Patient: Male, 17Final Diagnosis: Acute exertional compartment syndromeSymptoms: Foot drop • leg pain • paresthesiaMedication: —Clinical Procedure: FasciotomySpecialty: Orthopedics and TraumatologyObjective:Rare diseaseBackground:Acute exertional compartment syndrome (AECS) is a rare cause of leg pain often associated with a delay in diagnosis and potentially leading to irreversible muscle and nerve damage.Case Report:We present the case of a previously healthy, high-level athlete who presented with the acute onset of unilateral anterior leg pain and foot drop the day after a strenuous workout. He was diagnosed with compartment syndrome and rhabdomyolysis. His management included emergent fluid resuscitation, fasciotomies, debridement of necrotic muscle from his anterior compartment, and delayed primary closure. After six months of intensive outpatient physical therapy, including the use of blood flow restriction treatments, the patient returned to sports and received a NCAA Division I Football scholarship.Conclusions:We describe the details of this patient’s case and review the literature related to acute exertional compartment syndrome. The occurrence of acute compartment syndrome in the absence of trauma or fracture, though rare, can have devastating consequences following delays in treatment. AECS requires prompt diagnosis and surgical intervention to prevent these consequences. Diagnosis of atraumatic cases can be difficult, which is why awareness is equally as important as history and physical examination. While diagnosis is primarily clinical, it can be supported with direct intra-compartmental pressure measurements and maintaining a high index of suspicion in acute presentations of exertional limb pain.
Background: This work used software-guided radiographic measurement to assess the effects of progressive lateral column lengthening (LCL) on restoring alignment in a novel cadaveric model of stage II-B flatfoot deformity. Methods: A stage II-B flatfoot was created in 8 cadaveric specimens by transecting the spring ligament complex, anterior deltoid, and interosseous talocalcaneal and cervical ligaments. Weightbearing computed tomographic (WBCT) scans were performed with specimens under 450 N of compressive load in the intact, flat, and 6-, 8-, and 10-mm lateral column–lengthening conditions. Custom software-guided radiographic measurements of the lateral talo–first metatarsal (Meary) angle, anteroposterior talo–first metatarsal angle, naviculocuneiform overlap, and 2 new measures (plantar fascia [PF] distance and angle) were recorded on digitally reconstructed radiographs. Four anonymized analysts performed measurements twice. Intra- and interobserver agreement was assessed using intraclass correlation coefficients (ICCs). Results: Six-millimeter LCL restored alignment closest to the intact foot in this new cadaveric model, whereas 10-mm lengthening tended toward overcorrection. The PF line displaced laterally in the flatfoot condition, and LCL restored the PF line to a location beneath the talonavicular joint. Interobserver agreement was excellent for PF distance (ICC = 0.99) and naviculocuboid overlap (ICC = 0.91), good for Meary angle (ICC = 0.81) and PF angle (ICC = 0.69), and acceptable for the talonavicular coverage angle (ICC = 0.65). Conclusion: In this stage II-B cadaveric flatfoot model, cervical ligament transection was essential to create deformity after the medial hindfoot ligaments were transected. Software-guided radiographic measurement proved reliable; standardized implementation should improve comparability between studies of flatfoot deformity. The novel PF distance performed most consistently (ICC = 0.99) and warrants further study. With this model, we found that a 6-mm LCL restored alignment closest to the intact foot, whereas 10-mm lengthening tended toward overcorrection. Clinical Relevance: Future joint-sparing flatfoot corrections may consider using a relatively small LCL combined with other bony and/or anatomic ligament/tendon reconstructions.
Category: Diabetes Introduction/Purpose: With approximately 29.1 million diabetics in the United States and estimated total annual cost of $245 billion, diabetes and its associated complications continue to be an increasing burden on society. The management of diabetic foot ulcers accounts for a significant portion of those expenses. We propose a safe, efficacious and economically prudent model for the outpatient treatment of uncomplicated diabetic foot ulcers. Methods: Enrolled patients had initial sharp wound debridement by one of two foot and ankle fellowship trained orthopaedic surgeons. Patients were treated with total contact casting and subsequently evaluated every two weeks by nurses who utilized a clinical management algorithm and performed conservative sharp wound debridement (CSWD). Results of healing and complications were recorded. Digital photographs of the ulcers from each clinical encounter were retrospectively reviewed in a blinded fashion by two orthopaedic foot and ankle surgeons and compared to the nursing decisions at the time of treatment. Financial calculations estimated the potential cost savings by having nurses perform CSWD. State boards of nursing were systematically surveyed to assess current policies related to CSWD. Results: Average time to clinical healing was 6.03 weeks. There were no identified complications of CSWD performed by nurses. The sensitivity for the timely identification of wound deterioration was 100%, specificity = 86.49%, PPV = 68.75% and NPV = 100% with an overall accuracy of 89.58%. Thirty-six of 51 (70.59%) state boards of nursing responded to the survey with 33 of 36 (91.67%) defining CSWD as within the nursing scope of practice. The estimated cost savings by having nurses perform CSWD over a 6 week treatment period, with all other factors being equal, was $774.60 per patient. When extrapolated to the estimated number of diabetic foot ulcers annually within the United States, this could approach $1.8 to $2.1 billion in potential annual healthcare savings. Conclusion: CSWD of diabetic foot ulcers and calluses by trained nurses is a safe, effective and fiscally responsible clinical practice supported by greater than 90% of state boards of nursing. Utilizing a clinical decision algorithm, nursing evaluation and appropriate referral of ulcers at risk demonstrated 100% sensitivity and 89.58% accuracy. There were no complications associated with nurses performing conservative sharp debridement. When considering the most recent CDC estimates of 29.1 million diabetics with an 8% annual incidence of DFU, implementation of this clinical model on a national scale could result in approximately $2 billion in annual healthcare savings.
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