Ramirez, Cesar A.

Background: Chronic exertional compartment syndrome (CECS) is an often-overlooked cause of exertional lower leg pain that is frequently misdiagnosed. Overlapping symptoms and inconsistent diagnostic approaches may delay diagnosis and prolong morbidity. The purpose of this study was to characterize the diagnostic journey of patients ultimately treated surgically for CECS and to report postoperative outcomes. Methods: A retrospective chart review was performed following IRB approval. Patients diagnosed with CECS and treated operatively by the senior author between 2020 and 2025 were identified using Current Procedural Terminology ( CPT ), International Classification of Diseases, Ninth and Tenth Revision ( ICD-9 and ICD-10 ) codes. Demographics, symptom duration, prior diagnostic workup, operative details, and postoperative outcomes were collected. Median follow-up was 42 weeks (range, 15-184 weeks). Descriptive statistics were reported. Results: Thirteen patients met inclusion criteria (mean age, 27.3 years; mean BMI, 28.3). Mean symptom duration prior to definitive diagnosis was 51.5 months, and bilateral symptoms were present in 12 patients. Most patients underwent extensive diagnostic testing and multiple unsuccessful conservative treatment strategies before referral. All patients underwent endoscopic-assisted anterolateral compartment release, with open posterior compartment fasciotomy performed when clinically indicated. Nine patients underwent bilateral procedures. At final follow-up, all patients reported symptomatic improvement and return to baseline activity. Four patients required additional evaluation for persistent posterior compartment symptoms, and 2 ultimately underwent further posterior compartment release. There were no intraoperative complications. Conclusion: CECS remains a frequently delayed diagnosis because of nonspecific symptoms, substantial overlap with other causes of exertional lower-leg pain, and limitations of currently available diagnostic tools. Although the effect of diagnostic delay on postoperative outcomes could not be directly assessed, prolonged delays were associated with substantial diagnostic burden and management complexity. Following fasciotomy, all patients reported symptomatic improvement and return to baseline activity. Greater awareness of CECS and a structured diagnostic approach may help facilitate earlier recognition and treatment. Level of Evidence: Level IV, retrospective case series.

Background: Midfoot arthritis can cause debilitating dorsal midfoot pain and functional limitation. Deep peroneal nerve (DPN) neurectomy is a minimally invasive surgical option that addresses pain through selective denervation. Although favorable midterm outcomes have been reported, long-term durability remains unclear. The purpose of this study was to evaluate changes in patient-reported physical function and pain interference between midterm and long-term follow-up after DPN neurectomy using validated Patient-Reported Outcomes Measurement Information System (PROMIS) instruments. Methods: A retrospective review identified patients who underwent isolated DPN neurectomy for midfoot arthritis between 2017 and 2021 and completed PROMIS Physical Function (PF) and Pain Interference (PI) questionnaires at midterm and long-term follow-up. Mean follow-up was 2.9 years (midterm) and 6.1 years (long-term). PROMIS scores were compared using paired t tests. Clinically meaningful improvement was defined using established minimal clinically important difference (MCID) thresholds (+5.88 for PF, −5.49 for PI). Results: The final cohort included 32 patients (81.2% female, mean age 68.4 ± 7.3 year). PF improved from 37.7 ± 6.2 to 39.0 ± 7.5 (Δ = +1.3, 95% CI [−0.7 to +3.4], P = .188), whereas PI decreased from 62.6 ± 8.8 to 59.2 ± 9.0 (Δ = −3.4, 95% CI [−6.3 to −0.5], P = .020). Clinically meaningful improvement was achieved by 7 of 32 (21.9%) for PF and 15 of 32 (46.9%) for PI. Five patients experienced clinically meaningful worsening, including patients with stroke, chronic pain syndrome, or contralateral foot and ankle pathology or surgery. Conclusion: DPN neurectomy was associated with stable longitudinal PROMIS outcomes through extended follow-up, with a nonsignificant mean PF change of +1.3 points and a statistically significant but sub-MCID mean PI decrease of −3.4 points over approximately 6 years. Outcomes were heterogeneous; fewer than half of patients achieved clinically meaningful improvement in pain interference, and a subset experienced worsening. These findings suggest that DPN neurectomy may provide durable symptom stability in appropriately selected patients with refractory dorsal midfoot pain, although clinically meaningful benefit at the individual level is not universal. Level of Evidence: Level III, comparative series.

Abstract Reactive arthritis is an immune-mediated arthropathy caused by a preceding remote infection. Typically, reactive arthritis affects the joints of the lower extremities but can occur in the upper extremity. There are a few case reports of reactive arthritis primarily involving the joints of the hand and wrist, necessitating surgical intervention. We describe the case of a 37-year-old, right-hand dominant female who presented with severe left wrist pain. After obtaining radiographs, she was diagnosed with severe erosive changes in the radiolunate joint and distal radioulnar joint (DRUJ) and secondary reactive gonococcal arthritis of the DRUJ. The patient failed conservative measures and ultimately underwent radioscapholunate (RSL) arthrodesis, distal ulna resection, and wrist denervation. Postoperatively, she had resolution of her pain and an excellent functional outcome. Refractory reactive arthritis of the DRUJ can cause concomitant adjacent joint erosive changes. Performing RSL arthrodesis and distal ulna resection can provide an excellent functional outcome and still allow motion to be preserved through the midcarpal joint. IV: Case report level IV or higher evidence.

Intramedullary screw fixation (ISF) of metacarpal fractures is a well-established technique. Prior techniques either involve placement of the intramedullary screw in a retrograde fashion or placement of the guidewire in a retrograde fashion before placing the screw in an antegrade fashion. While effective, previously described techniques have risks of extensor tendon irritation, articular cartilage disruption, and limited access to multiple metacarpals from a single incision. We present a novel antegrade intramedullary screw placement and antegrade guidewire technique for ISF that avoids disruption of the metacarpal head and allows for access to multiple metacarpals through a single incision. Cadaveric evaluation confirmed consistent sparing of the distal carpal row and demonstrated the feasibility of this technique across the index through small finger metacarpals. Compared with previously described methods, this technique offers improved soft tissue preservation, reduced risk of tendon scarring, and enhanced surgical efficiency. Level of Evidence: Level IV—case report; cadaveric study.

ABSTRACT Fixation constructs used in orthopedic surgery are typically evaluated based on their initial mechanical strength. However, fixation failure often occurs under cyclic loading in dynamic environments where early motion and stress concentration are common. In the foot and ankle, nitonal staples and short locking plates have been developed to maximize construct stiffness and accommodate the limited bony surface area available for fixation. The implants have grown in popularity, but unlike other AO constructs, they have not been rigorously studied across multiple mechanical performance domains. Prior studies have not comprehensively compared dynamic nitinol constructs to static plates and screws across key mechanical performance metrics under fatigue conditions. Six fixation constructs (2‐leg staple, 4‐leg staple, 4‐leg + 2‐leg perpendicular staple, 4‐hole titanium plate, 5‐hole titanium plate with cross‐screw, and 4‐leg staple + dynamic disc + cross‐screw) were evaluated using standardized synthetic bone block models ( n = 5/group). Constructs were subjected to 100 cycles of loading. Pre‐ and post‐cycle values for compression ( N ), contact area (mm²), rigidity ( N ), and torque ( N ·cm) were measured. Paired t‐tests assessed intra‐construct degradation as well as post‐cycle inter‐construct differences. Additionally, ANOVA with Tukey HSD identified inter‐construct differences in degradation. Cohen's d quantified effect sizes. The 4‐leg + 2‐leg perpendicular construct had the highest post‐cycle compression (68.0 N) and contact area (447.2 mm²), with small to moderate degradation (d = –1.38; −0.99); the 4‐hole plate showed the greatest degradation ( p = 0.001, d = −3.48; p < 0.001, d = −4.45). Torque and rigidity degraded most in the 5‐hole plate (Δ = −94.4 N·cm, p = 0.0002, d = −6.21; Δ = −237.4 N, p = 0.015, d = −1.83), while dynamic constructs showed better retention. Dynamic nitinol constructs outperformed static plates and screws across all metrics, especially in preserving compression and contact while also resisting fatigue. Dual‐plane constructs—4‐Leg + 2‐Leg perpendicular and 5‐Hole Plate with Screw—demonstrated 2–3× higher initial rigidity than their single‐plane counterparts and showed superior fatigue resistance. Dynamic nitinol constructs demonstrated superior biomechanical durability compared to static plate‐and‐screw constructs, particularly when used in dual‐plane configurations. These findings support a shift in fixation strategy toward implants that maintain mechanical engagement under physiologic loading. In load‐bearing regions like the foot, fixation constructs must retain strength through repetitive stress. Dual‐plane dynamic nitinol implants provide continuous compression and greater fatigue resistance, making them a compelling alternative to static fixation. Future clinical studies should evaluate their impact on outcomes and hardware failure in early weightbearing protocols.