American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Perioperative Management

The effect of tourniquet use on postoperative opioid consumption after ankle fracture surgery - a retrospective cohort study

OBJECTIVES

A pneumatic tourniquet is often used during ankle fracture surgery to reduce bleeding and enhance the visibility of the surgical field. Tourniquet use causes both mechanical and ischemic pain. The main purpose of this study was to evaluate the effect of tourniquet time on postoperative opioid consumption after ankle fracture surgery.

METHODS

We retrospectively reviewed the files of 586 adult patients with surgically treated ankle fractures during the years 2014-2016. We evaluated post hoc the effect of tourniquet time on postoperative opioid consumption during the first 24 h after surgery. The patients were divided into quartiles by the tourniquet time (4-43 min; 44-58 min; 59-82 min; and ≥83 min). Multivariable linear regression analysis was used to evaluate the results.

RESULTS

Tourniquets were used in 486 patients. The use of a tourniquet was associated with an increase in the total postoperative opioid consumption by 5.1 mg (95 % CI 1.6-8.5; p=0.004) during the first 24 postoperative hours. The tourniquet time over 83 min was associated with an increase in the mean postoperative oxycodone consumption by 5.4 mg (95 % CI 1.2 to 9.7; p=0.012) compared to patients with tourniquet time of 4-43 min.

CONCLUSIONS

The use of a tourniquet and prolonged tourniquet time were associated with higher postoperative opioid consumption during the 24 h postoperative follow-up after surgical ankle fracture fixation. The need for ethical approval and informed consent was waived by the Institutional Review Board of Northern Ostrobothnia Health District because of the retrospective nature of the study.

Anterior Ankle Incision Healing Complications With and Without Tourniquet Use: A Retrospective Comparative Cohort Study

Anterior ankle incisions and tourniquet use in foot and ankle surgery have both been associated with increased incidence of incisional healing complications. Although a tourniquet is commonly used for procedures such as total ankle replacement and ankle arthrodesis that utilize an anterior ankle incision, it is possible to avoid tourniquet use while preserving adequate visualization with atraumatic layered dissection and closure, appropriate use of electrocautery, and ligation of vessels as needed. The primary aim of this study is to report rates of anterior ankle incisional healing complications both with and without tourniquet use. A retrospective chart review was performed on consecutive patients undergoing total ankle replacement or ankle arthrodesis through a multi-provider foot and ankle surgery practice between 2013 and 2018. A total of 121 patients, 58 (47.9%) in the tourniquet group and 63 (52.1%) in the no-tourniquet group, were included in this study with a median follow-up period of 36 (range 2-96) months. There was a higher rate of incisional healing complications for the tourniquet group (5.2%) compared to the no-tourniquet group (3.2%), however this did not reach statistical significance (p = .670). There was no significant difference in operative time between the tourniquet and no-tourniquet group (p = .405). The overall incisional healing complication rate was 4.1%. Although avoiding tourniquet use alone does not appear to significantly reduce anterior ankle incisional healing complications, the described technique has yielded an overall lower rate of incisional complications compared to those commonly reported in the literature.

A practical guide for perioperative smoking cessation

The perioperative management of patients who are smokers presents anesthesiologists with various challenges related to respiratory, circulatory, and other clinical problems. Regarding 30-day postoperative outcomes, smokers have higher risks of mortality and complications than non-smokers, including death, pneumonia, unplanned tracheal intubation, mechanical ventilation, cardiac arrest, myocardial infarction, and stroke. Given the benefits of smoking cessation and the adverse effects of smoking on perioperative patient management, patients should quit smoking long before surgery. However, anesthesiologists cannot address these issues alone. The Japanese Society of Anesthesiologists established guidelines in 2015 (published in a medical journal in 2017) to enlighten surgical staff members and patients regarding perioperative tobacco cessation. The primary objective of perioperative smoking cessation is to reduce the risks of adverse cardiovascular and respiratory events, wound infection, and other perioperative complications. Perioperative preparations constitute a powerful teachable moment, a "golden opportunity" for smoking cessation to achieve improved primary disease outcomes and prevent the occurrence of tobacco-related conditions. This review updates the aforementioned guidelines as a practical guide to cover the nuts and bolts of perioperative smoking cessation. Its goal is to assist surgeons, anesthesiologists, and other medical professionals and to increase patients' awareness of smoking risks before elective surgery.

Acute postoperative pain management protocols in podiatric surgery within Australia: a Delphi study

Background

There is limited evidence in the literature to describe an analgesic protocol that takes into consideration the extent of foot and ankle surgery. The aim of this study was to develop a guide for acute postoperative pain management for podiatric surgery in Australia, and to identify opportunities to improve the current list of scheduled medicines available to podiatric surgeons.

Methods

A Delphi method involving 3 survey rounds was employed for this study. Twelve expert panellists in the field of podiatric surgery and anaesthesiology were invited to participate, and 10 panellists remained by the end of the study. Round 1 involved 15 open-ended questions. These answers formed the basis of the 55 statements that were developed for the following 2 survey rounds, where panellists rated the appropriateness of each statement on a 9-point Likert scale. The third survey round was an opportunity for panellists to revise their answers to each statement in light of the majority response.

Results

For mild acute postoperative pain, non-opioid oral analgesics were recommended as an appropriate management option. For moderate and severe acute postoperative pain, both non-opioid and opioid products were found to be appropriate by the majority. It was agreed that oral opioids be reserved for breakthrough pain at all severity levels. All other statements in the Delphi study pertaining to drug hypersensitivities or allergies, stratification of pain management, opioid prescription concerns, and access to pain medications were accepted as appropriate by the majority of panellists.

Conclusion

The agreed approach to acute postoperative pain management for podiatric surgeons in Australia was with a stepwise approach, utilising multimodal therapy, and reserving oral opioids for breakthrough pain. Additionally, there was consensus for podiatric surgeons in Australia to have wider access to alternative analgesics and anti-emetics that have similar or improved efficacies with better safety profiles.

Endoscopic speed bridge: A new treatment for insertional Achilles tendinopathy

Surgical treatment may be indicated after failure of medical management of insertional Achilles tendinopathy, and may consist in simple calcaneoplasty, increasingly performed endoscopically, or in open detachment-reattachment. Isolated calcaneoplasty sometimes shows poor results in case of multiple overlooked lesions (bone, tendon, pre- or retro-tendinous bursitis). Detachment-reattachment may be indicated in case of tendon lesion, but incurred scar and infection related risk in up to 30% of cases in certain reports. In this context, we describe a new original technique using an endoscopic Achilles speed bridge, which we call the "snake technique" for the S-shaped order of performance of the 6 necessary approaches.

Vitamin D in the Foot and Ankle: A Review of the Literature

BACKGROUND

Vitamin D is an essential vitamin that targets several tissues and organs and plays an important role in calcium homeostasis. Vitamin D deficiency is common, particularly at higher latitudes, where there is reduced exposure to ultraviolet B radiation. We reviewed the role of vitamin D and its deficiency in foot and ankle pathology.

METHODS

The effects of vitamin D deficiency have been extensively studied, but only a small portion of the literature has focused on the foot and ankle. Most evidence regarding the foot and ankle consists of retrospective studies, which cannot determine whether vitamin D deficiency is, in fact, the cause of the pathologies being investigated.

RESULTS

The available evidence suggests that insufficient vitamin D levels may result in an increased incidence of foot and ankle fractures. The effects of vitamin D deficiency on fracture healing, bone marrow edema syndrome, osteochondral lesions of the talus, strength around the foot and ankle, tendon disorders, elective foot and ankle surgery, and other foot and ankle conditions are less clear.

CONCLUSIONS

Based on the available evidence, we cannot recommend routine testing or supplementation of vitamin D in patients with foot and ankle pathology. However, supplementation is cheap, safe, and may be of benefit in patients at high risk for deficiency. When vitamin D is supplemented, the evidence suggests that calcium should be co-supplemented. Further high-quality research is needed into the effect of vitamin D in the foot and ankle. Cost-benefit analyses of routine testing and supplementation of vitamin D for foot and ankle pathology are also required.

Understanding and Optimizing Tourniquet Use During Extremity Surgery

Tourniquet use during extremity surgery is commonplace and a relatively safe practice. The surgical team's knowledge of the patient history, proper assessment, and indications and contraindications for and risks of tourniquet use can prevent unwanted outcomes. Exploration of these critical areas reinforces perioperative nurses' awareness and understanding of safe tourniquet use. Additionally, a review of the physiological effect of tourniquets on the skin, the body's response to local compression, the risk of vascular compromise, and the effect of the tourniquet on postoperative pain and swelling provides insight into AORN recommended practice guidelines. This article summarizes the indications and assessments for and risks of tourniquet use for patients during extremity surgery. An understanding of these topics can improve surgical outcomes and promote safe perioperative care.

The Impact of Vitamin D Levels in Foot and Ankle Surgery

Hypovitaminosis D has been established as a global health problem. As an important regulator of skeletal health homeostasis throughout one's life, optimal levels are presumed. Debate, however, still exists surrounding the definition of normal vitamin D levels and what affect hypovitaminosis D has on fracture prevention, fracture healing, and successful arthrodesis. A literature search failed to show any level 1 studies examining hypovitaminosis D and union rates in foot and/or ankle arthrodesis procedures. Several retrospective studies do point to some sort of association between nonunion and hypovitaminosis D. Because of lack of high-level studies, a potential study design is proposed.

Significant prevalence of peripheral artery disease in patients with disturbed wound healing following elective foot and ankle surgery: Results from the ABI-PRIORY (ABI as a PRedictor of Impaired wound healing after ORthopedic surgerY) trial

Disturbed wound healing (DWH) following elective foot and ankle surgery is associated with a number of known risk factors. The purpose of this study was to determine if peripheral artery disease (PAD) is a potential risk factor that contributes to an increase in postoperative DWH. In a case-control study, we analyzed all patients undergoing elective foot and ankle surgery between January 1, 2014 and December 31, 2017 at two institutions and identified 51 patients with postoperative DWH. After matching with 51 control patients without DWH, all 102 patients were evaluated for PAD. The prevalence of PAD was significantly higher in the DWH group compared to the control group (41.2% vs 19.6%, p < 0.01). This difference was even more distinctive for patients with any abnormal ankle-brachial index (ABI) (51.0% vs 19.6%, p < 0.001). After adjustment for diabetes, hypertension, hypercholesterolemia, and smoking, any abnormal ABI or a history of PAD remained an independent risk factor for DWH (odds ratio 3.28; 95% CI 1.24-8.71). In this dual-center study, postoperative DWH was associated with significantly higher rates of PAD. These findings suggest that preoperative evaluation for PAD could be a helpful tool to identify patients at high risk for postoperative wound complications undergoing foot and ankle surgery. This trial is registered with drks.de, number DRKS00012580.

Clinical and Radiological Outcomes of Forefoot Offloading Versus Rigid Flat Shoes in Patients Undergoing Surgery of the First Ray

BACKGROUND

It is common clinical practice to use either flat or reverse camber shoes to protect the foot for up to 6 weeks after surgery for hallux valgus or hallux rigidus. To date there is a paucity of evidence as to whether there is any difference between these 2 postoperative shoes, in either patient satisfaction or clinical outcomes.

METHODS

One hundred consecutive patients undergoing scarf/Akin osteotomies or first metatarsophalangeal joint (MTPJ) arthrodesis were recruited. Patients were randomized 50:50 to either flat or reverse camber postoperative shoes. Patients undergoing ancillary lesser toe procedures were not excluded. Patient satisfaction was assessed by visual analog scale (VAS) pain score and Likert satisfaction survey. Radiographic outcomes were reviewed at 1 year observing differences in fusion rates or deformity recurrence. There were 47 patients in the reverse cam and 43 in the flat shoe group. No difference in primary forefoot operation, additional operation, age at surgery, or preop VAS pain score was seen.

RESULTS

At 6 weeks, there was no significant difference in postop VAS pain score. The flat shoe group was significantly more likely to be satisfied with their general mobility (86.0% vs 61.7%; P = .01) and with their stability in the shoe (90.7% vs 69.6%; P = .03). No significant difference was seen between groups for nonunion or hallux valgus recurrence rates.

CONCLUSION

Both forms of postoperative footwear were effective in enabling patients to mobilize and in preventing adverse outcomes. Patients were more likely to be satisfied with a flat postoperative shoe due to improved stability and ease of mobilizing. The results of this study aid surgeon decision making for postoperative footwear in forefoot surgery.

LEVEL OF EVIDENCE

Level II, prospective randomized controlled trial.

Are Prophylactic Perioperative Antibiotics Required for Isolated Forefoot Procedures, Such as Hammertoes?

RECOMMENDATION

Though limited clinical data exists, the administration of perioperative antibiotics is not required for isolated forefoot procedures in the absence of any risk factors, such as immunodeficiency or diabetes mellitus.

LEVEL OF EVIDENCE

Moderate.

DELEGATE VOTE

Agree: 67%, Disagree: 25%, Abstain: 8% (Super Majority, Weak Consensus).

What Prophylactic Antibiotic (Type, Dose and Route of Administration) Should Be Administered Perioperatively for Patients Undergoing Total Ankle Arthroplasty (TAA)?

RECOMMENDATION

The administration of prophylactic antibiotics before total ankle arthroplasty (TAA) potentially reduces the incidence of surgical site infection (SSI) and/or periprosthetic joint infection (PJI). Weight-based (of at least 2 g) cefazolin administered intravenously within 60 minutes before the procedure can be an adequate choice for antibiotic prophylaxis. If the patient has a beta-lactam anaphylaxis, we recommend an appropriate alternative antibiotic effective against Staphylococcus. It is unclear whether prophylaxis should be given as a single dose or as multiple doses.

LEVEL OF EVIDENCE

Strong.

DELEGATE VOTE

Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Prevention of Deep Venous Thromboembolism in Foot and Ankle Surgery

Although rare, deep vein thrombosis (DVT) and pulmonary embolism remain a concern for foot and ankle surgeons. Most prophylactic measures against DVT formation are synthesized from orthopedic hip and knee data, and therefore the routine use of these recommendations may place patients at risk for complications associated with unnecessary prophylaxis. In this article we review and present the most current literature specific to venous thromboembolism (VTE) in foot and ankle surgery. It is clear that, given our current literature, a case-by-case approach for VTE prophylaxis should be used following foot and ankle surgery.

Optimizing Outpatient Total Ankle Replacement from Clinic to Pain Management

Outpatient total ankle arthroplasty is a potential significant source of cost savings. The ability to institute an effective outpatient total ankle program depends on appropriate patient selection, surgeon experience with total ankle replacement, addressing preoperative patient expectations, the involvement of an experienced multidisciplinary care team including experienced anesthesiologists, nurse navigators, recovery room nursing staff and physical therapists, and most importantly, such a program requires complete institutional logistical support.

The value of radiography in the follow-up of extremity fractures: a systematic review

BACKGROUND

The added value of routine radiography in the follow-up of extremity fractures is unclear. The aim of this systematic review was to create an overview of radiography use in extremity fracture care and the consequences of these radiographs for the treatment of patients with these fractures.

MATERIALS AND METHODS

Studies were included if they reported on the use of radiography in the follow-up of extremity fractures and on its influence on treatment strategy, clinical outcome, or complications. A comprehensive search of electronic databases (i.e., PubMed, Embase, and Cochrane) was performed to identify relevant studies. Methodological quality was assessed with the Newcastle-Ottawa scale for cohort studies. Level of evidence was assessed using GRADE. The search, quality appraisal, and data extraction were performed independently by two researchers.

RESULTS

Eleven studies were included. All studies were retrospective cohorts. Of these, only two used a comparative design. Two of the included studies described fractures of both the upper and lower extremities, four studies concerned fractures of the lower extremity only, and five studies focused on fractures of the upper extremity. Pooling of data was not performed because of clinical heterogeneity. Eight studies reported on a change in treatment strategy related to radiography. Percentages ranged from 0 to 2.6%. The overall results indicated that radiographs in the follow-up of extremity fractures seldom alter treatment strategy, that the vast majority of follow-up radiographs are obtained without a clinical indication and that detection of a complication on a radiograph, in the absence of clinical symptoms, is unlikely. All included studies were regarded of a 'very low' level using GRADE.

CONCLUSIONS

Based on current literature, the added value of routine radiography in the follow-up of extremity fractures seems limited. Results, however, should be interpreted with care, considering that available evidence is of a low level.