Orthopedic Surgery Residency Program Rankings and Gender Diversity

Background Orthopedic surgery residency programs are some of the least gender-diverse specialty programs in medicine. Despite strong representation at the undergraduate and medical school levels and increased applications to orthopedic surgery residency programs by women, there is still a substantial gender gap at the resident level. This study explores the relationship between the gender diversity of orthopedic surgery residency programs and program rankings. Methodology Program rank, program director gender identity, and gender diversity data were collected for the top 100 programs by reputation in Doximity. Gender diversity was measured as the proportion of female residents in the program and alumni. Results The greatest percentage of women in a program was 33% and the smallest was 3%. After linear regression analysis, we found that there was a statistically significant positive correlation between program rank and the proportion of women. The higher ranked a program was, the greater the proportion of women. There was no significant correlation between program director gender, appointment year, and program rank. Conclusions These results suggest that, although there is still a long way to go before closing the gender gap in orthopedic surgery residency programs, higher-ranked programs are associated with greater gender diversity than their lower-ranked counterparts.

Return to Driving After Foot and Ankle Surgery: A Novel Survey to Predict Passing Brake Reaction Time

Introduction. Brake reaction time (BRT) is an accepted method for establishing recommendations for safe return to driving by the National Highway Traffic Safety Administration. Other than performing a BRT test in clinic, there is no established clinical tool to help physicians differentiate safe from unsafe drivers once patients reach general recovery milestones. The purpose is to present individual recommendations to the patient through a novel, validated survey evaluating safe return to driving after orthopaedic surgery of the right foot and ankle. Methods. A total of 171 patients undergoing 1 of 3 specific foot and ankle procedures were prospectively enrolled. A 4-question survey and BRT were completed 6 weeks postoperatively. The following questions were asked: (1) "I think my brake reaction time is slower than most drivers my age," (2) "I think my brake reaction time is faster than most drivers my age," (3) "I think my brake reaction time is about the same as most drivers my age," (4) "Based on what I think my brake reaction time is, I think I am ready to drive." Internal consistency was determined with Cronbach's α and item total correlation. External validity was determined by Spearman's correlation coefficient. A BRT less than 0.850 s was considered as a pass. Results. Of 171 patients, 162 (95%) with ages ranging from 21 to 83 years achieved a passing BRT by 7.6 weeks. After removing 1 question because of internal inconsistency, the optimal threshold for predicting passing BRT was 10/15 points or higher, which had 99% probability of success that a patient would pass the BRT (95% CI = 96%, 100%). Conclusion. This novel, 3-question driving readiness survey can accurately predict a passing BRT Achilles rupture repair, total ankle arthroplasty, and hallux valgus correction performed in the right foot and ankle as early as 6 weeks postoperatively.Level of Evidence: Level II: Comparative study.

Midterm Results of Radiographic and Functional Outcomes After Tibiotalocalcaneal Arthrodesis With Bulk Femoral Head Allograft

Background: Tibiotalocalcaneal (TTC) arthrodesis implementing adjunctive allografts is a method of limb salvage for patients with complex hindfoot osseous deficits, though outcome results are limited. The purposes of this study were to assess functional and radiographic outcomes after TTC arthrodesis with femoral head allograft and retrospectively identify prognostic factors. Methods: The authors reviewed 24 TTC arthrodesis procedures with bulk femoral head allografts performed by a single surgeon from 2004 to 2016. Radiographic union at the ankle and subtalar joints along with stability of the allograft were assessed. Patients who had clinically successful arthrodeses were contacted to score the Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) questionnaire, Visual Analog Scale (VAS) for pain, and Short Form-12 (SF-12) at a mean of 58.0 months (range, 28-102) postoperatively. Results: Complete radiographic union of involved joints was achieved in 15 patients (63%) and in 75% (36/48) of all joints; 21 ankles (88%) were assessed to be radiographically stable at final follow-up. Three patients (13%) underwent revision arthrodesis at a mean of 18.9 months postoperatively, and 21 patients (88%) did not require additional surgery as of final follow-up. Patients significantly improved to a mean FAAM-ADL score of 71.5 from 36.3 (P < .001). The mean VAS for pain significantly improved from 77.2 to 32.9 (P < .001). Male sex (P = .08) and a lateral operative approach (P = .03) both resulted in worse outcomes. Conclusion: Use of a femoral head allograft with TTC arthrodesis can offer improved functional scores and sustained radiographic outcomes.Level of Evidence: Level IV: Case series.

What Determines the Type and Dose of Antibiotic That Is Needed to Be Added to the Cement Spacer in Patients With Infected Total Ankle Arthroplasty (TAA)?

RECOMMENDATION

We recommend tailoring the antibiotic in cement spacers to the infecting organism if it has been identified, as is typically done in total knee and hip arthroplasty. Otherwise, broad-spectrum antibiotics may be utilized. Medical comorbidities should always be considered, especially with regard to renal function and allergy profile. A thermostable antibiotic should be added to cement.

LEVEL OF EVIDENCE

Consensus.

DELEGATE VOTE

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

What Is the Best Technique for Performing Aspiration of Patients With Total Ankle Arthroplasty (TAA)?

RECOMMENDATION

In the absence of evidence, we recommend that ankle joint aspiration to evaluate for periprosthetic joint infection (PJI) be performed under sterile conditions via the anteromedial approach. Ultrasound guidance may be used if available but is not necessary to obtain an acceptable synovial fluid sample.

LEVEL OF EVIDENCE

Consensus.

DELEGATE VOTE

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

Prevalence of Neuropathic Pain Symptoms in Foot and Ankle Patients

BACKGROUND

The management of pain in patients with foot and ankle pathology can be challenging. Cumulative data suggest that, in addition to nociceptive mechanisms, other neuropathic mechanisms can contribute to pain in a subset of people with orthopedic conditions, and can be found in 10.5% to 53% of patients with chronic pain, depending on the location of the pathology. Preoperative diagnosis of neuropathic pain (NP) can potentially change decision making and management of foot and ankle pathologies.

METHODS

We used a validated patient-reported pain questionnaire (painDETECT) as a cross-sectional study to investigate the prevalence of NP symptoms in a population of patients undergoing foot and ankle surgery. A total of 533 patients were prospectively included and completed the painDETECT questionnaire.

RESULTS

Sixty-six patients (12.4%) were classified as having a component of NP symptoms according to their painDETECT score. Current smokers (23.2%) had a significantly higher rate of developing NP symptoms than current nonsmokers (11.1%) ( P = .016). The location of the pathology and obesity had a moderate effect on the prevalence of NP symptoms. Patients with ankle-level pathology, excluding tarsal tunnel syndrome, had a marginally increased risk of having NP symptoms (15.4%) compared to patients with forefoot pathologies, excluding Morton's neuroma (7.5%, P = 0.06). Obesity also had a moderate effect on the NP risk, with 15.6% risk of NP symptoms for patients with BMI of 30 or more compared to 10% risk for patients with a BMI of less than 30 ( P = .06). Patients with NP symptoms reported significantly higher levels of current pain (7.2 vs 4.6, P < .001).

CONCLUSION

A considerable number of patients with foot and ankle problems requiring surgery had a neuropathic component of pain. Evaluation of their risk factors and level of pain may help with the diagnosis, decision making, and pain control. Further research is needed to evaluate the effect of preoperative NP on the short- and long-term results of surgeries.

LEVEL OF EVIDENCE

Level II, prospective cohort survey study.

Adult-Acquired Flatfoot Deformity

Adult-acquired flatfoot deformity (AAFD) comprises a wide spectrum of ligament and tendon failure that may result in significant deformity and disability. It is often associated with posterior tibial tendon deficiency (PTTD), which has been linked to multiple demographic factors, medical comorbidities, and genetic processes. AAFD is classified using stages I through IV. Nonoperative treatment modalities should always be attempted first and often provide resolution in stages I and II. Stage II, consisting of a wide range of flexible deformities, is typically treated operatively with a combination of soft tissue procedures and osteotomies. Stage III, which is characterized by a rigid flatfoot, typically warrants triple arthrodesis. Stage IV, where the flatfoot deformity involves the ankle joint, is treated with ankle arthrodesis or ankle arthroplasty with or without deltoid ligament reconstruction along with procedures to restore alignment of the foot. There is limited evidence as to the optimal procedure; thus, the surgical indications and techniques continue to be researched.

Prospective Evaluation of Utilization Patterns and Prescribing Guidelines of Opioid Consumption Following Orthopedic Foot and Ankle Surgery

BACKGROUND

Overprescription of narcotic pain medication is a major culprit in the present opioid epidemic plaguing the United States. The current literature on lower extremity opioid usage has limitations and would benefit from additional study. The purpose of our study was to prospectively assess opioid consumption patterns following outpatient orthopedic foot and ankle procedures.

METHODS

Patients undergoing outpatient orthopedic foot and ankle procedures who met inclusion criteria had the following prospective information collected: patient demographics, preoperative health history, patient-reported outcomes, anesthesia type, procedure type, opioid prescription and consumption details. The morphine equivalent dose was calculated for each prescription and then converted to the equivalent of a 5-mg oxycodone "pill." Univariable analyses were performed to identify variables with a statistically robust association with opioid consumption for inclusion in a multivariable linear regression. A stepwise backward regression was then performed to identify independent predictors of opioid consumption. Postoperative opioid utilization was reported for 988 patients (mean age: 49 years).

RESULTS

Overall, patients consumed a median of 20 pills whereas the median number of pills prescribed was 40. This resulted in a utilization rate of 50% and 20 631 pills left unused. Independent factors associated with higher opioid consumption were anesthesia type ( P < .004), age <60 years ( P < .001), preoperative visual analog scale (VAS) pain report of >6 ( P = .008), and bony procedures ( P = .008); residual standard error 16.73 ( F_7,844=14.3, P < .001).

CONCLUSION

Our study found that patients who underwent orthopedic foot and ankle procedures were overprescribed narcotic medication by nearly twice the amount that was actually consumed. Although we identified 4 independent factors associated with opioid consumption, the large residual standard error suggests that there remains a substantial degree of unexplained variance of opioid consumption observed in the patient population. Physicians face a challenging task of setting appropriate protocols when balancing pain relief and generalizable guidelines.

LEVEL OF EVIDENCE

Level II, prospective observational cohort study.

Effect of Postoperative Ketorolac Administration on Bone Healing in Ankle Fracture Surgery

BACKGROUND

In an effort to minimize narcotic analgesia and its potential side effects, anti-inflammatory agents offer great potential provided they do not interfere with bone healing. The safety of ketorolac administration after foot and ankle surgery has not been well defined in the current literature. The purpose of this study was to report clinical healing and radiographic outcomes for patients treated with a perioperative ketorolac regimen after open reduction and internal fixation (ORIF) of ankle fractures.

METHODS

A retrospective review was performed on all patients that received perioperative ketorolac at the time of lateral malleolar, bimalleolar, and trimalleolar ankle ORIF by a single surgeon between 2010 and 2016 with minimum 4 months follow-up. Patients received 20 tablets of 10 mg ketorolac Q6 hours. Radiographs were evaluated independently by 2 blinded fellowship-trained orthopedic foot and ankle surgeons to assess for radiographic healing. A total of 281 patients were included, with a median age of 51 years and 138 males (47%). Statistical analysis consisted of a linear mixed-effects regression.

RESULTS

In all, 265/281 (94%) were clinically healed within 12 weeks and 261/281 (92%) were radiographically healed within 12 weeks. Within the group of patients that did not heal within 12 weeks, mean time to clinical healing was 16.9 weeks (range = 14-25 weeks), and mean time to radiographic healing was 17.1 weeks (range = 14-25 weeks). In patients taking ketorolac, there were no cases of nonunion in our series (n = 281) and no significant difference found between fracture patterns and healing or complications ( P = .500).

CONCLUSIONS

Perioperative ketorolac use was associated with a high rate of fracture union by 12 weeks. This is the first study to examine the effect of ketorolac on radiographic time to union of ankle fractures. Additional studies are necessary to determine whether ketorolac helps reduce opioid consumption and improve pain following ORIF of ankle fractures.

LEVEL OF EVIDENCE

Level IV, case series.

A Prospective Randomized Study Evaluating the Effect of Perioperative NSAIDs on Opioid Consumption and Pain Management After Ankle Fracture Surgery

Category:

Trauma

Introduction/Purpose:

Currently there is an epidemic in the United States regarding opioid abuse. This has resulted in strict government prescribing regulations throughout the country and increasing efforts by orthopaedic surgeons to better manage postoperative narcotic analgesia. Non-steroidal anti-inflammatory drugs (NSAIDs) can serve as a powerful adjunct in managing postoperative pain and in turn minimize the need for opioid medications. It has recently been shown that ketorolac can be used after open reduction and internal fixation (ORIF) of ankle fractures without interfering with bone healing. Therefore, we set out to evaluate whether including ketorolac in the postoperative drug regimen reduces opioid consumption and pain after ORIF of ankle fractures.

Methods:

128 patients undergoing ORIF of an ankle fracture were prospectively randomized to treatment with or without ketorolac. Patients also had the option to simultaneously undergo regional anesthesia. Patients assigned to the treatment group were given 30 mg of IV ketorolac intraoperatively; prescribed 20 tablets of ketorolac 10 mg PO Q6 H and 30 tablets of Oxycodone/Acetaminophen 5/325 Q4-6 H PRN. Patients assigned to the control group were given 30 tablets of oxycodone/acetaminophen 5/325 Q4-6 H PRN only. A survey was distributed via Research Electronic Data Capture (REDCap) on postoperative days 1-7. Patients were asked to report their daily opioid consumption, pain level using the Visual Analog Scale (VAS), satisfaction with pain management, and side effects. Intention-to-treat analysis was performed. Normality of data was tested using the Shapiro-Wilk test. Differences between the control and treatment groups were tested using Mann-Whitney U or Student’s t-tests.

Results:

105/128 (82%) patients with mean BMI of 29.3 completed all study requirements. 54 received ketorolac with opioid medication and 51 received opioids alone. 43 men (41%) and 62 women (59%) participated with mean age of 48 years. Patients receiving ketorolac required less oxycodone/acetaminophen (p<0.013) and reported less pain (p<0.048) during postoperative days 1 and 2 compared to control patients(Figure 1). While opioid consumption did not significantly differ after day 2, patients treated with ketorolac maintained less pain (days 1-4, p<0.028); better sleep (days 1-5, p<0.037); lower frequency of pain (days 1-3; p<0.017); and greater satisfaction with pain management (days 1-3, p<0.047). Hypersensitivity was significantly less on day 1 (p=0.036) and paresthesias on day 3 (p=0.011). Surprisingly, there was no difference in nausea/constipation between groups (p>0.139).

Conclusion:

The addition of ketorolac to the postoperative drug regimen significantly reduced pain, while decreasing the use of opioid medication following ORIF of ankle fractures early in the postoperative period. Better pain management during postoperative days 1 and 2 is particularly important because patients on average consume the most opioids during this time. With the assurance that ketorolac does not interfere with bone healing, this NSAID is a valuable tool for helping patients manage postoperative pain with less narcotic analgesia.

Mid-term Results of Radiographic and Functional Outcomes After Tibiotalocalcaneal Arthrodesis with Bulk Femoral Head Allograft

Category:

Hindfoot

Introduction/Purpose:

Tibiotalocalcaneal (TTC) arthrodesis with bulk femoral head allograft has previously been reported as a way to fill large osseous hindfoot deficits in order to restore limb length, but few studies have been performed evaluating outcomes and prognostic factors. The purposes of this study were to assess functional and radiographic outcomes after TTC arthrodesis with femoral head allograft and retrospectively identify prognostic factors.

Methods:

A retrospective review of patients undergoing TTC arthrodesis with bulk femoral head allograft performed at an academic institution by a single fellowship-trained foot and ankle surgeon between 2004 and 2015 was conducted. Patient charts and operative reports were reviewed for patient and procedural variables, respectively. Radiographic union was assessed at the ankle and subtalar joints by another fellowship-trained foot and ankle surgeon not involved in any patient’s surgical care. Radiographic stability, defined as proper maintenance of hardware and graft positioning in the hindfoot, was also assessed. A procedure was “failed” if there was a need for revision surgery. Patients with a successful arthrodesis were contacted to score the Foot and Ankle Ability Measure-Active Daily Living (FAAM-ADL) questionnaire, visual analog scale (VAS) for pain, and Short Form-12 (SF-12) mental (MCS) and physical (PCS) components. 22 patients were identified, with average radiograph and functional follow-up times of 39.7 and 57.1 months, respectively.

Results:

Complete radiographic union of involved joints was achieved in 13 patients (59.1%) and in 72.7% (32/44) of all joints. Eighteen patients (81.8%) were assessed to be radiographically stable at final follow-up. Three patients (13.6%) underwent revision arthrodesis at a mean of 18.9 months postoperatively, and 19 patients (86.4%) did not require additional surgery as of final follow-up. At an average of 57.1 months postoperatively, patients significantly improved to a mean FAAM-ADL score of 71.5 from 36.3 (P<.001). The mean VAS for pain significantly improved from 76.8 to 32.9 (P<.001). The mean postoperative SF-12-MCS and SF- 12-PCS scores were 53.9 and 40.6. Additionally, 73.3% (11/15) reported being satisfied with their surgical outcomes. Male sex (P=.03) and a lateral operative approach (P=.03) both resulted in significantly worse outcomes.

Conclusion:

The utilization of a femoral head allograft with TTC arthrodesis in patients with large hindfoot defects is an acceptable method that can offer improved functional and sustained radiographic outcomes and patient satisfaction. Male sex and a lateral approach may be associated with an inferior prognosis.

Improvement of Outcomes During the First Two Years Following Total Ankle Arthroplasty

BACKGROUND

Many studies of total ankle arthroplasty (TAA) have focused on the range of motion and functional outcomes at the time of intermediate-term follow-up. The purpose of our study was to analyze the progression of ankle hindfoot range of motion and patient-reported measures through the first 2 years following TAA.

METHODS

The charts of 134 patients who had been treated with a TAA by a single surgeon were retrospectively reviewed, and 107 (109 TAAs) were included in the study. The overall range of motion in the sagittal plane was measured as the change in the position of the tibia relative to the floor on dedicated weight-bearing lateral radiographs made with the ankle in maximum plantar flexion and dorsiflexion preoperatively and at 3 months, 6 months, 1 year, and 2 years postoperatively. In addition, patients completed a visual analogue scale (VAS) for pain, the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports Subscales, and the Short Form-12 (SF-12) Physical (PCS) and Mental (MCS) Component Summary scores at each time interval.

RESULTS

The mean overall range of motion in the sagittal plane was 20.7° preoperatively and improved to 28.3°, 34.3°, 33.3°, and 33.3° at 3 months, 6 months, 1 year, and 2 years, respectively (p < 0.001). At each postoperative time point, the median VAS score was improved (p < 0.001) compared with the preoperative VAS score. Similarly, the FAAM and SF-12 scores were improved, compared with the preoperative score, at 6 months and later (p < 0.001). An increased range of motion correlated with a lower VAS score preoperatively (ρ = -0.31, p = 0.035) and at 1 year (ρ = -0.36, p = 0.003) postoperatively. An increased range of motion correlated with a higher FAAM ADL score at 3 months (ρ = 0.50, p = 0.012), 1 year (ρ = 0.26, p = 0.040), and 2 years (ρ = 0.39, p = 0.003) postoperatively.

CONCLUSIONS

Patients who underwent TAA had improvement, compared with preoperatively, in the overall sagittal plane range of motion up to 6 months and maintained improvement in pain and function scores up to 2 years. Pain scores remained improved throughout the 2-year follow-up period. A better range of motion was correlated with less pain as measured with the VAS. An increased range of motion postoperatively was correlated with better function as measured with the FAAM.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Prevalence of neuropathic pain in the foot and ankle patients

Category:

Other

Introduction/Purpose:

The management of pain in patients with foot and ankle pain can be challenging. Cumulative data suggest that, in addition to nociceptive mechanisms, other neuropathic mechanisms can contribute to pain in a subset of people with osteoarthritis. Neuropathic mechanism include central sensitization or peripheral neuropathic hyper activated pain. Heterogeneous pain mechanisms may explain variable responses to recommended pain therapies. Accurate classification of pain phenotype using clinically feasible tools has potential to improve pain management. The PainDETECT score, a validated patient-report questionnaire was developed to identify neuropathic pain. A recent study found a prevalence of 23% of neuropathic pain following ORIF of Ankle fractures. The purpose of this study is to examine the prevalence of neuropathic pain (NP) in a variety of foot and ankle disorders.

Methods:

This is a cross-sectional study investigating the prevalence of NP in a population of patients undergoing foot and ankle surgery. The patient cohort will include 500 patients. Patients were prospectively reviewed, prior to their surgery, using a patient-self-report questionnaire (painDETECT). Patients’ demographics, diagnosis, comorbidities and functional scores were also prospectively collected. painDETECT score of less than 13 was considered as Nociceptive, score of more than 18 was considered as Neuropathic. Scores of 12 to 18 were considered as Unclear. ANOVA and Student’s t-tests were performed to compare the pain VAS scores, duration of pain prior to surgery, severity of the disease and the prevalence of NP, and among different foot and ankle procedures (bone versus tissue, elective versus trauma) and procedural regions (hindfoot/ankle, midfoot, forefoot).

Results:

A total of 116 patients were included in this preliminary study. 9 patients (7.7%) were diagnosed with neuropathic pain and 24 (20.6%) were Unclear according to their results in the painDETECT. There were 28 patients scheduled for surgery due to recent trauma, none of which had neuropathic pain. One patient with neuropathic pain was scheduled for excision of Morton’s neuroma and 2 patients for removal of foreign body or hardware. There was no significant correlation with age, BMI or smoking status nor with the patients’ functional scores. Patients with NP described their worst and current level of pain significantly higher than those with nociceptive pain. (9.4 Vs 7.4 for worst pain and 6.9 Vs 4.6 for current level in a scale from 0-10, p-value<0.05).

Conclusion:

A considerable number of the patients with foot and ankle problems requiring surgeries also has pain of a neuropathic mechanism. It is more common in chronic pain than in trauma. This should be evaluated pre-op and taken into attention when deciding on a surgical intervention or pain management.

Influence of Depressive Symptoms on Hallux Valgus Surgical Outcomes

BACKGROUND

The relationship between depressive symptoms and patient outcomes after hallux valgus surgery has not been well-studied. We hypothesized that patients with depressive symptoms would have greater subjective dysfunction preoperatively and less functional improvement and satisfaction after surgery when compared with patients without depressive symptoms.

METHODS

A total of 239 adult patients who had surgical hallux valgus correction over a 2-year period were retrospectively enrolled. A telephone survey was administered prospectively at least 11 months postoperatively inquiring about overall satisfaction level with surgery and satisfaction with postoperative pain level. A scale of 0 to 6 was used, with 0 indicating complete dissatisfaction and 6 indicating complete satisfaction. Patients were divided into 2 groups based on depressive symptoms; a Short Form-12 mental component score (SF-12 MCS) of less than 45.6 points was considered indicative of active depressive symptoms based on literature correlating SF-12 scores with Patient Health Questionnaire-9 for depression. Given the great variability of depressive symptoms in patients with or without self-reported depression and medicated or unmedicated status, we elected to use the MCS classification of depressive symptoms for our analysis. Data from 239 patients were available for analysis, with an average age of 51.6 years and 207 women (87%). Two hundred eighteen patients (91%) completed preoperative functional scores, 160 patients (67%) completed the satisfaction survey at an average of 23 months postoperatively (range 11 to 43 months), and 154 patients (64%) completed postoperative functional scores an average of 21 months postoperatively (range, 11-44 months). Results Thirty-six of 239 patients (15%) with baseline functional scores exhibited depressive symptoms. There was no significant difference in baseline functional scores and pain levels between groups with the exception of the SF-12 MCS ( P < .001). Most outcomes improved significantly over time, including the SF-12 physical component score ( P = .013), Foot and Ankle Ability Measure (FAAM; P = .013), and FAAM Activities of Daily Living ( P = .046). The patients with depressive symptoms generally had lower scores at baseline and final follow-up in all functional scores, with the exception of visual analog scale (VAS). VAS pain scores started higher in the group of patients with depressive symptoms and ended lower. Satisfaction with postoperative pain was lower in the group with depressive symptoms when compared with patients without depressive symptoms (3.6 vs 4.5, P = .042). There was no significant difference in satisfaction after surgery between groups ( P = .251).

CONCLUSION

Patients with depressive symptoms had greater pain at baseline and less pain postoperatively when compared with patients without depressive symptoms; however, satisfaction levels with postoperative pain were lower in these patients. Furthermore, most functional scores were lower in patients with depressive symptoms, with the exception of the MCS. Reported history of depression was not associated with any significant difference in functional outcome scores or satisfaction. Further study is warranted to determine why patients with depressive symptoms fare worse after surgical hallux valgus correction by most subjective measures.

LEVEL OF EVIDENCE

Level III, comparative study.

Driving After Total Ankle Arthroplasty

Category:

Ankle

Introduction/Purpose:

With the increase in number of total ankle arthroplasty surgery, physician guidelines on when to begin to consider patients’ return to driving is valuable. The ability to accurately and efficiently determine when a patient can return to driving is important both from a patient safety and a medicolegal perspective. The purpose of the study was to determine when patients’ brake reaction time (BRT) returns to a safe value after right total ankle arthroplasty. We also aimed to identify predictive factors that may identify those patients who may not be safe to drive.

Methods:

After institutional review board approval, fifty-five patients undergoing right total ankle arthroplasty were recruited prospectively. Patient demographics include an age range of 43 to 83 years (median 63 years), of which 31 were male (56%) and 24 were female (44%). BRT was tested at six weeks and repeated weekly until patients achieved a passing BRT. A control group of twenty healthy patients was used to establish a passing BRT of 0.850 seconds. Patients were given a validated, novel driver readiness survey to complete of which a 10/15 point or higher score was considered passing.

Results:

At 6 weeks, 50 patients (91%) achieved a passing BRT and were considered safe to drive, and the passing group average BRT was 0.662 seconds. At 9 weeks, 52 patients (100%) of those who completed the study achieved a passing BRT. Patients that failed at 6 weeks had statistically greater visual analog scale (VAS) for pain (p=0.037) and significantly diminished ankle plantarflexion (p=0.029). There is a significant (p<0.001) and large (r=-0.455) correlation between BRT and the validated driver readiness survey scores. 5/5 (100%) patients that failed the BRT also failed the driver readiness survey (p=0.049). Interestingly, males were more likely to think they were ready to drive based on their driver readiness survey but were no more likely to pass the BRT than females (p=0.002).

Conclusion:

Over 90% of patients may be eligible to return to driving as early as 6 weeks post-operatively. Indications that a patient is not safe to return to driving at 6 weeks are higher VAS, limited plantarflexion, and a failed driver readiness survey. Although many factors determine whether a patient may safely return to driving, patients may be informed that BRT normalizes 9 weeks after right total ankle arthroplasty.

Incidence and Risk Factors for Complications of Exposed Kirschner Wires Following Elective Forefoot Surgery

Category:

Midfoot/Forefoot

Introduction/Purpose:

Kirschner wires (K-wires) are commonly utilized for temporary metatarsal and phalangeal fixation following forefoot corrective osteotomies. K-wires can remain in place for up to 6 weeks postoperatively and are at risk for wound complications. Their exposure to the outside environment and direct osseous communication makes infection an important concern for the clinician. Early removal, prophylactic antibiotics, and re-operation are potential sequelae of infected K-wires and can affect outcomes. The purpose of this study is to evaluate the incidence of complications of exposed K-wires after forefoot surgery and identify patient or perioperative risk factors for these complications.

Methods:

A single surgeon retrospective chart review of forefoot surgeries over the past 10 years was undertaken. Inclusion criteria were any adult undergoing elective forefoot surgery with the use of exposed K-wires. Incidence of wound complication defined as cellulitis, pin site drainage, or migration/loosening of the pin requiring prophylactic antibiotics or early removal was noted. Patient demographic data such as age, BMI, comorbidities, and smoking status were recorded. Perioperative data such as tourniquet time, type of anesthesia, and perioperative antibiotics was also recorded. Univariate analysis was performed via Mann-Whitney test for continuous variables and Chi square test for categorical variables. Multivariate analysis was performed for statistically significant risk factors.

Results:

1,217 Patients (2,018 K-wires) were analyzed. There was a 10% complication rate requiring prophylactic antibiotics or early removal (N=123). 40 patients required early pin removal, 54 patients were given oral antibiotics, and 29 patients required both. Female gender (p<0.001), BMI over 28 (p<0.001), general anesthesia (p=0.025), increased tourniquet time (p=0.003) and history of rheumatoid arthritis (p=0.047) were significantly associated with complications. Both male gender [OR 2.62] and tourniquet time [OR 1.01] remained significant on multivariate regression analysis. There was no increased risk of complications with a history of smoking or diabetes.

Conclusion:

The K-wire is an important modality for providing temporary immobilization of the smaller bones of the forefoot following deformity correction. Male gender, elevated BMI, history of rheumatoid arthritis, general anesthesia, and longer tourniquet time are associated with increased risk of pin infection requiring early removal and/or antibiotics. Further study is needed to determine whether optimizing inflammatory disease, using efficient perioperative technique, and utilizing local anesthesia may limit the risk of wound complications with K-wires in forefoot surgery.

Determination of minimum clinically important difference (MCID) in visual analog scale for pain scores after hallux valgus correction

Category:

Bunion

Introduction/Purpose:

Surgical outcome studies rely on patient reported outcome measurements to assess the effectiveness of treatment. The concept of minimal clinically important difference (MCID) proposes a necessary threshold to achieve clinically significant treatment results, and refers to the smallest change in outcome measure important from the patient’s perspective. In the context of visual analog scale (VAS) questionnaires, MCID refers to a clinically significant change in pain score. Determination of MCID in patient-oriented outcome questionnaires is necessary to further evaluate the effectiveness of hallux valgus surgery. Further, MCID analysis of hallux valgus surgical outcomes could provide improved insight into post-operative patient satisfaction. The purpose of this study was to determine the MCID in pre- to post-operative VAS pain score in patients undergoing surgical treatment of hallux valgus.

Methods:

Adult patients undergoing surgical treatment of hallux valgus were retrospectively included. Pre- and post-operative VAS pain scores (0-10) and surveys inquiring about satisfaction with pain level after surgery were collected at a minimum of 1-year post-surgery. Patients were categorized as responders or non-responders based upon a completed 6-point pain satisfaction scale. Patients reporting satisfaction scores 0-3 were categorized as non-responders, and 4-6 as responders. Four MCID calculation methods were used that have been described in previous literature: the standard deviation (SD) approach, the average change approach, the minimally detectable change (MDC) approach, and the change difference approach. The total percentage of patients meeting the calculated VAS threshold score for each MCID method was determined. The likelihood of meeting the VAS threshold for each MCID method based on responder status, hallux valgus severity, and correction status of concomitant hammertoe deformity was also determined using bivariate analysis.

Results:

170 patients were included with post-operative follow-up averaging 23.6 months. VAS MCID threshold scores were 1.77points (SD approach), 5.21points (average change approach), 1.98points (MDC approach), and 4.27points (change difference approach). The patient percentage meeting the VAS threshold score for each MCID approach was 73.5%, 40.6%, 73.5%, and 48.8%, respectively. Moderate deformity procedures (Ludloff) demonstrated greater likelihood than mild deformity procedures (Chevron, Modified McBride, Aikin, Silver) of meeting the average change, MDC, and change difference approach thresholds (p=0.036, 0.035, 0.034). Severe deformity procedures (Lapidus) demonstrated greater likelihood than mild deformity procedures of meeting the SD approach threshold (p=0.046). Hammertoe correction demonstrated greater likelihood than non-correction of meeting the average change approach threshold (p=0.038). Responders demonstrated greater likelihood than non-responders of meeting all MCID approach thresholds (p<0.001).

Conclusion:

This study demonstrated marked variability in determining VAS MCID for hallux valgus correction (range 1.77- 5.21 points). This study suggests an association between type of hallux valgus correction and likelihood of post-operative improvement, as there was greater chance of meeting MCID with correction of greater hallux valgus deformity or hammertoe deformity. MCID methods utilizing comparisons of responder status may not be appropriate for hallux valgus patients, as responders tended to improve with time and non-responders tended to decline. Additional investigation of the optimal MCID method for hallux valgus correction is necessary to narrow the range and determine surgical efficacy.

Functional Outcome Risk Score for Total Ankle Arthroplasty

Category:

Ankle

Introduction/Purpose:

Postoperative functional outcomes are important measures as the orthopaedic community responds to pay-for-performance and bundled payments. Considering the 1000-fold growth of total ankle arthroplasty (TAA) procedures in the Medicare population in the past two decades, this procedure will likely undergo increasing scrutiny of quality under Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015(MACRA). While BMI, coronal plane deformity, age, and rheumatoid arthritis influence outcomes and rate of complications after TAA, there has been no single identifiable factor that predicts poor functional outcomes. The aim of this study is to identify independent patient factors that are associated with lower functional outcomes at two years after TAA and compound these predictive factors into an easily calculable score to preoperatively stratify patients undergoing modern TAA.

Methods:

134 consecutive patients (136 ankles) with a mean age of 64 years (range, 31 to 79 years) and 70 (51%) men that had undergone TAA by a single surgeon from May 2011 to May 2015 were retrospectively enrolled. In addition to 2-year functional outcomes for each patient, 22 data point were collected including preoperative range of motion; baseline functional scores; and a comprehensive health history. FAAM ADL scores at 2-years were grouped into excellent (>90 points), good (75-90), or fair (<75). Univariable analyses tested for the association between demographics, medical history, functional outcomes, and procedure factors using chi-squared tests for categorical variables and either one-way ANOVAs or Kruskal Wallis tests for continuous variables. Model coefficients from a multivariable ordinal logistic regression analysis for the significant predictors of excellent, good, or fair outcomes were used to create a summed risk score to predict inferior 2-year outcome scores.

Results:

Ninety-one patients met the inclusion criteria. The only predictors associated with inferior functional outcomes were (1) baseline ADL score (2) no calcaneal osteotomy for coronal plane deformity (3) lateral or deltoid ligament reconstruction and (4) post-traumatic/chronic sprain etiology and BMI >30. From the multivariable ordinal logistic regression, baseline ADL scores less than 40 had a weight of 2 while an ADL score of 40-55 had a weight of 1. The remaining factors were weighted 3, 2, 1 for ligament reconstruction, no calcaneal osteotomy, and obese+sprain. Of the 23 patients with a calculated risk of 0-2, 18 did excellent and 2 did fair. Conversely, of the 22 patients with a calculated risk score of 4+, only 2 did excellent and 15 did fair (Table 1).

Conclusion:

Over twenty baseline and surgical factors were considered when creating a clinical scoring system that compounds the effect of risk factors on postoperative foot and ankle functional outcome measures at two years. Ligament reconstruction was the highest weighted factor(3-points), which suggests soft tissue stabilization needs to be considered in conjunction with boney correction. As previous literature supports, preoperative coronal plane deformity when corrected appropriately can lead to greater likelihood for superior outcomes when compared to patients without this deformity. This novel risk score takes into account 5 easily-obtainable factors and may help to better set patient expectations prior to TAA.

Value of Supine Positioning in Repair of Achilles Tendon Ruptures

Category:

Hindfoot

Introduction/Purpose:

The optimal method of Achilles tendon repair remains undefined. Few previous studies have quantified the financial expenses of Achilles tendon repairs in relation to functional outcomes in order to assess the overall value of the accepted repair techniques. The purpose of this study is to demonstrate the value of supine positioning during open repair (OS) of acute Achilles tendon ruptures through the quantification of operative times, costs, and outcomes in comparison to the commonly performed percutaneous prone (PP) repair technique.

Methods:

A retrospective review was conducted on 67 patients undergoing OS and 67 patients undergoing PP primary Achilles tendon repair with two surgeons at four surgical locations. Total operating room usage times and operating times were collected from surgical site records. Total operating room times were used to estimate the costs of room usage and anesthesia, while costs of repair equipment were collected from the respective manufacturers. Patients undergoing OS repair completed the Foot and Ankle Ability Measure (FAAM) questionnaire, with activities of daily living (ADL) and sports subscales, Short Form-12 (SF-12), with mental (MCS) and physical (PCS) health subcategories, and the visual analog scale (VAS) for pain preoperatively and at final follow-up.

Results:

Even with a significantly longer mean surgical time (P=.035), OS repairs had a shorter duration of total operating room time when compared to that of PP repairs (58.4 versus 69.7 minutes, P<.001). Estimated time-dependent costs were lower in OS repairs ($739 versus $861 per procedure, P<.001), while the estimated average total per procedure cost was also lower for OS repairs ($801 versus $1,910 per procedure, P<.001). For patients undergoing OS repair, FAAM-ADL (P<.001), FAAM-Sports (P<.001), SF-12-PCS (P<.001) all increased and VAS grades (P<0.001) decreased from time of initial encounter to final follow-up and were comparable to reported outcomes in the current literature. The complication rate in OS repairs (6.0%) was lower than PP repairs (11.9%), with revisions only occurring in the latter technique.

Conclusion:

Performing open Achilles tendon repair in the supine position offers substantial value, or “health outcomes achieved per dollar spent”, to providers due to decreased total operating room times and costs with satisfactory functional outcomes.

Combined Popliteal Catheter with Single Injection Versus Continuous Infusion Saphenous Nerve Block

Category:

Ankle, Bunion, Hindfoot, Lesser Toes, Midfoot/Forefoot, Sports, Trauma

Introduction/Purpose:

Surgical and analgesic advancements have increasingly allowed more foot and ankle procedures to be performed on an outpatient basis. Dual nerve blockade of saphenous and popliteal nerves minimizes post-operative pain, and continuous infusion via catheter can provide extended pain relief. In our experience, the combination of popliteal nerve catheters and single-shot saphenous nerve block effectively eliminates post-operative pain after most foot and ankle surgery. However, the early return of pain in the saphenous nerve distribution can cause early discomfort and even readmission for pain control. We hypothesized that patients receiving continuous popliteal nerve infusion with single-injection saphenous nerve block (single) will have greater post-operative pain than those patients receiving continuous popliteal and saphenous nerve infusion (dual).

Methods:

A cohort of 62 patients undergoing outpatient foot and ankle surgery by a single fellowship trained orthopaedic surgeon were prospectively, sequentially enrolled. The surgeon rated each procedure for degree of saphenous involvement as limited, moderate, or extensive. Demographics, American Society of Anesthesiologists physical status classification system (ASA), anesthesia time and post-anesthesia care unit (PACU) time were documented. Total analgesia requirement and reported numeric pain score (NPS) at rest and with activity were recorded. Student’s t-test and chi-square test were utilized for single and dual block comparisons, and one-way ANOVA tested for differences in saphenous involvement.

Results:

The dual catheter group took significantly less opioid medication on post-operative day (POD) 1 compared to the single catheter group (Table 1; p=0.02). The dual catheter group reported significantly greater satisfaction with pain at POD 1 and POD 3 (p=0.03) and a significantly lower NPS at POD 1 and POD 2 (p=0.005). This trend is observed in all 3 subgroups of medial involvement. Patients in the single catheter group report about twice as much pain as patients in the dual catheter group when medial involvement was limited (7.4 v 3.8; p=0.033) or moderate (5.9 v 3.4; p=0.025). For patients with extensive medial involvement, pain was reduced when dual blocks were employed (5.4 v 6.7), but this difference was not significant (p=0.288).

Conclusion:

Patients in the single catheter group reported more pain and less satisfaction with pain control on POD 1, suggesting dual catheter use is superior to managing early post-operative pain in outpatient foot and ankle surgery. Interestingly, degree of medial involvement did not seem to correlate with better pain control within the dual group; in contrast, patients with less medial involvement reported better pain relief with dual than with a single catheter. From a pain management perspective, discharging patients on the day of routine outpatient foot and ankle surgery is appropriate with the judicious use of perioperative continuous infusion nerve catheters.

Total Ankle Arthroplasty

Category:

Ankle, Ankle Arthritis

Introduction/Purpose:

Reports of ankle range of motion and how it affects patient outcomes following total ankle arthroplasty (TAA) have been mixed. Furthermore, recent studies have relied on clinical exam to obtain postoperative range of motion and have lacked preoperative functional scores. The purpose of our study was to analyze how preoperative range of motion and functional scores change with time following TAA using postoperative functional scores and radiographs for range of motion calculations.

Methods:

A retrospective chart review was performed on 107 patients (109 ankles) that had undergone fixed-bearing implant TAA by a single surgeon between 2010 and 2015. Preoperative range of motion was gathered clinically in office by the senior author. Postoperative range of motion through the ankle joint was evaluated with dedicated weight-bearing maximum dorsiflexion and plantarflexion lateral radiographs at 3 and 6 months, 1 and 2 years. The range of motion was measured using the angle measurement tool on the picture archiving and communication system. Patients completed visual analogue scale (VAS) for pain and the Foot and Ankle Ability Measure (FAAM) questionnaire subcategorized into activities of daily (ADL) and sports subscale preoperatively and at postoperative intervals of 3 and 6 months, 1 and 2 years. The mean age was 65 years (range, 31-83 years). Mean BMI was 28.1 (range, 14.9-44.9). There were 53 males (50%).

Results:

The mean total arc of ankle motion preoperatively was 20.7 degrees and improved significantly to 28.3, 34.3, 33.3, and 33.3 degrees at 3 and 6 months, 1 and 2 years, respectively (P<0.001) (Figure 1). Mean VAS pain and mean FAAM ADL preoperative scores improved significantly at each postoperative time point as seen in Figure 1 (P<0.001). Increased ankle range of motion was correlated with lower VAS preoperatively (r=-0.38, P=0.007), and at 1 year (r=-0.36, P<0.001), and 2 years (r=-0.2, P=0.033) postoperatively. Increased ankle range of motion was significantly correlated with higher FAAM-ADL at 3 months (r=0.48, P=0.012), 1 year (r=0.24, P<0.034), and 2 years (r=0.37, P<0.001) postoperatively.

Conclusion:

Patients undergoing fixed-bearing TAA had continued and sustained improvement from preoperative total arc of motion, pain, and function at each postoperative visit, up to 2 years. Ankle range of motion was noted to peak at 6 months, while pain and FAAM-ADL continued to improve up to 2 years postoperatively. Patients with greater ankle range of motion correlated with less pain and improved function at 1 and 2 years postoperatively. Though pain and function may continue to improve even as far out as 2 years postoperatively, it is not likely that range of motion will continue to increase.

Combined Popliteal Catheter With Single-Injection vs Continuous-Infusion Saphenous Nerve Block for Foot and Ankle Surgery

BACKGROUND

The increasing scope and complexity of foot and ankle procedures performed in an outpatient setting require more intensive perioperative analgesia. Regional anesthesia (popliteal and saphenous nerve blocks) has been proven to provide satisfactory pain management, decreased postoperative opioid use, and earlier patient discharge. This can be further augmented with the placement of a continuous-flow catheter, typically inserted into the popliteal nerve region. This study investigated the use of a combined popliteal and saphenous continuous-flow catheter nerve block compared to a single popliteal catheter and single-injection saphenous nerve block in postoperative pain management after ambulatory foot and ankle surgery.

METHODS

A prospective study was conducted using 60 patients who underwent foot and ankle surgery performed in an outpatient setting. Demographic data, degree of medial operative involvement, American Society of Anesthesiologists physical classification system, anesthesia time, and postanesthesia care unit time were recorded. Outcome measures included pain satisfaction, numeric pain scores (NPS) at rest and with activity, and opioid intake. Patients were also classified by degree of saphenous nerve involvement in the operative procedure, by the surgeon who was blinded to the anesthesia randomization.

RESULTS

Patients in the dual-catheter group took significantly less opioid medication on the day of surgery and postoperative day 1 (POD 1) compared to the single-catheter group ( P = .02). The dual-catheter group reported significantly greater satisfaction with pain at POD 1 and POD 3 and a significantly lower NPS at POD 1, 2, and 3. This trend was observed in all 3 subgroups of medial operative involvement.

CONCLUSION

Patients in the single-catheter group reported more pain, less satisfaction with pain control, and increased opioid use on POD 1, suggesting dual-catheter use was superior to single-injection nerve blocks with regard to managing early postoperative pain in outpatient foot and ankle surgery.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Return to Driving After Foot and Ankle Surgery

Category:

Ankle, Ankle Arthritis, Arthroscopy, Bunion, Sports

Introduction/Purpose:

The time frame for safe return to driving is an important question amongst physicians and patients following orthopaedic surgery of the right lower extremity. There is no universally validated foot and ankle psychometric test that confirms patients’ ability to safely return to driving after surgery. The purpose of the study is to report a novel, validated survey that can be used to confirm safe return to driving after orthopaedic surgery of the right foot and ankle.

Methods:

Patients that had undergone right achilles rupture repair, total ankle arthroplasty, and hallux valgus correction by four fellowship-trained foot and ankle surgeons were prospectively included over a trial period of 4 months. A four-question survey (see Figure 1) was administered at the 6 week post-operative office visit. Breaking reaction time (BRT) was then assessed using the Reaction Time Tester, Model RT-2 S (Advanced Therapy Products, Glen Allen, VA). A passing BRT for safe return to driving was considered 0.850 seconds. Statistical analysis was performed and Cronbach’s alpha was calculated to determine validity of the survey relative to BRT results. One hundred and twenty-two patients were included with ages ranging from 21 to 76 years (average 45 years).

Results:

One hundred and nine (89%) of 122 patients achieved a braking time of 0.850 seconds or less. Using time-to-event analysis, 95% of patients passed at 7.6 weeks. With a “strongly agree” or “agree” response to question 4, the survey predicts a 96% certainty of passing the BRT. At first, validating the psychometric test across all three procedures resulting in a poor Cronbach’s a of 0.6. When question 3 was removed from statistical analysis, the Cronbach’s alpha was 0.76 and the psychometric test was validated for all studied procedures. Upon calculating a composite score from the 3-question survey, the optimum threshold for a passing braking time was at least 10 points resulting in a very good AUC score of 0.948.

Conclusion:

This novel, three-question driving readiness survey can accurately predict a passing breaking reaction test. This provides foot and ankle surgeons with a valuable tool to objectively determine if a patient can safely return to driving after achilles repair, total ankle arthroplasty, and hallux valgus correction. Further study is required to determine whether patients who come to clinic weeks before their standard post-operative follow up appointment with the belief that they are ready to drive also pass the BRT. Additional validation of the survey would be valuable across other foot and ankle procedures.

Anterior Talofibular Ligament Abnormalities on Routine Magnetic Resonance Imaging of the Ankle

Category:

Ankle, Sports, Trauma

Introduction/Purpose:

The anterior talofibular ligament (ATFL) is one of the most commonly injured structures of the lower extremity after an ankle sprain. Evidence of remote injury to this structure is frequently encountered on magnetic resonance imaging (MRI) of the ankle, with uncertain clinical significance. Previous studies in the orthopaedic literature have discussed the prevalence of abnormal MRI findings in asymptomatic patients, most notably with regards to the spine and shoulder. More recently, a study on the prevalence of peroneal tendon abnormalities on routine MRI of the ankle was published. However, to our knowledge, no such study exists for the ATFL. The purpose of this study is to determine the prevalence of abnormal findings of the ATFL on MRI in asymptomatic individuals.

Methods:

All foot and ankle MRIs performed at our institution over a 4-month period were considered for inclusion in our study. Studies were excluded if performed on patients with documented ankle inversion injuries, ankle sprains, lateral ankle trauma, tenderness over the ATFL, or ankle instability. A total of 320 MRIs were eligible for inclusion. The integrity of the ATFL was noted in addition to the primary pathology.

Results:

The median age of the patients included in this study was 51 years with 203 females (63%) and 117 males (37%). One hundred eighteen (37%) of the 320 MRIs demonstrated some ATFL pathology. The most commonly encountered ATFL pathologies were thickening (38%), chronic tear (35%), attenuation (25%) and acute tear (2%).

Conclusion:

The results of this study demonstrate that a sizeable percentage of asymptomatic individuals (37%) will have ATFL abnormalities on magnetic resonance imaging of the foot and ankle. This study can have important clinical implications for patients who present with concerning MRI findings that do not correlate clinically. Based on our results, orthopaedic surgeons or any other physician providing musculoskeletal care can provide counseling and reassurance to patients who present with ATFL pathology on MRI but an absence of clinical findings. Much like MRI of the shoulder or spine, abnormalities must be correlated with the clinical exam.

Driving After Hallux Valgus Surgery

BACKGROUND

The purpose of the study was to determine when patients can safely return to driving after first metatarsal osteotomy for hallux valgus correction.

METHODS

After institutional review board approval, 60 patients undergoing right first metatarsal osteotomy for hallux valgus correction surgery were recruited prospectively. Patients' brake reaction time (BRT) was tested at 6 weeks and repeated until patients achieved a passing BRT. A control group of twenty healthy patients was used to establish as passing BRT. Patients were given a novel driver readiness survey to complete.

RESULTS

At 6 weeks, 51 of the 60 patients (85%) had BRT less than 0.85 seconds and were considered safe to drive. At 6 weeks, the passing group average was 0.64 seconds. At the 8 weeks, 59 patients (100%) of those who completed the study achieved a passing BRT. Patients that failed at 6 weeks had statistically greater visual analog scale (VAS) pain score and diminished first metatarsophalangeal (MTP) range of motion (ROM). On the novel driver readiness survey, 8 of the 9 patients (89%) who did not pass disagreed or strongly disagreed with the statement, "Based on what I think my braking reaction time is, I think that I am ready to drive."

CONCLUSION

Most patients may be informed that they can safely return to driving 8 weeks after right metatarsal osteotomy for hallux valgus correction. Some patients may be eligible to return to driving sooner depending on their VAS, first MTP ROM, and driver readiness survey results.

LEVEL OF EVIDENCE

Level II, comparative study.

Effect of Post-Operative Toradol Administration on Bone Healing After Ankle Fracture Fixation

Category:

Ankle, Trauma

Introduction/Purpose:

Ketorolac has been reported to delay bone healing when administered after spine surgery, and there is hesitancy to use non-steroidal anti-inflammatories (NSAIDs) in the fracture setting despite its reliable ability to relieve surgical pain. The effect of ketorolac administration after foot and ankle surgery has not been well-defined in the literature to date. The purpose of this study is to report clinical and radiographic outcomes for patients treated with a perioperative ketorolac regimen after open reduction and internal fixation (ORIF) of ankle fractures. A secondary purpose is to determine whether there are other patient factors that affect radiographic healing in this population. We hypothesize that the time to radiographic healing with ketorolac use after ORIF of ankle fractures is no different than a historical control.

Methods:

A retrospective chart review was performed on all patients that received perioperative ketorolac at the time of lateral malleolar, bimalleolar, and trimalleolar ankle ORIF by a single surgeon between 2010 and 2016 with minimum 4 months follow-up. Patients were prescribed 5 days of 10 mg ketorolac every 6 hours. Radiographs were evaluated independently by two blinded fellowship-trained foot and ankle surgeons to assess for radiographic healing of lateral malleolus, medial malleolus, and posterior malleolus fractures at 6, 12, and 16 weeks post-operatively. Two hundred and ninety-four patients were included with an average age of 50 years with 138 males (47%). Literature review was performed to determine an appropriate historical control of time to radiographic healing after ankle ORIF for comparison. Statistical analysis consisted of a linear mixed-effects regression which was performed to estimate the effect of time and covariates, taking into account repeated measurements on the same subject.

Results:

Radiographic healing was demonstrated by 16 weeks in 221 of 281 (79%) lateral malleolus fractures, 105 of 132 medial malleolus fractures (80%), and 53 of 57 (93%) posterior malleolus fractures (see Figure 1). Median healing times were 12, 11, and 6 weeks for lateral, medial, and posterior malleoli fractures respectively. There was no significant difference in time to radiographic healing of lateral malleolus when compared to a historical control of 16.7 weeks to union. Active tobacco use was an independent risk factor for delayed radiographic healing (p < 0.05). Diabetes mellitus and age greater than 50 years were independent factors associated with faster healing of the lateral malleolus fractures (p < 0.05). Rheumatoid arthritis, oral steroid use, and obesity had no effect on radiographic healing.

Conclusion:

Perioperative ketorolac use did not affect radiographic healing of ankle fractures after ORIF. As expected, active tobacco use was associated with slower radiographic healing. There is no evidence that ketorolac use further delayed union in smokers, but this may warrant further study. We unexpectedly identified diabetes mellitus and older age as factors associated with faster healing which also warrants further study. This is the first study to date examining the effect of ketorolac on radiographic time to union of ankle fractures. Further study may help determine whether ketorolac helps reduce opioid consumption and improve pain following ORIF of ankle fractures.

Influence of Depression and Anxiety on Hallux Valgus Surgical Outcomes

Category:

Bunion, Midfoot/Forefoot

Introduction/Purpose:

Depression and anxiety can negatively affect outcomes after orthopaedic surgery. The relationship of depression/anxiety with patient outcomes after hallux valgus surgery is not well-studied. The purpose of this study is to evaluate our cohort of patients undergoing hallux valgus surgery and determine whether depression and/or anxiety correlate with different pain and satisfaction levels. We hypothesize that patients with depression/anxiety will have greater subjective dysfunction pre- operatively and less satisfaction after surgery when compared to those patients without depression/anxiety.

Methods:

This retrospective study included adult patients that had undergone surgical treatment for hallux valgus over a 2-year period. Basic demographic data was collected as well as baseline visual analog scale (VAS), SF-12 mental component, and VR-12 mental component. History of depression and/or anxiety and medications were recorded. All patients were called by phone to administer a 3-question survey at least 9 months after surgery. Data from 267 patients were available for analysis. The average patient age was 51.7 years and there were 232 females (87%). 233 patients (87%) completed preoperative functional scores, and 187 patients (70%) were reached by phone at an average of 21 months post-operatively for a satisfaction survey. Pairwise Wilcoxon tests with correction for multiple tests, unpaired student’s t tests, and a multivariate regression analysis were performed to analyze the data.

Results:

Of the 267 patients included in the study, 70 patients (26%) reported a history of depression and/or anxiety. Patients with a history of depression/anxiety had similar baseline demographics compared to patients without depression/anxiety including nearly 90% female sex and about 20 months post-operative follow-up (see Table 1). The group with depression/anxiety was older (55.9 years versus 50.2 years, p = 0.003), and a greater proportion of cases had severe deformity (27% versus 16%, p = 0.47). Patients with depression/anxiety scored significantly lower on baseline SF-12 and VR-12 mental scores; VAS was also lower but this was not statistically significant. Post-operative VAS and satisfaction with surgery and post-operative pain level were not statistically different between groups.

Conclusion:

Although patients with hallux valgus and depression/anxiety may have lower baseline mental scores and higher pain levels, their outcomes after bunion surgery are similar to those patients without depression/anxiety. The group of patients with depression/anxiety had a greater percentage of severe deformities as compared to the unaffected group yet maintained similar outcomes. Depression/anxiety may affect outcomes after certain orthopaedic procedures, however this study failed to show significantly inferior outcomes in this population of patients after hallux valgus surgery.

Autograft Choice in Young Female Patients: Patella Tendon versus Hamstring

With the increasing incidence of anterior cruciate ligament (ACL) reconstruction in women and younger patients, the optimal graft choice in the young female patient has become the subject of much debate. This study aimed to evaluate patient-reported outcomes, objective knee stability, complication rates, and the incidence of failure after ACL reconstruction using bone-patellar tendon-bone (BPTB) autograft compared with hamstring (HS) autograft in young female patients. Female patients who underwent primary ACL reconstruction with BPTB or HS autograft between ages 15 and 25 years were identified. Medical records were reviewed for postoperative complications and subsequent procedures on the operative knee. Patients were evaluated with functional surveys, physical examination including Lachman and pivot-shift tests, and arthrometric testing with a KT-1000 arthrometer. There were 37 patients in the BPTB group and 28 patients in the HS group. For patients who did not undergo revision, significant differences were not found in visual analog score (p = 0.94), Lysholm score (p = 0.81), Kujala score (p = 0.85), or Tegner level (p = 0.81). No difference was detected in the rate of return to a level of activity at or above the same level prior to injury (p = 0.31). Significantly more patients in the BPTB group were graded 1a Lachman and negative pivot shift compared with the HS group (p < 0.001). There was a significant difference in mean side-to-side manual maximum arthrometric testing (p < 0.001). There were significantly fewer subsequent procedures and a lower rate of graft failures in the BPTB group. We detected no difference in subjective functional outcomes following ACL reconstruction. However, a higher failure rate in the HS reconstructions and greater laxity by arthrometric testing may indicate increased objective stability with the use of BPTB autograft in the young female patient population. The level of evidence for this article is (level III, retrospective cohort).

Acute and Chronic Lateral Ankle Instability Diagnosis, Management, and New Concepts

Lateral ankle instability is a common entity that can result in degenerative arthritis if left untreated. Acute ligament injuries should primarily be treated nonoperatively with a course of physical therapy and functional bracing. Chronic ankle instability is defined as mechanical or functional and can be diagnosed using a combination of history, physical examination, stress radiographs, and magnetic resonance imaging. After failure of nonoperative treatment, surgical treatment with anatomic ligament repair and inferior extensor retinaculum augmentation has the best clinical outcomes. Patients with high athletic demands, ligamentous instability, and failure of initial surgical treatment may do better with an anatomic ligament reconstruction or combined ligament repair with peroneus brevis transfer. Those patients with underlying foot deformity benefit from deformity correction in addition to ligament repair or reconstruction. Ankle arthroscopy is an important component of ankle instability to treat the commonly associated intraarticular lesions; however, all-arthroscopic ligament repair is associated with a high complication rate, and techniques may not be perfected as of yet.

Should All Shoulder Dislocations be Closed Reduced? Assessment of Risk of Iatrogenic Injury in 150 Patients

AIMS

The purpose of this study was to determine if there was an association between iatrogenic fractures and closed reduction of shoulder dislocations.

PATIENTS AND METHODS

In a retrospective case series, 150 consecutive patients with acute first time shoulder dislocations were evaluated. Patient demographics, direction of dislocation, associated injuries, reduction methods, number of attempts, and type of anesthesia/analgesia were determined. Pre- and post-reduction radiographs and medical record were reviewed to identify the presence of proximal humerus fractures.

RESULTS

There were thirty nine fracture-dislocations (26%) of the proximal humerus. Eight patients (5%) failed reduction on initial attempt. Four of these (3%) were unable to be reduced in the emergency room and were taken to OR for reduction. There was no statistically significant difference in reduction maneuver or type of anesthesia/analgesia used when comparing fracture-dislocations to dislocations only (p<0.05). No new fractures after reduction were identified.

CONCLUSION

Iatrogenic fractures of the proximal humerus due to reduction of a shoulder dislocation are extremely rare. None were identified in this review of 150 patients. We believe that closed reduction is safe even in the setting of fracture dislocations.

Two Cases of Retained Cement after Hip Hemiarthroplasty. Don't Forget the Basics

Hemiarthroplasty as a treatment for femoral neck fractures is controversial with evolving understanding of its complications. One set of complications relates to the use of cement for these procedures. This case study presents two cases that were complicated by retained cement in the acetabulum that was identified in final intraoperative check with x-rays. In both cases, the incision was reopened and retained fragments were removed. We aim to remind the orthopaedic surgery community that this complication can occur even to the careful, experienced surgeon and to recommend the steps necessary to minimize the risk of its occurrence.

Paramecium species ingest and kill the cells of the human pathogenic fungus Cryptococcus neoformans

A fundamental question in the field of medical mycology is the origin of virulence in those fungal pathogens acquired directly from the environment. In recent years, it was proposed that the virulence of certain environmental animal-pathogenic microbes, such as Cryptococcus neoformans, originated from selection pressures caused by species-specific predation. In this study, we analyzed the interaction of C. neoformans with three Paramecium spp., all of which are ciliated mobile protists. In contrast to the interaction with amoebae, some Paramecium spp. rapidly ingested C. neoformans and killed the fungus. This study establishes yet another type of protist-fungal interaction supporting the notion that animal-pathogenic fungi in the environment are under constant selection by predation.