Faculty Bibliography

Background/Purpose: Compartment syndrome is a well-known surgical emergency within the scope of Podiatry. However, cases can be atraumatic and present without the traditional findings of pain, pallor, paresthesia, pulselessness, paralysis, and poikilothermia. Thus, posing a diagnostic dilemma for clinicians, leading to delayed surgical intervention and poor outcomes. We report a rare case of acute exertional compartment syndrome and include a discussion on current literature to increase awareness of atypical presentations of compartment syndrome. Methods/Results: A 27-year-old healthy female with no significant past medical history was treated for intractable right foot pain following an extended period of marching. Physical examination was remarkable for non-palpable pedal pulses, pain out of proportion, extensive soft tissue edema, and a warm-to-cold temperature gradient of the extremity. The diagnosis of compartment syndrome was confirmed via catheter evaluation of compartmental pressures. Emergent fasciotomy of the right foot was performed, and delayed primary closure was performed six days later. After discharge from the hospital, the patient was inconsistent in follow up visits. Later repeat imaging of the right foot revealed stress fractures and nondisplaced fractures throughout the tarsometatarsal region. At her most recent visit, the patient complained of persistent paresthesias, skin discoloration, and pain to the right foot for which she is receiving symptomatic management for.
Conclusion(s): Diagnosis in this patient was likely delayed due to strict adherence to a post-traumatic model of compartment syndrome. Broadening awareness to the variable presentations of compartment syndrome is an important step to improve patient outcomes.
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»:The United States has faced substantial increases in health-care expenditure, with specifically large increases in spine surgery costs. »:Many different formulas are utilized to determine value in spine surgery, including cost- benefit analyses, cost-effectiveness analyses, and cost-utility analyses, with the overall determination of value being quality/cost. »:Quality often is calculated indirectly using either process measures or outcome measures and represents the potential benefit of a given intervention, usually over a specific time period to yield quality-adjusted life years. »:Costs are particularly difficult to calculate given the interhospital, regional, national, and global variability, as well as indirect costs of an intervention, and many different methods are utilized to estimate costs. »:Spine surgeons should be familiar with the elements that compose cost-effectiveness and their potential shortcomings in order for providers and health-care policy makers to identify the highest-quality studies and interventions that provide the greatest benefit to patients.

The World Health Organization describes traumatic injuries as a "neglected epidemic" in developing countries, accounting for more deaths annually than HIV/AIDS, malaria, and tuberculosis combined. Low- and middle-income countries rely on volunteer assistance to address the growing surgical disease burden of traumatic injuries. Efforts to increase the availability of international electives for orthopaedic trainees can help with the short-term need for surgical personnel abroad and facilitate sustainability through capacity building, maximizing long-term benefits for all parties. The volunteer invariably benefits from this cross-cultural experience with many citing improved skills in communication, clinical diagnostics, appreciation of equality and diversity, and cost-consciousness. A consolidated discussion regarding barriers and implementation strategies can assist interested individuals and institutions plan for future volunteering endeavors.

STUDY DESIGN:This is a retrospective case review. OBJECTIVE:The objective of this study was to present an anatomic approach to transpsoas interbody fusion without psoas stimulated electromyography (sEMG) and to evaluate the rate of neurological and approach-related complications. BACKGROUND:The transpsoas approaches have become commonly utilized for lumbar interbody fusion and may have certain advantages compared with other methods of interbody stabilization. Traditionally, transpsoas approaches have been performed utilizing sEMG as it has been purported to reduce the risk of injury to the lumbar plexus; however, an anatomic approach to transpsoas surgery is also possible as cadaveric studies have demonstrated the anatomy of the psoas muscle and lumbar plexus. METHODS:Patients who underwent transpsoas interbody fusion using an anatomic approach without psoas sEMG between 2005 and 2018 were enrolled in this study. The preoperative and postoperative medical records for this cohort were carefully reviewed to identify any new or persistent radicular symptoms, neurological deficits or approach-related complications. RESULTS:A total of 133 patients (48 males, 85 females) underwent transpsoas interbody fusion at 222 levels in this cohort-which had a mean age of 63 (61, 65) years and body mass index of 28.8 (27.8, 29.9). New neurological complications were seen in 5 patients (3.8%) and 5 patients (3.8%) were found to have new postoperative radicular pain, up to 3 months postoperatively. The total number of perioperative, approach-related complications was 7 (5.3%) for the entire cohort. CONCLUSION:An anatomic transpsoas approach to the interbody space without psoas sEMG demonstrated a rate of neurological and approach-related complications that was comparable or superior to the rate of complications reported using the traditional transpsoas approach with sEMG.