Oculo-Auriculo-Vertebral Dysplasia With Craniocervical Instability and Occult Tethered Cord Syndrome. An Addition to the Spectrum? First Case Report and Review of the Literature Oculo-auriculo-vertebral spectrum (OAVS) is an uncommon congenital disorder of abnormal development of the first and second pharyngeal arches. This spectrum is characterized by craniofacial microsomia, epibulbar dermoids, ear abnormalities, renal and cardiac defects, and a wide range of vertebral segmentation and formation disorders. Frequently, the cervicothoracic spine is involved. Only recently, the morbidity attributed to the spinal abnormalities has gained attention. Strategy and timing of spine surgery has become increasingly important in patients with OAVS. Here, we report a case of OAVS with characteristic vertebral cervical and thoracic involvement and its sequelae requiring multiple spinal procedures, further complexed by an unprecedented occult tethered cord syndrome, which was successfully treated by surgical detethering. In this context, the recent literature on spinal anomalies is reviewed.

Preoperative Vitamin D Deficiency Is Associated With Higher Postoperative Complications in Arthroscopic Rotator Cuff Repair Introduction: Rotator cuff tears are one of the most common injuries worldwide, yet it is difficult to predict which patients will have poor outcomes after arthroscopic rotator cuff repair (RCR). The purpose of this study was to identify an association between preoperative vitamin D (25D) levels and postoperative complications in arthroscopic RCR. Methods: From a national claims database, patients undergoing arthroscopic RCR with preoperative 25D levels were reviewed. Patients were stratified into 25D-sufficient (≥20 ng/dL) or 25D-deficient (<20 ng/dL) categories and examined for development of postoperative complications. Multivariate logistic regression was performed using age, sex, and Charlson Comorbidity Index (CCI) as covariates. From this, risk-adjusted odds ratios (ORs) were calculated comparing complications between the two groups. Results: One thousand eight hundred eighty-one patients with measured preoperative 25D levels were identified; 229 patients were 25D deficient (12.2%). After adjusting for age, sex, and Charlson Comorbidity Index, 25D-deficient patients had increased odds of revision RCR (OR 1.54, 95% confidence interval 1.21 to 1.97, P < 0.001) and stiffness requiring manipulation under anesthesia (OR 1.16, 95% confidence interval 1.03 to 2.03, P = 0.035). Conclusions: Vitamin D deficiency is associated with a greater risk of postoperative surgical complications after arthroscopic RCR and may be a modifiable risk factor. Further investigation on preoperative vitamin D repletion is warranted.

The Evaluation of Single-Sided Total Knee Arthroplasty Versus Simultaneous Bilateral Total Knee Arthroplasty Improvements and Postoperative Progression Based on Patient-Based Outcome Scoring: A Rural Retrospective Clinical Orthopaedic Study Introduction: Both graduated single-sided total knee arthroplasty (SSTKA) and simultaneous bilateral total knee arthroplasty (SBTKA) are viable options for bilateral knee arthritis, and deciding which option to pursue is still debated. We aim to compare the two modalities using the patient-based oxford knee score and Visual analog pain scores in micropolitan settings. Methods: Oxford knee score and Visual analog pain scores were administered preoperatively and postoperatively 1, 6, and 12 months to 115 patients who underwent total knee arthroplasty. The 115 cohort was divided into two groups, those who underwent SSTKA and those who received SBTKA. Results: Cross-group analysis showed a significant difference with oxford scores at the 1-month postoperative interval (P = 0.026). The within-group analysis of the delta oxford knee scores displayed postoperative improvement at the 0.05 level of significance at 1, 6, and 12 months. Discussion: This study indicates that the patient-based outcome measures for the SBTKA group lagged behind the SSTKA group. The overall improvement a year out from surgery is comparable, and both groups had significant improvement in function. The SBTKA patient group had markedly lower functional outcome measures based on oxford scores at 1 month post-op compared with the SSTKA group; this may help in decision-making and patient selection.

Consumer Prices for Surgical Management of Ankle Arthritis: Limited Availability and Wide Variability Background: Healthcare costs for the surgical management of ankle arthritis continue to rise. Patients are generally unaware of the prices of the services they use. Understanding the costs associated with surgical management of ankle arthritis is an important facet of patient care. The purposes of this study were to (1) determine the access to the surgical cost of total ankle arthroplasty (TAAs) and ankle arthrodesis and (2) the variability of the price between the two procedures. Methods: Fifty foot and ankle centers (25 academic, 25 private) that perform TAAs and ankle arthrodeses were contacted using a standardized patient script. The described patient was a 63-year-old man who had failed conservative treatment of ankle arthritis. Each institution was contacted up to three times in an attempt to obtain a full-bundled surgical quote for a TAA and an ankle arthrodesis. Results: Twenty-one centers (42%, 14 academic, 7 private) were able to provide a quote for a TAA and an ankle arthrodesis. The mean bundled price for a TAA was $50,332 (SD ± $25,744), with the mean academic and private center quote being $56,529 and $37,937, respectively. The mean bundled price for an ankle arthrodesis was $41,756 (SD ± $26,033), with the mean academic and private center quote being $48,116 and $29,037, respectively. No statistically significant difference was found between the bundled prices for TAA and ankle arthrodesis. Discussion: This study demonstrated limited availability of consumer prices for TAA and ankle arthrodesis. When comparing different institutions for surgical management of ankle arthritis, there was a wide range of quotes for both TAA and ankle arthrodesis. When comparing the choice of surgical management for ankle arthritis, no statistically significant difference was observed in price between TAA and ankle arthrodesis.

Sustainable Orthopaedic Surgery Residency Training in East Africa: A 10-Year Experience in Kenya Low- and middle-income countries (LMICs) have continued to lag behind high-income countries in all measurable outcomes of health care. As concluded by the World Health Organization during the 2013 Global Forum on Human Resources for Health, an adequate healthcare workforce is mandatory to provide universal health coverage. Despite efforts to increase the numbers of healthcare workers, an extreme deficit in highly trained surgeons remains. Several options exist to provide training for surgeons in LMICs, including local training by local surgeons, sending local surgeons abroad for training, or local training by short-term or long-term visiting surgeons from high-income countries. This article further discusses the benefits and challenges of each option and reviews the 10-year outcomes of the Orthopaedic Surgery Residency Program at the CURE Kenya Hospital in Kijabe, Kenya. The program has graduated nine orthopaedic surgeons who are all practicing in Africa, five of which are full-time attending consultants in residency training programs. An additional eight residents are currently in the program. Sustainable orthopaedic training can be accomplished in LMICs as demonstrated by the ongoing success of the CURE Kenya Orthopaedic Surgery Residency Program. Additional efforts to expand and replicate this model may assist in providing improved access to high-quality universal healthcare in LMICs.

Acute Exertional Compartment Syndrome of Bilateral Upper Extremities After a Push-up Contest Acute exertional compartment syndrome (AECS) involving the upper extremity is a rare form of compartment syndrome that occurs after physical activity. Despite its infrequent occurrence, AECS has devastating sequelae, including muscle necrosis and nerve injury. It is imperative to promptly evaluate for AECS in any patient who has notable pain and sensory changes in the context of recent physical activity because of the dire consequences of a missed diagnosis. A 34-year-old man presented to the emergency department with excruciating pain and diffuse paresthesias in his bilateral arms and forearms after participating in a push-up contest. He also had pain with passive stretch of his triceps. Because of these physical examination findings and uncontrollable pain, a clinical diagnosis of AECS was made and was managed with fasciotomies. Postoperatively, the patient's pain and paresthesias slowly resolved, and he was eventually able to return to work at full capacity as a construction worker. This example of AECS of bilateral upper extremities emphasizes that it is a condition that, although rare, is real and must be taken seriously. With appropriate clinical suspicion, a prompt diagnosis can be made, and potentially devastating consequences can be avoided.

Case Report

Sliding Hip Screw for Fixation of Fracture Through a Previously Arthrodesed Hip
Kenneth J. Nelson, Matthew D. Laughlin, Cristóbal S. Berry-Cabán

Self-mutilation of the Fifth Finger in an Infant due to Iatrogenic Ulnar Nerve Neurapraxia: A Clinical Case Report and Review of the Literature
Menahem Singer, Louis Schorr

Late Repair, One Year After a Knee Twisting Injury, of a Missed Femoral Trochlea Osteochondral Fragment, With Bioabsorbable Nails, in a 14-Year-Old Boy
Panos Megremis, Orestis Megremis, Rodanthi Margariti

Paradoxical Embolization of the Bilateral Subclavian Arteries After High Tibial Osteotomy
Takahito Miyake, Osamu Obayashi, Akio Kanda, Hideshi Okada, Shinji Ogura, Kazuo Kaneko

Youth Kicker's Knee: Lateral Distal Femoral Hemiphyseal Arrest Secondary to Chronic Repetitive Microtrauma
Michael Dempewolf, Kevin Kwan, Benjamin Sherman, John A. Schlechter