcaneal shortening depends on sagittal angle of the cut.

Septic Arthritis of the Hip and Enterocutaneous Fistula Formation After Hip Arthroscopy: A Case Report of Psoas Abscess Misdiagnosed as Labral Pathology.

CASE: We describe a case of septic hip arthritis and enterocutaneous fistula formation caused by the seeding of a hip joint during hip arthroscopy performed in the setting of a psoas abscess. Treatment consisted of multiple debridements and femoral head resection with subsequent total hip arthroplasty. CONCLUSIONS: This case highlights the importance of a thorough history, physical examination, and assessment of available imaging before proceeding to surgery, even when the procedure is one considered to have minimal risks, such as arthroscopy.

Treatment of Distal Interphalangeal Ganglion Cysts by Volar Corticosteroid Injection.

BACKGROUND: Various options exist for operative and nonoperative treatment of symptomatic distal interphalangeal (DIP) ganglion cysts. We describe the technique and efficacy of a novel treatment of DIP ganglion cysts using a volar, transtendon, intra-articular injection of corticosteroid. METHODS: This was a single center, retrospective study (2010-2015) of 21 patients who received a volar, intra-articular corticosteroid injection for treatment of DIP ganglion cysts. The patients were contacted via mailing with a short survey. For those potential study participants who did not respond to the mailing or were not seen in follow-up, contact was made via telephone. The primary study outcome was resolution of the cyst; secondary outcomes included pain and postinjection complications. RESULTS: A total of 21 patients (14 female; 7 male) with 23 DIP ganglion cysts were treated in this study. The dominant hand was involved in 56.5% cases. Twelve (52.2%) resolved or had near complete resolution following injection at an average follow-up of 20 months. CONCLUSIONS: For patients with DIP ganglion cysts, this newly described technique of volar, transtendon, intra-articular injection of corticosteroid provides a safe and effective treatment. This technique allows for ease and consistency of needle placement for intra-articular corticosteroid delivery while minimizing the potential soft tissue and infection concerns described with other techniques.

A Prospective, Randomized, Double-Blinded Controlled Trial Comparing Ibuprofen and Acetaminophen Versus Hydrocodone and Acetaminophen for Soft Tissue Hand Procedures.

PURPOSE: To compare the efficacy of opioid versus nonopioid analgesic regimens after elective, soft tissue hand surgery. We hypothesized that there would be no difference in patient-perceived pain relief between these 2 groups. METHODS: This prospective, randomized, double-blinded controlled trial included patients undergoing elective soft tissue hand procedures (carpal tunnel release, trigger finger release, first dorsal compartment release, or ganglion cyst excision). Patients were randomized before surgery into 2 treatment groups: acetaminophen/hydrocodone 325/5 mg (AH, opioid group) or acetaminophen/ibuprofen 500/400 mg (AIBU, nonopioid group) and followed for 2 weeks after surgery evaluating daily pain intensity scores-visual analog scale (VAS), medication pain relief (Likert pain relief score), need for rescue opioid prescription at 1 week, and days until pain-free. RESULTS: Sixty patients were randomized, 30 in the AH group and 30 in the AIBU group. There was no difference in the average VAS score. There was improved pain relief in the AIBU group, but the difference did not reach significance. There was no difference in time until pain-free, with a median of 5 days in the AH group and 3 days in the AIBU group. Two patients in each group required rescue opioid medication. Side effects were significantly more common in the AH group (n = 7; 23%) than the AIBU group (n = 1; 3%), but none were severe. CONCLUSIONS: We recommend surgeons consider a combination of acetaminophen and ibuprofen as a safe and effective postoperative pain regimen for soft tissue hand surgery procedures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

A Novel Technique for the Treatment of Jersey Fingers.

The avulsion of the flexor digitorum profundus from its insertion, or "jersey finger," is a relatively common injury. Numerous modifications have been made to the classification and treatment of this injury since its initial description. We describe a novel variation of the surgical management of jersey finger.

Patient Outcomes as a Function of Shoulder Surgeon Volume: A Systematic Review.

PURPOSE: To examine surgical complications, length of stay, surgical time, cost, revision rates, clinical outcomes, current surgical trends. and minimum number of cases in relationship to surgeon volume for shoulder arthroplasty and rotator cuff repair. METHODS: We performed a systematic review of studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All studies that met inclusion criteria from January 1990 to January 2016 were included. Inclusion criteria included Level IV evidence or greater, contained specific surgeon volume, and were written in or translated into English. Exclusion criteria included non-English manuscripts, abstracts, and review papers. A written protocol was used to extract relevant data and evaluate study results. Data extracted included volume-specific data pertaining to length of stay, operating time, complications, and cost. RESULTS: A total of 10 studies were included. Seven studies evaluated arthroplasty with 88,740 shoulders, and 3 studies evaluated rotator cuff repair with 63,535 shoulders. Variation was seen in how studies defined low- versus high-volume surgeon. For arthroplasty, <5 cases per year met the criteria for a low-volume surgeon and were associated with increased length of stay, longer operating room time, increased in-hospital complications, and increased cost. Mortality was not significantly increased. In rotator cuff surgery, <12 surgeries per year met the criteria for low volume and were associated with increased length of stay, increased operating room time, and increase in reoperation rate. CONCLUSIONS: Our systematic review demonstrates increased surgical complications, length of stay, surgical time, and surgical cost in shoulder arthroplasty and rotator cuff repair when performed by a low-volume shoulder surgeon, which is defined by those performing <5 arthroplasties and/or <12 rotator cuff repairs per year. LEVEL OF EVIDENCE: Level III, systematic review of Level II and III studies.

Phonation threshold pressure and flow in excised human larynges.

OBJECTIVES/HYPOTHESIS: To determine the phonation threshold pressure (PTP) and phonation threshold flow (PTF) in excised human larynges; determine the effects of posterior glottal width, glottal area, and gender on PTP and PTF; test the hypothesis that hysteresis is present in excised human laryngeal phonation; and compare these results to those from canine experiments and human subject measurements. STUDY DESIGN: Induced phonation of excised human larynges in the laboratory. METHODS: Nine human larynges were harvested within 24 hours postmortem. PTP and PTF at phonation onset and offset were measured on a bench apparatus. The effects of posterior glottal width, glottal area, and gender were examined. RESULTS: Large intersubject variability was observed in PTP and PTF. PTP was comparable to those measured in vivo, whereas PTF was substantially higher. One-way ANOVA showed no significant dependence of PTP and PTF on posterior glottal width. Hysteresis was observed, with offset PTP and PTF lower than onset values. Offset measurements had significantly less variability than onset measurements (P = .012 for PTP, P = .0001 for PTF). CONCLUSIONS: This study is one of the first to report onset and offset PTP and PTF in fresh excised human larynges. The high PTF observed likely reflects a large direct current flow component due to vocal fold bowing. Offset PTP and PTF values may be intrinsically more reliably measured than onset values. The large intersubject variability in PTP and PTF may have implication for the clinical application of these aerodynamic parameters of phonation.

Three-dimensional arytenoid movement induced by vocal fold injections.

OBJECTIVES/HYPOTHESIS: To quantitatively characterize arytenoid movement induced by vocal fold injection augmentation in an excised larynx model. STUDY DESIGN: : Laboratory and computational. METHODS: Vocal folds of human cadaveric larynges were injected with calcium hydroxylapatite. High-resolution computed tomography scans were obtained before and after injection. Densities corresponding to the arytenoid and cricoid cartilages were extracted and processed with custom MATLAB routines to generate selective three-dimensional reconstructions of the larynx. Pre- and postinjection positions of the arytenoid were compared. RESULTS: Vocal fold injections resulted in predominantly small-magnitude medial rotation and medial translation of the arytenoid. Movements in other directions as would be expected in physiologic adduction were not observed. CONCLUSIONS: Vocal fold injection augmentation induced passive movement of the arytenoid that has not been described previously. This movement does not reproduce the trajectory of physiologic adduction. This finding has implications for the treatment of unilateral vocal fold paralysis without arytenoid repositioning maneuvers.