Preoperative Risk Factors for Complications in Elective Ankle and Hindfoot Reconstruction

Preoperative Hypoalbuminemia Not Associated With Total Ankle Arthroplasty Outcomes

BACKGROUND.

This study aims to investigate the effect of hypoalbuminemia on the rates of 30-day complication, readmission, and reoperation following total ankle arthroplasty (TAA).

METHODS.

The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2007 to 2019 to identify 710 TAA patients. Patients were then stratified into normal (n = 673) or low (n = 37) albumin groups. Demographics, medical comorbidities, concomitant procedures, hospital length of stay, and 30-day complication, readmission, and reoperation rates were compared between groups. Preoperative serum albumin level was also used as a continuous variable when analyzing postoperative outcomes.

RESULTS.

The overall cohort was predominantly male (51.5%), and the mean age was 65.02 (range, 45-87) years. We found there to be no statistically significant difference in demographics between cohorts. However, hypoalbuminemia patients were significantly more likely to use long-term steroids for a chronic condition (normal = 6.1%, low = 18.9%; P = .009). Additionally, there was no difference in 30-day complication (normal = 3.0%, low = 0.0%; P = .618), readmission (normal = 2.4%, low = 0.0%; P = .632), and reoperation (normal = 1.0%, low = 0.0%; P = 1.000) rates between groups.

CONCLUSION.

The results of this study show that malnourished patients are not at an increased risk of 30-day complication, readmission, or reoperation following TAA despite having a worse preoperative comorbidity profile.

LEVEL OF EVIDENCE

Level III, Retrospective cohort study.

Gender Differences in Achilles Tendon Ruptures-A Retrospective Study and a Review of the Literature

Achilles tendon ruptures are common injuries typically sustained during sport with higher incidence in men, though little is understood regarding sex-specific risk factors or outcomes following injury management. This cross-sectional clinical study and systematic review aimed to examine sex-specific Achilles tendon rupture incidence and outcomes following intervention. This study included patients who sustained a rupture between 2011-2021, were ≥18 years old, and who had a minimum follow-up of at least six months, and evaluated age, sex, sport involvement, mechanism of injury, and postoperative complications and revision. Separately, a systematic literature review in the PubMed, EMBASE, and Cochrane databases was performed. A total of 705 male and 158 female patients were included in this retrospective study. 71.1% of men and 52.5% of women sustained a sports-related rupture (p < .001), with sport involvement demonstrating a positive correlation with revision rate (coefficient = 0.09, p = .02). A total of 21 studies with 250,907 patients (87,514 male, 35,792 female) were included in the systematic review. All studies revealed an increased incidence of ATR in men. Functional outcomes were worse in women, and female sex was an independent risk factor for postoperative complications and need for revision surgery. This study demonstrated a higher incidence of sports-related ATR in men than women, likely related to their higher ball sport participation. Although the retrospective analysis did not find a significant difference in complication or revision rates, the systematic review demonstrates poorer functional outcomes, with increased likelihood for postoperative complication and revision surgery in women as compared to men.

The impact of pre-operative mental health on outcomes of foot and ankle surgery: A scoping review

BACKGROUND

Evidence suggests that certain groups of orthopaedic patients have an increased prevalence of mental health disorders than the general population. This scoping review aims to evaluate the effect of pre-operative mental health on outcomes of foot and ankle surgery.

METHODS

A literature search was performed in four databases. Studies investigating a relationship between preoperative mental health and postoperative patient reported outcome measures (PROMs), complications, readmissions or reoperations were included.

RESULTS

Of the 19 studies investigating the effect of preoperative mental health on PROMs, 16 (84.2%) reported a significant relationship between poorer preoperative mental health and inferior postoperative PROMs. Poorer mental health was associated with an increased rate of complications, readmissions and/or reoperations in four studies.

CONCLUSIONS

Poorer preoperative mental health is associated with significantly inferior outcomes following foot and ankle surgery. Clinicians should evaluate mental health to stratify likely outcomes and aid in the management of patient expectations.

LEVEL OF EVIDENCE

Level IV: Scoping review of Level II-IV studies.

The Role of Preoperative Opioid Use in Foot and Ankle Surgery: A Systematic Review

Prescription opioids, particularly for treating musculoskeletal pain, are a significant contributor to the opioid epidemic in North America. There is also evidence to suggest that chronic use of opioids is associated with poor outcomes after orthopedic surgery. However, whether this association is relevant in foot and ankle surgery is still unclear. Accordingly, a systematic review of the literature was undertaken to assess the impact of preoperative opioid use in patients undergoing foot and ankle surgery concerning postoperative pain, complications, and postoperative opioid dependence. Four databases, including EMBASE, MEDLINE, PubMed, and CINAHL, were searched to March 2022 for studies reporting preoperative opioid use and its effect on postoperative outcomes or opioid use after foot and ankle surgery. A total of 22,092 patients were included in the final synthesis of 8 studies. Most of which were level 3 evidence (5 studies). Around 18% of the patients used opioids preoperatively. Preoperative opioid use was associated with more quantities and prolonged use of opioids postoperatively. Two studies showed an increased risk of complications postoperatively in patients who used opioids preoperatively compared to the nonopioid group. Preoperative opioid use in patients undergoing foot and ankle surgeries is associated with increased and prolonged use of opioids postoperatively and may therefore predict the potential for misuse.

Effect of Obesity on Patient-Perceived Outcomes After First Metatarsophalangeal Joint Arthrodesis

BACKGROUND

While first metatarsophalangeal joint (MTPJ) arthrodesis is a common and effective procedure, there is a paucity of studies examining obesity's effect on outcomes of 1st MTPJ arthrodesis. This study's purpose was to evaluate patient-reported outcomes following 1st MTPJ arthrodesis in obese versus non-obese patients.

METHODS

A retrospective cohort study of 94 patients undergoing first MTPJ fusion over the age of 18 with a diagnosis of hallux valgus or hallux rigidus was performed. Surgical and postoperative outcomes were examined preoperatively and at 6 and 12 months follow-up via Visual Analog Pain scale (VAS), and Short Form 36 (SF-36) surveys, and data were stratified into 2 patient groups: BMI < 30 (n = 62, mean age 63.9 ± 9.1 and ≥ 30 (n = 32, mean age 61.9 ± 8.4).

RESULTS

Average overall VAS and SF-36 physical component scores improved significantly at 6 months (P < .001, .006) and 1 year postoperative visits (P < .001, .007) with no differences in survey scores, outcomes, or complications between weight groups.

CONCLUSION

Our study showed first MTPJ fusion improves short-term pain and physical quality-of-life in arthritic obese and non-obese patients without differences in nonunion, complications, or patient-reported measures.

LEVEL OF EVIDENCE

Level III, Prognostic, Case-Control Study.

Retrospective Review of Complications and Revision Rates Between Isolated Talonavicular vs Talonavicular and Subtalar (Double) Arthrodesis vs Triple Arthrodesis

Background

Hindfoot fusion procedures are common for the treatment of end-stage arthritis or deformity. Surgical treatments for these conditions include talonavicular joint (single) arthrodesis, talonavicular and subtalar (double) arthrodesis, or talonavicular, subtalar, and calcaneocuboid (triple) arthrodesis. This study evaluated the complication rate, revision surgery rate, and hardware removal rate for those treated with either single, double, or triple arthrodesis.

Methods

A retrospective review was conducted for patients who underwent single (Current Procedural Terminology [CPT] code 28740), double (CPT 28725 and 28740), or triple (CPT 28715) arthrodesis to treat hindfoot arthritis/deformity (International Classification of Diseases, Ninth Revision [ICD-9] code: 734, International Classification of Diseases, Tenth Revision [ICD-10] codes: M76821, M76822, and M76829) from 2005 to 2022 using the South Carolina Revenue and Fiscal Affairs databank. Data collected included demographics, comorbidities, procedure data, and postoperative outcomes within 1 year of principal surgery. Student t test, chi-squared test, and multivariable logistic regression analysis were utilized during data analysis.

Results

A total of 433 patients were identified, with 248 undergoing single arthrodesis, 67 undergoing double arthrodesis, and 118 undergoing triple arthrodesis. There was no significant difference between single, double, and triple arthrodesis in the rate of complications, hardware removals, revision surgeries, or 30-day readmission when controlling for confounding variables. However, a decrease in Charlson Comorbidity Index (CCI) was found to be predictive of an increase in the revision surgery rate (OR = 0.46, 95% CI 0.22-0.85, P = .02).

Conclusion

We found no difference in the rate of complications, hardware removals, or revision surgeries in those undergoing single, double, or triple arthrodesis. Surprisingly we found that a lower Charlson Comorbidity Index, indicating a healthier patient had a significant relationship with a higher rate of revision surgery. Further study including radiographic indications for surgery or the impact of overall health status on revision surgery rates may further elucidate the other components of this relationship.

Level of Evidence

Level III, cohort study.

Preoperative Opioid Use Predicts Poorer Outcomes of Total Ankle Arthroplasty and Hindfoot Fusions

BACKGROUND

This study aimed to determine the impact of preoperative opioid use on outcomes of patients undergoing ankle or hindfoot arthrodesis, or total ankle arthroplasty (TAA).

METHODS

We conducted a retrospective review of 190 patients undergoing an ankle or hindfoot arthrodesis (n=122) or TAA (n=68) between December 2015 and September 2020 with a single fellowship-trained orthopaedic foot and ankle surgeon at an academic medical center. Data collected included demographics, medical comorbidities, treatment history, complications and reoperation rates, patient-reported outcome measures (PROMs) (eg, Foot and Ankle Outcome Score [FAOS]), and opioid use.

RESULTS

Patients with preoperative opioid use were more likely to continue usage at 90 (r = 0.931, P < .001) and 180 (r = 0.940, P < .001) days postoperatively. For the entire cohort, complication and reoperation rates were 48.9% and 13.2%, respectively. While preoperative opioid use groups did not differ in the overall complication rate, users had significantly more infections (user = 12.5%, nonuser = 3.3%; P = .036) and reoperations (user = 22.5%, nonuser = 10.7%; P = .049). When analyzing postoperative opioid prescriptions, there were many significant correlations with preoperative PROMs, mainly FAOS, such that increased postoperative opioid use was associated with worse subjective outcomes.

CONCLUSION

Preoperative opioid users are more likely to continue postoperative opioid use, experience infections, and undergo reoperations.

LEVEL OF EVIDENCE

Level III: Retrospective cohort study.

Adverse Surgical Outcomes Linked to Co-occurring Smoking and Risky Alcohol Use Among General Surgery Patients

OBJECTIVE

To assess associations between co-occurring preoperative smoking and risky alcohol use on the likelihood of adverse surgical outcomes.

BACKGROUND

Risky alcohol use and smoking are the known surgical risk factors with a high co-occurrence and additive adverse effects on multiple organ systems that impact surgical health, yet no research has evaluated the impact of co-occurrence on surgical outcomes.

METHODS

This investigation analyzed 200,816 patients from the Michigan Surgical Quality Collaborative database between July 1, 2012, to December 31, 2018. Patients were classified based on past year risky alcohol use (>2 drink/day) and cigarette smoking into 4 groups: (1) risky alcohol and smoking, (2) risky alcohol only, (3) smoking only, and (4) no risky alcohol/smoking. We fitted logistic regression models, applying propensity score weights incorporating demographic, clinical, and surgical factors to assess associations between alcohol and smoking and 30-day postoperative outcomes; surgical complications, readmission, reoperation, and emergency department (ED) visits.

RESULTS

Risky alcohol and smoking, risky alcohol only, and smoking only were reported by 2852 (1.4%), 2840 (1.4%), and 44,042 (22%) patients, respectively. Relative to all other groups, the alcohol and smoking group had greater odds of surgical complications, readmission, and reoperation. Relative to the no alcohol and smoking group, the alcohol only group higher odds of reoperation and smoking only group had higher odds of emergency department visits.

CONCLUSIONS

The combination of smoking and risky drinking conferred the highest likelihood of complications, readmission, and reoperation before surgery. Co-occurring alcohol and smoking at the time of surgery warrants special attention as a patient risk factor and deserves additional research.

Low Preoperative Albumin Associated With Increased Risk of Superficial Surgical Site Infection Following Midfoot, Hindfoot, and Ankle Fusion

BACKGROUND

This study investigates the effect of malnutrition, defined by hypoalbuminemia, on rates of complication, readmission, reoperation, and mortality following midfoot, hindfoot, or ankle fusion.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2019 to identify 500 patients who underwent midfoot (n = 233), hindfoot (n = 261), or ankle (n = 117) fusion. Patients were stratified into normal (n = 452) or low (n = 48) albumin group, which was defined by preoperative serum albumin level <3.5 g/dL. Demographics, medical comorbidities, hospital length of stay (LOS), and 30-day complication, readmission, and reoperation rates were compared between groups. The mean age of the cohort was 58.7 (range, 21-89) years.

RESULTS

Hypoalbuminemia patients were significantly more likely to have diabetes (P < .001), be on dialysis (P < .001), and be functionally dependent (P < .001). The LOS was significantly greater among the low albumin group (P < .001). The hypoalbuminemia cohort also exhibited a significantly increased likelihood of superficial infection (P = .048). Readmission (P = .389) and reoperation (P = .611) rates did not differ between the groups.

CONCLUSION

This study shows that malnourished patients have an increased risk of superficial infection following foot and ankle fusions but are not at an increased risk of readmission or reoperation, suggesting that low albumin confers an elevated risk of surgical site infection.

LEVELS OF EVIDENCE

Level III, Retrospective cohort study.

Impact of smoking cessation on healing after foot and ankle surgery

INTRODUCTION

Perioperative smoking is the main risk factor for the development of postoperative cutaneous wound healing complications. We require that all patients undergoing elective foot and ankle surgery stop smoking (6 weeks before and 3 months after) and this abstinence is monitored with a preoperative cotinine test. We therefore wanted to understand how this impacted wound healing in elective foot and ankle surgery: do wounds heal differently in patients who quit smoking for surgery, former smokers and nonsmokers?

HYPOTHESIS

Our hypothesis was that patients who stopped smoking for an upcoming surgery had the same wound healing complications as nonsmokers and former smokers.

MATERIALS AND METHODS

This was a historical, single-center, single-surgeon cohort study of adult patients who underwent an elective ankle or foot surgery between June 2016 and July 2017. Patients were divided into 3 groups: group 1 smokers who stopped for surgery, group 2 former smokers, and group 3 nonsmokers. The primary endpoint was the occurrence of wound healing complications during the wound care consult scheduled 3 weeks after surgery.

RESULTS

A total of 256 patients with a mean age of 58±14.2 years (range, 18-88) were included. Group 3 had more women and a lower BMI than the other groups, but all the other demographic characteristics were similar. Smoking cessation was achieved in group 1 on average 2.5±1.3 months (range, 1-6) before surgery. There were a total of 20 wound healing complications or 7.5% of the cohort: 13% in group 1, 11.1% in group 2 and 6.4% in group 3. The univariate analysis found that the odds ratio was 2.3 when comparing Group 1 to Group 3 and 1.85 when comparing group 2 to group 3 (p=413). No significant risk factors for wound healing complications were found.

DISCUSSION/CONCLUSION

Smoking cessation for foot and ankle surgery seems to limit the risk of wound healing complications, with results close to those of former smokers and nonsmokers. Mandatory smoking cessation before surgery could be one of the solutions to prevent this frequent complication.

LEVEL OF EVIDENCE

III.

Patients With Opioid Use Disorder Have Increased Readmission Rates, Emergency Room Visits, and Costs Following a Hallux Valgus Procedure

BACKGROUND

Patients with a history of opioid use disorder (OUD) tend to have more complications, higher readmission rates, and increased costs following orthopaedic procedures. This study evaluated patients undergoing hallux valgus correction for their odds of increased (1) readmission rates, (2) emergency room (ER) visits, and (3) costs.

METHODS

Patients undergoing hallux valgus corrections with OUD history were identified using a national Medicare administrative claims database of approximately 24 million orthopaedic surgery patients. OUD patients were matched to non-opioid use disorder (NUD) patients in a 1:4 ratio by age, sex, Elixhauser-Comorbidity Index (ECI), diabetes mellitus, hyperlipidemia, hypertension, and tobacco use. The query yielded 6318 patients (OUD = 1276; NUD = 5042) who underwent a hallux valgus correction. Primary outcomes analyzed included odds of 90-day readmission rates, 30-day ER visits, and 90-day episode-of-care costs. Demographics, odds ratios (ORs), ECI, and cost were assessed as appropriate using a Pearson χ² test, logistic regression, and a t test. A P value <.05 was considered statistically significant.

RESULTS

There were no significant differences in demographics between OUD and NUD patients. OUD patients had higher incidence and odds of 90-day readmission (9.56% vs 6.04%; OR = 1.55; P < .001) and 30-day ER visits (0.86% vs 0.35%; OR = 2.42; P = .021) and incurred greater 90-day episode-of-care costs ($7208.28 vs $6134.75; P < .001) compared with NUD patient controls.

CONCLUSION

The study demonstrates the possible influence of OUD on higher odds of readmission, ER visits, and costs following a hallux valgus correction.

LEVELS OF EVIDENCE

Level III: Retrospective cohort study.

Complications After Percutaneous Osteotomies of the Calcaneus

Background:

Open hindfoot surgery is associated with a relatively high rate of complications, including neurovascular injuries and wound healing problems compared with percutaneous techniques. However, there is a scarcity of literature describing the outcomes of these percutaneous techniques given their relatively recent adoption. The present study aims to assess the rate of postoperative complications for 3 commonly performed percutaneous calcaneal osteotomies.

Methods:

One hundred eighteen patients (unilateral feet) were treated with one of 3 common percutaneous calcaneal osteotomies. Sixty-five patients (55.1%) were treated with a medializing calcaneal osteotomy for hindfoot valgus, 32 patients with a Zadek osteotomy (27.1%) for insertional Achilles tendinopathy, and 21 patients (17.8%) with a modified Dwyer osteotomy for hindfoot varus. Fisher exact test was used to assess for associations between categorical variables.

Results:

The mean age was 46.2 years and there was a mean follow-up of 16.1 months. The overall rate of postoperative complications was 3.4% (n = 4), and no significant differences were found between the different osteotomy types. Complications included 2 cases (1.7%) of transient neuritis, 1 case of prolonged wound drainage (0.8%), and 1 nonunion (0.8%). None of the complications were associated with any recorded preoperative comorbidity.

Discussion:

In this series, we found that percutaneous calcaneal osteotomies are a safe alternative method for the treatment of conditions involving the hindfoot. The rate of postoperative complications may be less when compared to the reported rates of open hindfoot correction and should be considered in patients with a traditionally high risk of developing a postoperative complication.

Level of Evidence:

Level IV, retrospective analysis.

Achilles Tendon Repairs: Identification of Risk Factors for and Economic Impact of Complications and Reoperation

BACKGROUND

Compared with nonoperative management, Achilles tendon repair is associated with increased rates of complications and increased initial healthcare cost. However, data are currently lacking on the risk factors for these complications and the added healthcare cost associated with common preoperative comorbidities.

HYPOTHESIS

Identify the independent risk factors for complications and reoperation after acute Achilles tendon repair and calculate the added cost of care associated with having each preoperative risk factor.

STUDY DESIGN

Retrospective cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

A retrospective review of a large commercial claims database was performed to identify patients who underwent primary operative management for Achilles tendon rupture between 2007 and 2016. The primary outcome measures of the study were risk factors for (1) postoperative complications, (2) revision surgery, and (3) increased healthcare resource utilization.

RESULTS

A total of 50,279 patients were included. The overall complication rate was 2.7%. The most common 30-day complication was venous thromboembolism (1.2%). The rate of revision surgery was 2.5% at 30 days and 4.3% at 2 years. Independent risk factors for 30-day complications in our cohort included increasing age, hyperlipidemia, hypertension, female sex, obesity, and diabetes. Independent risk factors for revision surgery within 2 years included female sex, tobacco use, hypertension, obesity, and the presence of any postoperative complication. The average 5-year cost of operative intervention was $17,307. The need for revision surgery had the largest effect on 5-year overall cost, increasing it by $6776.40. This was followed by the presence of a postoperative complication ($3780), female sex ($3207.70), and diabetes ($3105).

CONCLUSION

Achilles tendon repair is a relatively low-risk operation. Factors associated with postoperative complications include increasing age, hyperlipidemia, hypertension, female sex, obesity, and diabetes. Factors associated with the need for revision surgery include female sex, hypertension, obesity, and the presence of any postoperative complication. Female sex, diabetes, the presence of any complication, and the need for revision surgery had the largest added costs associated with them.

CLINICAL RELEVANCE

Surgeons can use this information for preoperative decision-making and during the informed consent process.

Tobacco smoking is associated with more pain and worse functional outcomes after torsional ankle fracture

OBJECTIVE

The purpose of this study was to assess the impact of current and remote tobacco smoking on clinical and functional outcomes after torsional ankle fracture.

METHODS

Nine hundred thirty-five patients treated surgically for torsional ankle fracture over 9 years were reviewed. Tobacco smoking status at the time of injury was defined as current (48.3%), former (11.7%), and nonsmoker (40.0%). Complications, unplanned secondary procedures, pain medication use, and functional outcome scores, as measured by Foot Function Index and Short Musculoskeletal Function Assessment (SMFA) surveys.

RESULTS

Mean age was 44.8 years, with 50.3% male. More than 6 months following injury current smokers were more likely than former smokers and nonsmokers to report ankle pain (67.8% vs 45.8% vs 47.5%) and to use prescription pain medicines (23.0% vs 10.4% vs 6.3%), all P < .05. Multiple logistic regression found current tobacco use to be an independent predictor for prescription pain medication use, and worse scores for the Foot Function Index, SMFA Dysfunction, and SMFA Bothersome scores, all P < .05. Complications occurred in 15.5% of all patients, and 10.7% underwent unplanned secondary operations. Tobacco smoking was not associated with more complications or secondary procedures.

CONCLUSION

Current smokers are more likely to use prescription pain medications several months after injury and have worse patient-reported functional outcome scores after surgical treatment of torsional ankle fractures than former smokers and nonsmokers.

Malpractice claims in forefoot surgery

Foot and hallux valgus surgery are amongst the most commonly performed surgeries, with a growing number of procedures leading to litigation. The aim of this conference is to provide an update on the causes of malpractice claims and the associated risk factors. What are the causes of litigation? Acute or chronic residual pain, stiffness, metatarsalgia, consolidation delays, secondary displacements, suboptimal results are the most common causes found in litigious proceedings. What are the risk factors? Surgeon-related and patient-related risk factors exist. Percutaneous surgery or the development of outpatient hospitalization are not specific risk factors. From the point of view of practitioners, the application and traceability of recommendations for antibiotic prophylaxis, for thromboembolic disease, or for the checklist are essential, allowing causes of blame to be easily avoided. Information is fundamental. Since the Law of the 4th of March 2002, the surgeon-patient relationship has changed. Pre-operative information archived in the practitioner's file is essential. This includes written and oral information which is consented to and understood by the patient. Thus, the understanding and compliance with immediate post-operative instructions or adherence to the post-operative program are success factors regarding the surgical outcome. The patient must also be informed and aware of their own individual risk factors (e.g. smoking and immunosuppression, particularly) which require greater caution. What is the best way to reduce the risk of these claims being made? It is about traceability: traceability of clinical examination, procedures, information and exchanges with the patient. It is only under this principle that the surgeon-patient relationship can be clearer, respectful and consequently less conducive to litigation. LEVEL OF EVIDENCE: V; expert opinion.

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.

The Impact of Patient Age on Foot and Ankle Arthrodesis Supplemented with Autograft or an Autograft Alternative (rhPDGF-BB/β-TCP)

A recent survey of orthopaedic surgeons asking about risk factors for nonunion following foot and ankle arthrodesis revealed that patient age is considered to be a relatively low risk factor, despite the potential for autologous graft quality to deteriorate with increasing age. The purpose of the current study was to evaluate the impact of patient age and graft type on fusion rates following hindfoot and ankle arthrodesis.

Relationship Between Preoperative Opioid Use and Postoperative Pain in Patients Undergoing Minimally Invasive Stand-Alone Lateral Lumbar Interbody Fusion

BACKGROUND

Opioid use in the management of pain secondary to spinal disorders has grown significantly in the United States. However, preoperative opioid use may complicate recovery in patients undergoing surgical procedures.

OBJECTIVE

To test our hypothesis that prolonged preoperative opioid use may lead to poorer patient outcomes following minimally invasive stand-alone lateral lumbar interbody fusion (LLIF) for lumbar degenerative disc disease.

METHODS

A consecutive series of patients from a single institution undergoing LLIF between December 2009 and January 2017 was retrospectively analyzed. Patients were categorized according to the presence or absence of prescribed preoperative opioid use for at least 3 mo. Outcomes included the Oswestry Disability Index (ODI), visual analog scale (VAS), and Short Form 36 Physical and Mental Summary Scores (SF-36 PCS, SF-36 MCS).

RESULTS

Of 107 patients, 57 (53.1%) were prescribed preoperative opioids. There was no significant difference in preoperative ODI, VAS score, SF-36 PCS, or SF-36 MCS between opioid use groups. Mean postoperative ODI was greater in patients with preoperative opioid use at 41.7 ± 16.9 vs 22.2 ± 16.0 (P = .002). Mean postoperative VAS score was greater in patients prescribed preoperative opioids, while magnitude of decrease in VAS score was greater in opioid-naïve patients (P = .001). Postoperative SF-36 PCS was 33.1 ± 10.6 in the opioid use group compared to 43.7 ± 13.1 in the nonuse group (P = .001).

CONCLUSION

Following LLIF, patients prescribed preoperative opioids had increased postoperative lumbar pain, disability, and subjective pain.

Incidence and risk factors for surgical site infection following elective foot and ankle surgery: a retrospective study

Background

This study aimed to investigate the incidence of surgical site infection (SSI) in elective foot and ankle surgeries and identify the associated risk factors.

Methods

This was designed as a retrospective study, including patients who underwent elective surgery of foot and ankle between July 2015 and June 2018. Data on demographics, comorbidities, and perioperative parameters were collected from the medical records, the laboratory report, the operation report, and the outpatient follow-up registration database. SSI was defined in accordance with the Center for Disease Control criteria. Univariate and multivariate logistic regression analyses were used to identify the independent risk factors for SSI.

Results

A total of 1201 patients undergoing 1259 elective foot/ankle surgeries were included, of whom 26 (2.1%) had an SSI, representing an incidence rate of 1.3% for superficial SSI and 0.8% for deep SSI, respectively. The results for organism culture showed Pseudomonas aeruginosa in 7 cases, methicillin-resistant Staphylococcus aureus (MRSA) in 6, methicillin-susceptible Staphylococcus aureus (MSSA) in 5, methicillin-resistant coagulase-negative Staphylococci (MRCNS) in 2, Escherichia coli in 2, and Proteus mirabilis in 1 case. Five factors were identified to be independently associated with SSI, including prolonged preoperative stay (OR, 1.21; 95% CI, 1.09 to 1.30), allograft or bone substitute (OR, 3.76; 95% CI, 1.51 to 5.30), elevated FBG level (OR, 1.17; 95% CI, 1.04 to 1.26), lower ALB level (OR, 2.33; 95% CI, 1.19 to 3.05), and abnormal NEUT count (OR, 1.72; 95% CI, 1.27 to 2.12).

Conclusions

SSI following elective foot and ankle surgeries is low, but relatively high in forefoot surgeries, requiring particular attention in clinical practice. Although most not modifiable, these identified factors aid in risk assessment of SSI and accordingly stratifying patients and therefore should be kept in mind.

Non-Orthopedic Encounters Increase Opioid Exposure in Joint Osteoarthritis: A Single-Institution Analysis

BACKGROUND

There has been little-to-no evidence to support the use of opioid analgesia as a treatment modality for osteoarthritis (OA). Chronic opioid use has been associated with peri-operative and post-operative complications with joint reconstruction. The purpose of this study is to compare opioid-prescribing habits for OA between orthopedic and non-orthopedic physicians to identify encounters that increase opioid exposure.

METHODS

A retrospective chart review was performed on opioid-naive adult patients with outpatient opioid prescriptions for OA at a single academic institution between 2013 and 2018. Patients with prior surgery or opioid prescriptions were excluded. Independent t-tests and analysis of variance were used to compare prescription characteristics among providers.

RESULTS

A total of 9625 opioid prescriptions were identified. Non-orthopedic providers account for 92% of prescriptions vs 8% by orthopedic surgeons. The greatest number of prescriptions is written by Internal Medicine (37.1%) and Family Medicine physicians (36.0%). Non-orthopedic physicians prescribe a greater number of prescriptions per patient, dosages, and refills (P < .001 for all). Non-orthopedic encounters are associated with increased risk for prescription dosages ≥50 MME/d (odds ratio 5.81, 95% confidence interval 4.35-7.81, P < .001) and 90 MME/d (odds ratio 18.2, 95% confidence interval 4.43-35.70, P < .001).

CONCLUSION

The majority of opioid prescriptions for OA are written by non-orthopedic providers, with higher prescription rates, dosages, and more refills than orthopedic surgeons. OA is a common condition that will benefit from multi-disciplinary awareness to minimize unnecessary opioid exposure and reduce potential complications with joint arthroplasty.

Should "Pain Clearance" Be Routine for Elective Surgery?

For elective surgery, preoperative planning for patients with comorbidities tends to address risk stratification, cardiac clearance, and anticoagulation. This commentary suggests that chronic opioid use should be normalized as a comorbidity requiring "pain clearance" prior to elective surgery. Doing so would likely enhance team communication, optimize patient care, decrease stigma, and facilitate care transitioning and long-term planning.

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.

Outcome After Surgical Treatment of Calcaneal Osteomyelitis

BACKGROUND

Surgical procedures for calcaneal osteomyelitis are partial calcanectomy (PC), total calcanectomy (TC), and below-knee amputation (BKA). With calcaneal osteomyelitis, limb-saving surgery was described to have secondary BKA rates of 4% to 20%, while secondary amputation rates after BKA are unknown. The aim of this study was to describe and compare overall revision and secondary amputation rates for each surgical option in our institution's cohort and to identify risk factors for secondary amputation.

METHODS

Fifty patients treated between 2002 and 2017 were included. Revisions, secondary amputations, and possible risk factors for secondary amputation and overall revision were statistically analyzed.

RESULTS

Minor revisions rates were 57.1% in PCs, 100% in TCs, and 27.8% in BKAs. Secondary amputation was performed in 28.6% of the PCs, in 50% of the TCs, and in 5.6% of the BKAs. No statistically significant differences between overall revision and secondary amputation rates were found. C-reactive protein values greater than 5 mg/L at the index procedure were significantly associated with overall revision while we could not identify risk factors for secondary amputation.

CONCLUSION

This study represents the largest group of patients treated for calcaneal osteomyelitis in the literature. In limb-preserving surgical options, secondary BKA rates are higher than previously known. Primary BKA is a procedure with a low reamputation rate of 5.6%. PC can be considered, with 28.6% needing more proximal amputation. In TC, all patients underwent revision surgery and 50% had to undergo secondary BKA. Therefore, we hesitate to consider total calcanectomy as a surgical option in calcaneal osteomyelitis anymore.

LEVEL OF EVIDENCE

Level IV, case series.

A Novel In Vivo Model to Study Impaired Tissue Regeneration Mediated by Cigarette Smoke

Cigarette smoke is associated with several pathologies including chronic respiratory diseases and cancer. In addition, exposure to cigarette smoke is correlated with impaired wound healing, where a significant decrease in the regenerative capacity of smokers is well documented and broadly considered a negative risk factor after trauma or surgery. So far, some in vitro and in vivo models have been described to study how exposure to cigarette smoke diminishes the regenerative potential in different organisms. However, although useful, many of these models are difficult and expensive to implement and do not allow high-throughput screening approaches. In order to establish a reliable and accessible model, we have evaluated the effects of cigarette smoke extract (CSE) on zebrafish development and regeneration. In this work, zebrafish embryos and larvae were exposed to low doses of aqueous CSE showing severe developmental abnormalities in a dose-dependent manner. Furthermore, when adult zebrafish were subjected to caudal fin amputation, we observed a significant decrease in the regenerative capacity of animals exposed to CSE. The effect was exacerbated in male and aged fish compared to female or young organisms. The establishment of a zebrafish model to assess the consequences of cigarette smoke and its effects on animal physiology could provide a new tool to study the underlying mechanisms involved in impaired tissue regeneration, and aid the development of novel approaches to treat complications associated with cigarette smoke toxicity.

Infection and Rerupture After Surgical Repair of Achilles Tendons

Background:

Surgical repair of an Achilles tendon rupture has been shown to decrease rerupture rates. However, surgery also increases the risk of complications, including infection.

Purpose:

To determine the risk factors for infection and rerupture after primary repair of Achilles tendon ruptures.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective review was performed on 423 patients who underwent operative treatment of Achilles tendon ruptures between the years 2008 and 2014. The primary outcome of interest was the total rate of infection, and the secondary outcome of interest was the incidence of rerupture within 2 years of operation.

Results:

A total of 423 patients were analyzed, with a mean age of 46 years (range, 16-83 years) and a mean body mass index of 31.4 kg/m² (range, 17-55 kg/m²). The overall infection rate was 2.8%, and the rerupture rate was 1%. The median time between surgery and superficial surgical site infection was 30 days, and the median time between surgery and rerupture was 38 days. Longer tourniquet times (100.3 ± 34.7 minutes vs 69.9 ± 21.4 minutes; P = .04) and greater estimated blood loss (15.0 ± 9.1 mL vs 5.1 ± 12.0 mL; P = .01) were associated with an increased rate of deep surgical site infections. Patients who had longer operation and tourniquet times trended toward higher rerupture rates (P = .06 and .08, respectively). When compared with nonsmokers, current and previous smokers had an increased incidence of superficial or deep surgical site infections (6.25% vs 1.42%; P = .02). Age, sex, race, body mass index, alcohol use, diabetes, past steroid injections, and mechanism of injury did not contribute to complication rates.

Conclusion:

Achilles tendon repairs were associated with a low risk of infection and rerupture. Patients with longer tourniquet times, higher estimated blood loss, and a history of smoking were at increased risk for surgical site infections. Patients with longer operative times had increased rates of rerupture.