Ankle Procedures Research Articles

Tarsal Coalition Resection in Children: Is it Effective?

Tarsal coalitions in children are a group of disorders that typically present as a rigid flatfoot deformity. Operative treatment generally consists of resecting the coalition alone or resection plus flatfoot reconstructive procedures. The purpose of this study was to evaluate the rate and risk factors for complications, including infection, recurrence, and reoperation, following the surgical management of tarsal coalitions in children. This is a retrospective cohort study on the surgical outcomes of pediatric tarsal coalitions alone or in combination with adjunctive procedures. This study was conducted between 01/01/2008 and 12/31/2019 and utilized electronic health records and chart review was performed to describe patient demographic, clinical, perioperative characteristics, and whether patients have subsequent foot and ankle procedures after the index resection surgery. The study cohort included 165 feet belonging to 144 patients. The age range at time of surgery was 12 years of age (11-14). Of the 165 feet, 18 (10.9%) experienced a postoperative complication, including six infections of which two required reoperation, six recurrences all requiring reoperation, and six reoperations not due to recurrence. Patients with a postoperative complication demonstrated increased age (13.9 years vs 12.4 years, p=0.007), obesity (33.3% vs 13.6%, p=0.026), and/ or preoperative hindfoot valgus deformity (33.3% vs 7.5%, p=0.004). The overall postoperative complication rate was 10.9%. Results of this study provided important information for providers as they discuss different treatment approaches and anticipated outcomes with patients and their families.

UK Foot and Ankle Thromboembolism (UK-FATE).

Venous thromboembolism (VTE) is a potential complication of foot and ankle surgery. There is a lack of agreement on contributing risk factors and chemical prophylaxis requirements. The primary outcome of this study was to analyze the 90-day incidence of symptomatic VTE and VTE-related mortality in patients undergoing foot and ankle surgery and Achilles tendon (TA) rupture. Secondary aims were to assess the variation in the provision of chemical prophylaxis and risk factors for VTE. This was a multicentre, prospective national collaborative audit with data collection over nine months for all patients undergoing foot and ankle surgery in an operating theatre or TA rupture treatment, within participating UK hospitals. The association between VTE and thromboprophylaxis was assessed with a univariable logistic regression model. A multivariable logistic regression model was used to identify key predictors for the risk of VTE. A total of 13,569 patients were included from 68 sites. Overall, 11,363 patients were available for analysis: 44.79% were elective (n = 5,090), 42.16% were trauma excluding TA ruptures (n = 4,791), 3.50% were acute diabetic procedures (n = 398), 2.44% were TA ruptures undergoing surgery (n = 277), and 7.10% were TA ruptures treated nonoperatively (n = 807). In total, 11 chemical anticoagulants were recorded, with the most common agent being low-molecular-weight heparin (n = 6,303; 56.79%). A total of 32.71% received no chemical prophylaxis. There were 99 cases of VTE (incidence 0.87% (95% CI 0.71 to 1.06)). VTE-related mortality was 0.03% (95% CI 0.005 to 0.080). Univariable analysis showed that increased age and American Society of Anesthesiologists (ASA) grade had higher odds of VTE, as did having previous cancer, stroke, or history of VTE. On multivariable analysis, the strongest predictors for VTE were the type of foot and ankle procedure and ASA grade. The 90-day incidence of symptomatic VTE and mortality related to VTE is low in foot and ankle surgery and TA management. There was notable variability in the chemical prophylaxis used. The significant risk factors associated with 90-day symptomatic VTE were TA rupture and high ASA grade.

Venous Thromboembolism in Outpatient Elective Foot and Ankle Procedure Patients Who Is at Risk?

Venous thromboembolism (VTE) is a rare but potentially serious complication following elective foot and ankle (F&A) procedures. The absence of guidelines for thromboprophylaxis in elective procedures underscores the importance of identifying patients at risk. This study aimed to identify key risk factors of VTE in patients who underwent elective foot and ankle (F&A) operations. Data was collected from the IBM MarketScan Database (2009-2019) for patients >18 years old without prior VTE who underwent elective F&A procedures. Patients were divided into 3 groups based on region of operation (forefoot, mid/hindfoot, lower leg/ankle). VTE incidence (including deep vein thrombosis and/or pulmonary embolism) was recorded 30 and 90 days postprocedure. Risk factors for VTE were identified through multivariate logistic regression. Among the 301 256 patients who underwent elective F&A procedures, the overall 90-day incidence of VTE was 0.95%. The findings revealed that 31.9% of VTE incidents occurred within the first 2 weeks after operation, and 29.2% still occurred after 6 weeks. Analysis of the anatomical region of operation demonstrated that the lowest rate of 90-day VTE was amongst patients undergoing forefoot procedures (0.70%). There was a higher risk for VTE in patients undergoing midfoot/hindfoot procedures (1.22%, OR = 1.81) and lower leg/ankle procedures (1.76%, OR = 2.31). Additional risk factors for VTE included thrombophilia (4.02%, OR = 3.37), male sex (1.30%, OR = 1.47), increasing age (1.02% age 65+, OR = 1.41), and a high Charlson Comorbidity Index (1.12%, OR < 0.82 for scores <5). This study identifies the incidence and timing for VTE after elective F&A procedures. Furthermore, this study defines the risk factors associated with increased odds of VTE after elective F&A procedures. These findings are helpful in educating patients about a continued risk for VTE throughout the 90-day postoperative period and beyond. These results can also be utilized to stratify patients who need thromboprophylaxis based on the individual risk level. Level III: Retrospective cohort study.

Opioid Prescribing Trends Among Workers' Compensation Patients Undergoing Foot and Ankle Surgery.

The purpose of this study was to evaluate opioid usage and prescribing trends among workers' compensation (WC) patients who underwent foot or ankle operative procedures compared with a control group. A retrospective review was conducted for WC and non-WC patients who underwent foot or ankle procedures in a single academic orthopaedic surgery practice. Outcome measures were total morphine milligram equivalents (MME) and number of opioid prescriptions. A total of 118 patients were identified, including 51 patients in the WC group and 67 in the non-WC group. After index surgery, 67% (34 of 51) of WC patients had 2 or more additional opioid prescriptions compared to 39% (26 of 67) of non-WC patients (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.4-6.7; P = .003). Collectively, there were greater prescriptions of oxycodone MME (P = .002) and hydrocodone MME (P = .07) in the WC cohort. Workers' compensation patients seem to be prescribed and consume opioids at a higher rate postoperatively. It is important for treating physicians to be aware of these trends, and discussions with patients regarding expected opioid use when planning surgical intervention may be beneficial. Physicians may need to set expectations preoperatively and suggest there are limits on the amount of opioids that can safely be prescribed. Level III, Retrospective cohort study, Prognostic.

Weight changes following Achilles debridement with flexor hallucis longus transfer: A retrospective analysis

Obesity poses a growing concern, with global predictions estimating over half the population to be overweight or obese by 2030 (1). While prior research has extensively explored the impact of obesity on hip and knee surgeries, a notable gap persists in understanding weight changes following foot and ankle procedures. This retrospective study focuses on the relationship between Body Mass Index (BMI) and Achilles debridement with flexor hallucis longus (FHL) transfer. Despite prevailing research on the adverse effects of obesity on orthopedic outcomes, few studies examine the reciprocal influence of surgeries on weight. A retrospective analysis of 136 patients undergoing primary Achilles debridement with FHL transfer was conducted. Data encompassing BMI, demographic information, and medical comorbidities were extracted from electronic medical records (EMRs). A clinically meaningful BMI change was considered as a 5 % variation. Inferential statistics in the form of analysis of variance, t-test, and linear regression were employed for data analysis. Among the 136 patients in the study, no statistically significant BMI changes were noted up to two years after surgery (p = 0.9967). While obesity remains a significant factor in foot and ankle surgery complications, our study suggests that Achilles debridement with FHL transfer does not induce significant weight changes. Further research exploring factors influencing weight changes and varying outcomes across demographics is warranted. Level of evidenceIII.

Oblique Dorsiflexion Osteotomy of the Distal Tibia for Fixed Ankle Equinus: Surgical Technique.

There are significant challenges in the treatment of a severe rigid ankle equinus caused by a flat-topped talus, arthrogryposis, burn sequelae, or extensive scarring. Conventional approaches, such as soft tissue releases, often fail due to joint incongruence or compromised soft tissues, thereby necessitating supramalleolar osteotomies. The classic transverse supramalleolar osteotomy (TSO) of the distal tibia can lead to secondary anterior translation of the centre of rotation of the ankle and alters mechanical and anatomical axes. An alternative technique involves an oblique closing wedge osteotomy of the distal tibia, with a fulcrum near the ankle joint. This technical note delineates the planning parameters and procedural steps for the oblique dorsiflexion osteotomy of the distal tibia (ODODT). Using an anterior approach to the distal tibia, the "alpha angle," which determines the size of the closing wedge required for the foot to be plantigrade, is resected with a fulcrum at the most posterior part of the ankle joint, ensuring that the posterior cortex remains intact. The inclination of this resected wedge is planned preoperatively and is referred to as the "beta angle." This aims to equalise the lengths on both sides of the osteotomy. For osteotomy fixation, 2 or 3 cannulated screws in lag mode are employed. Postoperatively, a short cast boot is used for 6 weeks. The ODODT is a salvage solution for severe rigid ankle equinus when first-line foot and ankle procedures are impractical due to tibiotalar incongruence or poor soft tissues. Advantages include minimal translation of the centre of rotation of the ankle, excellent stability when the posterior cortex remains intact, avoidance of large internal fixation devices, and cost-effectiveness, making it suitable for low-resource settings. Olleac R, Farfan F, Acosta L, et al. Oblique Dorsiflexion Osteotomy of the Distal Tibia for Fixed Ankle Equinus: Surgical Technique. Strategies Trauma Limb Reconstr 2024;19(2):104-110.

Efficiency of Foot and Ankle Surgeries Completed on the Preoperative Stretcher vs Operating Room Table: A Randomized Controlled Trial.

Extremity surgeons frequently operate on the preoperative stretcher rather than the operating room (OR) table. This study sought to identify differences between stretcher-based (SB) and OR table-based (TB) procedures with regard to time efficiency and OR team member preferences. We conducted a prospective randomized controlled trial comparing the efficiency of SB vs OR TB foot and ankle procedures. Fifty-two patients undergoing a hardware removal, isolated gastrocnemius recession, soft tissue procedure, or foreign body removal at our day surgery unit were included. Start time and exit time were recorded. "Start time" was the number of minutes between the patient entering the OR and first incision. "Exit time" was the number of minutes between the procedure ending and the patient exiting the OR. Surveys were disseminated to OR staff who participated in the included cases. The total measured time in the OR was an average 6 minutes shorter in the Stretcher group compared to the OR Table group (10 minutes vs 16 minutes, P < .001). SB procedures were associated with a significantly shorter start time (median difference = 4 minutes, P = .001), but not exit time (median difference = 1 minute, P = .058). No difference was found in actual surgical time. Thirty (96.8%) OR team members perceived SB procedures as enhancing OR efficiency, and 30 (96.8%) respondents considered SB procedures to be equal or superior to OR TB procedures in terms of patient safety. All would recommend or strongly recommend SB procedures. We found SB foot and ankle procedures to require less room time than OR TB procedures. Particularly for high-volume specialties, an average 6 minutes saved per case may meaningfully improve overall OR efficiency. Most OR team members believed that SB surgery improves OR efficiency and is the safer option for OR team members. Level II, randomized controlled trial, survey.

THE INCIDENCE OF VTE IN FOOT AND ANKLE SURGERY IN THE UK: UK FOOT AND ANKLE THROMBO-EMBOLISM AUDIT (UK-FATE)

IntroductionVTE is a possible complication of foot and ankle surgery, however there is an absence of agreement on contributing risk factors in the development of VTE. The primary outcome of this study was to analyse the 90-day incidence of symptomatic VTE following foot and ankle surgery and to determine which factors may increase the risk of VTE.MethodsThis was a national, multi-centre prospective audit spanning a collection duration of 9 months (2022/2023). Primary outcomes included incidence of symptomatic VTE and VTE related mortality up to 90 days following foot and ankle surgery and Achilles tendon rupture, and analysis of risk factors.ResultsIn total 11,363 patients were available for analysis. 5,090 patients (44.79%) were elective procedures, 4,791 patients (42.16%) were trauma procedures (excluding Achilles ruptures), 398 patients (3.50%) were acute diabetic procedures, 277 patients (2.44%) were Achilles ruptures undergoing surgery and 807 patients (7.10%) were Achilles ruptures treated non-operatively. There were 99 cases of VTE within 90 days of admission across the whole group (Total incidence = 0.87%), with 3 cases of VTE related mortality (0.03%). On univariate analysis, increased age and ASA grade showedhigher odds of 90-day VTE, as did previous cancer, stroke, history of VTE, and type of foot and ankle procedure / injury (p&lt;0.05). However, on multivariate analysis, the only independent predictors for 90-day VTE were found to be the type of foot and ankle procedure (Achilles tendon rupture = Odd's Ratio 11.62, operative to 14.41, non-operative) and ASA grade (grade III/IV = Odd's Ratio 3.64).ConclusionThe incidence of 90-day post procedure VTE in foot and ankle surgery in this national audit was low. Significant, independent risk factors associated with the development of 90-day symptomatic VTE were Achilles tendon rupture management and high ASA grade.

WHAT DO BOFAS MEMBERS PERCEIVE TO BE THE BARRIERS AND FACILITATORS OF DAY-CASE SURGERY FOR MAJOR FOOT AND ANKLE PROCEDURES? A SCOPING SURVEY OF SURGEONS

IntroductionRecent advances in minimally invasive surgery and improved post-operative pain management make it possible to perform major foot/ankle operations as day-case. This could have significant impact on length of stay, saving resources and is in keeping with government policy. However, there are theoretical concerns about complications and low patient satisfaction due to pain.MethodsThe survey was developed following review of the literature and was approved for distribution by the BOFAS (British Orthopaedic Foot &amp; Ankle Society) scientific committee. An online survey (19 questions) was sent to UK foot and ankle surgeons via the BOFAS membership list. Major foot/ ankle procedures were defined as surgery that is usually performed as an inpatient in majority of centres and day-case as same day discharge, with day surgery as the intended pathway.ResultsA total of 132 surgeons responded, 80% from Acute NHS Trusts. The majority (78%) thought that more procedures could be performed as day-case at their centre. Currently 45% of respondents perform less than 100 day-case surgeries per year for these procedures. Despite post-operative pain and patient satisfaction being theoretical concerns for day-case surgery in this population; these outcomes were only measured by 34% and 10% of respondents respectively. The top perceived barriers to performing more major foot and ankle procedures as day-case were: Lack of physiotherapy input pre/post-operatively (23%), Lack of out of hours support (21%).ConclusionsThere is consensus among surgeons to do more major foot/ ankle procedures as day-case. Despite theoretical concerns about post-operative pain and satisfaction this was only measured by a third of those surveyed. Out of hours support and physiotherapy input pre/ post-op were perceived as the main barriers. There is a need to scope the provision of physiotherapy pre/post-operatively and out of hours support at sites where this is a perceived barrier.

RATE OF COVID-19 INFECTION AND 30-DAY MORTALITY BETWEEN BLUE AND GREEN (DEDICATED COVID-19 FREE) PATHWAYS: RESULTS FROM UK-FALCON AUDIT

ObjectivesThe primary aim was to determine the differences in COVID-19 infection rate and 30 day mortality in patients undergoing foot and ankle surgery between different treatment pathways over the two phases of the UK-FALCON audit, spanning the first and second national lockdowns.DesignMulticentre retrospective national audit.SettingThis was a combined retrospective (Phase 1) and prospective (Phase 2) national audit of foot and ankle procedures in the UK in 2020.ParticipantsAll adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 46 participating centres in England, Scotland, Wales and Northern Ireland. Patients were categorised as either a green pathway (designated COVID-19 free) or blue pathway.Results10,846 patients were included, 6,644 from phase 1 and 4,202 from phase 2. Over the 2 phases the infection rate on a blue pathway was 1.07% (69/6,470) and 0.21% on a green pathway (9/4,280). In phase 1, there was no significant difference in the COVID-19 perioperative infection rate between the blue and green pathways in any element of the first phase (pre-lockdown (p = .109), lockdown (p = .923) or post-lockdown (p = .577)). However, in phase 2 there was a significant reduction in perioperative infection rate when using the green pathway in both the pre-lockdown (p &lt; .001) and lockdown periods (p &lt; .001). There was no significant difference in COVID-19 related mortality between pathways.ConclusionsThere was a five-fold reduction in the perioperative COVID-19 infection rate when using designated COVID-19 green pathways; however the success of the pathways only became significant in phase 2 of the study. The study shows a developing success in using green pathways in reducing the risk to patients undergoing foot and ankle surgery.

The variation of anticoagulation prescribed in foot and ankle surgery in the UK – UK foot and ankle thrombo-embolism audit (UK-FATE)

IntroductionVenous thrombo-embolism (VTE) is a recognised complication of foot and ankle surgery. There are multiple possible anticoagulation treatments available in the UK to mitigate the risk of developing VTE. Our primary objective was to assess the variability of chemical anticoagulation prescribed in patients undergoing foot and ankle procedures. MethodsThis was a UK-based national, multicenter, prospective audit spanning a collection duration of 9 months on all foot and ankle procedures, carried out in 68 UK centers between 1st June 2022 and 30th November 2022, with a further 3-month follow up period. All patients who underwent a foot and ankle surgical procedure (including Achilles tendon rupture treatment) were included in this study. ResultsData on a total of 13,569 patients was submitted. Following data cleansing, 11,363 patients were available for further analysis, with anticoagulation data available for 11,099 patients. There were eleven different chemical anticoagulation treatments recorded across the cohort. A total of 3630 (31.95 %) patients received no chemical anticoagulation. The patients receiving chemical anticoagulation medication could be split into 4 main groups. The most common chemical anticoagulation received was low molecular weight heparin (LMWH) (6303, 84.4 % of patients receiving chemical anticoagulation). Aspirin was given in 4.1 % (308 patients), a Factor Xa inhibitor in 10 % (744 patients) and other anticoagulants (e.g. Warfarin) in 1.5 % (114 patients). The overall VTE rate in this sub analysis of patients receiving chemical anticoagulation, was 1.1 % (83 cases out of 7469). There was no significant difference seen in incidence of VTE between types of anticoagulants, when confounding factors were considered. The duration of post-operative chemical prophylaxis used by participants for most chemical anticoagulants was 6 weeks (64.50 %). ConclusionThere was significant variability of chemical anticoagulants reported in the study, with five different categories of anticoagulants used (including no chemical anticoagulation), and none clearly superior/inferior. The duration of anticoagulation was consistent across types of thromboprophylaxis.

Critical Portions of a Foot or Ankle Surgical Procedure From Patient and Surgeon Perspectives.

Over the past decade, overlapping procedures in orthopaedic surgery have come under increased public scrutiny. Central to this discussion is what should constitute a "critical portion" of any surgical procedure-a definition which may differ between patients and surgeons. This study therefore aimed to assess which components of three common foot and ankle procedures are considered "critical" from both the patient and surgeon perspectives. For this survey-based study, questionnaires were administered to patients who presented to an orthopaedic foot and ankle clinic and separately administered to foot and ankle surgeons through e-mail. The questionnaires broached all steps involved in three common foot and ankle procedures: open reduction and internal fixation of ankle fracture, Achilles tendon repair, and ankle arthroscopy. Respondents were asked to characterize each step as "always critical," "often critical," sometimes critical," rarely critical," or "never critical." A combined "always critical" and "often critical" response rate of greater than 50% was used to define a step as genuinely critical. Patient and surgeon responses were thereafter compared using Mann-Whitney U and Kruskal-Wallis tests ( P -value <0.05 was considered significant). Notably, both patients and surgeons considered informed consent, preoperative marking of the surgical site, preoperative time-out, surgical soft-tissue dissection, and certain procedure-specific steps (critical portions) of these procedures. By contrast, only patients considered skin incision and wound closure to be critical steps. Patients and surgeons were largely in agreement as to what should comprise the critical portions of several common foot and ankle procedures. Certain discrepancies did exist, however, such as skin incision and closure, and both groups were also in general agreement regarding what was not considered a critical component of these operations. Such findings highlight a potential opportunity for improved preoperative patient education and patient-physician communication. Level IV: Evidence from well-designed case-control or cohort studies.

Comparative Studies of Bone Graft and Orthobiologics for Foot Ankle Arthrodesis: A Critical Review.

Graft materials available to supplement hindfoot and ankle arthrodesis procedures include autologous (autograft) or allogeneic bone graft (allograft) but also bone graft substitutes such as demineralized bone matrix, calcium sulfate, calcium phosphate, and tricalcium phosphate/hydroxyapatite. In addition, biologic agents, such as recombinant human bone morphogenetic protein-2 or recombinant human platelet derived growth factor-BB (rhPDGF-BB), and preparations, including platelet-rich plasma or concentrated bone marrow aspirate, have been used to facilitate bone healing in ankle or hindfoot arthrodesis. The purpose of this review was to summarize the available clinical evidence surrounding the utilization and efficacy of the above materials and biological agents in ankle or hindfoot arthrodesis procedures, with emphasis on the quality of the existing evidence to facilitate clinical decision making.

Surprise Billing in Foot and Ankle Surgery and Its Effect on Patient Satisfaction

Introduction/Purpose: Patients undergoing foot and ankle surgery may find themselves facing unexpected medical bills. This is known as surprise billing and has caused financial hardship for many patients, prompting policymakers to pass the “No Surprise Act”. The purpose of this study was to determine the incidence of surprise bills in patient undergoing foot and ankle surgery and the effect of surprise billing on patient satisfaction. Methods: This was a retrospective study of patients who underwent a foot and ankle surgery from May 2021 to November 2022 at a large multi-state institution. Patients completed a questionnaire regarding the incidence of surprise bills following their surgery, the details regarding those bills, and how those bills affected the surgical satisfaction. Results: Of the 771 responses, 23% of participants received at least one surprise bill following their foot and ankle procedure, with 39% of these bills being greater than $1000. The most common surprise bill came from the surgical facility (46%) followed by anesthesia (42%). Furthermore, the incidence of surprise billing before and after the implementation of the “No Surprise Act” on January 1st, 2022 was not found be significantly different (p=0.134). Patients who received surprise bills reported being significantly less satisfied with their surgery (p &lt; 0.001) and felt their billing experience affected their surgical satisfaction. Conclusion: Despite recent legislative efforts, surprise billing in foot and ankle surgery is common and can negatively affect patient surgical satisfaction. Although surgeons may be unable to limit the amount of bills patients receive postoperatively, increased communication and education regarding the perioperative billing process may prove to be beneficial for both patient satisfaction and the doctor-patient relationship.

"I Can’t Exercise Because My Foot Hurts Me Too Much." Does BMI Change after Common Foot and Ankle Surgeries? A Retrospective Review

Introduction/Purpose: The World Health Organization reports that 1.9 billion people worldwide have a body mass index (BMI) that classifies them as being either overweight (BMI &gt; 25) or obese (BMI &gt; 30). Patients often claim, prior to orthopaedic surgery, that their physical activity and exercise is negatively impacted by their orthopaedic condition. Hip and Knee arthroplasty literature has established that patients with high preoperative BMI continue to have high BMI post-operatively, despite also reporting improvements in their joint pain. No such studies exist in foot and ankle surgery. The purpose of this study was to analyze changes in BMI after many common foot and ankle surgeries. Methods: A retrospective review of all patients undergoing bunion correction, flatfoot correction, 1st MTP arthrodesis, and midfoot arthrodesis procedures between November 2018 and December 2022 was conducted in this IRB approved, single center study. BMI data was collected from the electronic medical record for preoperative and 12 months postoperative time points. Descriptive statistics were reported for age, gender, diabetes, A1c for diabetic patients, smoking status, and overall follow up time. Repeated measures of analysis of variation were conducted with one between-groups factor being type of surgery. Results: 196 patients were included in the study. The average age was 62.1 years, 151(76.6%) patients were female. Average BMI amongst all patients preoperatively was 29.58 +/- 5.21, and postoperatively 29.79 +/- 5.33, with an overall average increase in BMI of 0.2182 +/- 2.21. Upon subgroup analysis, all surgical cohorts yielded an increase in postoperative BMI (bunion +0.2489 +/- 2.06, double arthrodesis +0.4767 +/- 1.37, 1st MTP fusion +0.2293 +/- 2.07, midfoot arthrodesis +0.0251 +/- 3.10) although these changes did not reach significance (p value 0.425). There was no significant difference observed in changes in BMI between surgical groups (p value 0.958). BMI outcomes were normally distributed with acceptable equality of error variances (Levene’s test p- values &gt; 0.270). Conclusion: The current statistics surrounding the prevalence of overweight and obesity are staggering. The results of this study demonstrate that elective orthopaedic surgery of common foot and ankle procedures do not facilitate a change in BMI one year postoperatively, despite the goal of reducing chronic pain and increasing physical function, which is often cited as the primary restriction to exercise amongst patient populations. Additional studies are warranted to further elucidate changes in BMI to adequately council patients regarding postoperative expectations. Study Data Summary

Incidence and associated factors of surgical site infection in patients undergoing foot and ankle surgery: a 7-year cohort study

Surgical site infections (SSI) constitute 31% of all hospital-acquired conditions, with ankle and foot surgical procedures showing an incidence of SSI ranging from 0.5% to 6.5%. This study aimed to assess the incidence of both superficial and deep surgical site infections in foot and ankle surgery, along with associated factors. Conducted as a retrospective cohort study, it included 2180 patients undergoing foot and ankle surgery in a private hospital between 2014 and 2020, encompassing elective and trauma cases. Outcome variables comprised SSI, while predictor variables encompassed sex, age, diabetes mellitus, systemic arterial hypertension, smoking, American Society of Anesthesiologists (ASA) score, and body mass index. Logistic regression models were employed to identify associations between study variables. The incidence of surgical site infections stood at 4% (83/2180), comprising a rate of 2.8% (57/2180) for superficial infections and 1.2% (26/2180) for deep infections. Smoking (OR 2.9, 95%CI 1.4–5.3) and ASA score >2 (OR 3.4, 95%CI 1.2–8.4) emerged as independent factors associated with surgical site infections. The group with deep infections exhibited higher proportions of smokers (p = 0.002), systemic arterial hypertension (p = 0.018), trauma surgery (p = 0.049), and an ASA score >2 (p = 0.011). Overall infection incidence in this cohort reached 4%, with trauma cases, smoking, hypertension, and an ASA score >2 independently linked to deep infections. Surgeons should be cognizant of these risk factors when managing prophylactic antibiotic regimens for patients.

Efficiency and perceived safety of foot and ankle procedures performed on the preoperative stretcher versus operating room table.

Foot and ankle surgeons often perform minor surgeries on the preoperative stretcher instead of the operating room table. We examined whether stretcher-based and operating room table-based procedures differed with respect to operating room efficiency and staff perceptions. We retrospectively reviewed medical records of patients undergoing minor foot and ankle surgery at an ambulatory surgery centre. We collected 'time to start', the duration between patient arrival in the operating room and incision time, and 'time to exit', the duration between procedure end time and patient exit from the operating room. Staff were surveyed regarding their perceptions of stretcher-based and operating room table-based procedures. 'Time to start' was significantly shorter for stretcher-based procedures, but 'time to exit' was not. Seventeen (81%) staff members thought stretcher-based procedures increased operating room efficiency. Thirteen (62%) thought stretcher-based procedures bettered staff safety. Nineteen (91%) thought stretcher-based procedures were equivalent to or better than operating room table-based procedures for patient safety. Most (67%) would recommend stretcher-based procedures. We found small but significant time savings associated with stretcher-based procedures. Without adapting surgical scheduling practices, the impact of stretcher-based procedures on overall operating room efficiency is questionable. Nevertheless, the majority of OR staff think stretcher-based procedures increase OR efficiency and are safer for staff. Level IV, Retrospective case series.

Workers' Compensation: The Burden on Healthcare Resource Utilization After Foot and Ankle Surgery.

The purpose of this study is to investigate the amount of healthcare resources dedicated to patients with WC after common foot or ankle procedures compared with a procedure-matched control group. A retrospective review was performed of patients with WC and without WC undergoing foot and ankle procedures. Measures of healthcare burden included clinical communications, documents, prescriptions, office visits, and days to return to work and clinic discharge. Collectively, 142 patients met the inclusion criteria. Patients with workers' compensation had increased office communication encounters (P < 0.001), processed documents (P < 0.001), medication prescriptions (P < 0.001), number of office visits (P < 0.001), number of days until return to work (P < 0.001), and days until final disposition from clinic (P < 0.001). Patients with workers' compensation were more likely to have postoperative complications (OR 2.1; 95% CI, 1.0 to 4.3; P = 0.04), secondary surgeries (OR 8.2; 95% CI, 2.3 to 29.4; P < 0.001), and new complaints during the perioperative period (OR 1.9; 95% CI, 0.9 to 4.0; P = 0.07) but were less likely to cancel appointments (OR 0.41; 95% CI, 0.19 to 0.86; P = 0.02). When undergoing common foot and ankle orthopaedic procedures, patients with WC demonstrated increased healthcare utilization of resources. This included more office staff work burden dedicated to patients with WC for longer amounts of time, effectively doubling the effort of a non-WC cohort.

The Workers Compensation Burden: Does Compensation Status Lead to Increased Utilization of Healthcare Resources Following Foot and Ankle Surgery?

Category: Other Introduction/Purpose: The association between workers’ compensation (WC) patients and the increased risk of complications and poor outcomes following orthopaedic procedures has been well documented. Recent studies have shown that WC patients have a higher rate of subsequent pain or injury than non-WC patients following common foot and ankle procedures. Due to the increased risks of complications, poor outcomes, and chronic pain amongst WC patients following orthopaedic procedures, it is possible that these patients consume more healthcare resources than non-WC patients during the post-surgical period. This study aimed to investigate the amount of healthcare resources utilized by WC patients following a foot or ankle procedure compared with a procedure-matched control group. Methods: A retrospective review was conducted of all WC and non-WC patients who had undergone foot (CPT 28001-28899) or ankle (CPT 27600-27899) procedures by a single surgeon from October 2017 through January 2020. Patients were excluded based on age ( &lt; 18 or &gt;70), bilateral procedures, presence of neuropathy, disability, and insufficient follow-up. Data collection included demographic, social, surgical, perioperative follow-up, and complications. Measures of healthcare burden included patient communications, physical encounters, processed documents, overall total prescriptions, the total number of office visits, days to return to work, and days to discharge from the clinic. Data analysis was performed with SPSS version 28. Comparisons were conducted with Mann-Whitney U test, chi-square test, or Fisher’s exact test. Power analysis determined the sample size with a 0.05 alpha level, 0.80 power, and 0.5 effect size. Results: 142 patients met the inclusion criteria including 71 WC patients and 71 non-WC patients. Measures of healthcare burden were greater in WC patients. WC patients had more communication encounters (median 6 vs 3; P&lt;.001), processed documents (median 6 vs 1; P&lt;.001), total prescriptions (median 5 vs 3; P&lt;.001), the total number of office visits (median 8 vs 6; P&lt;.001), days to return to work (median 119 vs 74; P&lt;.001), and days to discharge (median 267 vs 194; P&lt;.001). WC patients were also more likely to have postoperative complications (OR 2.1; P=.045), secondary surgeries (OR 8.2; P&lt;.001), and new complaints during follow-up (OR 1.9; P=.070). WC was less likely to cancel appointments (OR 0.4; P=.028). Conclusion: WC patients demonstrate increased healthcare resource utilization compared to the non-WC population. WC was associated with a higher burden on office staff requiring more time commitment to a single patient. Double the effort was evident on some measured parameters. WC patients also receive more medication prescriptions overall and are more likely to have complications, subsequent surgery, and new complaints remote to the inciting injury.

Determining the Causal Effect of Statins on Reducing the Incidence of Venous Thromboembolism after Ankle Fractures

Category: Ankle; Other Introduction/Purpose: It can be challenging to decide when to give preventative medication for venous thromboembolism (VTE). It is challenging to identify VTE in its early phases, and surgeons disagree on when prophylaxis should be given and when to suspect VTE. Additionally, patients who are not at a high risk of VTE are advised not to take prophylaxis due to the potential risk of bleeding adverse events and the evidence does not fully support providing prophylaxis in isolated foot and ankle procedures (BAE). The effectiveness of prevention, particularly in isolated foot and ankle fractures, is debatable, and research into how patients react to statins is necessary. By utilizing causal inference techniques, this research simulates a randomized control trial (RCT) from observational data. Methods: Out of a total of 1,175 patients, 238 had confirmed VTE 180 days after the incidence of ankle fracture (Case group, n=238). The inclusion criteria were 1- ankle fracture diagnosed by a physician and confirmed radiologically via X-ray or CT scan; 2- Age of 18 years or older; 3- Symptomatic VTE confirmed by a clinician and through radiologic (Duplex ultrasound, CT angiography, and/or angiography). To infer causal effects, we took the three following steps: first, the causal diagram must be created. Second, the set of variables necessary for causal inference must be identified. Third, the average treatment effect should be estimated for different treatment regimens. Results: Table 1 shows the incidence of VTE among patients who had VTE chemoprophylaxis. A non-significant 2.9% increase in VTE incidence was found, 95% CI [-1%, 7%]. The results state that, if a patient is already taking Statins, the incidence of VTE is reduced by 1%, 95% CI [-4.2%, 2.8%] as compared to patients who are not taking the drug which is not statistically significant. This indicates that there is no significant difference between administering VTE prophylaxis or not, in patients that are already consuming Statins. On the contrary, for patients in the sample that are not already taking Statins, the VTE incidence increases by 6%, 95% CI [1.6%, 10%] compared to no treatment administration which is significant since the confidence interval does not contain 0. Conclusion: Our findings provide more evidence that VTE prophylaxis may not, on average, be successful in lowering the incidence of VTE after ankle fracture, particularly in individuals who do not take Statins. To put it another way, doctors may decide not to give extra prophylaxis to avoid VTE in isolated ankle fractures if a patient is on Statins. Here, we established the causal inference methodology that can help us reproduce the results of an expensive RCT.