Ankle Surgery Patients Research Articles

Tranexamic Acid in Foot and Ankle Surgery: A Systematic Review and Meta-analysis

Introduction. Tranexamic acid (TXA) use has become common in orthopedic surgeries. Despite the growing number of publications related to its use, no recent systematic reviews have been published examining TXA use in foot and ankle surgery. The purpose of this review article is to provide a summary of the current available literature regarding TXA use in foot and ankle surgery and to further the understanding of its safety and efficacy. Methods.This systematic review utilized PubMed, Ovid, CINAHL, Clinical Key, Medline, and Embase, and the search was conducted through December 22, 2022. Key words used in the search included: “tranexamic acid,” “TXA,” “foot,” “ankle,” “calcaneal,” and “surgery.” The outcomes within the studies analyzed included measures of perioperative blood loss (intra-operative blood loss, 24-hour post-operative blood loss, blood loss from hour 24 to hour 48, post-operative hemoglobin (Hgb), and post-operative hematocrit [Hct]), as well as wound complications and vascular events. Meta-regression was included to assess the impact of age on between-study variation. Results. Ten studies met preliminary inclusion criteria. Upon further inspection, eight met full inclusion criteria for the meta-analysis. Despite a growing amount of literature on the topic, there is still a paucity of literature published on TXA use in foot and ankle surgery. Current literature suggests that foot and ankle surgery patients treated with TXA may have reduced 24-hour post-operative blood loss (MD=-183.41 mL, 95% CI=-247.49 to -119.34 mL, p<0.001), increased post-operative hemoglobin (MD=0.71 g/dL, 95% CI=0.11 to 1.31 g/dL, p=0.020) and hematocrit (MD=2.66%, 95% CI=0.07 to 5.24%, p=0.040) when compared to similar patients not receiving TXA. The use of TXA in foot and ankle surgery did not lead to increased thromboembolic complications. Meta-regression indicated no clinically relevant association of age to between-study variation. Conclusions. TXA was found to be a safe treatment that did affect wound healing or infection rates while decreasing perioperative blood loss. Further research should be performed to evaluate the long-term effects of TXA administration on patient outcomes after foot and ankle surgery.

Venous Thromboembolism: Assessing Risk Factors in Elective Foot and Ankle Surgery Patients

Category: Midfoot/Forefoot; Ankle Introduction/Purpose: Venous thromboembolism (VTE) after foot and ankle surgery is a significant concern for patients and surgeons. The absence of guidelines for thromboprophylaxis in elective procedures underscores the importance of understanding risk factors. This study aimed to identify key risk factors of VTE in patients who underwent elective foot and ankle surgery, analyzing the rates based on the anatomical location of the surgery and the post-operative period. Methods: Data was collected from IBM MarketScan Database (2009-2019) for patients >18y without prior VTE who underwent elective foot/ankle surgery. Patients were divided into three groups based on region of surgery (forefoot, mid/hindfoot, lower leg/ankle), and VTE incidence was recorded 30- and 90-days post-surgery. Risk factors for VTE were identified through multivariate logistical regression analysis. Results: Among the 301,256 patients who underwent elective foot and ankle surgeries, the overall incidence of VTE within 90 days was 0.95%. The findings revealed that 31.8% of VTE incidents occurred within the first two weeks after surgery, and 29.2% still occurred after 6 weeks. An analysis of the anatomical region of surgery demonstrated that the lowest rate of VTE was amongst patients undergoing forefoot surgery (0.70%). There was a higher incidence and risk for VTE in patients undergoing midfoot/hindfoot surgery (1.22%, OR = 1.75) and lower leg/ankle surgery (1.76%, OR= 2.53). Additional risk factors for VTE included thrombophilia (OR = 5.06), male sex (OR = 1.43), increasing age (OR > 1.25), and a high Charlson Comorbidity Index (OR < 0.82 for scores < 5). Conclusion: This study identifies the incidence and timing for VTE after elective foot and ankle surgery. Furthermore, this study defines the risk factors associated with increased odds of VTE after elective foot and ankle surgeries. These findings are helpful in educating patients about a continued risk for VTE throughout the 90-day postoperative period. These results can also be utilized to stratify patients who need thromboprophylaxis based on the individual risk level.

Poster 357: Tranexamic Acid in Foot and Ankle Surgery: A Systematic Review and Meta-analysis

Objectives: Tranexamic acid (TXA) use has become common in Orthopedic surgeries. Despite the growing number of publications related to its use, no recent systematic reviews have been published examining TXA use in foot and ankle surgery. The aim of this review article is to provide a summary of the current available literature regarding TXA use in foot and ankle surgery and to further the understanding of its safety and efficacy. Methods: This was a systematic review following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines as outlined on the PRISMA checklist. Databases utilized included PubMed, Ovid, CINAHL, Clinical Key, Medline, and Embase, and the search was conducted through May 21, 2022. Key words used in the search included: “tranexamic acid,” “TXA,” “foot,” “ankle,” “calcaneal,” and “surgery.” The outcomes within the studies analyzed included measures of perioperative blood loss (intra-operative blood loss, 24-hour postoperative blood loss, blood loss from hour 24 to hour 48, postoperative hemoglobin (Hgb), and postoperative hematocrit (Hct)), as well as wound complications and vascular events. Wound complications and vascular events were defined as infection, hematoma formation, necrosis, dehiscence, DVT, PE, myocardial infarction (MI), acute coronary syndrome (ACS), cardiovascular event (CVA), limb ischemia (LI), gastrointestinal hemorrhage (GIH), nerve damage, and any other conditions specified as wound complications or vascular events within individual studies. The Cochrane Collaboration’s Risk of Bias 2 (RoB2) tool was used to assess the risk of bias in the studies included. The quality of the studies included was scored using a modified Coleman methodology score (MCMS). Primary treatment outcomes having data from three or more studies available were summarized in forest plots using RevMan 5.4.1 software (The Cochrane Collaboration, Copenhagen, Denmark). Random-Effects models were used to calculate mean differences with 95% confidence intervals for each outcome measure. Heterogeneity of studies was assessed using Tau2, Chi2, and I2 statistics. Statistical significance was set at α=0.05 for all comparisons. Results: The literature search produced 1125 papers. The full texts of 16 studies were assessed using inclusion and exclusion criteria and seven studies met preliminary inclusion criteria. Upon further inspection, five met full inclusion criteria for the meta-analysis. All groups receiving TXA had statistically significantly lower blood loss values at 24 hours. One study found a statistically significant increase in blood loss from 24-48 hours in their A group (TXA) versus non-TXA. Three study groups demonstrated statistically significantly higher values of postoperative hemoglobin in patients receiving TXA versus patients not receiving TXA. Three study groups demonstrated statistically significantly higher values of postoperative hematocrit in patients receiving TXA versus patients not receiving TXA. No studies found statistically significant differences in wound complications between TXA and non-TXA groups. Conclusions: Despite a growing amount of literature on the topic, there is still a paucity of literature published on TXA use in foot and ankle surgery. Additional literature is required to determine the best strategy for TXA use to optimize patient outcomes. Current literature suggests that foot and ankle surgery patients treated with TXA may have reduced 24-hour postoperative blood loss, increased postoperative hemoglobin and hematocrit when compared to similar patients not receiving TXA. The use of TXA in foot and ankle surgery did not lead to increased thromboembolic complications.

Case mix-based changes in health status: A prospective study of elective surgery patients in Vancouver, Canada.

Hospital activity is often measured using diagnosis-related groups, or case mix groups, but this information does not represent important aspects of patients' health outcomes. This study reports on case mix-based changes in health status of elective (planned) surgery patients in Vancouver, Canada. We used a prospectively recruited cohort of consecutive patients scheduled for planned inpatient or outpatient surgery in six acute care hospitals in Vancouver. All participants completed the EQ-5D(5L) preoperatively and 6months postoperatively, collected from October 2015 to September 2020 and linked with hospital discharge data. The main outcome was whether patients' self-reported health status improved among different inpatient and outpatient case mix groups. The study included 1665 participants with completed EQ-5D(5L) preoperatively and postoperatively, representing a 44.8% participation rate across eight inpatient and outpatient surgical case mix categories. All case mix categories were associated with a statistically significant gain in health status (p < .01 or lower) as measured by the utility value and visual analogue scale score. Foot and ankle surgery patients had the lowest preoperative health status (mean utility value: 0.6103), while bariatric surgery patients reported the largest improvements in health status (mean gain in utility value: 0.1515). This study provides evidence that it was feasible to compare patient-reported outcomes across case mix categories of surgical patients in a consistent manner across a system of hospitals in one province in Canada. Reporting changes in health status of operative case mix categories identifies characteristics of patients more likely to experience significant gains in health.

Kinetics of functional recovery after foot and ankle surgery. Comparison of EFAS and SF36 scores

IntroductionThe EFAS score is a new recently validated European quality of life score for foot and ankle surgery, comprising 6 questions on activities of daily living (ADL) and 4 on sport. The aim of the present study was to assess the kinetics of functional recovery on the EFAS and SF36 scores, and to assess correlations between the two at 0 to 6 months then 6 months to 1 year in a population of foot and ankle surgery patients, globally and per pathology. HypothesisHindfoot and ankle surgery requires at least 1 year's follow-up for assessment of recovery, whereas 6 months is sufficient to assess forefoot recovery. Material and methodsA multicenter prospective cohort study included all patients undergoing surgery for foot and ankle pathology between December 2015 and July 2016. Statistical analysis, global and per pathology, was performed preoperatively and at 6 months and 1 year. ResultsIn total, 98 patients were assessed at 1 year. In the global population, EFAS ADL score improved by 17.1±22.1 points (hindfoot, 16.9±24.6; forefoot, 19.7±21.4) and global SF36 score by 8.7±17.1 points (hindfoot, 10.2±19.1; forefoot, 9.6±15.9). Both scores progressed between 6 months and 1 year for hindfoot pathologies, whereas they remained constant after 6 months for the forefoot. The EFAS score showed weak correlation with SF36. ConclusionRecovery kinetics differs according to type of foot and ankle pathology. The EFAS score is more suitable than the SF36. Level of evidenceII.

EFAS Score—Validation of Spanish and Estonian Versions by the Score Committee of the European Foot and Ankle Society (EFAS)

BackgroundThe Score Committee of the European Foot and Ankle Society (EFAS) developed, validated, and published the EFAS Score in 11 languages (Dutch, English, German, Finnish, French, Italian, Polish, Portuguese, Persian, Swedish, Turkish). From other languages under validation, the Spanish and Estonian versions completed data acquisition and underwent further validation. MethodsThe EFAS Score was developed and validated in three stages: 1) item (question) identification (completed during the initial validation study), 2) item reduction and scale exploration (completed during the initial validation study), 3) confirmatory analyses and responsiveness of the Spanish and Estonian versions (completed during the initial validation study in seven other languages). The data were collected pre-operatively and post-operatively at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using classical test theory and item response theory. ResultsThe internal consistency of the scale was confirmed in the Spanish and Estonian versions (Cronbach’s Alpha>0.8). Responsiveness was good, with moderate to large effect sizes in both languages, and evidence of a statistically significant positive association between the EFAS Score and patient-reported improvement. ConclusionsThe Spanish and Estonian EFAS Score versions were successfully validated in orthopaedic ankle and foot surgery patients, with a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.net.

Accuracy of Pain Tolerance Self-assessment Versus Objective Pressure Sensitivity.

Effective treatment of postoperative pain after elective surgery remains elusive, and the experience of pain can be variable for patients. The patient's intrinsic pain tolerance may contribute to this variability. We sought to identify whether there was a correlation between subjective report of intrinsic pain tolerance and objective measurement of pressure dolorimetry (PD). We also sought to identify whether a correlation existed between PD and Patient Reported Outcome Measurement Information System (PROMIS) scores of pain intensity, physical function, and mood. PD is a validated, objective method to assess pain tolerance. Markers of general mental and physical health are correlated with pain sensitization and may also be linked to pain tolerance. PROMIS scores, dolorimetry measurements, and survey data were collected on 40 consecutive orthopaedic foot and ankle surgery patients at the initial clinic visit. Patients were included if they had normal sensation on the plantar foot and no prior surgery or plantar heel source of pain. Objective dolorimetry data reflecting 5/10 pain for the patients were 24 N/cm 2 (±8.9). Patients estimated their pain threshold as 7.3/10 (±2.1). No correlation was found between objective and subjective pain threshold identified. A moderate negative correlation of R = -0.44 was observed regarding PROMIS-M with dolorimetry data ( P < -0.05). PROMIS-M score >60 had a significant decrease in pain threshold to 15.9 ± 8.5 N/cm 2 compared with 25.7 ± 8.9 N/cm 2 for those who were less depressed with a PROMIS<60 ( P < 0.05). Subjective pain tolerance is not correlated with the patient's own objective pain threshold or markers of mental health and should not be used to assist clinical decision making. PROMIS-M is inversely correlated with objective pain. Higher PROMIS-M scores are associated with a lower objective pain threshold. Level II-Lesser Quality Randomized Controlled Trial or Prospective Comparative Study.

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.

Do Geographic Region, Pathologic Chronicity, and Hospital Affiliation Affect Access to Care Among Medicaid- and Privately Insured Foot and Ankle Surgery Patients?

Studies have shown that patients enrolled in Medicaid have difficulty obtaining access to care compared with patients with private insurance. Whether variables such as geographic location, state expansion versus nonexpansion, and private versus academic affiliation affect access to care among foot and ankle surgery patients enrolled in Medicaid has not been previously established. The purpose of this study was to assess the differences in access to care between patients who are privately insured and those with Medicaid in need of foot and ankle consultation. Secondary objectives include assessment of whether access to care for foot and ankle patients with Medicaid differs between those with acute and chronic conditions, Medicaid expanded and unexpanded states, geographic regions within the United States, and academic versus private practices. Twenty providers from each of five Medicaid-expanded and five nonexpanded states in different US geographic regions were randomly chosen via the American Orthopaedic Foot & Ankle Society directory. One investigator contacted each office requesting the earliest available appointment for their fictitious relative's acute Achilles tendon rupture or hallux valgus. Investigator insurance was stated to be Medicaid for half of the telephone calls and Blue Cross Blue Shield (BCBS) for the other half. Appointment success rate and average time to appointment were compared between private insurance and Medicaid. Results were further compared across geographic regions, between private and academic practices, and between urgent acute injury (Achilles rupture) and chronic nonurgent injury (hallux valgus). Appointments were successful for all 100 (100%) calls made with BCBS as the insurer, in comparison to 73 of 100 calls (73%) with Medicaid (P < 0.001). Both acute and chronic injury had significantly higher success rates with BCBS than Medicaid (P < 0.001). The appointment success rate was significantly lower with Medicaid than with BCBS (P ≤ 0.01) in all of the geographic regions. The success rate with Medicaid (66.7%) was significantly lower than with BCBS (100.0%, P < 0.001) for private practice offices, but not for academic practices. Patients with Medicaid experience fewer options when obtaining appointments for common nonemergent foot and ankle problems and may experience less difficulty scheduling appointments at academic rather than private institutions. The medical community should continue to seek and identify potential interventions which can improve access to orthopedic care for all patients and increase the visibility of practices that accept Medicaid.

Do Geographic Region, Pathologic Chronicity, and Hospital Affiliation Affect Access to Care Among Medicaid- and Privately-Insured Foot and Ankle Surgery Patients?

Category:OtherIntroduction/Purpose:Studies have shown that patients enrolled in Medicaid have difficulty obtaining access to care compared to patients with private insurance. Whether variables such as geographic location, state expansion vs. non-expansion, and private versus academic affiliation affect access to care among foot and ankle surgery patients enrolled in Medicaid has not been previously established.Methods:Twenty providers from each of five Medicaid-expanded and five non-expanded states in different U.S. geographic regions were randomly chosen via the American Orthopaedic Foot & Ankle Society (AOFAS) directory. One investigator contacted each office requesting the earliest available appointment for their fictitious relative’s acute Achilles tendon rupture or hallux valgus. Investigator insurance was stated to be Medicaid for half of phone calls, and Blue-Cross Blue-Shield (BCBS) for the other half. Appointment success rate and average time to appointment were compared between private insurance and Medicaid. Results were further compared across geographic regions, between private and academic practices, and between urgent acute injury (Achilles rupture) and chronic non-urgent injury (hallux valgus).Results:Appointments were successful for all 100 (100%) calls made with BCBS, in comparison to 73 of 100 calls (73%) with Medicaid (p<0.001). Both acute and chronic injury had significantly higher success rates with BCBS than Medicaid (p<0.001). Appointment success rate was significantly lower with Medicaid than with BCBS (p<=0.01) in all geographic regions. Success rate with Medicaid (66.7%) was significantly lower than with BCBS (100.0%, p<0.001) for private practice offices, but not for academic practices.Conclusion:Patients with Medicaid experience difficulty in obtaining appointments for common non-emergent foot and ankle problems and may experience increased difficulty scheduling appointments at private rather than academic institutions. The medical community should continue to seek and identify potential interventions which can improve access to orthopaedic care for all patients, regardless of insurance status.

Tranexamic Acid Use in Foot and Ankle Surgery.

Background:There is a potential role for tranexamic acid (TXA) use in foot and ankle procedures; however, the benefits of this intervention have not been fully elucidated. The purpose of this study was to explore the safety, outcomes, and medical complication profile of the use of intravenous TXA in patients undergoing foot and ankle surgery.Methods:A prospective study with retrospective review of 241 patients undergoing elective and traumatic foot and ankle procedures was performed. One gram of intravenous (IV) TXA was administered prior to incision. Patients were followed and evaluated for medical comorbidities, intraoperative blood loss, wound complication, superficial and deep infections, hematoma formation, medical complications, 30-day hospital readmission rate, and return visits to the emergency department or urgent care setting prior to first postoperative visit. Descriptive statistics were used for subgroup analysis. Mean postoperative follow-up was 4.5 months.Results:Estimated blood loss in all cases was less than 20 mL. There was 1 case of superficial cellulitis (1/241, 0.4%), 1 deep infection after Achilles tendon repair (1/241, 0.4%), 4 cases of delayed wound healing (4/241, 1.6%), 1 instance of deep vein thrombosis (1/241, 0.4%), and 2 cases of postoperative pulmonary embolism (2/241, 0.8%). There were no instances of postoperative hematoma formation. There were no additional recorded thromboembolic events. There were no adverse drug reactions. There were no 30-day hospital readmissions or return visits to the emergency department or urgent care setting before the first postoperative visit. In a subgroup analysis, there was no significant difference in wound complications or infections between nondiabetics and diabetics (P > .05) and traumatic and nontraumatic cases (P > .05).Conclusions:The use of IV TXA in foot and ankle surgeries was associated with low risk of wound complications, infections, hematoma formation, thromboembolic events, and overall complication rates with minimal side effect profile. Perioperative tranexamic acid use may prove to be beneficial in foot and ankle surgery patients but especially in higher-risk patients such as those with diabetes, trauma, and those that are immunocompromised.Level of Evidence:Level IV, case series.

Does Postoperative Gabapentin Administration Reduce Opioid Consumption after Foot and Ankle Surgery?

Category:Ankle; Hindfoot; Midfoot/ForefootIntroduction/Purpose:Prescription opioids are commonly used to control postoperative pain in foot and ankle surgery, but present potentially detrimental side effects including sedation, respiratory depression, and addiction. In foot and ankle surgery, pain is a common cause of delayed hospital discharge and decreased willingness to move, thereby slowing recovery. Gabapentin acts by decreasing lesion-induced hyperexcitability of posterior horn neurons and central sensitization, and has been explored as a potential addition to patients’ pain regimen. Although studies have previously assessed the effect of gabapentin on pain relief, to our knowledge none have evaluated whether gabapentin is effective in opioid consumption reduction beyond the immediate postoperative period. The purpose of this study is to assess whether gabapentin acts synergistically to improve postoperative pain among patients undergoing foot and ankle surgery.Methods:Patients from a single institution who underwent elective foot and ankle surgery were identified using CPT codes 27700, 27702, 27870, 28705, 28715, 28725, 28730, and 28740. All patients prescribed opioids postoperatively were included. A retrospective chart review was conducted for each patient to identify prescription dose, number of pills, date in which prescription was filled, and dates of refills for oxycodone, hydrocodone, oxycodone-acetaminophen, hydrocodone-acetaminophen, tramadol, and gabapentin. Medication information was collected only for prescriptions by the operating surgeon, nurse practitioner, physician assistant, resident, or fellow which were pertinent to the foot/ankle surgery performed; prescriptions from other services or providers were not included in order to ensure that the medications prescribed were specific to postoperative pain. Opioid quantities were converted to morphine equivalents and compared at various time intervals between patients who were prescribed only opioids, and patients who were prescribed opioids and gabapentin.Results:Among patients not taking opioids or gabapentin preoperatively, total morphine equivalents prescribed was significantly less among patients prescribed postoperative gabapentin (177.3 OME) in comparison to those prescribed only opioids (442.2 OME) (p=0.0018) in the 3-6 week postoperative interval. When all patients were analyzed, including those taking preoperative opioids or gabapentin, patients who received postoperative gabapentin were also prescribed significantly fewer OME at weeks 1-2 (p= 0.0270), weeks 3-6 (p = 0.0006), and weeks 7 - 12 (p = 0.0149).Conclusion:Gabapentin may be effective in reducing postoperative opioid consumption beyond the immediate postoperative period among elective foot and ankle surgery patients. Prospective clinical trials are warranted to further validate these results.

EFAS Score – validation of Finnish and Turkish versions by the Score Committee of the European Foot and Ankle Society (EFAS)

BackgroundThe Score Committee of the European Foot and Ankle Society (EFAS) developed, validated, and published the EFAS Score in seven European languages (English, German, French, Italian, Polish, Dutch, Swedish). From other languages under validation, the Finnish and Turkish versions finished data acquisition and underwent further validation. MethodsThe EFAS Score was developed and validated in three stages: 1) item (question) identification (completed during initial validation study), 2) item reduction and scale exploration (completed during initial validation study), 3) confirmatory analyses and responsiveness of Finnish and Turkish version (completed during initial validation study in seven other languages). The data were collected pre-operatively and post-operatively at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using classical test theory and item response theory. ResultsThe internal consistency of the scale was confirmed in the Finnish and Turkish versions (Cronbach's Alpha >0.8). Responsiveness was good, with moderate to large effect sizes in both languages, and evidence of a statistically significant positive association between the EFAS Score and patient-reported improvement. ConclusionsThe Finnish and Turkish EFAS Score versions were successfully validated in the orthopaedic ankle and foot surgery patients, including a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.co.

Effect of Postoperative Gabapentin Administration on Opioid Consumption

Category:Foot & Ankle SurgeryIntroduction/Purpose:Prescription opioids are commonly used to control postoperative pain in foot and ankle surgery, but present potentially detrimental side effects including sedation, respiratory depression, and addiction. In foot and ankle surgery, pain is a common cause of delayed hospital discharge and decreased willingness to move, thereby slowing recovery. Gabapentin acts by decreasing lesion-induced hyperexcitability of posterior horn neurons and central sensitization, and has been explored as a potential addition to patients’ pain regimen. Although studies have previously assessed the effect of gabapentin on pain relief, to our knowledge none have evaluated whether gabapentin is effective in opioid consumption reduction beyond the immediate postoperative period. This study aims to assess whether gabapentin acts synergistically to improve postoperative pain among patients undergoing foot and ankle surgery.Methods:Patients from a single institution who underwent elective foot and ankle surgery were identified using CPT codes 27700, 27702, 27870, 28705, 28715, 28725, 28730, and 28740. Those prescribed opioids postoperatively were included. A retrospective chart review was conducted for each patient to identify prescription dose, number of pills, date in which prescription was filled, and dates of refills for oxycodone, hydrocodone, oxycodone-acetaminophen, hydrocodone-acetaminophen, tramadol, and gabapentin. Medication information was collected only for prescriptions by the operating surgeon, nurse practitioner, physician assistant, resident, or fellow which were pertinent to the foot/ankle surgery performed; prescriptions from other services or providers were not included in order to ensure that the medications prescribed were specific to postoperative pain. Opioid quantities were converted to morphine equivalents and compared at various time intervals between patients who were prescribed only opioids, and patients who were prescribed opioids and gabapentin.Results:Among patients prescribed gabapentin plus opioids, total opioids prescribed (in morphine equivalents, OME) was 68.33, 221.25, 87.50, and 400.83 at weeks 1-2, 3-6, 7-12, and greater than 12, respectively. Although not statistically significantly different, patients prescribed only opioids had greater average amounts of opioids prescribed at all time intervals, equaling 98.34 OME, 553.52 OME, 540.53 OME, and 766.25 OME at weeks 1-2, 3-6, 7-12, and greater than 12, respectively. When excluding patients taking opioids preoperatively, total morphine equivalents prescribed was significantly less among patients prescribed gabapentin (196.94 OME) in comparison to those prescribed only opioids (457.41 OME) (p=0.0255).Conclusion:The findings of this study suggest that gabapentin may be effective in reducing postoperative opioid consumption beyond the immediate postoperative period among elective foot and ankle surgery patients. Gabapentin may be particularly beneficial within the three to six week postoperative period. Prospective clinical trials are warranted to further validate these results.

Prevalence and Safety of Left-Footed Driving in Right Foot Surgery Patients: A Retrospective Survey and Driving Simulation Study

Category:Post-operative DrivingIntroduction/Purpose:For many patients, returning to driving after right foot and ankle surgery is a concern, and it is not uncommon for patients to ask if driving may be performed with their left foot. A paucity of literature exists to guide physician recommendations for return to driving. The purpose of this study is to describe the driving habits of patients after right-sided foot surgery and assess the safety of left foot driving using a driving simulator.Methods:Patients who underwent right foot or ankle operations between January 2015 and December 2015 were retrospectively identified. A survey assessing driving habits prior to surgery and during the recovery period was administered via REDCap database through email or telephone. Additionally, simulated driving scenarios were conducted using a driving simulator in 20 patients to compare characteristics of left versus right foot driving.Results:Thirty six of 96 (37%) patients who responded to the survey reported driving with the left foot postoperatively. No trends were found associating left foot driving prevalence and socioeconomic status. In driving simulations, patients exceeded the speed limit significantly more (p<0.001) and hit other vehicles more (p<0.026) when driving with the right foot than the left. Time to fully brake and fully release the throttle in response to vehicular hazards were significantly prolonged in left foot driving compared to right (p = 0.019 and p = 0.034, respectively).Conclusion:A significant proportion of right foot and ankle surgery patients engaged in left foot driving during postoperative recovery. Driving with the left foot may prolong brake and throttle release times, and is therefore not recommended.

Measurement properties of PROMIS short forms for pain and function in orthopedic foot and ankle surgery patients.

To examine the measurement properties of the German PROMIS short forms for pain intensity (PAIN), pain interference (PI) and physical function (PF) in orthopedic foot and ankle surgery patients. Patient-rated outcomes were collected from consecutive patients of our foot and ankle registry before and 6months after surgery. Measurement properties were tested according to the COnsensus-based Standards for the selection of health status Measurement Instruments (COSMIN). The German Foot Function Index (FFI-D) served as a legacy measure. 748 patients were included in our cross-sectional sample. Longitudinal and test-retest data were available for 202 and 65 patients, respectively. Construct validity of all short forms was good. All Cronbach's α and intraclass correlation coefficients were > 0.7. The smallest detectable change (SDC) was highest for PF (8.9) and lowest for PI (6.5). Minimal important change was 4 to 5 points and thus smaller than SDC for all instruments. We observed a baseline ceiling effect for PF. PI showed insufficiently correlated change scores with FFI-D disability change scores, and therefore failed the responsiveness testing. Our study showed some adequate psychometric properties, but also certain aspects regarding interpretability and responsiveness that researchers must be aware of when using PROMIS short forms of pain and function in foot and ankle surgery patients.

Prevalence and Safety of Left-Footed Driving Following Right Foot Surgery Patients Including a Driving Simulation.

For many patients, returning to driving after right foot and ankle surgery is a concern, and it is not uncommon for patients to ask if driving may be performed with their left foot. A paucity of literature exists to guide physician recommendations for return to driving. The purpose of this study was to describe the driving habits of patients after right-sided foot surgery and assess the safety of left-footed driving using a driving simulator. Patients who underwent right foot or ankle operations between January 2015 and December 2015 were retrospectively identified. A survey assessing driving habits prior to surgery and during the recovery period was administered via a REDCap database through email or telephone. Additionally, simulated driving scenarios were conducted using a driving simulator in 20 volunteer subjects to compare characteristics of left- versus right-footed driving. Thirty-six of 96 (37%) patients who responded to the survey reported driving with the left foot postoperatively. No trends were found associating left-footed driving prevalence and socioeconomic status. In driving simulations, patients exceeded the speed limit significantly more (P < .001) and hit other vehicles more (P < .026) when driving with the right foot than the left. The time to fully brake and fully release the throttle in response to vehicular hazards was significantly prolonged in left-footed driving compared with right (P = .019 and P = .034, respectively). A significant proportion of right foot ankle surgery patients engaged in left-footed driving during postoperative recovery. Driving with both the right and left foot presents a risk of compromised safety. This study provides novel objective data regarding the potential risks of unipedal left-footed driving using a standard right-footed console, which indicates that driving with the left foot may prolong brake and throttle release times. Further studies are warranted for physicians to be able to appropriately advise patients about driving after foot and ankle surgery. Level IV, case series.

Postoperative Tourniquet Pain in Patients Undergoing Foot and Ankle Surgery.

Background Tourniquets are commonly used to reduce bleeding intraoperatively during orthopedic surgery. There are variable guidelines for ideal tourniquet pressure and duration; the practice of fixed, high tourniquet pressures remains common. The purpose of this study was to assess the correlation between excessive tourniquet pressure and duration and the incidence of tourniquet pain in foot and ankle surgery patients.Methods A retrospective cohort study was conducted on 128 patients who underwent foot and ankle surgery with tourniquet use. Baseline systolic blood pressure (SBP), tourniquet pressure and duration, intraoperative opioid consumption, post-anesthesia care unit (PACU) pain scores, PACU opioid consumption, and PACU length of stay (LOS) were collected. Linear regression analysis was used to test for the statistical correlation between the tourniquet pressure and duration and postoperative pain scores, narcotic use, and PACU LOS.ResultsA tourniquet pressure of 280 mmHg was used in 90% of the cases (N = 128). Only 2.5% of the patients had tourniquet pressures 100-150 mmHg above SBP. The mean tourniquet time was 107.5 minutes ± 39.8. Linear regression showed a significant positive correlation between tourniquet time and morphine equivalents used in the perioperative period (r = 0.410; p < 0.001) and the length of PACU stay (r = 0.250; p = 0.012).Conclusion Prolonged tourniquet times at high pressures, not based on limb occlusion pressure LOP, lead to increased pain and opioid use and prolonged PACU LOS. Basing tourniquet pressures on LOPs could likely improve the safety margin of the tourniquets; however, randomized clinical trials are needed.

Postoperative Tourniquet Pain in Patients Undergoing Foot and Ankle Surgery

Category: Other Introduction/Purpose: The tourniquet is commonly used in orthopedic surgeries on the upper and lower extremities to reduce blood loss, improve visualization, and expedite the surgical procedure. However, tourniquets have been associated with multiple local and systemic complications, including postoperative pain. Guidelines vary regarding ideal tourniquet pressure and duration, while the practice of fixed, high tourniquet pressures remains common. The relationship between tourniquet pressure, duration, and postoperative pain has been studied in various orthopaedic procedures, but these relationships remain unknown in foot and ankle surgery. The purpose of this study was to assess for correlation between excessive tourniquet pressure and duration and the increased incidence of tourniquet pain in foot and ankle surgery patients. Methods: Retrospective chart review was performed for 132 adult patients who underwent foot and ankle surgery with concomitant use of intraoperative tourniquet at a single institution between August and December of 2015. Patients with history of daily opioid use of 30 or more morphine oral equivalents for greater than 30 days, patients who underwent foot and ankle surgery without regional nerve block, patients deemed to have failed regional nerve block, and patients who underwent foot and ankle surgery without tourniquet use were excluded. Patient’s baseline systolic blood pressure, tourniquet pressure and duration, tourniquet deflation time, tourniquet reinflation pressure and duration, intraoperative blood pressure and heart rate changes, intra-operative opioid consumption, PACU pain scores, PACU opioid consumption, and PACU length of stay were collected. Statistical correlation between tourniquet pressure and duration and postoperative pain scores, pain location, narcotic use, and length of stay in PACU was assessed using linear regression in SPSS. Results: Average age of patients was 47.6 years (Range: 16 - 79). Tourniquet pressure was 280 mmHg in 90.6% of patients (Range: 250-300 mmHg). Only 3.8% percent of patients had tourniquet pressures 100-150 mmHg above systolic blood pressure. Mean tourniquet time was 106.2 ± 40.1 min. Tourniquet time showed significant positive correlation with morphine equivalents used in the perioperative period (N = 121; r = 0.406; p &lt; 0.001). Long tourniquet times (= 90 minutes) were associated with greater intraoperative opioid use than short tourniquet times (= 90 minutes) (19 mg ± 22 mg vs. 5 mg ± 11.6 mg; p &lt;0.001). Tourniquet duration and PACU length of stay had a positive association (R2 = 0.4). Conclusion: The majority of cases of foot and ankle surgery at our institution did not adhere to current tourniquet use guidelines, which recommend tourniquet pressure between 100 and 150 mmHg above patient’s systolic blood pressure. Prolonged tourniquet times at high pressures not based on limb occlusion pressure, as observed in our study, lead to increased pain and opioid use and prolonged time in PACU. Basing tourniquet pressures on limb occlusion pressures could likely improve the safety margin of tourniquets, however randomized studies need to be completed to confirm this.

Vitamin D levels in 577 consecutive elective foot & ankle surgery patients

BackgroundVitamin D deficiency is a global concern impacting upon large communities and certain disease populations. It can adversely affect the outcome of orthopaedic operations. We aimed to perform an audit of the Vitamin D status of patients in two centres in the United Kingdom undergoing elective foot and ankle surgery. MethodsSerum 25-hydroxyvitamin-D (vitamin D) levels were obtained prospectively in 577 consecutive elective patients undergoing elective foot and ankle surgery between October 2014 and March 2017 (29 months). Variables including age, gender, ethnicity, location, season, month and procedure type were recorded. Results577 patients were included over the study period. 62.0% were female. Mean age was 53.2 (median 54.5, range 16.7–86.6). 300 patients were treated in Northampton and 277 in Leicester. The serum 25-hydroxyvitamin-D levels for the patient group were normally distributed. The mean was 52.3nmol/L (SD 28.0; range 7.5–175) and the median 47.5nmol/L. 21.7% were grossly deficient, 31.9% deficient, 28.9% insufficient and 17.5% within normal range. Age, gender and procedure type did not statistically affect vitamin D levels (p=0.5, t-test). Ethnicity, location and Winter season did affect Vitamin D levels (p<0.05). August was the most significant month with levels significantly higher than January, February, March, April, June, November and December (p<0.05, one-way ANOVA). ConclusionsOnly 1 in 5.7 patients had a normal Vitamin D level and 1 in 4.6 were grossly deficient. Ethnicity and patient location significantly affected Vitamin D results. Summer months were noted to demonstrate significantly the highest levels and August the highest. We did not find that age or gender affected Vitamin D levels in our cohort.