Cigarette smoking increases complication rate in forefoot surgery

Effect of co-morbidities on outcomes of first metatarsophalangeal joint fusion: A systematic review

Introduction

The pre-existing co-morbidities have a major impact on the outcomes of Orthopaedic procedures as shown by the several studied in various contexts. However, the specific influence of these co-morbidities on first metatarsophalangeal joint fusion remains relatively underexplored. This study aims to address this gap by examining the association between co-morbidities such as obesity, smoking, diabetes, advancing age, and rheumatoid arthritis, and the outcomes of first metatarsophalangeal joint fusion.

Methods

A comprehensive search was conducted across multiple databases, including MEDLINE, EMBASE, and CINAHL. Relevant articles were identified and processed using Covidence, with independent assessment conducted to ensure inclusion criteria were met. The focus of the review was on analysing the effects of specific co-morbidities on fusion outcomes.

Results

Seven qualifying studies were identified for full-text extraction, revealing significant heterogeneity across the literature, which hindered direct statistical comparisons. The findings presented inconclusive effects of obesity on fusion outcomes, with ambiguous impacts observed for diabetes mellitus and smoking. Additionally, no discernible variance was observed in functional outcomes across different age groups. Furthermore, steroid usage in rheumatoid arthritis cases demonstrated delayed fusion in revision procedures, while primary outcomes remained uncertain.

Conclusion

This systematic review highlights the need for further research with standardised methodologies to better understand the correlation between pre-existing co-morbidities and outcomes in first metatarsophalangeal joint fusion. By elucidating these relationships, clinicians can better tailor treatment approaches and optimise patient care in this specific Orthopaedic context.

Level of evidence

Level III.

Predictive Factors of Postoperative Pain in Patients With Tibiotalocalcaneal Arthrodesis With an Intramedullary Nail: A Retrospective Review

Tibiotalocalcaneal arthrodesis has been shown in literature to have good results in regards to low complication rates and deformity correction. While previous studies have investigated functional outcomes and complication rates, no large-scale studies have looked at pain outcomes. The present study performed a retrospective review of 154 extremities to analyze how a patient's comorbidities and characteristics influence pain outcomes following a tibiotalocalcaneal arthrodesis. The present study found an average change of pain from 7.1 to 3.0 in at least a 6 month follow up. We found that a diagnosis of chronic pain and tobacco use had statistically significant less pain improvement compared to patients without chronic pain or current tobacco use. We determined no statistically significant difference in pain outcomes for patients with or without Charcot deformity. Lastly, we found that with older patients there was more pain improvement observed. We physicians can educate current tobacco users of the improved pain outcomes with tobacco cessation prior to surgery. We recommend a multidisciplinary approach for pain in patients with a pre-operative diagnosis of chronic pain and to educate patients on realistic postoperative pain outcomes.

Safety Profile of Synthetic Elastic Degradable Matrix for Soft Tissue Reconstruction in Foot & Ankle Surgery

BACKGROUND

Augmentation of soft tissue repairs has been helpful in protecting surgically repaired tissues as they heal. FlexBand (Artelon, Marietta, Georgia) is a synthetic, degradable, polycaprolactone-based polyurethane urea (PUUR) matrix that has been investigated and used for soft tissue repair in a variety of settings. The purpose of this study was to evaluate the safety profile of a PUUR matrix in a large cohort of patients undergoing soft tissue repairs about the foot and ankle.

METHODS

A retrospective chart review of consecutive patients who underwent surgery using FlexBand to augment a soft tissue repair was performed to evaluate for major and minor complications related to the PUUR matrix. Results. A total of 105 patients with an average >6 months follow-up were included. The most common procedures were spring ligament repair, Achilles tendon repair, and Brostrom. There were 12 complications. Four major complications occurred with only 1 requiring PUUR matrix removal. Patients with wound complications had a higher body mass index (BMI) and rate of smoking.

CONCLUSION

Complication rates involving PUUR matrix in soft tissue foot and ankle reconstruction procedures are low and comparable with historical complication rates. The PUUR matrix is safe for use in a variety of soft tissue procedures about the foot and ankle.Level of Evidence: Level 4, Retrospective case-series.

Complications in nail surgery and how to avoid them

Complications in nail surgery are not that frequent. Apart from complications that are common to every hand procedure, intense pain is the major issue with nail surgery. To prevent complications, good knowledge of anatomy and physiology is required to avoid misdiagnosis or inappropriate technique. However, some complications, such as postoperative nail dystrophy, are unavoidable, and must be known and discussed with the patient prior to the procedure in order to prevent disappointment that may lead to medico-legal cases. This paper will discuss the most frequent complications encountered.

Do We Need Routine Postoperative Prophylactic Oral Antibiotics in Elective Foot and Ankle Surgery?

Background

Previous studies about antibiotic prophylaxis in foot and ankle surgery have focused on perioperative intravenous administration, with few studies reporting on the efficiency of postoperative oral antibiotics. The purpose of this study is to investigate differences in the rate of postoperative infection and wound complications between patients with and without postoperative oral antibiotics and to identify independent risk factors for these complications following foot and ankle surgeries.

Methods

A retrospective review of all elective foot and ankle surgeries with at least a 6-month follow-up was performed over a 2-year time span. Patients were divided into 2 groups based on if they received postoperative oral antibiotics. We compared the rates of postoperative infections and wound complications between the 2 groups. The surgical site, the number of Current Procedural Terminology codes, and the number of surgical incisions were also noted. Multivariable logistic regression analysis was performed to identify independent risk factors of postoperative infection and wound complications.

Results

A total of 366 patients were included in this study-240 with antibiotics and 126 without antibiotics. There was no significant difference in the rates of postoperative infection and wound complications between the 2 groups. The rate of superficial infection, deep infection, and wound complications was 1.7%, 0.8%, and 5.8% in the antibiotic group vs 3.2%, 0.0%, and 4.0% in patients without antibiotics, respectively. Multivariable logistic regression analysis identified independent risk factors of postoperative infection and wound complications as follows: smoking (OR: 4.7), male (OR: 4.0), history of neoplasm (OR: 6.7), and multiple incisions (OR: 4.1).

Conclusion

Our results suggest that routine postoperative prophylactic oral antibiotics are not needed following elective foot and ankle surgeries. However, certain risk factors may increase the risk for postoperative infection and wound complications in foot and ankle surgery.

Level of Evidence

Level III, case-control study.

A Preliminary Look at the Macrovascular System for Transmetatarsal Amputation Success

OBJECTIVE

Transmetatarsal amputation (TMA) is a commonly used level of amputation that preserves most of the foot's function and independence. However, many TMAs fail, and patients go onto higher amputations. The primary endpoint of this study is to determine if source artery occlusions are correlated with TMA flap failure.

METHODS

A total of 82 patients with TMAs were retrospectively reviewed for healing rates between 2009 and 2019 at a single center. Forty-five of the patients had an angiogram, which was analyzed for source artery and overall TMA failure. Of the initial 82 patients, a cohort of 12 had documentation of specific flap failure and an angiogram performed. This cohort of 12 patients was used for correlation of flap failure with source artery occlusion.

RESULTS

Overall, the TMA healing rate was 45.28%. No correlation was noted between a specific source artery occlusion and overall TMA failure. However, a moderate positive correlation was seen with dorsalis pedis artery and peroneal artery occlusions and dorsal flap failure. No correlation was seen with the posterior tibial artery and plantar flap failure. A moderate negative correlation was seen with peroneal artery occlusion and plantar flap failure.

CONCLUSIONS

The authors concluded that retrograde flow through the angiosome principle is what allowed for successful outcomes in TMAs. Physicians are urged to carefully plan, dissect, and preserve these vessels to help prevent TMA flap failure, especially in patients with vascular risk or disease.

Evaluation of the new defined EFAS score (European foot and ankle society score) in relation to already established functional scores (FFI, MOXFQ) after cartilage reconstructive therapy (AMIC®) for osteochondral lesion of the talus

BACKGROUND

In 2011, the European Foot and Ankle Society developed a Score (EFAS Score) to generate a standardized questionnaire for several European languages. The aim of this study is to analyse how the newly defined score correlates with already established function scores.

METHODS

This study is a monocentric prospective study. The questionnaires were completed at least 12 months postoperatively at the same time point. All patients had undergone surgery with the Autologous Matrix-Induced Chondrogenesis® procedure for osteochondral lesions of the talus.

RESULTS

A total of 69 patients (33 women, 36 men) participated in the study. The EFAS Score correlates very strongly with the Manchester-Oxford Foot Questionnaire (MOXFQ) and strongly with the Foot Function Index (FFI).

CONCLUSION

This study shows that the EFAS Score correlates significantly with the FFI and the MOXFQ. The EFAS seems to be a more patient-friendly alternative due to fewer questions and response choices.

Complications of Lesser Toe Surgery: How To Avoid Them before Surgery and How To Assess and Treat Them When They Have Occurred

Complications following lesser toe surgery are challenging to manage. The keys to treatment of any of these conditions are, first, to try to avoid them through identification of patient- and surgeon-related variables that contribute to their development and, second, following the occurance of a complication, to understand what can and cannot be corrected with surgical and nonsurgical management. This review provides a comprehensive assessment of current literature, demonstrates best practices and approaches to lesser toe complications, and provides an illustration of clinical examples.

Factors Predictive of Early Complications Following Total Ankle Arthroplasty

Background:

The safety of outpatient total ankle arthroplasty (TAA), and factors predictive of early complications are poorly understood. The objective of this study was to determine the frequency of early complications in patients undergoing outpatient TAA compared to a matched inpatient TAA cohort. Factors predictive of early complications following TAA are elucidated.

Methods:

A retrospective review of prospectively collected data from the 2011-2018 American College of Surgeons–National Surgical Quality Improvement Program (ACS-NSQIP) database was performed. An unadjusted analysis comparing complication rates in outpatient, and inpatient TAA was performed followed by a propensity score–matched cohort analysis. A multivariate logistic regression model was then used to identify significant independent predictors for complications, reoperation, and readmission following TAA.

Results:

A total of 1487 patients (198 outpatient, 1289 inpatient) undergoing TAA were included in the study. Inpatient TAA was associated with increased 30-day readmission compared with outpatient TAA (3.54% vs 0.51%, P = .032) in a matched cohort analysis. Thirty-eight (2.6%) patients had a minor complication, with 16 (1.1%) patients having a major complication after TAR. Nineteen (1.3%) patients underwent reoperation, and 42 (2.8%) patients were readmitted within 30 days of the index TAR. Multivariate analysis identified factors predictive of early complications to include length of stay (LOS) >2 days, smoking, hypertension, bleeding disorders, and diabetes mellitus.

Conclusion:

From this relatively limited data set, outpatient TAA appears to be safe for management of end-stage ankle arthritis in select patients. Inpatient status was associated with an increased rate of 30-day readmission following TAA. Postoperative length of stay >2 days, smoking, hypertension, bleeding disorders, and diabetes mellitus were identified to be associated with early postoperative complications following TAA in this cohort.

Level of Evidence

Level III, retrospective cohort study.

Nonunion Rates in Hind- and Midfoot Arthrodesis in Current, Ex-, and Nonsmokers

BACKGROUND

Nonunion rates in hind or midfoot arthrodesis have been reported as high as 41%. The most notable and readily modifiable risk factor that has been identified is smoking. In 2018, 14.4% of the UK population were active smokers. We examined the effect of smoking status on union rates for a large cohort of patients undergoing hind- or midfoot arthrodesis.

METHODS

In total, 381 consecutive primary joint arthrodeses were identified from a single surgeon's logbook (analysis performed on a per joint basis, with a triple fusion reported as 3 separate joints). Patients were divided based on self-reported smoking status. Primary outcome was clinical union. Delayed union, infection, and the need for ultrasound bone stimulation were secondary outcomes.

RESULTS

Smoking prevalence was 14.0%, and 32.2% were ex-smokers. Groups were comparable for sex, diabetes, and body mass index. Smokers were younger and had fewer comorbidities. Nonunion rates were higher in smokers (relative risk, 5.81; 95% CI, 2.54-13.29; P < .001) with no statistically significant difference between ex-smokers and nonsmokers. Smokers had higher rates of infection (P = .05) and bone stimulator use (P < .001). Among smokers, there was a trend toward slower union with heavier smoking (P = .004).

CONCLUSION

This large retrospective cohort study confirmed previous evidence that smoking has a considerable negative effect on union in arthrodesis. The 5.81 relative risk in a modifiable risk factor is extremely high. Arthrodesis surgery should be undertaken with extreme caution in smokers. Our study shows that after cessation of smoking, the risk returns to normal, but we were unable to quantify the time frame.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Can financial payments incentivize short-term smoking cessation in orthopaedic trauma patients? Evidence from a discrete choice experiment

BACKGROUND

Smoking increases the risk of complications and related costs after an orthopaedic fracture. Research in other populations suggests that a one-time payment may incentivize smoking cessation. However, little is known on fracture patients' willingness to accept financial incentives to stop smoking; and the level of incentive required to motivate smoking cessation in this population. This study aimed to estimate the financial threshold required to motivate fracture patients to stop smoking after injury.

METHODS

This cross-sectional study utilized a discrete choice experiment (DCE) to elicit patient preferences towards financial incentives and reduced complications associated with smoking cessation. We presented participants with 12 hypothetical options with several attributes with varying levels. The respondents' data was used to determine the utility of each attribute level and the relative importance associated with each attribute.

RESULTS

Of the 130 enrolled patients, 79% reported an interest in quitting smoking. We estimated the financial incentive to be of greater relative importance (ri) (45%) than any of the included clinical benefits of smoking cessations (deep infection (ri: 24%), bone healing complications (ri: 19%), and superficial infections (ri: 12%)). A one-time payment of $800 provided the greatest utility to the respondents (0.64, 95% CI: 0.36 to 0.93), surpassing the utility associated with a single $1000 financial incentive (0.36, 95% CI: 0.18 to 0.55).

CONCLUSIONS

Financial incentives may be an effective tool to promote smoking cessation in the orthopaedic trauma population. The findings of this study define optimal payment thresholds for smoking cessation programs.

The influence of smoking on foot and ankle surgery: a review of the literature

The effect of tobacco smoking on foot and ankle procedures is likely to be more pronounced when compared to other orthopaedic surgery. This is due to the peripheral nature of the vasculature involved. This paper reviews the current clinical evidence on the effects of smoking foot and ankle surgery. In the trauma setting, the evidence suggests that wound complications and non-unions are significantly higher in the smoking population. In the elective setting there is a significantly increased risk of non-union in ankle and hindfoot arthrodeses in smokers. In the setting of diabetes, ulceration rate in smokers is higher and there may be a higher risk of amputation.

Transmetatarsal Amputation Outcomes When Utilized to Address Foot Gangrene and Infection: A Retrospective Chart Review

A transmetatarsal amputation (TMA) is a widely utilized procedure to address foot gangrene and infection. Although a common procedure, so too are the associated complications. The purpose of this review was to evaluate TMA healing and to explore if there were associated variables correlating with healed vs. failed to heal TMA sites. To do so, the Medical Department Orthopaedics Division Electronic Database, West Virginia University, College of Medicine was retrospectively searched to identify all cases of TMAs (CPT code 28805) during the period of January 2011 through June 2019, and those variables that might impact TMA healing. Then both univariate and multivariable logistic regression analyses were performed to investigate the associations between these variables and TMA healing, and sensitivity analyses were also conducted to determine if the results resisted the influence of one unmeasured confounder. There were 39 patients (41 procedures) who would undergo a TMA. The mean average patient age was 53 (range 29-73) years old. The median postoperative follow-up period was 617 (range 199-3632) days. TMA mortality data revealed 0 deaths at 30 days, 2 (5.1%) at 1 year, 8 (20.5%) at 5 years. In our study, 29 (70.7%) of the TMAs would achieve primary healing at a median of 31 (range 16-253) days. When comparing the TMA healed group to the failed to heal group the following independent variables were considered: diabetes mellitus, HgA1c >8%, neuropathy, peripheral arterial disease, chronic kidney disease, active smoking status, previous surgery, and a clean margin metatarsal bone pathology specimen positive for osteomyelitis. Of the aforementioned, only neuropathy (odds ratio [OR] = 0.056, 95% confidence interval [CI] = 0-0.501, p = .0062) and positive bone margin (OR = 0.144, 95% CI = 0.022-0.835, p = .0385) were found to be significant in univariate logistic regression analysis. In multivariable logistic regression analyses where the potential confounders age, gender, and body mass index were accounted for, of the 8 independent variables of interest, only neuropathy (OR = 0.037, 95% CI = 0-0.497, p = .0036) remained significantly associated with the healing status. Neuropathy was present in 17 (58.6%) of the healed TMAs and in 12 (100%) of the failed to heal TMAs. However, the positive bone margin failed to reach statistical significance (OR = 0.079, 95% CI = 0-1.39, p = .1331). Results from another multivariable logistic regression model where a quadratic term for age was added revealed that positive bone specimen correlated with the TMA healing status with significance (OR = 0.051, 95% CI = 0.001- 0.560, p = .0404). A positive clean margin bone specimen was found in 3 (10.3%) of the healed TMAs and in 4 (44.4%) of the failed to heal TMAs. The sensitivity analysis where current ulceration was used as an unmeasured confounder indicated that the results regarding the association between neuropathy or positive bone margin and TMA healing, though inconclusive, resisted the influence of this unmeasured confounder. Hopefully these findings will be a beneficial addition to the current TMA literature and as such, further assist with informed surgical decision making.

CE: The Effects of Smoking on Bone Health and Healing

The number of orthopedic surgeries performed in the United States has increased substantially over the past several years. The most recent data available from the Agency for Healthcare Research and Quality indicate that five of the 10 operative procedures most commonly performed during inpatient stays involve the musculoskeletal system. Cigarette smoking is one of the most prevalent and preventable risk factors for musculoskeletal disorders and orthopedic surgery complications. This article discusses the effects of smoking on bone health, the importance of smoking cessation among patients scheduled for or recovering from orthopedic surgery, and the vital role nurses play in supporting patient efforts to lead a tobacco-free life.

Comorbidities Associated With Poor Outcomes Following Operative Hammertoe Correction in a Geriatric Population

Background:

Although complications following hammertoe correction surgery are rare, older patients with comorbid conditions are often considered poorer operative candidates compared with younger, healthier patients because of a suspected increased risk of adverse outcomes. The aim of this study was to determine if the presence of multiple comorbidities was associated with increased complications or unsuccessful patient-reported outcomes following operative hammertoe correction in geriatric patients.

Methods:

Prospectively collected data was reviewed on 78 patients aged 60 years or older who underwent operative correction of hammertoe deformity. Patient demographics, comorbidities, and postoperative complications were recorded. Patient-reported outcomes were assessed using preoperative and postoperative visual analog scale for pain and Short Form Health Survey Physical and Mental Component Summary with 1 year of follow-up. Patients were divided into 2 groups based on number of comorbidities (0 or 1 vs > 2) and then compared. The average age of patients was 69.4 years and the prevalence of comorbidities in the study population was as follows: 11.5% smokers, 25.6% on blood thinners, 15.4% with rheumatoid arthritis, 7.7% with diabetes mellitus, 2.6% with peripheral arterial disease, 6.4% with chronic obstructive pulmonary disease, 11.5% with coronary artery disease, and 23.1% with osteoporosis.

Results:

Fifty-three patients (67.9%) had 0 or 1 comorbidity and 25 (32.1%) had 2 or more comorbidities. Compared to the 0 or 1 comorbidity group, the presence of multiple comorbidities was associated with an adjusted odds ratio (OR) for superficial wound infection of 4.18 (P = .045) and deformity recurrence requiring surgery OR of 23.15 (P = .032). Patient-reported outcomes were similar between comorbidity groups.

Conclusions:

This study further informs foot and ankle specialists to maintain increased surveillance for postoperative complications and unsuccessful outcomes in patients with multiple comorbidities. Although geriatric patients still report significant improvements in both pain and function, patients with underlying medical conditions should be counseled about their increased risks when pursuing operative hammertoe correction.

Level of Evidence:

Level III, retrospective comparative series.

Weak smoking cessation awareness in primary health care before surgery: a real-world, retrospective cohort study

Objective: Tobacco smoking is a well-established risk factor for postoperative complications. Research on preoperative smoking cessation in primary health care is scarce.Design: This was a retrospective cohort study.Setting: The Stop Smoking before Surgery Project (SSSP) started in Porvoo, Finland, in May of 2016, involving both primary health care and specialized health care. The goals of the project were smoking awareness and preoperative smoking cessation.Subjects: Our study involved 1482 surgical patients operated at Porvoo Hospital between May and December of 2016.Main outcome measures: We studied the recording of smoking status in all patients, and ICD-10 diagnosis of nicotine dependency and the initiation of preoperative smoking cessation in current smokers. Variables were studied from electronic patient records, comparing primary health care referrals and surgical outpatient clinic records.Results: Smoking status was visible in 14.2% of primary health care referrals, and in 18.4% of outpatient clinic records. Corresponding rates for current smokers (n = 275) were 0.0 and 8.7% for ICD-10 diagnosis of nicotine dependence, and 2.2 and 15.3% for initiation of preoperative smoking cessation. The differences between primary health care referrals and outpatient clinic records were statistically significant for all three variables (p ≤ .001).Conclusion: In primary health care, very little attention was paid to preoperative smoking cessation. Rates were significantly better at the surgical outpatient clinic, but still low. We could not demonstrate any certain effect of the intervention. Our results call for future research on ways to improve smoking cessation rates.Key pointsTobacco smoking is a well-established risk factor for postoperative complications. Research on preoperative smoking cessation in primary health care is scarce.We found weak smoking awareness and weak smoking cessation intervention numbers among both primary and specialized health care doctors. Our results indicate an urgent need for an efficient preoperative smoking cessation model involving both primary and specialized health care.

The effect of current and former tobacco use on outcomes after primary reverse total shoulder arthroplasty

BACKGROUND

The purpose of this study was to determine the influence of current and former tobacco use on minimum 2-year clinical and radiographic outcomes after reverse total shoulder arthroplasty (RTSA).

METHODS

Review of primary RTSA patient data identified 186 patients with at least 2 years of follow-up. Patients were classified as nonsmokers (76 patients), former smokers (89 patients), or current smokers (21 patients). Assessment included preoperative and postoperative visual analog scale pain scores, American Shoulder and Elbow Surgeons scores, strength, range of motion, complications, revisions, and narcotic use. Radiographs were analyzed for signs of loosening or mechanical failure.

RESULTS

Overall mean age of the patients was 70 (48-87) years, and mean follow-up was 2.6 (2.0-5.7) years. Smokers (62.1 years) were significantly younger than nonsmokers (70.7 years) and former smokers (70.8 years; P = .00002). All patients had significant improvements in pain, American Shoulder and Elbow Surgeons score, strength, and forward flexion range of motion; however, smokers had higher visual analog scale pain scores (mean, 2.5) than nonsmokers (mean, 1.8) or former smokers (mean, 1.0; P = .014). Otherwise, no differences were found regarding any of the postoperative parameters (P > .05).

CONCLUSIONS

Aside from increased patient-reported pain, current tobacco use does not appear to negatively affect outcomes after primary RTSA. The RTSA design obviates the need for a functioning rotator cuff, possibly mitigating tobacco's negative effects previously demonstrated in rotator cuff repair and anatomic total shoulder arthroplasty. Former users obtained outcomes similar to those of nonusers, suggesting that tobacco use is a modifiable risk factor to achieve optimal pain relief after RTSA.

The Effect of Tobacco Use on Incision Healing in Total Ankle Arthroplasty: A Review of 114 Patients

The purpose of this study was to compare wound complication rates after total ankle replacement in 3 groups of patients based on tobacco status. The total cohort was divided into 3 groups based on tobacco history. Group 1 included patients who were actively tobacco users. Group 2 included patients with a history of tobacco user. Group 3 served as the control group and included patients who had never used tobacco. Available charts were reviewed for patients who underwent primary total ankle arthroplasty by 1 surgeon. Patient demographics, tobacco history, and postoperative wound complications were recorded. A total of 114 patients with tobacco history were available for follow-up and were included in this study, which ranged from March 2012 to July 2017. Group 1 included 11 active smokers. Group 2 included 38 former smokers, and group 3 had a total of 65 never smokers included. The average follow-up was 28 months for group 1 (range 10-55 months), 34.1 months for group 2 (range 12-60 months), and 32.8 months for group 3 (range 11-60 months). The wound complication rate was noted to be statistically significant when comparing active smokers to never smokers using Fisher's exact test (P = .0223). When comparing former smokers with never smokers, the difference in wound complication rate did not reach statistical significance (P = 0.7631). All patients underwent at least 1 concomitant procedure at the time of initial ankle replacement. Our findings show that total ankle replacement wound healing complication rates are significantly higher in active tobacco users. There was no significant difference in wound healing complications when comparing former tobacco users versus never tobacco users. Levels of Evidence: Level III: Retrospective comparative study.

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.

Smoking Effects in Foot and Ankle Surgery: An Evidence-Based Review

BACKGROUND

The purpose of this article was to review the basic science pertaining to the harmful effects of cigarette smoke, summarize recent clinical outcome studies, and examine the benefits of smoking cessation and the efficacy of current smoking cessation strategies.

METHODS

The literature concerning basic science, clinical outcomes, and smoking cessation was reviewed; over half (56%) of the 52 articles reviewed were published in the last 5 years.

RESULTS

Smoking is associated with low bone mineral density, delayed fracture union, peri-implant bone loss, and implant failure. Orthopedic surgical patients who smoke have increased pain and lower overall patient satisfaction, along with significantly increased rates of wound healing complications.

DISCUSSION/CONCLUSION

Active smoking is a significant modifiable risk factor and should be discontinued before foot and ankle surgery whenever possible. Orthopedic surgeons play an important role in educating patients on the effects of smoking and facilitating access to smoking cessation resources.

LEVEL OF EVIDENCE

Level V, expert opinion.

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.

Functional Medium-Term Results After Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus: A 5-Year Prospective Cohort Study

Autologous matrix-induced chondrogenesis (AMIC) has gained popularity in the treatment of osteochondral lesions of the talus. Previous studies have presented promising short-term results for AMIC talar osteochondral lesion repair, a 1-step technique using a collagen type I/III bilayer matrix. The aim of the present study was to investigate the mid-term effects. The 5-year results of a prospective cohort study are presented. All patients underwent an open AMIC procedure for a talar osteochondral lesion. Data analysis included general demographic data, preoperative magnetic resonance imaging findings, intraoperative details, and German version of the Foot Function Index (FFI-D) scores preoperatively and at 1 and 5 years after surgery. The primary outcome variable was the longitudinal effect of the procedure, and the influence of various variables on the outcome was tested. Of 47 consecutive patients, 21 (45%) were included. Of the 21 patients, 8 were female (38%) and 13 were male (62%), with a mean age of 37 ± 15 (range 15 to 62) years and a body mass index of 26 ± 5 (range 20 to 38) kg/m². The defect size was 1.4 ± 0.9 (range 0.2 to 4.0) cm². The FFI-D decreased significantly from preoperatively to 1 year postoperatively (56 ± 18 versus 33 ± 25; p = .003), with a further, nonsignificant decrease between the 1- and 5-year follow-up examination (33 ± 25 versus 24 ± 21; p = .457). Similar results were found for the FFI-D subscales of function and pain. The body mass index and lesion size showed a positive correlation with the preoperative FFI-D overall and subscale scores. These results showed a significant improvement in pain and function after the AMIC procedure, with a significant return to sports by the 5-year follow-up point. The greatest improvement overall was seen within the first year; however, further clinical satisfaction among the patients was noticeable after 5 years.

The effect of smoking on the outcomes of lateral ankle ligament reconstruction

BACKGROUND

Although smoking is known to be harmful to the musculoskeletal system, no studies have investigated its effects on the outcomes of ankle ligament surgery. We determined the effects of smoking on the clinical and radiological outcomes of lateral ankle ligament reconstruction using tendon allografts according to smoking status.

METHODS

From among 105 patients with chronic ankle instability who were treated with anatomical reconstruction of the anterior talofibular ligament and the calcaneofibular ligament using semitendinosus tendon allografts and bio-tenodesis screws, 70 ankles, from 23 smokers and 47 non-smokers, were analyzed. Visual analog scale (VAS) pain scores, American Orthopedic Foot and Ankle Society ankle-hindfoot scores, Karlsson scores and complications were routinely determined at each follow-up visit. Anterior translation and the talar tilt angle on radiographic stress views were also assessed.

RESULTS

The mean follow-up period was 21.8 months (12-68 months). No significant differences were observed between the two groups with respect to age, gender, body mass index, or the duration of preoperative symptoms. The mean preoperative pain VAS scores were 5.8 and 5.3 among non-smokers and smokers, respectively. Postoperatively, the mean pain VAS score improved to 1.4 in both groups (p < 0.001). Clinical and radiographic measures did not show significant changes according to the presence of smoking after surgery. However, two wound complications, 1 delayed healing and 1 superficial necrosis, occurred in non-smokers, whereas five, 2 delayed healing, 2 superficial infections and 1 superficial necrosis in smokers (p = 0.035).

CONCLUSION

The radiographic outcomes of smokers were comparable to those of non-smokers in the short term, whereas wound complications were more common in the smoker group.

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

A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.

Wound Closure in Smoking Peripheral Arterial Disease Patients With Treatment-Refractory Ulcerations: A 12-Month Follow-up Case Series

Despite ongoing smoking cessation efforts and optimized perfusion, failed wound closure in the presence of peripheral arterial disease (PAD) and diabetes are common. A clinical effectiveness review was conducted in actively smoking diabetic patients diagnosed with PAD, treated with serial applications of a viable intact cryopreserved human placental membrane (vCPM) (Grafix, Osiris Therapeutics Inc, Columbia, MD) for recalcitrant lower extremity ulcerations (n = 6). More than half of the patients were not candidates for revascularization. Baseline vascular status in 5 of 6 lower-extremity wounds remained unchanged throughout the entire course of vCPM treatment. Daily cigarette consumption averaged 18 cigarettes per patient. Mean wound duration and mean surface area was 53 weeks and 4.6 cm2, respectively. Mean number of vCPM applications and time to closure was 7.0 grafts in 7.8 weeks. There were no wound-related infections or amputations and no vCPM-related adverse events. All 6 wounds remained closed at the 12-month follow-up visit. In conclusion, vCPM demonstrated clinically effective outcomes in 6 previously nonhealing ulcerations despite ongoing smoking habits in the presence of PAD and diabetes.

Can a urine dipstick test be used to assess smoking status in patients undergoing planned orthopaedic surgery? a prospective cohort study

AIMS

Smoking is associated with post-operative complications but smokers often under-report the amount they smoke. Our objective was to determine whether a urine dipstick test could be used as a substitute for quantitative cotinine assays to determine smoking status in patients.

PATIENTS AND METHODS

Between September 2013 and July 2014 we conducted a prospective cohort study in which 127 consecutive patients undergoing a planned foot and ankle arthrodesis or osteotomy were included. Patients self-reported their smoking status and were classified as: 'never smoked' (61 patients), 'ex-smoker' (46 patients), or 'current smoker' (20 patients). Urine samples were analysed with cotinine assays and cotinine dipstick tests.

RESULTS

There was a high degree of concordance between dipstick and assay results (Kappa coefficient = 0.842, p < 0.001). Compared with the quantitative assay, the dipstick had a sensitivity of 88.9% and a specificity of 97.3%. Patients claiming to have stopped smoking just before surgery had the highest rate of disagreement between reported smoking status and urine testing.

CONCLUSION

Urine cotinine dipstick testing is cheap, fast, reliable, and easy to use. It may be used in place of a quantitative assay as a screening tool for detecting patients who may be smoking. A positive test may be used as a trigger for further assessment and counselling. Cite this article: Bone Joint J 2016;98-B:1418-24.

Arthroscopic Subtalar, Double, and Triple Fusion

Arthroscopic approaches to subtalar, double, and triple arthrodesis allow relative preservation of the soft tissue envelope compared with traditional open approaches. The surgical technique involving the use of a 4.5-mm 30° arthroscope via sinus tarsi portals is described. All 3 joints of the triple joint can be prepared for fusion with motorized burrs. Rigid fixation is achieved with cannulated screws. High union rates and low complication rates have been reported.

Effect of Obesity on Outcomes of Forefoot Surgery

BACKGROUND

Forefoot surgery typically is elective, so it is important to define risk factors to educate patients on potential complications. The purpose of this study was to determine if obesity is an independent risk factor that contributes to increased complication rates after forefoot surgery.

METHODS

Through a retrospective review of records, 633 patients were identified who had forefoot surgery at one institution between 2008 and 2010. All patients who currently smoked or smoked in the past were excluded to eliminate a confounding factor, as smoking is known to increase complication rates, leaving 427 patients for inclusion, 299 nonobese (BMI less than 30) and 128 obese (BMI more than 30). Medical records were reviewed for the occurrence of complications, including nonunion, delayed union, delayed wound healing, infection, and persistent pain.

RESULTS

The overall complication rate was 9%, with similar rates between obese (10%) and nonobese patients (9%). The only specific complication approaching significance (P = .13) was a higher rate of infection in obese patients (4 % compared to 1%), which could be attributed to the higher percentage of diabetic patients in the obese group. Diabetic patients, regardless of weight, had significantly higher rates of infection (P = .03), with a trend toward higher rates of overall complications and delayed wound healing (P = .08 and P < .06, respectively).

CONCLUSION

Obesity was not shown to lead to more frequent complications after forefoot surgery. Diabetes was associated with significantly higher rates of infection, regardless of weight. Though not significant, there was a trend toward higher rates of overall complications and delayed wound healing in diabetic patients as well.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Common surgery, uncommon complication

Ingrown nail surgery is the one of the most common surgeries in outpatient clinics that are generally perfomed in response to patient complaints. Still, making simple observations, taking patient histories and conducting further tests are often neglected by outpatient clinics. Consequently, it is important to be aware if ingrown nail is associated with any underlying diseases that can lead to major complications.

In this article, we report on two cases ending in amputation that were performed with Winograd’s partial matrix excision procedure for ingrown nails. Such a complication is rare, unexpected, and most unwanted in forefoot surgery. After a detailed analysis of the situation, we discovered that both patients were smokers, and one of them had Buerger’s disease. These conditions led to the ingrown nails in addition to poor wound healing.

This case report emphasizes the fact that even when performing minor procedures, obtaining a detailed history and conducting an examination are of paramount importance. Patient selection is also a considerable factor, especially for patients who are smokers, who may experience a worst case surgical scenario.