Category: Midfoot/Forefoot; Lesser Toes Introduction/Purpose: Hammertoe deformities are commonly encountered and frequently require surgical intervention for pain relief and shoewear accommodation. Various techniques exist for surgical management, but proximal interphalangeal (PIP) joint fusion with Kirschner (K) -wire fixation remains an inexpensive, popular treatment. The decision to place a K wire that spans the metatarsophalangeal (MTP) joint versus only fixating the digit through the proximal phalanx is entirely dependent on provider preference and situational context. This study was performed to evaluate the effect of length of wire fixation on clinical outcomes after hammertoe reconstruction. Methods: A retrospective review of all hammertoe reconstructions by a single fellowship trained foot and ankle surgeon from 2017-2021 was performed. Hammertoe reconstructions involved PIP arthrodesis with double wire fixation and other supplemental balancing procedures as indicated. Pins were routinely removed at between 5-6 weeks and protected heel weightbearing was generally advised. Wire length was chosen at the discretion of the surgeon intraoperatively. Patients were excluded if no radiographic follow-up was available after pin removal. Patient outcomes were evaluated with radiographs and clinic notes to assess pin length, pin complications/breakage, return to the OR, MTP congruency, and PIP union rate. A logistic regression was performed to determine the odds ratio for digit congruency and non-union status. Results: 88 toes (45 patients) underwent hammertoe reconstruction with K wire fixation. Of these toes, 47 had wires that spanned the MTP and 41 that did not. There were 65 congruent MTP joints and 23 incongruent joints. 16 of the incongruent joints were pinned across the MTP while 31 in the congruent group were pinned. One toe in the MTP group required return to the OR for removal of a broken wire, compared to zero in the phalanx group (p=1.0). No pins broke in the phalanx group, compared to 3 in the MTP group (p=0.25). One toe in the proximal phalanx group had their pins pull out early but no return to the OR was needed. There were 26 (63.4%) PIP radiographic nonunions, compared to 21 (44.7%) in the MTP group (p=0.12). Conclusion: Wire failure was a rare occurrence in either group. Breakage only occurred in the MTP group, but only required one surgical intervention for removal. Pinning the MTP may allow for improved deformity correction and increased stability of the hammertoe reconstruction. Pin breakage can occur, but it may be of little clinical significance. The increased stability and control of MTP correction may be worth the potential risk of pin breakage. Pin breakage may be avoided potentially by using thicker wires, earlier removal, and protected weightbearing.

Patients diagnosed with cancer often experience pain during their treatment course, making it difficult to care for themselves and continue with their activities of daily living. When cancer is found at later stages, the pain can become severe and constant; reducing their quality of life and significantly affecting mental and physical well-being. Despite opioids being known to provide adequate analgesia for higher pain levels, they are often the reason for under-dosing because of their adverse effects and concern for addiction. There are also patients who do not respond well to opioids because of genetic anomalies or personal preference. Therefore, there is a need for novel non-opioid cancer pain treatments. There are many new cancer pain treatments that are emerging. This manuscript discusses cancer pain, risk factors, epidemiology, guidelines for the treatment of cancer pain, personalization of cancer pain therapy, breakthrough pain, cancer-induced peripheral neuropathy, established cancer pain treatment options, and novel emerging cancer pain treatment options.

Category: Midfoot/Forefoot Introduction/Purpose: Arthrodesis of the first metatarsophalangeal (MTP) joint is a well established procedure with excellent outcomes for patients with forefoot disorders including hallux rigidus and hallux valgus Routine bone grafting is not typically required, but bone graft may be necessary in the setting of revision surgery, non-union, or erosive bone loss to encourage biologic fusion and fill bone voids. Options for bone graft include either allograft or autograft. Typical locations for autograft harvesting would include calcaneus, distal tibia, or iliac crest. Due to potential harvesting morbidity and time associated with an extra incision, allograft bone is frequently utilized. In this study, we describe the outcomes of an approach to first MTP fusion with simultaneous medial sesamoidectomy with morselizing the bone for utilization as autograft. Methods: A retrospective review of all first MTP arthrodesis cases performed by one fellowship-trained foot and ankle surgeon were identified. Operative reports and radiographs were reviewed identifying patients that underwent simultaneous medial sesamoidectomy for autograft purposes. Routine bone graft was not typically used for primary first MTP fusion. In the setting of nonunion surgery, revisions, or bone loss, autograft bone was harvested as needed to facilitate fusion. Medial sesamoidectomy was performed via the same dorsal approach without use of an additional incision. The bone was morselized and used to fill voids within the first MTP as needed. Supplemental calcaneal autograft was harvested if the harvest was not adequate (i.e. substantial bone voids). Indications for sesamoidectomy harvesting were noted. The primary outcome reviewed was fusion rate. Overall nonunion rates and patient outcomes were collected and compared between those undergoing sesamoidectomy for grafting and those undergoing standard procedure arthrodesis. Results: During the study period, 74 patients underwent first MTP arthrodesis. Of these, 20 underwent concurrent sesamoidectomy grafting with 11 requiring additional calcaneal grafting. Of the 20, 16 had prior surgeries and 4 had extensive erosive arthritis requiring grafting. Indications for the sesamoidectomy group included 5 primary cases of erosive hallux rigidus, 2 cases of hallux valgus, 3 nonunions, 3 failed Cartiva implants, 2 cases of avascular necrosis, 3 failed arthroplasties, 1 conversion bunionectomy, and 1 conversion from Keller procedure (Table 1). All 20 patients went on to successful union. In the non- sesamoidectomy group the fusion rate was 92.6% (p=0.57). All patients in the sesamoidectomy group were satisfied with their surgical outcome, and no revisions were required. Conclusion: This study found highly successful fusion rates in a potentially higher risk population (i.e. bone loss and revision cases) with the use of local autografting from the medial sesamoid. The medial sesamoid serves as a cost-effective, freely-available, successful graft material for first MTP arthrodesis that can be done quickly via the same incision, reducing potential need for other painful donor sites and the cost associated with allograft. This technique can be particularly useful in the context of revision arthrodesis, failed implants with conversion to arthrodesis, and in arthrodesis with osteoporotic bone or cases with significant erosive arthritis.

: Peripheral nerve blocks (PNB) have become standard of care for enhanced recovery pathways after surgery. For brachial plexus delivery of anesthesia, both supraclavicular (SC) and infraclavicular (IC) approaches have been shown to require less supplemental anesthesia, are performed more rapidly, have quicker onset time, and have lower rates of complications than other approaches (axillary, interscalene, etc.). Ultrasound-guidance is commonly utilized to improve outcomes, limit the need for deep sedation or general anesthesia, and reduce procedural complications. Given the SC and IC approaches are the most common approaches for brachial plexus blocks, the differences between the two have been critically evaluated in the present manuscript. Various studies have demonstrated slight favorability towards the IC approach from the standpoint of complications and safety. Two prospective RCTs found a higher incidence of complications in the SC approach – particularly Horner syndrome. The IC method appears to support a greater block distribution as well. Overall, both SC and IC brachial plexus nerve block approaches are the most effective and safe approaches, particularly under ultrasound-guidance. Given the success of the supraclavicular and infraclavicular blocks, these techniques are an important skill set for the anesthesiologist for intraoperative anesthesia and postoperative analgesia.

Lateral epicondylitis (LE), also known as tennis elbow, is the most common cause of elbow pain in adults, with approximately 1-3% of the general population being afflicted. Although the condition is usually self-limiting, pain can be a major hindrance, limiting daily activity and the work capacity of patients. As a result, many treatment options have become available with the aim to shorten the duration of the disease and increase the quality of life. Steroid injections, NSAIDs, topical creams, platelet-rich plasma, physical therapy, and kinesiotaping are considered conservative treatments, while surgical options are last-resort treatments reserved for refractory LE. In this review, we will provide a brief summary of LE and focus on addressing conservative and minimally invasive interventional options for the treatment of LE. (C) 2020 Published by Elsevier Ltd.