Ankle Procedures Research Articles

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 <.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.

The Efficacy and Safety of Tranexamic Acid in Foot and Ankle Surgery: A Systematic Review and Meta- Analysis

Category: Basic Sciences/Biologics; Other Introduction/Purpose: Tranexamic acid (TXA) use is increasing in Orthopedic practice specially among arthroplasty surgeons. It was proven to decrease the estimated blood loss and need for blood transfusion in hip, knee and shoulder arthroplasty as well as pelvis and acetabulum surgery. There was no reported increase risk of thromboembolic events with the use of TXA in orthopedic practice. This systematic review and meta analysis aimed on reporting on the available evidence on the use of TXA in foot and ankle surgery. Methods: The current meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Electronic-based search on MEDLINE (PubMed), EMBASE, Google Scholar, SCOPUS, and Cochrane databases to November 2021. Clinical studies on tranexamic acid use in foot and ankle surgeries reporting at least one of the desired outcomes; estimated blood loss (EBL), Hemoglobin difference between pre- and post-op, or complications were included. To assess risk of bias, the Joanna Briggs institute critical appraisal tool was used for case series and the Newcastle Ottawa scale for comparetive studies. The level of evidence was assigned according to the Cochrane Book Review Group. Results: A total of 718 foot and ankle procedures were included. Out of those, 491 (68.38%) procedures received tranexamic acid while 221 (31.64%) served as controls and did not receive tranexamic acid. In the TXA group, 34 (6.92%) procedures received local TXA injection in one study, while the remaining majority of 457 (93.08%) procedures received intravenous (IV) TXA. Among the control group, saline was used a placebo in 113 (51.13%) controls in 3 studies, while no placebo was used in the remaining 108 (48.87%) controls. The pooled mean EBL for the TXA group was 57.75 mL [95% CI: 44.80 to 70.70, I2 = 98.31%] while the pooled mean EBL for the control group was 299.26 mL [95% CI: 212.43 to 386.09, I2= 98.96%] with statistical significance Figure 1. No significant difference was found between the two groups in terms of change of hemoglobin and risk of thromboembolic events and other complications. Figure 2,3 Conclusion: This systematic review and metaanalysis showed that the use of TXA in foot and ankle surgery was safe with no increased risk in thromboembolic events. The lower risk of bleeding using TXA despite being stastically significant, did not reach clinical significance and did not affect the post operative hemoglobin level. TXA can be considered in foot and ankle surgery in special cases with higher risk of bleeding or in cases where the use of tourniquet is contraindicated.

Tranexamic Acid Utilization in Foot and Ankle Surgery: A Meta-analysis.

Tranexamic acid (TXA) has been widely used in various orthopaedic subspecialities to decrease blood loss, transfusions, and wound complications. However, the role of TXA in foot and ankle surgery is not clearly delineated. This meta-analysis aims to report the efficacy and safety of TXA in relation to foot and ankle surgical procedures. Database searches were conducted for eligible studies from data inception through January 2022. Clinical studies on the use of TXA in foot and ankle procedures reporting the desired outcomes were included. Outcomes were estimated blood loss, change in hemoglobin, and overall complications. Risk of bias was assessed using the Newcastle-Ottawa quality assessment scale and the Joanna Briggs Institute (JBI) critical appraisal tool. Nine studies met the inclusion criteria. A total of 752 foot and ankle procedures were included, in which 511 (67.95%) procedures received TXA whereas 241 (32.05%) served as controls and did not receive TXA. The pooled data of change in hemoglobin and overall complications showed no difference between the TXA and control group. Estimated blood loss was significantly lower in the patients who received TXA. In conclusion, TXA use was associated with lower estimated blood loss in foot and ankle surgeries without increased risk of thromboembolic events, wound complications, or changes in hemoglobin. Level IV, meta-analysis.

Return to Driving after Elective Foot and Ankle Surgery: A Systematic Review

(1) Background: This systematic review summarizes the available studies investigating when it is safe for most patients to return to driving and when to modify for individual patients following elective foot and ankle procedures. (2) Methods: A systematic review of the literature was performed using three different electronic databases to identify English-language studies from 1999 to present that investigate the return to driving after right-sided elective foot and ankle procedures. (3) Results: A total of eight studies met inclusion criteria. All the studies investigated brake reaction time (BRT) as measured by a driving simulator as their primary outcome. Patients undergoing right ankle or subtalar arthroscopy should wait 2 weeks to drive, after total ankle arthroplasty or corrective hallux valgus surgery patients should wait 6 weeks, and the appropriate time to return to driving after ankle arthrodesis is still uncertain. Additionally, various clinical factors can be used to predict who may still be unfit to drive past the usual length of time. (4) Conclusions: The recommendations from these reviewed studies can guide physicians when counseling their patients on when they can expect to safely return to driving after a specific elective foot and ankle procedure. However, these recommendations should be tailored to the patient specifically based upon how they are doing clinically.

What Role Does a Colored Under Glove Have in Detecting Glove Perforation in Foot and Ankle Procedures?

Many orthopaedic surgical teams practice double gloving or use colored indicator gloving techniques to reduce contamination intraoperatively. Although the likelihood of glove perforation can be affected by the procedure type and surgeon habits, as well as the surgeon's technique, these factors have not been considered to determine the glove perforation rate, and the role of a colored under glove during operations seems less investigated. (1) What proportion of foot and ankle procedures result in perforation of outer gloves or under gloves? (2) What factors (such as the type or duration of operation) appear to be associated with the likelihood of glove perforation? (3) Does the use of a colored indicator under glove make it more likely that a surgeon would perceive the perforation of an outer glove intraoperatively? Between September 2020 and August 2021, the author performed 577 surgical foot or ankle procedures. Of those, patients who underwent subsequent operations under general or spinal anesthesia were considered as potentially eligible. Further, 16% (93) were excluded because the procedures were performed with the patient under local anesthesia, and another 1% (eight patients) were not analyzed (incomplete datasets for emergency operations performed at night). Finally, 82% (476 patients) were examined. To ensure statistical independence, gloves used in right-side operations in bilateral procedures and the most proximal surgery in unilateral procedures were included. Preoperatively, the surgeon was randomly assigned to use either a combination of two regular surgical gloves or a regular outer glove worn over a colored indicator under glove. Patient diagnosis, type of procedure, tourniquet time, and gloving type were recorded. There was no difference in potentially relevant confounding variables, such as the proportion of procedures performed on bone (78% [188 of 242] versus 83% [195 of 234]; p = 0.13), nor in tourniquet time (58 ± 30 minutes versus 62 ± 31 minutes; p = 0.45) between the regular glove and indicator glove groups. At the end of each procedure, the surgeon was asked whether he believed either the outer or under glove was perforated, and whether the use of a colored under glove increased the proportion of procedures in which the surgeon correctly ascertained that a perforation had occurred. To determine the proportion of gloves that were perforated, a standardized water-leak method was used, and the proportion of gloves with perforations based on several parameters of interest, including bone versus soft tissue operation and tourniquet time, was compared. During 476 foot and ankle procedures, the overall glove perforation proportion was 19% (92 of 476 procedures). Under-glove perforation was observed in 4% (17 of 476 procedures) of the operations. There was no difference in glove perforation proportions between bone and soft tissue operations (76 of 383 versus 16 of 93; odds ratio [OR] = 0.84, 95% confidence interval [CI] 0.46 to 1.52; p = 0.56). As tourniquet time (operation time) increased, the glove perforation proportion also increased (Exp[B] = 1.02; 95% CI 1.01 to 1.03; p < 0.001). The use of indicator under gloves increased the surgeon's intraoperative detection of glove perforation (in 68% of procedures [32 of 47] versus 29% [13 of 45]; OR = 5.3; 95% CI 2.2 to 12.8; p < 0.001). Surgical glove perforation occurred in approximately one of five foot and ankle procedures. Based on the results of this study, I recommend using colored indicator under gloves and replacing the under glove when replacing the outer glove after perforation is seen in order to detect contamination early and reduce any intraoperative contamination related to glove injury. Level I, therapeutic study.

The Impact of Harm Review Service on Patients Awaiting Elective Orthopaedic Foot and Ankle Surgery for More Than 52 Weeks.

Background and objectiveThere 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.Materials and methodsThe 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.ResultsA 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.ConclusionThis 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.

Rate of COVID-19 infection and 30 day mortality between blue and green (dedicated COVID-19 safe) pathways: Results from phase 1 and 2 of the UK foot and ankle COVID-19 national (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 UK national lockdowns. SettingThis 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. ParticipantsAll 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). Results10,846 patients were included, 6644 from phase 1 and 4202 from phase 2. Over the 2 phases the infection rate on a blue pathway was 1.07% (69/6470) and 0.21% on a green pathway (9/4280). 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 < .001) and lockdown periods (Odd’s Ratio 0.077, p < .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 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.

Development of a Risk Stratification Scoring System to Predict General Surgical Complications for Patients Undergoing Foot and Ankle Surgery.

Preventing postoperative complications is crucial for patients, surgeons, and health care facilities. We developed a risk stratification scoring system to optimize postoperative outcomes for patients undergoing foot and ankle surgery. A total of 35,580 patients who underwent foot and ankle procedures from 2005 to 2017 were identified as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). To assess the risk of a postoperative complication, we identified several independent risk factors associated with 30-day postoperative complications, then proceeded to develop a point-based risk scoring system. To validate our scoring system, we used it on a cohort of patients from the database who underwent foot and ankle surgery. Risk factors that correlated with postoperative complications included tobacco abuse, age (≥65 years), diabetes mellitus, hypertension, elevated creatinine level (≥1.3 mg/dL), hypoalbuminemia (<3.5 g/dL), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hyponatremia (<135 mEq/L), and anemia (hematocrit value, men <42%; women <38%). Point scores for each factor were: anemia, +10; hypoalbuminemia, +9; elevated creatinine level, +6; CHF, +4; diabetes mellitus, +3; hyponatremia, +3; COPD, +2; hypertension, +2; age, +1; and tobacco abuse, +1. For the validation cohort, we stratified patients according to risk as low (0-20 points), medium (21-30 points), and high (≥31 points) risk. In terms of having a postoperative complication, compared with low-risk patients, patients who were at medium risk had an odds ratio of 4.7 (95% CI, 2.8-7.9) and those at high risk had an odds ratio of 8.3 (95% CI, 4.8-14.5). [Orthopedics. 2022;45(3):139-144.].

Contemporary outcomes of limb-salvage procedures using Vascular Quality Initiative–Medicare-linked data: Racial and ethnic disparities persist

BackgroundSeveral reports have shown that ethnic and racial minority patients with chronic limb-threatening ischemia (CLTI) are more likely to undergo major amputation. Whether this disparity is driven by limited access to care, statistical discrimination, or biologic factors has remained a matter of debate. We studied the effects of race and ethnicity on the short- and long-term outcomes of limb-salvage procedures among patients with new-onset CLTI. MethodsWe identified all patients who had undergone first time (open or endovascular) revascularization for CLTI between January 2010 and December 2016 in the Vascular Quality Initiative–Medicare-linked database. These patients were divided into two groups: non-Hispanic White (NHW) and racial and ethnic minority (REM). The early end points included length of stay and operative mortality. The 2-year outcomes included major amputation, freedom from subsequent revascularization, number of limb salvage reinterventions, and all-cause mortality. Subanalyses comparing NHW and Hispanic patients and NHW and Black patients were also performed. ResultsOf 16,249 patients presenting with CLTI, 73.9% were NHW. The REM patients were younger (mean age, 69.9 ± 11.3 years vs 74.2 ± 10.5 years; P < .001) and more likely to be women (45.9% vs 37.7%; P < .001). Other baseline differences included a higher rate of smoking history, coronary artery disease, chronic obstructive pulmonary disease, and chronic kidney disease for the NHW group. In contrast, the REM patients were more likely to have diabetes and hypertension and were more likely to present with tissue loss (78% vs 76.6%; P = .04). The preoperative ankle brachial index and procedure type (endovascular vs open) were similar between the two groups. On multivariable analysis, the NHW group had had a 13% increase in the length of stay and a 25% decrease in operative mortality. Of the 2-year outcomes, the limb salvage estimate was 86% for the NHW group and 77.1% for the REM group (P < .001). A comparison between the two groups showed similar rates of freedom from subsequent revascularization (67.9% vs 67.1%; P =.2). The REM patients had had higher rates of overall survival (70.3% vs 68.4%; P = .01) compared with their NHW counterparts. The patients in the REM group were also more likely to have undergone more than two limb salvage reinterventions during follow-up (14.2% vs 8.6%; P < .001). After adjusting for potential confounders, the REM patients had significantly greater odds of major amputation at 2 years (adjusted hazard ratio, 1.49; 95% confidence interval, 1.36-1.63; P < .001). ConclusionsThe results from the present Vascular Quality Initiative–Medicare-matched study have shown that REM patients continue to face a higher major amputation risk despite equivalent attempts at limb salvage. Further studies to identify the risk factors and evaluate intervention strategies that might be more effective in preventing amputation in this particular population are warranted.

Return to Driving after Elective Foot &amp; Ankle Surgery: A Systematic Review

Category:Ankle; Arthroscopy; Midfoot/Forefoot; OtherIntroduction/Purpose:Studies investigating when patients can safely return to driving are becomingly increasingly numerous in the orthopedic literature because of the recognition of the importance of the activity to the lives of most adults. Previous systematic reviews have proven helpful by collecting and summarizing these studies to establish concise guidelines that can be presented to patients during the counseling surrounding a procedure. Having these guidelines can be even more crucial when discussing elective procedures. This systematic review summarizes the available studies investigating when it is safe to return to driving following elective foot and ankle procedures.Methods:A systematic review of the literature was performed using PubMed, Embase, and CINAHL to identify English-language studies from 1999 to present that investigate return to driving after right-sided elective foot and ankle procedures. Qualitative assessment of each of the included studies was performed independently by two authors. Then data from each study was extracted and broken down into distinct categories for comparison: study details, population, control group, method of evaluation, and results.Results:Eight studies met inclusion criteria. All of the studies investigate brake reaction time (BRT), via a driving simulator, as their primary outcome. A variety of objective and subjective secondary outcomes were collected. Patients undergoing right ankle or subtalar arthroscopic procedures have no significant difference in BRT compared to controls at 2 weeks post-operatively. 92% of patients undergoing right ankle arthroplasty had a BRT that was not significantly different to the control group at 6 weeks post- operatively. Patients who had an ankle arthrodesis had significantly delayed BRT compared to controls even past 1-year post- operatively. The majority of patients after corrective hallux valgus surgery have no significant difference in BRT at 6 weeks post- operatively compared to their pre-operative baselines depending upon how they are doing clinically. The included studies used a variety of patient reported outcomes that were helpful in predicting which patients would fail the driving simulation at the various timepoints.Conclusion:The recommendations from these reviewed studies can guide physicians when counseling their patients on when they can expect to safely return to driving after a specific, elective foot and ankle procedure. However, these recommendations are reliant on routine healing post-operatively and may need to be adjusted if a patient is experiencing any complications. A variety of patient surveys and other subjective scores can be very helpful in assuring a routine post-operative course.

Elective Foot &amp; Ankle Procedures in the Geriatric Populations: Worth the Mobility Gains

Category:Ankle; Hindfoot; Midfoot/ForefootIntroduction/Purpose:Chronic, non-traumatic pathologies of the foot and ankle can be mobility-limiting for patients of all ages. Given 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, previous work has shown that decreased mobility of elderly patients affects longevity and is linked to increased rates of all-cause and non- cancerous morbidity and mortality. Currently, little is known about the effect of elective foot and ankle procedures on mobility in patients of all ages. Therefore, the objective of this study was to compare posteroperative changes in LifeSpace Mobility Assessment (LSA) scores of adult and elderly patients following foot and ankle surgery.Methods:A prospective study of 184 patients undergoing elective ankle, hindfoot, and midfoot procedures conducted by a single surgeon between September 1, 2015 and August 31, 2019 was undertaken following IRB approval. Patient-reported LSA scores were collected at preoperative and routine 6-month and 12-month follow-up clinic appointments. Patient demographic and surgical data were recorded, and they were divided into groups by age over and under 65 years. Demographics and surgical characteristics were compared utilizing 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 assumed to be 0.05 and 0.8, respectively.Results:The younger (<65) group included 140 patients (mean age 44.1, SD 13.2), while 44 patients were observed in the elderly (>=65) age group (mean age 70.4 years, SD 8.4 (p<0.0001). The elderly group had significantly more patients with hypertension requiring medical management (p=0.012), but no other differences in perioperative comorbidities or demographics were observed. A higher proportion of elderly patients underwent surgery for conditions of osteoarthric origin, while younger patients underwent surgery more frequently for soft tissue pathology (p=0.033). The average LSA score of elderly patients at the preoperative visit was 58.3 (SD 38.0) versus 79.3 (SD 38.8) in the younger cohort (p=0.041). Both the young and elderly patient cohorts regained and surpassed their 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.Conclusion:This study demonstrates that while elderly patients may begin with lower mobility than younger patients with foot and ankle pathology, operative treatment can improve their mobility dramatically up to comparable levels of operatively-treated younger patients. Our results, in tandem with literature showing the drastic deleterious effects of decreased mobility in the elderly, suggest that the discussion to pursue or hold on surgical correction of chronic foot and ankle disease in the patients over the age of 65 must take into account the mobility benefits of surgery.

Complications Associated with Anesthetic Choice for Elective Foot and Ankle Surgery

Category:Ankle; Ankle Arthritis; Arthroscopy; Bunion; Diabetes; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports; TraumaIntroduction/Purpose:Wide-awake anesthesia (local anesthesia without sedation) is rarely utilized during elective foot and ankle surgery. As such, the rate of post-operative complications following wide-awake foot and ankle surgery is unknown. The aim of this study was to compare rates of early post-operative complications for wide-awake anesthesia to general/local anesthesia with sedation for elective foot and ankle procedures conditional on a wide range of observable patient characteristics and risk factors.Methods:Patients that underwent an elective foot or ankle surgery were identified in the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) dataset. The rate of thirty-day post-operative complications was compared between patients who received wide-awake anesthesia and those who received general/local anesthesia with sedation using logistic regressions that controlled for patient risk factors.Results:Between 2005 and 2017, 85,363 patients were identified has having any foot and ankle procedure. After excluding observations with missing anesthesia type data information and non-elective foot and ankle procedures, the analytic cohort had 16,743 patients. There were 1,401 (8.4%) patients who underwent wide-awake anesthesia and 15,342 (91.6%) patients who underwent general/local anesthesia with sedation over the entire sample. Starting in 2007, there was an annual increase in the likelihood of using general/local anesthesia with sedation for foot and ankle procedures of 0.7 percentage points (p = 0.001). Overall, general/local anesthesia with sedation increased the odds of experiencing any complication within the first thirty days by 1.523 (95% CI 1.152 - 2.014).Conclusion:Although wide-awake surgery is rarely performed for elective foot and ankle procedures, utilization of local anesthesia without sedation may result in fewer post-operative complications in the first thirty days. Existing trends in the use of sedation for foot and ankle procedures show that physicians are increasingly favoring general/local anesthesia with sedation, but our findings caution against this choice and suggest that post-operative complication rates may correspondingly increase.

Declining Trends in Medicare Reimbursement in Orthopaedic Foot and Ankle Surgery

Category:Ankle; Ankle Arthritis; Arthroscopy; Bunion; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports; Trauma; OtherIntroduction/Purpose:With the increasing complexity of physician reimbursement models, understanding reimbursement trends is crucial to the financial sustainability of orthopaedic practices nationwide. Inflation-adjusted Medicare physician reimbursement for total joint arthroplasty has decreased by approximately 33% from 2000 to 2019. Recent trends in orthopaedic foot and ankle reimbursement are unknown. Thus, our study sought to analyze trends in Medicare reimbursement rates from 2000 to 2020 for common orthopaedic foot and ankle surgical procedures.Methods:The financial database of a single academic tertiary care center was queried to identify the CPT codes most frequently utilized in orthopaedic foot and ankle care. Next, the Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for the top 30 CPT codes utilized, and physician reimbursement data extracted. Monetary data was subsequently adjusted for inflation utilizing the consumer price index and reported in 2020 US dollars (USD). Average annual and the total percent change in reimbursement were calculated for included procedures.Results:After adjusting for inflation, the average physician reimbursement decreased by 31.6% for all included foot and ankle procedures from 2000 to 2020, with 23/30 codes decreasing by more than 30%. The greatest decrease in reimbursement observed from 2000 to 2020 was for open treatment of calcaneal fracture at 48.3% ($2,254.17 to $1,164.97), followed by flexor tendon repair at 48.2% ($741.02 to $357.39), and open treatment of pilon fracture at 43.9% ($2,451.37 to $1,076.36).Conclusion:Over the past two decades, physician reimbursement for foot and ankle procedures has dramatically decreased by up to 48.3%. Continued downward trends in orthopaedic foot and ankle physician reimbursement may lead to decreased access to quality foot and ankle care.

Is There a Difference in PROMIS Outcomes Between Patients Who Received K-Wire or Intramedullary Implant PIP Joint Arthrodesis for Hammertoe Deformity?

Category:Lesser ToesIntroduction/Purpose:Hammertoe corrective procedures are common foot and ankle procedures. Traditionally Kirshner wire (K-wire) fixation has been the gold standard in terms of fixation. Due issues such as pin loosening, failure, tract infection, fibrous pseudoarthrosis, and recurrent deformity with K-wire fixation, newer intramedullary implants have become widely used in the foot and ankle community. These implants have increased cost compared to K-wire fixation. The primary purpose of this study is to evaluate PROMIS T-scores for physical function (PF), pain interference (PI), and depression domains in patients who have undergone PIP arthrodesis by either K-wire or intramedullary fixation. The secondary goal is to determine if there are any differences in these two fixation groups in regard to complication or recurrence rates.Methods:From January 2010 to November 2019, prospective Patient Reported Outcome Measure Information System (PROMIS) score data was retrospectively reviewed for patients who had undergone a hammertoe deformity correction at a multi- surgeon tertiary foot and ankle clinic. Inclusion criteria was patient's older than 18 years, failed conservative management, undergone correction of lesser toe deformity with either K wire fixation or intramedullary fixation. Exclusion criteria was inadequate PROMIS data, previous fracture in same toe, revision surgery, both K wire and intramedullary fixation in the same toe. Preoperative scores were evaluated compared to postoperative scores at multiple time points. Chart review was also performed for patient demographics, complications, and revision surgery. PROMIS physical function (PF), depression, and pain interference (PI) scores were evaluated. Patients with incomplete data sets were excluded from the study. Complications and number of reoperations were noted for each group.Results:252 patients met inclusion criteria, 111 and 138 patient in the intramedullary (IM) and K-wire groups (KW) respectively. Univarate analysis demonstrated significant improvement in PROMIS PF and PI in IM group compared to KW group. Multivariate analysis demonstrated the following: KW group demonstrates a 2.9 point decrease in PROMIS PF post-operative scores relative to the IM group (95% CI -4.75 to -0.99; p = 0.003). The IM implants had significantly higher PF scores than the K-wire group at final follow up (p<0.05). BMI, smoking, and Medicare/Medicaid insurance demonstrated worse PF scores (p<0.05). PROMIS PI did not demonstrate a difference between groups (95% CI -0.377 to 3.724; p = 0.110). The KW group did not demonstrate increase recurrance rate (OR 0.348 95% CI 0.118-1.027; p = 0.056), but did trend towards a higher complication rate compared to the IM group (OR 2.049, 95% CI 0.92 to -4.54; p = 0.078).Conclusion:There is evidence that use of intramedullary implants for operative correction of hammertoe deformity is superior to K-wire fixation in regard to post-operative patient reported measures, specifically the PROMIS domains of physical function. Intramedullary implant use does not increase complication or recurrence rates. Additionally, advanced age, increased BMI, positive smoking status, and Medicare or Medicaid payor status negatively affect patient reported outcomes, which can be used to council patients appropriately. The limitations are that cost of intramedullary implants, are more expensive when compared to conventional K-wires.

Development of A Risk Stratification Scoring System to Predict General Surgical Complications in Foot and Ankle Surgery Patients

Category:Ankle; Ankle Arthritis; Arthroscopy; Basic Sciences/Biologics; Bunion; Diabetes; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports; TraumaIntroduction/Purpose:Preventing postoperative complications is crucial for patients, surgeons, and healthcare facilities. A risk stratification scoring system was created to help optimize risk factors for general surgical complications in foot and ankle surgery patients.Methods:A total of 85,363 patients that underwent foot and ankle procedures from 2005 to 2017 were identified as part of the American College of Surgeons National Surgical Quality Improvement Program. Independent risk factors associated with postoperative complications within 30 days of surgery were identified and used to develop a point-scoring system to estimate the relative risk for experiencing complications. For validation, the system was tested on a subset of patients from the database who had foot and ankle surgery.Results:The 30-day postoperative complication incidence after foot and ankle surgery was 19.1%. Risk factors associated with postoperative complications were tobacco abuse, age (>64), diabetes mellitus, hypertension, elevated creatinine (>1.3 mg/dL), hypoalbuminemia (<3.5 g/dL), and anemia (male hematocrit <42; female <38). Point scores from each factor were: anemia, +7; hypoalbuminemia, +4; hypertension, +4; elevated creatinine, +3; diabetes mellitus, +3; age over 64, +2; and tobacco abuse, +1. In the validation cohort, patients categorized as low risk (0-5), using the point scoring system had a 2.5% rate of 30-day complications; patients categorized as medium risk (6-10) had a 7.5% complication rate (relative risk = 2.0; 95% CI, 1.7-2.3 compared with low risk) and high risk (>=11), 33.1% (relative risk = 3.7; 95% CI, 3.2-4.3).Conclusion:This point scoring system predicts risk for general postoperative complications after foot and ankle surgery. These data may help foot and ankle surgeons identify areas of clinical concern with patients to reduce the risk of experiencing postoperative complications.

Analysis of Complications Following Distal Ankle Nerve Blocks for Foot and Ankle Procedures

Category:Ankle; Arthroscopy; Bunion; Hindfoot; Midfoot/Forefoot; OtherIntroduction/Purpose:Popliteal nerve blocks are a common procedure employed by anesthesiologists to augment intraoperative anesthesia and provide postoperative pain control. Unfortunately, these can be associated with unintended complications including pain, numbness, and foot drop, sometimes without clear resolution. Studies from Kahn (2017), Anderson (2015), Park (2018), Lauf (2020) suggest complications higher than previously reported with Lauf (2020) finding short-term complication rates of 10.1% and 4.1% long-term as confirmed by EMG. Our study looked to address the complication rates from an alternative anesthetic procedure, a distal ankle nerve block involving anesthesia to the five nerve(s) more intimately involved in the surgical procedure. This alternative technique may provide equivalent anesthetic properties and pain relief as popliteal blocks, with fewer complications for many patients across various demographics.Methods:We retrospectively reviewed patient charts and messaging from 2019 to 2021 that received a distal ankle field block for various surgical procedures including ankle arthroscopy, ankle fractures, and lateral ankle stabilizations. The five nerves anesthetized in the distal ankle nerve block included the tibial, superficial and deep peroneal, sural, and saphenous. Thus far, 61 surgeries have been reviewed and analyzed for neuropathic complications and confirmed via EMG.Results:Of the 61 patients analyzed, 3 patients were found to have a superficial peroneal neuropathy that included dorsal numbness as a result of the distal ankle block, resulting in a 4.92% complication rate. 1 patient required a rescue block to be performed postoperatively for pain. The remaining 57 patients recovered appropriately and without complications. No motor complications have been found from patients receiving distal ankle nerve blocks, as performed by the senior author.Conclusion:With the absence of motor complications and markedly reduced incidence of sensory complications, distal ankle nerve blocks may be a beneficial alternative to popliteal nerve blocks for various foot and ankle orthopedic surgeries. As motor complications can result in life-altering disability, an anesthetic procedure with reduced negative motor outcomes can improve surgery and recovery prognosis. Future directions for this study include adding more patients to increase the sample size, as well as continuing to follow current patients, monitoring symptoms or complications.

Economic value of podiatry service in limb salvage alliance.

Over the past decade, multidisciplinary "toe and flow" programs have gained great popularity, with proven benefits in limb salvage. Many vascular surgeons have incorporated podiatrists into their practices. The viability of this practice model requires close partnership, hospital support, and financial sustainability. We intend to examine the economic values of podiatrists in a busy safety-net hospital in the Southwest United States. An administrative database that captured monthly operating room (OR) cases, clinic encounters, in-patient volume, and total work relative value units (wRVUs) in an established limb salvage program in a tertiary referral center were examined. The practice has a diverse patient population with >30% of minority patients. During a period of 3years, there was a significant change in the number of podiatrists (from 1 to 4) within the program, whereas the clinical full-time employees for vascular surgeons remained relatively stable. The limb salvage program experienced >100% of growth in total OR volumes, clinic encounters, and total wRVUs over a period of 4years. A total of 35,591 patients were evaluated in a multidisciplinary limb salvage clinic, and 5535 procedures were performed. The initial growth of clinic volume and operative volume (P< .01) were attributed by the addition of vascular surgeons in year one. However, recruitment of podiatrists to the program significantly increased clinic and OR volume by an additional 60% and >40%, respectively (P< .01) in the past 3years. With equal number of surgeons, podiatry contributed 40% of total wRVUs generated by the entire program in 2019. Despite the fact that that most of the foot and ankle procedures that were regularly performed by vascular surgeons were shifted to the podiatrists, vascular surgeons continued to experience an incremental increase in operative volume and >10% of increase in wRVUs. This study shows that the value of close collaboration between podiatry and vascular in a limb salvage program extends beyond a patient's clinical outcome. A financial advantage of including podiatrists in a vascular surgery practice is clearly demonstrated.

Are Preoperative PROMIS Scores Associated with Postoperative ED Visits?

Category:OtherIntroduction/Purpose:Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores have been shown to be predictive of postoperative success in orthopedic foot and ankle patients. The purpose of this study was to determine if an association exists between pre-operative PROMIS scores and patients going to the emergency department (ED) in the first 60 days following their operation.Methods:PROMIS scores, including physical function (PF) and pain inference (PI), were collected from 290 patients prior to foot and ankle procedures. Patients with presence of ongoing infection were excluded. Electronic medical record (EMR) data was retrospectively gathered for each patient to determine if they visited the ED for any reason during the first 60 days following their operation. A Backward Stepwise Logistic Regression analysis was conducted for postoperative ED visits with p<0.1 in univariate analysis required for entry into the model.Results:The median age was 50.0 with an interquartile range (IQR) of 20.0, while the median BMI was 33.1 with an IQR of 11.6. In univariate analysis, Preoperative PROMIS PF and PI scores were significantly associated with ED visits within the first 60 days after surgery. Patients who visited the ED had lower preoperative PROMIS PF (median 34.9 (IQR 10.2)) and higher PROMIS PI (median 66.9 (IQR 9.1)) compared to patients who did not visit the ED, PROMIS PF (median 38.0 (IQR 10.2)) and PROMIS PI (63.6 (IQR 9.0)), respectively. In multivariate analysis, only PROMIS PF was associated with lower risk of ED visits OR 0.92 (95% CI.85-.99). Other factors independently associated with ED visits included non-traumatic surgical indication OR 3.7 (95% CI 1.1- 12.9), any pulmonary disease OR 4.2 (95% CI 1.4-12.8), ASA classification OR 4.4 (95% CI 1.3-14.9), and wound complications OR 10.2 (95% CI 2.6-39.9).Conclusion:Patients with lower PROMIS PF scores preoperatively were significantly more likely to visit the ED postoperatively. While all of the factors found to be associated with ED visits are not modifiable by the surgeon, preoperative PROMIS scores could quickly and easily be used to identify patients for potential interventions. This study demonstrates the potential of the PROMIS outcomes system outside of quantifying surgical outcomes. Further study is being conducted to investigate the optimal PROMIS PF cutoff for best identifying patients at risk for ED visits.

Marked Mobility Improvement: Men and Women Respond Similarly to Operative Treatment of Foot &amp; Ankle Pathologies

Category:Ankle; HindfootIntroduction/Purpose:Differences between men and women in the perception, incidence, and outcomes of various orthopaedic injuries are well-documented. Recent studies have noted that women display increased ankle ligamentous laxity and double the rate of ankle sprains in relation to their male peers. Current studies indicate that, in general, women and men respond similarly to surgical correction of such pathologies. However, a gender difference in mobility has not been investigated. Given the mobility implications associated with chronic foot and ankle conditions, a need exists to better characterize baseline and postoperative functionality in men and women. The objective of this study was to assess changes in LifeSpace Mobility Assessment (LSA) scores of male and female patients following surgical correction of non-traumatic ankle, hindfoot, and midfoot conditions.Methods:A prospective study of elective ankle, hindfoot, and midfoot procedures conducted by a single surgeon between September 1, 2015 and August 31, 2019 was undertaken following IRB approval. LSA scores on 184 patients - 137 women and 53 men - were collected at preoperative, 3-month, 6-month, and 12-month clinic visits. The electronic medical record was queried for patient demographic and surgical data. Demographics, surgical factors, and patient-reported LSA scores were compared utilizing an independent sample t-test for continuous, normally distributed data. All categorical data was analyzed with a chi- squared or Fischer's exact tests. Alpha and beta were set at 0.05 and 0.8, respectively.Results:The average age of female participants was 51.2 (SD 16.4) years and 48.2 (SD 17.1) years for male participants (p=0.273). There were no significant differences in frequencies of comorbidities (p>0.05). Men and women in this cohort underwent elective foot and ankle surgery for a similar diseases processes, most commonly soft tissue pathology, followed by osteoarthritis (p=0.440). Women had significantly lower LSA scores at preoperative (63.7 [SD 38.1] vs. 84.8 [SD 35.9], p=0.002), 3 month postoperative (52.5 [SD 33.8] vs. 69.9 [SD 34.5], p=0.006), and 1 year postoperative (81.2 [SD 37.2] vs. 105.5 [SD 18.2], p=0.019) timepoints relative to their male peers. No differences in mobility at 6 months postop were observed (p=0.714). Overall, women and men had similar absolute increases in postoperative mobility at 1-year after surgery (17.5 vs. 20.7, p>0.05) as well as similar percentage of increased mobility (27% vs. 24%, p>0.05).Conclusion:The present study provides further evidence of the gender differences in chronic foot and ankle pathologies. Both sexes improved similarly pre to postoperatively, however, women did not reach the same level of absolute mobility as their male counterparts. Prior studies have shown that women characterize a greater degree of limitation with foot and ankle conditions as 'normal' relative to men, making it plausible that they delay treatment until they become more severely symptomatic than men. This persistent deficit highlights the importance of early recognition of mobility impairment in order to preserve function among the sexes in foot and ankle care.

Donor Site Morbidity of Calcaneal, Distal and Proximal Tibial Cancellous Autografts in Foot and Ankle Surgery: A Systematic Review and Meta-Analysis of 2296 Grafts

Category:OtherIntroduction/Purpose:Non-union of foot and ankle arthrodesis sites has been associated with revision surgery, morbidity and increased healthcare costs, so many surgeons elect to augment the fusion site with autologous bone grafts to improve union.While iliac crest autografts are considered the historical gold standard, other donor sites distal in the lower extremity such as calcaneus, proximal and distal tibia have been successfully used in foot and ankle surgery. This study aims to report on the safety and donor site morbidity of distal lower extremity (calcaneal, proximal and distal tibial) bone autografts. We summarized the findings in a comprehensive infographic illustration. We are unaware of any similar meta-analyses to date.Methods:Following the PRISMA guidelines, 2 independent investigators searched several databases in December 2020 using the following keywords and their synonyms: ('Bone graft', 'donor site morbidity', 'calcaneal graft', 'Proximal tibia graft', and 'distal tibia graft'). Besides, the reference lists from previous review articles were searched manually for eligible studies. The primary outcomes of interest were (1) Chronic pain, (2) Fracture and (3) infection whereas the secondary outcomes were (1) neurological complications, (2) sensory disturbance and hypertrophic scars, (3) other complications such as shoe-wear difficulties and gait disturbance. Inclusion criteria were: studies on complications and adverse events of lower extremity bone autografts (calcaneal, proximal tibial, and distal tibial bone autografts) reporting at least one desired outcome. Studies not reporting any of the outcomes of interest or if the full text is not available in English were excluded. Studies reporting on bone marrow aspirate or autografts for non-orthopedic indications were also excluded.Results:After removal of duplicates, 5981 studies were identified. After screening, 85 studies remained for full-text assessment, and 15 studies qualified for the meta-analysis with a total of 2296 bone grafts.1557(67.8%) were calcaneal grafts, 625 (27.2%) were proximal tibial grafts, and 114 (5%) were distal tibial grafts. The mean age of all patients was 52.43+-16 [CI=51.77-53.08] years.The mean follow-up duration was 1.86+-1.70[CI=1.79-1.93] years. The primary surgery was reported for 2129 grafts(92.7%).Out of those, foot and ankle procedure represented 97.4% of the procedures. In calcaneal bone grafts, there were 28 cases of chronic pain [1.97%,CI:1.10-2.50%, I2=66%], 5 fractures [0.32%,CI:0.10-0.60%, I2=0%], 20 sural neuritis [1.28%,CI:0.70-1.80%, I2=0%), and no wound infections. In proximal tibial grafts there were 13 cases of chronic pain [2.08%,CI:1.01-3.2%, I2=34.5%], 1 fracture [0.16%,CI:0.10-0.50%, I2= 0%], and 3 superficial wound infections [0.48%,CI:0.10-1.01, I2=0%]. In the distal tibial grafts there were no cases of chronic pain or wound infections, 1 fracture [0.90%,CI:0.80-2.6%,I2=0%], and 5 saphenous neuritis [4.5%,CI: 0.70- 8.40%,I2=65%].Conclusion:Calcaneal, distal tibial, and proximal tibial bone autografts are safe with a low rate of overall and major complications. We report an overall complication rate of 6.8%, which is less than half of that previously reported for iliac crest grafts. The authors recommend using distal lower extremity grafts for foot and ankle primary surgeries instead of iliac crest grafts when indicated. Clinical trials with large sample sizes are required.