Ankle Procedures Research Articles

Safe and Effective Is Not Always Acceptable: The Case for PASS Scores in Foot and Ankle Orthopaedic Surgery

Category: Other Introduction/Purpose: Determining the success of a clinical intervention can be challenging even with modern patient-reported outcomes. Traditionally studies have used the Minimum Clinically Important Difference (MCID), the smallest difference in an outcome that is felt to have clinical significance. More recently some authors have emphasized the alternative model of the Patient Acceptable Symptomatic State (PASS), the threshold of a PRO defining where patients consider their overall status to be acceptable. PASS scores have not yet seen wide use in the foot and ankle literature, but may add insight to surgical outcomes beyond simply measuring the minimal changes implied by the MCID. Methods: The most universal patient-reported outcome in the foot and ankle literature is the simple Visual Analog Pain Scale (VAS), in which a patient rates their pain along an analog scale between 0 to 10 cm. Articles in Foot and Ankle International from December 2020 to August 2022 that reported VAS pain scores and variance following an intervention were included. Although specific PASS thresholds for VAS scores in many conditions in the foot and ankle have not been determined analytically, values ranging from 2.0 to 3.0 are typical for orthopaedic conditions, corresponding to the intuitive statement “I would like my pain to be less than 2 or 3 out of 10.” A PASS threshold of 2.0 has been used previously in the foot and ankle literature. The studies were therefore analyzed against PASS thresholds for the VAS of 2.0, 2.5, and 3.0. Results: Twenty-one studies were included. Five had multiple internal groups, yielding a total of 27 total sets of VAS scores.All 27 (100%) showed improvements well beyond the MCID and were considered successful. 17 (81%) of the 21 studies subjectively described their intervention as “reliable”, “good”, “effective” or “satisfactory”. Despite this, 8 (38%) of the 21 studies reported final mean VAS scores for all internal groups above a PASS threshold of 2.0. An analytically calculated weighted average final VAS pain score for all studies was 1.78 +/-1.89. Based upon this, the expected percentages of patients included in FAI studies whose results failed to meet VAS PASS thresholds were 45% for a threshold of 2.0, 35% for a threshold of 2.5, and 26% for a threshold of 3.0. Conclusion: Studies in the foot and ankle literature almost universally report positive results, both subjectively in their discussions and by statistically demonstrating improvement of patient-reported outcomes beyond the MCID. PASS threshold analysis yields a much less positive interpretation and emphasizes the number of negative outliers in the population who do not find their outcome acceptable. A fuller picture of the outcome of foot and ankle procedures and overall patient satisfaction can be gained from reporting both changes in the mean and comparing final outcomes to PASS thresholds.

Narcotic Use and Prescribing Trends Among Workers Compensation Patients Undergoing Foot and Ankle Surgery

Category: Midfoot/Forefoot; Hindfoot Introduction/Purpose: Previous studies have shown that workers compensation patients (WC) have worse outcomes, and higher complications rates after orthopaedic surgery. Despite orthopaedic surgeons being the third highest prescribers of narcotic pain medication in the United States there have been no studies to specifically evaluate narcotic use among the WC population. The purpose of this study was to investigate narcotic use among WC patients who underwent foot or ankle operative procedures compared with a procedure matched control group. Methods: A retrospective review was conducted for WC and non-WC patients ages 18 to 70 years old who underwent foot (CPT 28001-28899) or ankle (CPT 27600-27899) procedures in an orthopaedic surgery practice from October 2017 through January 2020. Data collection included demographics, social, surgical, perioperative follow-up and complications. Outcomes measures were timing and number of narcotic prescriptions, total morphine milligram equivalents (MME), and procedure type. 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 sample size with a 0.05 alpha level, 0.80 power, and 0.5 effect size. Results: 142 total patients met inclusion criteria, with 71 WC patients and 71 non-WC patients. There were no differences regarding the type of foot or ankle procedure performed (p=0.598). WC patients had double the number of overall narcotic prescriptions (median 2 vs 1; p < 0.001). WC patients were prescribed in total 1,125 oxycodone MME and 871.8 hydrocodone MME (P < 0.001), versus 750 oxycodone MME and 450 hydrocodone MME among the non-WC group (p < .008). There was no difference in the number of tramadol prescriptions (p = 0.571). WC patients experienced more days between the date of last narcotic prescription and both index surgery date (median 27 vs 1, p = 0.001) and initial clinic visit date (median 105 vs 49, p = 0.002). Conclusion: This data demonstrates that WC patients portend worse outcomes and utilize narcotics at twice the rate and for longer periods of time post-operatively than non-WC patients. Increased narcotic use may potentiate narcotic dependence and likely leads to worse outcomes. Treating physicians must be aware of these trends in order to best manage these patients. Physicians may need to have longer discussions with WC patients regarding narcotic use post operatively as well as about outcomes and goals of surgery. Physicians should set early expectations with WC patients and clear limits on the amount of narcotics they are willing to prescribe postoperatively.

Bone Cutting Efficiency and Heat Generation Using a Traditional Fluted Burr and a Novel Fluteless Resurfacing Tool

Category: Basic Sciences/Biologics; Other Introduction/Purpose: Meticulous bone removal is a critical step in many orthopaedic foot and ankle procedures including arthrodesis, decortication, and hardware removal. Power tools, including burrs, allow for increased efficiency and potentially more uniform bone removal; however, due to friction generated, there is a known risk of thermal-induced osteonecrosis. A fluteless resurfacing tool (RT) has been manufactured in hopes of optimizing cutting properties by increasing cutting efficiency and decreasing bone-burr contact heat generation. The purpose of this cadaveric study was to compare the cutting rate and heat generated using a traditional fluted burr (FB) and a fluteless RT on human cadaveric bone (Figure 1). We hypothesized that during bone removal, the fluteless RT would provide faster cutting rates than a traditional burr. Methods: Twenty cadaveric metatarsals were tested with four predetermined cutting forces to evaluate heat generation and cutting rate for the fluted burr and fluteless resurfacing tool over 40 seconds or until a depth of 4 mm was reached. Cutting rate was calculated from displacement transducer data. Heat generation was measured by thermocouples placed in the bone adjacent to the burring site. Assuming a body temperature of 37°C, a 10°C increase in heat was used as the threshold of inducing osteonecrosis. Results: At 1.0 N and 1.7 N, the thermal osteonecrosis threshold was reached at comparable times between burrs, while the bone removed by the resurfacing tool was on average five times greater than fluted burr at 1.0 N and over twice as great at 1.7 N. Statistical analysis of these common cutting forces showed the resurfacing tool had significantly higher cutting rates (P < 0.01). As a result, the fluted burr produced higher temperatures for the same amount of bone removal (P < 0.01). Conclusion: In a cadaveric study, the fluteless resurfacing tool demonstrated higher bone cutting rates and lower heat generation for the same amount of bone removed than a traditional fluted burr.

A CLINICAL COMPARATIVE STUDY OF ULTRASOUND-GUIDED POPLITEAL NERVE BLOCK WITH 0.5% BUPIVACAINE HYDROCHLORIDE WITH AND WITHOUT 8MG DEXAMETHASONE FOR KNEE SURGERIES

Objective: This study aimed to see how adding dexamethasone 8 mg to 0.5% bupivacaine affected the length of sensory and motor blockage of the popliteal sciatic nerve in ankle and foot surgeries.
 Methods: This prospective randomized clinical comparison trial enrolled 60 patients with American Society of Anesthesiologists (ASA) physical status grades III and IV, aged 50-80 y, scheduled for ankle and foot procedures from March 2023 to July 2023. Patients were assigned into two groups of 30 at random. 28 ml of 0.5% bupivacaine and 8 mg dexamethasone were given to Group D. Group N was given 28 ml of o.5% bupivacaine and 2 ml of NS. Here, 20 ml was used for sciatic nerve block and 10 ml for saphenous nerve block.
 Results: The mean onset of sensory block in group D was 23.2±6.8 min, while 21.7±6.9 min in group N (p 0.3999). This was not statistically significant. The onset of motor block was 22.9±7.9 in group D and 22.3±7.1 in group N, which were statistically insignificant (p 0.7581). The duration of the motor block in group D was 11.3±3.2 h, whereas it was 5.9±2.3 h in group N (p 0.0001), which was statistically significant. The length of the sensory block in group D was 14.9±3.8 h, while it was 8.3±3.4 h in group N (p 0.0001), which was also statistically significant. The VAS score in group N was significantly higher than in group D; it began 3 h after surgery and remained at 4 h, 5 h, 6 h, 8 h, 10 h, and 12 h. All 30 patients in Group N required their first rescue analgesia during the first 12 h postoperatively. In contrast, only 12 patients (40%) required their first analgesia within the first 12 h, and 18 (60%) requested their first analgesia within the second 12 h.
 Conclusion: Adding 8 mg dexamethasone to 0.5% Bupivacaine hydrochloride in ultrasound-guided popliteal and saphenous nerve blocks for ankle and foot procedures extends postoperative sensory and motor block duration.

Elective Foot and Ankle Procedures in the Patients Greater than 65 Years of Age: Worth the Mobility Gains.

Chronic, non-traumatic pathologies of the foot and ankle can be mobility-limiting for patients of all ages. The objective of this study was to compare postoperative changes in LifeSpace Mobility Assessment (LSA) scores of adult and elderly patients following elective foot and ankle surgery. A prospective study of 184 patients undergoing elective ankle, hindfoot, and midfoot procedures conducted by one surgeon between 2015 and 2019 was undertaken. Patient-reported LSA scores were collected at preoperative, 6-month, and 12-month follow-up. Patient data was compared using an independent sample t-test for continuous, normally distributed data and a chi-squared or Fischer's exact test for categorical data. Alpha and beta were .05 and .8. Patients were divided based on age. 140 patients were observed in the younger (<65) group, 44 patients were observed in the elderly (≥65) group. The average LSA score of elderly patients at the preoperative visit was 58.3 (SD 38.0) vs 79.3 (SD 38.8) in the younger cohort (P = .041). Both patient cohorts saw decreased mobility at 3-month postoperative visits but surpassed preoperative mobility scores by 6 months and 1 year postop. No difference in average mobility score was observed between young (85.6, SD 36.1) and elderly (90.1, SD 34.3) cohorts at 1-year follow up. Given the increased rates of perioperative comorbidities and the heightened risks of intraoperative complications, physicians may be more inclined to manage elderly patients with longer periods of conservative treatment for similar pathologies. However, these results imply that elderly patients experience similar improvements after surgery to younger cohorts and should not be excluded from surgical consideration. Our results, in tandem with literature showing the deleterious effects of decreased mobility in the elderly, suggest that the discussion to pursue or hold surgical correction of chronic foot and ankle disease in patients over age 65 must consider the mobility benefits of surgery.

M1 And M2 Monocytes In Concentrated Bone Marrow Aspirate As Predictive Biomarkers For Clinical Response After Foot And Ankle Procedures

M1 And M2 Monocytes In Concentrated Bone Marrow Aspirate As Predictive Biomarkers For Clinical Response After Foot And Ankle Procedures

Contemporary Review: An Overview of the Utility of Patient-Reported Outcome Measurement Information System (PROMIS) in Foot and Ankle Surgery.

Patient-Reported Outcome Measurement Information System (PROMIS) has favorable psychometric and administrative properties in orthopaedic clinical research. It facilitates clinically meaningful data collection while minimizing administration time and survey fatigue and improving compliance. PROMIS is a critical component of patient-centered care and shared decision making, as it provides enhanced communication and engagement between patients and providers. As a validated instrument, it may also aid in measuring value-based health care quality. The goal of the current work is to provide an overview of PROMIS metrics used in orthopaedic foot and ankle, including advantages and disadvantages compared to legacy scales and PROMIS's applicability in specific foot and ankle conditions based on psychometric properties. We provide a review of the literature regarding the utilization of PROMIS as an outcome measure for specific foot and ankle procedures and conditions.

Perceived barriers and facilitators of day-case surgery for major foot and ankle procedures? A cross-sectional survey of United Kingdom surgeons.

Advances in minimally invasive surgery and improved post-operative pain management make it possible to consider performing even major foot/ankle operations as day-case. This could have significant benefits for patients and the health service. However there are theoretical concerns about post-operative complications and patient satisfaction due to pain. To scope the current practice of foot and ankle surgeons on day-case surgery for major foot and ankle procedures in the United Kingdom (UK). An online survey (19 questions) was sent to UK foot and ankle surgeons via the British Orthopaedic Foot & Ankle Society membership list in August 2021. Major foot and 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 treatment pathway. 132 people responded to the survey invitation with 80% working in Acute NHS Trusts. Currently 45% of respondents perform less than 100 day-case surgeries per year for these procedures. 78% felt that there was scope to perform more procedures as day-case at their centre. Post-operative pain (34%) and patient satisfaction (10%) was not highly measured within their centres. Lack of adequate physiotherapy input pre/post-operatively (23%) and lack of out of hours support (21%) were the top perceived barriers to performing more major foot and ankle procedures as day-case. There is consensus among UK surgeons to do more major foot/ankle procedures as day-case. Out of hours support and physiotherapy input pre/ post-op were perceived as the main barriers. Despite theoretical concerns about post-operative pain and satisfaction this was only measured by a third of those surveyed. There is a need for nationally agreed protocols to optimise the delivery of and measurement of outcomes in this type of surgery. At a local level, the provision of physiotherapy and out of hours support should be explored at sites where this is a perceived barrier.

THE IMPACT OF HARM REVIEW SERVICE ON PATIENTS AWAITING ELECTIVE ORTHOPAEDIC FOOT AND ANKLE SURGERY FOR MORE THAN 52 WEEKS

There has been a significant increase in waiting times for elective surgical procedures in orthopaedic surgery as a result of the coronavirus disease 2019 (COVID-19) pandemic. As per the hospital policy, patients awaiting elective surgery for more than 52 weeks were offered a consultant-led harm review.The aim of this study was to objectively assess the impact of this service on the field of foot and ankle surgery.The data from harm review clinics at a District General Hospital related to patients waiting to undergo elective foot and ankle procedures in the year 2021 (wait time of more than 52 weeks) were assessed. Clinical data points like change in diagnosis, need for further investigations, and patients being taken off the waiting list were reviewed. The effect of the waiting time on patients’ mental health and their perception of the service was assessed as well.A total of 72 patients awaiting foot and ankle procedures for more than 52 weeks were assessed as a part of the harm review service. It was noted that 25% of patients found that their symptoms had worsened while 66.1% perceived them to be unchanged. Twelve patients (16.9%) were sent for updated investigations. Twenty-one patients (29.5%) were taken off the waiting lists for various reasons with the most common one being other pressing health concerns; 9% of patients affirmed that the wait for surgery had a significant negative impact on their mental health.This study concludes that the harm review service is a useful programme as it helps guide changes in the diagnosis and clinical picture. The service is found to be valuable by most patients, and its impact on the service specialities and multiple centres could be further assessed to draw broad conclusions.

Rates and Factors Associated With Hardware Removal in Physeal Ankle Fractures: Analysis of the Pediatric Health Information System

Background: Ankle fractures are among the most common physeal fractures in children. When surgical management is warranted, subsequent hardware removal remains controversial. This study was designed to determine rates of hardware removal in patients with physeal ankle fractures and identify risk factors for removal. Procedure data was utilized to compare rates of subsequent ankle procedures in patients with hardware removed and hardware retained. Methods: We conducted a retrospective cohort study utilizing data from the Pediatric Health Information System (PHIS) for the years 2015 through 2021. We longitudinally followed patients treated for distal tibia physeal fractures to determine the rates of hardware removal and subsequent ankle procedures. Patients with open fractures or polytrauma were excluded. We used univariate, multivariate, and descriptive statistics to characterize the rates of hardware removal, identify factors associated with removal, and assess the rates of subsequent procedures. Results: This study included 1008 patients who underwent surgical management of a physeal ankle fracture. The mean age at index surgery was 12.6 years with an SD of 2.2 years, and 60% of patients identified as male. Two hundred forty-two patients (24%) had their hardware removed at an average time of 276 days (range, 21-1435 days) following index surgery. Patients with Salter Harris III (SH-III) or Salter Harris IV (SH-IV) fractures had hardware removed more often than patients with Salter-Harris II (SH-II) fractures (28.9% vs 11.7%, P &lt; .01). Four-year rates of subsequent ankle procedures are similar between patients with hardware removed and hardware retained. Conclusion: The rate of hardware removal in children with physeal ankle fractures is higher than previously reported. Patients of younger age, higher income, and with fractures involving the epiphysis (SH-III and SH-IV) are more likely to undergo hardware removal. Level of Evidence: Level III, retrospective study.

The Importance of Patient Resilience on Outcomes Following Foot and Ankle Orthopaedic Surgery

Category: Other; Ankle Introduction/ Purpose: Recovery from orthopedic surgery requires a degree of both physical and mental resilience during recovery and rehabilitation. The brief resilience scale (BRS) is a validated and reliable 6-item screening tool that measures resilience as the ability to bounce back or recover from stress. BRS can provide unique and important information about patients coping with health-related stressors. To date, there is little evidence describing the use of BRS as a pre-operative benchmark to evaluate outcomes following foot and ankle orthopedic injuries and procedures. We aim to determine how patient resilience, as measured with BRS, may predict the impact of orthopedic conditions and recovery from foot and ankle surgery. Methods: All patients undergoing foot and ankle orthopedic surgery at a single institution were enrolled in U-COSMOS, a HIPAA-compliant, automated outcomes data repository. All patients undergoing surgery completed BRS pre-operatively. We used a BRS cutoff of &lt; 3 (lower resilience, LR), 3-3.9 (intermediate resilience, IR), and &gt;=4 (high resilience, HR) to create three cohorts. Patients also completed a PROMIS Physical Function (PF) Computer Adaptive Test (CAT), PROMISE Pain Interference (PI) CAT, PROMISE Depression (D) CAT, and Global Health (GH) Short Form pre-operatively as well as 3-, 6-, 12-, and 24- months post-operatively, as applicable. Patients with a minimum follow-up of 180 days were included for analysis, and the longest available follow-up was used. Differences in outcomes between the three BRS groups were determined non-parametrically using a Kruskal–Wallis one-way analysis of variance. Results: A total of 586 patients were included for analysis, with an average follow-up of 389 days. The patients were categorized as low resilience (n=44), intermediate resilience (n=229), and high resilience (n=323). Patients in the high resilience cohort had significantly higher PF and lower PI and Depression scores both pre-operatively (p &lt; 0.05 for all) and post-operatively (p &lt; 0.001 for all). The greatest disparity was found in depression where low resilience patients were greater than 1 SD worse than high resilience patients (Figure 1). Similar trends are observed for physical and mental global health. In addition to having higher absolute baseline and follow-up scores, the change of PF and PI is also significantly higher for high resilience patients (p = 0.02). Conclusion: Patients with high pre-operative resilience demonstrate better pre-operative physical function and pain interference scores compared to lower resilience patients and show greater improvement at 12 months post-op. We also found that lower BRS scores are associated with decreased pre- and post-operative mental health outcomes, including PROMIS Depression. Further analysis of the role of BRS in pre-operative assessment will help guide shared treatment decision-making. Identifying interventions for patients with low resilience will likely lead to improve surgical outcomes.

Non-emergent Conditions of the Ankle, Hindfoot, and Midfoot in Elderly Patients Are as Mobility Limiting as Congestive Heart Failure.

Mobility limitations are well linked to increased morbidity and mortality. Older patients with chronic pathologies of the foot and ankle can suffer from significant mobility limitations; however, the magnitude of limitation experienced by this cohort is not well characterized. Conversely, the effects of congestive heart failure (CHF) on patient mobility are routinely assessed via the New York Heart Association (NYHA) classification. New York Heart Association classification is determined by a patient's physical activity limitation and is strongly correlated to functional status. We hypothesized that non-emergent conditions of the foot and ankle would be as mobility limiting as CHF. Life-Space Mobility Assessments (LSAs) were prospectively collected from orthopaedic patients at their preoperative visits and from CHF patients at a cardiology clinic. Patients over the age of 50 years were included in this study. Congestive heart failure patients NYHA class II or greater were included. The non-emergent foot and ankle cohort included Achilles tendonitis, ankle joint cartilage defects, ankle arthritis, subtalar arthritis, and midfoot arthritis. Patient demographics and LSA scores were analyzed using Mann-Whitney U and chi-squared tests. A total of 96 elderly, non-emergent foot and ankle operative patients and 45 CHF patients met inclusion criteria. All medical comorbidities, except smoking status, were significantly more prevalent in the CHF cohort. No statistical difference was observed between CHF and preoperative foot and ankle LSA scores (56.1 vs 62.4, P = .320). Life-Space Mobility Assessment scores in the foot and ankle cohort were significantly improved relative to CHF patients, at 6-month and 1-year postoperative visits (P = .028, P < .0001, respectively). Non-emergent ankle, hindfoot, and midfoot pathology is associated with similar mobility limitation to that of NYHA class II and III CHF. Older patients undergoing elective foot and ankle procedures exceeded the mobility of CHF patients at 6 months post-operation, and the mobility gains persisted at 1-year post-operation. Level II: Prospective cohort study.

A Scoping Survey of BOFAS Membership: What are the Perceived Barriers and Facilitators of Day- Case Surgery for Major Foot and Ankle Procedures in the UK?

Category: Ankle Introduction/Purpose: Recent 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 is no consensus of barriers reducing foot/ankle operations being performed as day-case.The aim of this survey was to scope the practice of UK foot and ankle surgeons in terms of perceived barriers and facilitators to performing day-case surgery for major foot/ankle procedures. Methods: An online survey (19 questions) was sent to UK foot and ankle surgeons via BOFAS (British Orthopaedic Foot &amp; Ankle Society) membership list in August 2021. Major foot/ankle procedures are defined as surgery that is usually performed as an inpatient and day-case as same day discharge, with day surgery as the intended treatment pathway. Results: A total of 132 respondents: 80% working in Acute NHS Trusts. 78% of respondents 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). The top 2 perceived barriers to performing more major foot and ankle procedures as day-case were: no physiotherapy provision pre/ post-operatively 23%, no out of hours support for patients 21%. Conclusion: There 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 to increasing the number day-case procedures. There is a need for nationally agreed protocols to optimise the delivery of care for this patient group and to scope the provision of physiotherapy pre/post-operatively at sites where this is a perceived barrier.

Patients' Opinions on Critical Portions of Surgical Procedures in Foot and Ankle Surgery

Category: Other; Ankle Introduction/Purpose: Over the last decade, simultaneous or overlapping procedures in orthopedic surgery have come under increased media attention and public scrutiny. While little is known about what surgeons consider to be 'critical portions' of the myriad of foot and ankle procedures performed, even less is known about the expectations and opinions of patients themselves. In this study we aimed to elucidate patients' expectations of foot and ankle surgeons regarding their presence at different portions of a given surgery and what portions of a surgery they considered to be 'critical'. Methods: In this survey, data was collected using a questionnaire that was filled out by 49 patients presenting to an orthopedic foot and ankle tertiary referral clinic. The questions were designed around three common foot and ankle procedures: open reduction, internal fixation of fractures (ORIF), Achilles tendon repair, and ankle arthroscopy. For each procedure, the key steps were identified, and the responding patient was asked to characterize each step as 'Always Critical' 'Often Critical' 'Sometimes Critical' 'Rarely Critical' or 'Never Critical.' Additionally, demographics, education level, number of prior surgeries, and profession were also collected from the patients. Data were described using means, ranges, and percentages. Results: Of the 49 patients surveyed, the average age was 52.9 years old; 59% were female and 41% were male; 76% of respondents were college graduates, 8% completed some college, and 12% were high school graduates. Overall, 12% of respondents work in a healthcare related field. The average number of previous surgeries was 2.0, with a minimum of 0 and a maximum of 14. In all three procedures, the steps for which more than 50% of the patients identified as 'Always Critical' were discussion of risks, benefits, and alternatives, marking the surgical site, pre-operative time-out, skin incision for ORIF, soft tissue dissection, reduction of fracture, fracture fixation with hardware, repair of the tendon, and scoping the ankle. Across all three procedures, transferring the patient between operating table and bed, applying a sterile bandage, and applying a splint were categorized as the least critical portions of the procedure (Figure 1). Conclusion: The result of this study offers insight on what the most critical portion of three common foot and ankle procedures from the patient's perspective. Generally speaking, patients perceived initial dissection and even closure to be critical, in addition to procedural elements such as fracture reduction. Ongoing research aims to correlate these findings with the perceptions of foot and ankle surgeons themselves. Nonetheless, it highlights the potential discrepancy in perceptions between clinicians and patients as it pertains to 'critical portions' of a given procedure.

Venous Thromboembolism in Foot and Ankle Surgery: How Common is It?

Category: Other; Ankle; Ankle Arthritis; Bunion; Sports Introduction/Purpose: Venous thromboembolism (VTE) is a feared complication following orthopaedic surgery. The limited research exploring the rate of VTE following different types of foot and ankle surgery makes it difficult to establish clear guidelines for prescribing VTE prophylaxis. Therefore, the purpose of this study was to determine the rate of VTE in patients undergoing various types of foot and ankle procedures. Methods: A large online retrospective database that utilizes ICD and CTP codes was queried to determine the rate of VTE that occurred within 1-month of surgery in common foot and ankle procedures. Surgeries investigated included: Arthrodesis, Total Ankle Arthroplasty, Bunionectomy, Hammer Toe Correction, Watson-Jones, and Achilles repair. Only patients that did not receive postoperative anticoagulation or antiplatelet agents were included in the analysis. Demographic data was also collected. Results: From 2011 to 2022, 27,872 patients underwent Arthrodesis, 1,513 had a Total Ankle Arthroplasty, 31,808 had a Bunionectomy, 26,828 had Hammer Toe correction, 7,545 had a Watson-Jones procedure, and 8,770 had an Achilles repair. Of these procedures, Achilles repair had the highest rate of postoperative VTE (1.32%), followed by Watson-Jones (1.21%), Arthrodesis (0.89%), Ankle Arthroplasty (0.86%), Hammer Toe (0.76%) and Bunionectomy (0.65%). The overall rate of VTE in all procedures was found to be 0.84% (880/104,336). Conclusion: Venous thromboembolism is a serious complication following foot and ankle surgery. The unknown incidence of VTE in common foot and ankle surgeries may contribute to the lack of clear guidelines for prescribing VTE prophylaxis. This study helps to define rates of VTE in patients not receiving prophylaxis that underwent Arthrodesis, Ankle Arthroplasty, Bunionectomy, Hammer Toe, Watson-Jones, and Achilles repair. More studies are needed to help establish clear guidelines for foot and ankle surgeons to follow.

Standard Crutches vs Rolling Knee Scooters: Analysis of Patient Satisfaction and Risk of Falling after Foot and Ankle Surgery

Category: Other; Hindfoot; Midfoot/Forefoot Introduction/Purpose: Rolling knee scooters and standard crutches are commonly used following foot and ankle surgery for patients who are required to keep weight off the extremity. In all non-weight bearing situations, muscle atrophy, lack of stability, and decreased blood flow increasing the risk of clots. Postoperative falls within 30 days after surgery have been shown to significantly increase morbidity and correlate directly with age. While it is known that falls following procedures are a definitive concern and should be guarded against, there is a deficiency in reporting with regards to the use of knee scooters and the commonality of falls in the postoperative period while using them in comparison to more traditional means of ambulatory aid like crutches. Methods: From June 2021 to February 2022, 120 patients were prospectively enrolled after foot and ankle procedures at a single institution that required a non-weight bearing period of at least 2-weeks. Patients completed surveys at each post-operative visit until they were weight-bearing asking them to report ambulatory aid device utilized, level of satisfaction, time using the device, number of falls, and complications. Patient demographics, including sex, age, BMI, smoking history, co-morbidities were retrospectively collected and analyzed using descriptive statistics (means, standard deviations, ranges). The relative incidence of a fall occurring was calculated among the entire cohort, with each separate fall counting individually. A regression analysis was performed to identify any patient factors associated with the occurrence of falls. T-tests will be performed to compare the relative chance of a postoperative fall or device-related complication between patients using rolling scooters and those using crutches and assess for significance (p&lt;.05). Results: 106 patients (59 female and 47 male) either used a rolling knee scooter or crutches. For 65 ankle procedures and 41 forefoot procedures, the average age was 51.6 +- 16.0, BMI was 28.6 +- 5.59. Regression analysis of all falls found that only age (p=0.058) was slightly, but not significantly associated with a greater fall risk. Demographic factors such as sex, BMI, procedure type (forefoot vs. hindfoot), and previous experience with the device were not associated with a greater fall risk (p&gt;0.05). Patients were more likely to have used crutches for a previous injury compared to knee scooters (p=.006). Knee scooters were used significantly more often and had higher patient satisfaction compared to crutches (p=0.043, p=0.03). Patients using crutches reported a total of 22 falls compared to 14 total falls knee scooters (p=0.188). Overall, patients would rather use knee scooters than crutches for future foot and ankle surgeries (p=0.001). Conclusion: Both standard crutches and rolling knee scooters are safe and effective methods of non-weight bearing ambulatory aid after foot and ankle procedures. Older patients may be associated with a greater risk of falling regardless of ambulatory aid device utilized. Although there were no significant differences in number of falls between patients who used crutches vs. scooters, patients were significantly more satisfied with rolling knee scooters and more likely to use them in the future.

Functional Outcomes of Early Weight Bearing after Modified Kidner Procedure

Category: Midfoot/Forefoot; Sports Introduction/Purpose: The Kidner procedure is performed to treat the symptomatic accessory navicular that has failed nonoperative treatment. Classically, the Kidner procedure involves excision of the accessory navicular with detachment and advancement of the posterior tibial tendon to the base of the navicular tuberosity. Various modifications of the Kidner procedure have been reported in the literature in which the accessory navicular is excised but without complete detachment of the PTT. Typically, the PTT is reinforced back to the navicular tuberosity insertion, usually with a suture anchor. The standard postoperative protocol includes non weightbearing for six weeks. Early weight bearing is gaining popularity in the foot and ankle community. No study to date has evaluated outcomes with early weight bearing after a Kidner procedure. Methods: This is a retrospective comparative study of 34 patients who underwent a Kidner procedure involving excision of the accessory navicular with detachment and reattachment of the posterior tibial tendon with suture or a suture anchor. Surgery was performed by two fellowship trained foot &amp; ankle surgeons from a single institution. A total of 16 patients (17 feet) were included in the early weightbearing protocol group (2 weeks). A set of matched patients (n=17) with a similar age and surgical date were used as the control group with standard weight bearing at 6 weeks postoperative. Postoperative function and complications were obtained from a retrospective chart review of prospectively collected data until final follow up (mean, 18 weeks). This was a qualitative assessment specifically looking at whether early weight bearing led to increased complications and/or decreased function compared to standard weight bearing at six weeks. Results: Of the 34 total patients, there were no cases of postoperative posterior tibial tendon rupture or failure of the repair. In the early weight bearing group, there was one complication. This patient had a chronic flatfoot and developed a posterior tibial tendonitis at 6 months postoperative after returning to routine activity. This required boot immobilization and physical therapy. The standard weight bearing group had four complications. Two patients had posterior tibial tendon weakness and prolonged rehabilitation at 4 and 6 months postoperative. One patient had stiffness and pain at 6 months postoperative. And one patient developed a deep vein thrombosis at 3 weeks postoperative. Otherwise, all patients had returned to routine shoewear and resumed their normal activities, including sports, at final follow up. Conclusion: Early weight bearing after foot and ankle procedures is becoming increasingly popular. This study found that early weight bearing at 2 weeks postoperative after the Kidner procedure has no increased complication rates compared to standard weight bearing at 6 weeks postoperative. Based on the complications that occurred in the standard weight bearing group, early weight bearing may actually be protective against complications that occur with prolonged immobilization, such as weakness, stiffness, and deep vein thromboses.

Rate of COVID-19 Infection and 30 Day Mortality Between Blue and Green (Dedicated COVID-19 Safe) Pathways: Results From the UK Foot and Ankle COVID-19 National-Audit

Category: Other Introduction/Purpose: Objectives: The 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. Methods: Setting: This was an ambispective (retrospective Phase 1 and prospective Phase 2) national audit of foot and ankle procedures in the UK in 2020 completed between 13th January 2020 and 30th November 2020.Participants: All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were 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 (no protocols to prevent COVID-19 infection). Results: 10,846 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 (Odd's Ratio 0.077, p&lt;.001). There was no significant difference in COVID-19 related mortality between pathways. Conclusion: There was a five-fold reduction in the perioperative COVID-19 infection rate when using designated COVID-19 green pathways over the whole study period; however the success of the pathways only became significant in phase 2 of the study, where there was a 13-fold reduction in infection rate. The study shows a developing success to using green pathways in reducing the risk to patients undergoing foot and ankle surgery.

Patient Reported Outcomes Following Hindfoot Fusion Utilizing the Triple Arthrodesis Procedure

Category: Hindfoot; Ankle Arthritis Introduction/Purpose: Fusions are used as a salvage procedure to improve stability and return patient to regular functions of daily activities. Triple Arthrodesis is a fusion of three joints, talonavicular, subtalar, calcaneocuboid. There is limited literature on the patient-reported long-term outcomes for this procedure. The aim of this study is to quantify the patient-reported outcomes for the Triple Arthrodesis procedure. Methods: A retrospective analysis was conducted for patients that underwent Triple Arthrodesis at our facility from 2014-2021. Using the electronic medical record (EMR), basic patient demographics, time since surgery, presence of osteoarthritis or rheumatoid arthritis, development of infection, nonunion, hardware failure, and history of previous foot and ankle procedures were all noted. Additionally, we recorded the hardware used during the operation and whether concomitant procedures were performed during the time of surgery. To evaluate outcomes, we used the Patient Reported Outcomes Measurement Information System (PROMIS) survey and Foot Function Index (FFI) scores. Results: A total of 132 patients were included in this study with 50 participants completing the PROMIS and FFI surveys. The average time point at which the outcomes were collected was 5.50 years postoperatively. Postoperative PROMIS scores for physical function, pain interference, and depression were all within one standard deviation of the reference population. The average PROMIS physical function was 38.35, pain interference was 61.52, and depression was 49.82 for this population. The mean FFI scores were 58.56 for pain, 60.06 for disability, 48.06 for activity limitation. There was a significant decrease in postoperative pain scores when compared to preoperative pain of 5.4 to 2.55 (p=0.023). Four patients experienced wound infection, four patients experienced nonunion, six patients required revisional surgery, and three patients experienced hardware failure. Conclusion: Preliminary results Triple Arthrodesis may be beneficial in decreasing pain and lead variable long-term patient satisfaction. We plan to include further statistical analysis comparing the various types of fixation techniques used and the resultant PROMIS and FFI scores. Additionally, we are currently continuing patient calls to collect more completed PROMIS and FFI reports.

Surgical Site Infection after Foot and Ankle Surgery: A Retrospective Analysis of Incidence using a Low Concentration Chlorhexidine Gluconate (CHG) 0.05% in Sterile Water

Category: Other; Ankle; Bunion; Diabetes; Sports; Trauma Introduction/Purpose: Surgical site infection (SSI) after foot and ankle procedures adversely impacts both the quality and cost of health care delivery; increasing hospital length of stay, the number of re-operations, and readmission rate(s). The purpose of the present study was to assess the incidence of SSI in patients who underwent foot and ankle surgery with concurrent intraoperative lavage containing low concentration Chlorhexidine Gluconate (CHG) 0.05% in sterile water. Methods: Seventy-three patients underwent reconstructive foot and ankle procedures which utilized low concentration CHG 0.05% for intraoperative lavage between September 2020 and October 2021, at a single institution. Minimum follow-up for inclusion was at least 90 days; procedures with concurrent use of topical vancomycin powder, or prophylactic antibiotics postoperatively were excluded. Demographic data, and the incidence of complications including postoperative erythema, delayed wound healing, dehiscence, SSI, as well as reoperations were recorded. Univariate and multivariate analyses were performed. Results: Twelve complications occurred in 73 patients (16%): 1 erythema (1.4%), 4 delayed wound healing (5.5%), 1 dehiscence (1.4%), and 6 SSI's (8.2%). Of the 6 SSIs, 2 were superficial and 4 deep; representing an incidence rate of 2.7 and 5.5%, respectfully. Six reoperations were performed in 4 patients for deep SSI; 3 (75%) had a previously documented history of SSI after orthopedic surgery. A history of previous SSI infection after orthopedic surgery was identified as an independent predictor of future SSI following foot and ankle surgery (p &lt;.05). No associations were identified for purported risk factors. Conclusion: The present study is the first to assess the utility of a low concentration CHG 0.05% as an intraoperative irrigation agent for the purpose of mitigating postoperative SSI after foot and ankle surgery. The data suggests a low incidence of deep SSI in patients without a documented history of previous SSI after orthopedic surgery; without the concurrent use of topical vancomycin or prophyaltic antibitiocs, postoperatively. Additional studies are warranted to better understand the potential association identified.