Advanced practice registered nurses and physician assistants, collectively termed advanced practice providers (APPs), have been part of telehealth for many years. During the COVID-19 pandemic, APPs experienced the growth in roles, responsibilities, and tools used for telehealth care delivery. This article uses examples from 3 health systems to highlight the ways in which telehealth use was expanded due to the pandemic, how APP roles were altered across the United States during and after the pandemic, and implications for future practice.

The COVID-19 pandemic exacerbated staffing challenges in intensive care units, with increased burnout and moral distress cited as major problems. A healthy work environment is critical to nurses' success and wellbeing. During the pandemic, a survey by the American Association of Critical-Care Nurses revealed decreased composite scores in each of the 6 critical elements of a healthy work environment. Hospital units that improved even 1 critical element reported higher job satisfaction. The use of telehealth tools by expert nurses expanded care delivery during the pandemic by improving response to acutely and critically ill patients while supporting hospital-based nurses. All of the critical elements of a healthy work environment are relevant to the tele-critical care nurse's role and challenges. This article describes how tele-critical care nurses were affected by the pandemic and how healthy work environment strategies promoted successful nurse and patient outcomes.

Mallet hallux injuries are relatively rare, and management can range from conservative treatment to surgical fixation. Only a few cases of surgically treated are reported, and there is no consensus on the superiority of one technique to others in surgical treatment. We reviewed various options for surgical fixation of Mallet hallux injury and presented a case of mallet hallux injury treated with Kirschner wires with an extension blocking technique.Level of Evidence: V.

There is still a lack of information on the role of Tranexamic acid (TXA) in total ankle arthroplasty (TAA). The purpose of this study is to comprehensively review, consolidate, and analyze findings from existing research on the effectiveness and safety of TXA in TAA. The comprehensive literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) using PubMed, Embase, Web of Science, and Cochrane databases, for original, English-language studies investigating the efficacy and safety of TXA in TAA, through February 2023. Evaluated data for the meta-analysis included estimated blood loss (EBL), change in perioperative hemoglobin, need for transfusion, and complications including DVT/PE, and wound complications. A total of nine studies were included in this study. In total, 450 TAA were included, with 244 receiving TXA (54.2%) and 206 not receiving TXA (45.8%). TXA in TAA significantly decreased EBL. A significantly lower rate of wound complications in the TXA group with the relative risk (RR) of 0.51. We classified wound complications into wound infection and delayed wound healing/dehiscence. A significant decrease in the rate of wound infection and a tendency showing a decrease in the rate of delayed wound healing/dehiscence in the TXA group were noted: the RR of 0.29, and 0.63, respectively. TXA did not increase the incidence of DVT/PE following TAA. In conclusion, the utilization of TXA during TAA demonstrated a statistically significant reduction in EBL and relative risk for wound complications. However, further RCTs with larger sample sizes will be necessary to establish a more robust conclusion regarding the efficacy and safety of TXA in TAA. Level III, systematic review and meta-analysis.

BackgroundFishing is a popular recreational activity that stresses the shoulder. With the expanding prevalence of reverse total shoulder arthroplasty (rTSA), it is important to better understand return to fishing. MethodsA retrospective chart review from the electronic medical record was performed on patients undergoing primary rTSA by the designated surgeon with a minimum 6 month follow up. Demographic and surgical variables included age, sex, side of surgery and need for revision.Return to fishing metrics included casting distance and reason to not return to sport. Satisfaction and pain scores were also recorded. ResultsNineteen patients self-identified as participating in fishing before undergoing rTSA. Fifteen patients (79 %) were male and mean age was 68.47 years ( ± 9.95 years). 15 participants (79 %) indicated that they were able to return to fishing after their rTSA with a mean age of 67.07 years ( ± 10.64 years). Of those who returned to sport, 14 participants (93 %) indicated that their pain was better than it was before rTSA. Average VAS pain score of the return to sport group was 1.67 ( ± 2.79, range 0–7). Postoperative casting distance was the same in 10 patients (67 %). The most common reason for not returning to fishing was issues with pain and function. ConclusionrTSA could allow for return to fishing with similar functional status. Switching casting technique and grip may help improve return to sport. Implant considerations may improve stability and ROM which may help further augment return to fishing.

Rural patients have unique health-care factors influencing outcomes of arthroplasty, hypothetically putting these patients at increased risk for complications following total joint arthroplasty. The aim of this study is to better understand differences in patient outcomes and satisfaction between rural and urban patients receiving care in an urban setting and to provide more equitable care. A retrospective chart review was performed on patients undergoing primary total hip arthroplasty at a single large academic center between January 2013 and August 2020. Demographic, operative, and hospital outcomes were obtained from the institutional electronic medical record. Rurality was determined by rural-urban code (RUC) classifications by zip code with RUC codes 1-3 defined as urban and RUC 4-10 defined as rural. Patients from urban areas were more likely to visit the emergency department within 30 days postoperatively (P= .006) and be readmitted within 90 days (P < .001). However, unplanned (P < .001) admissions were higher in the rural group. There was no statistical difference in postoperative complications (P= .4). At 6 months, rural patients had higher patient-reported outcome measures (PROMs) including Hip Disability and Osteoarthritis Outcome Score total (P= .05), Hip Disability and Osteoarthritis Outcome Score interval (P= .05), self-reported functional improvement (P < .05), improvements in pain (P < .05), and that the surgery met expectations (P < .05). However, these values did not reach minimal clinically important difference. There may be differences in emergency department visits, readmissions, and PROMs in rural vs urban populations undergoing total hip arthroplasty in an urban setting. Patient access to care and attitudes of rural patients toward health care may underlie these findings. Understanding differences in PROMs, satisfaction, and hospital-based outcomes based on rurality is essential to provide equitable arthroplasty care.

Diagnosis and management of neuropathic pain (NP) in foot and ankle patients remain challenging. We investigated the plausibility of using Patient-Reported Outcomes Measurement Information System (PROMIS) Neuropathic Pain Quality (PQ-Neuro) as an initial screening tool to detect NP and track the treatment effects. Patients with heel pain were prospectively recruited and grouped to no-NP, mild-NP, and severe-NP based on the initial PROMIS PQ-Neuro t scores. Pain Interference (PI), Physical Function (PF), and Self-Efficacy (SE) scores were evaluated at baseline, 30-day, and 90-day follow-up. Other factors such as age, smoking, body mass index (BMI), low back/neck pain, anxiety/depression, and medications were analyzed. Linear mixed modeling was used to assess the main effects of time and NP on PROMIS t scores, comparing minimal clinically important difference (MCID). Forty-eight patients with mean age of 52.4 years were recruited. Using the PROMIS PQ-Neuro as the assessment tool, 33 patients (69%) were detected to have NP at baseline-23 (48%) mild and 10 (21%) severe. BMI was the only independent factor associated with NP (P = .011). Higher baseline PQ-Neuro t score was significantly associated with higher follow-up PQ-Neuro (P < .001), PI (P = .005), and lower SE (P = .04) across time points. Patients with NP showed lower PF at baseline with significantly less improvement in PF (3 vs 9.9, P = .035) and did not meet MCID. Baseline PROMIS PQ-Neuro ≥46 was significantly associated with worse PI and SE across all time points, with less clinically significant improvements in PF. Prevalence of NP in heel pain patients was high. The PROMIS PQ-Neuro may serve as a valuable tool for detection of NP and guiding clinical treatment decision pathways for heel pain patients. Level III, prospective cohort study.

Background: Although its pathophysiology is not clear, the presence of a plantar heel spur has been considered a cause of heel pain in plantar fasciitis. This study investigated demographic and radiographic differences between a plantar fasciitis patient group with plantar heel spur and the age/sex-matched control group with plantar heel spur. Methods: Patients who visited the office under the diagnosis of plantar fasciitis and had a plantar heel spur were compared to an age/sex-matched control group who visited the office with other foot and ankle issues except for heel pain. All patients in both the control and case groups had radiographically proven presence of a plantar heel spur. Demographics and radiographic findings between the 2 groups were compared, and a multivariable logistic regression analysis was performed to identify independent risk factors that are associated with plantar fasciitis symptoms. Results: A total of 100 patients were included in the plantar fasciitis study group (PF+S) and age/sex-matched control group (C+S). BMI was higher in the study group than in the control group: 35.2 vs 30.9 ( P = .002). The size of the plantar heel spur was larger in the study group than in the control group: 5.9 vs 4.6 mm ( P = .017). A multivariable regression analysis identified that obesity (BMI &gt; 30, odds ratio [OR] = 2.675) and the size of plantar heel spur &gt;5.3 mm (OR = 2.642) were associated with PF+S. Conclusion: We found an association of both obesity and increased average plantar heel spur length on lateral radiographs in patients with painful plantar fasciitis compared to patients without plantar fasciitis but with plantar heel spurs. The presence of a plantar heel spur alone did not account for the symptoms of plantar fasciitis. Level of Evidence: Level III, comparative case study.

Conversion of patellofemoral arthroplasty to total knee arthroplasty (TKA) has been described as similar to primary TKA, although it may come with more challenges and worse outcomes. With the increased rate of revision following conversion TKA vs primary TKA, robotically assisted TKA provides an alternative technique to manual conversion. We present 3 cases of robot-assisted conversion of prior patellofemoral arthroplasty to TKA with good mechanical and clinical outcomes and no intraoperative complications.

Foreign body ingestion in the paediatric population, especially when the details surrounding the ingestion are unknown, can be particularly difficult to manage. Magnets pose a unique challenge, as their magnetic field and caustic properties can instigate significant damage to the gastrointestinal tract if not treated in a timely manner. We report the case of a teenage male who presented to the emergency department with a chief complaint of cramping and abdominal pain. He was found to have multiple metallic foreign bodies within the lumen of the stomach, the distal ileum and the ascending colon/ileocecal valve region, which he did not have any recollection of ingesting. The management of an unknown multiple-magnet ingestion in the older paediatric population is not well documented, and this case may provide unique insight for the management of similar cases.