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Webb AR, Manz WJ, Fuqua A, Coleman MM, Bariteau JT, Kadakia RJ. Effect of Obesity on Patient-Perceived Outcomes After First Metatarsophalangeal Joint Arthrodesis. Foot Ankle Spec 2024; 17:58-66. [PMID: 36124436 DOI: 10.1177/19386400221118894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Alex R Webb
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | - Wesley J Manz
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | - Andrew Fuqua
- Emory University School of Medicine, Atlanta, Georgia
| | - Michelle M Coleman
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | - Jason T Bariteau
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | - Rishin J Kadakia
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
- Department of Orthopaedics, Emory University, Atlanta, Georgia
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Chao M, Manz WJ, Fink J, Coleman MM, Kadakia RJ, Bariteau JT. Body Mass Index (BMI) Cutoffs and Racial, Ethnic, Sex, or Age Disparities in Patients Treated With Total Ankle Arthroplasty. Foot Ankle Orthop 2023; 8:24730114231184189. [PMID: 37484537 PMCID: PMC10359662 DOI: 10.1177/24730114231184189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023] Open
Abstract
Background The rising prevalence of obesity among American adults has disproportionately affected Black adults and women. Furthermore, body mass index (BMI) has historically been used as a relative contraindication to many total joint arthroplasty (TJA) procedures, including total ankle arthroplasty. The purpose of this study was to investigate potential disparities in patient eligibility for total ankle arthroplasty based on race, ethnicity, sex, and age by applying commonly used BMI cutoffs to the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Methods Patients in the ACS-NSQIP database who underwent TAA from 2011 to 2020 were retrospectively reviewed in a cross-sectional analysis. BMI cutoffs of <50, <45, <40, and <35 were then applied. The eligibility rate for TAA was examined for each BMI cutoff, and findings were stratified by race, ethnicity, sex, and age. Independent t tests, chi-squared tests, and Fisher exact tests were performed to compare differences at an α = 0.05. Results A total of 1215 of 1865 TAA patients (65.1%) were included after applying the exclusion criteria. Black patients had disproportionately lower rates of eligibility at the most stringent BMI cutoff of <35 (P = .004). Hispanic patients had generally lower rates of eligibility across all BMI cutoffs. In contrast, Asian American and Pacific Islander patients had higher rates of eligibility at the BMI cutoffs of <35 (P = .033) and <40 (P = .039), and White non-Hispanic patients had higher rates of eligibility across all BMI cutoffs. Females had lower eligibility rates across all BMI cutoffs. Ineligible patients were also younger compared to eligible patients across all BMI cutoffs. Conclusion Stringent BMI cutoffs may disproportionately disqualify Black, female, and younger patients from receiving total ankle arthroplasty. Level of Evidence Level III, retrospective cross-sectional study.
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Affiliation(s)
- Myra Chao
- Emory University School of Medicine, Atlanta, GA, USA
| | - Wesley J. Manz
- Emory University School of Medicine, Atlanta, GA, USA
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Juliet Fink
- Emory University School of Medicine, Atlanta, GA, USA
| | - Michelle M. Coleman
- Emory University School of Medicine, Atlanta, GA, USA
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Rishin J. Kadakia
- Emory University School of Medicine, Atlanta, GA, USA
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jason T. Bariteau
- Emory University School of Medicine, Atlanta, GA, USA
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Manz WJ, Fink J, Novack J, Jacobson J, Bariteau JT. Association of First Metatarsal Phalangeal Joint Fusion for Hallux
Rigidus With Patient-Reported Pain and Mental Health Outcomes in Patients Taking
Psychotropic Medications. Foot Ankle Orthop 2023; 8:24730114231157731. [PMID: 36968813 PMCID: PMC10037740 DOI: 10.1177/24730114231157731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
Background: Limited literature examines the relationship between surgical outcomes in
chronic foot and ankle conditions and concurrent psychiatric care. The
present study aimed to investigate patient-reported and surgical outcomes of
patients treated for a psychiatric disorder undergoing first
metatarsophalangeal (MTP) fusion for hallux rigidus. We hypothesized that
patients on psychotropic medications would have greater subjective pain
preoperatively and less improvement in physical and mental functionality
postoperatively when compared with nonmedicated patients. Methods: A single-center, retrospective review of prospectively collected data was
conducted on 92 patients undergoing first MTP fusion with a preoperative
diagnosis of hallux rigidus from 2015 to 2019. At their preoperative,
6-month postoperative, and 1-year postoperative visits, patients were
administered visual analog pain scale (VAS) and 36-Item Short Form Health
Survey (SF-36) functionality surveys. Patients were subsequently identified
by chronic use of psychotropic medication preoperatively and grouped for
analysis (MED, n = 42; NO MED, n = 50). Results: Postoperative mean VAS pain scores were lower for all studied patients at 6
months (VAS = 1.6 ± 2.3) and 1 year postoperatively (VAS = 1.1± 1.8)
relative to the preoperative visit (VAS = 4.7 ± 2.8)
(P ≤ .0001 and P ≤ .0001, respectively).
No differences in mean VAS pain scores nor SF-36 physical component summary
scores were detected at preoperative, 6-month, or 1-year visits between NO
MED and MED groups. Mean SF-36 mental component summary scores for those in
the MED group were lower at preoperative (NO MED = 83.8, MED = 71.8,
P = .006) and 6-month postoperative (NO MED = 86.1,
MED = 72.7, P = .037) visits than those in the NO MED
group, a trend not observed at the 1-year postoperative mark (NO MED = 84.1,
MED = 76.8, P = .228). There were no observed differences
in operative time (P = .219), tourniquet time
(P = .359), nor time to full weightbearing
(P = .512) between MED and NO MED groups. Additionally,
no differences in postoperative complication rates were observed between
groups. Conclusion: In patients treated with psychotropically active medications with hallux
rigidus, MTP Fusion appears to be a reasonable treatment choice with similar
outcomes for patients requiring psychotropically active medications to the
outcomes of those patients not requiring psychotropically active
medications. Level of Evidence: Level III, retrospective comparative study.
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Affiliation(s)
- Wesley J. Manz
- Emory University School of Medicine,
Atlanta, GA, USA
- Department of Orthopaedic Surgery,
Emory University School of Medicine, Atlanta, GA, USA
| | - Juliet Fink
- Emory University School of Medicine,
Atlanta, GA, USA
| | - Joseph Novack
- Emory University School of Medicine,
Atlanta, GA, USA
| | - Joseph Jacobson
- Emory University School of Medicine,
Atlanta, GA, USA
- Department of Orthopaedic Surgery,
Emory University School of Medicine, Atlanta, GA, USA
| | - Jason T. Bariteau
- Emory University School of Medicine,
Atlanta, GA, USA
- Department of Orthopaedic Surgery,
Emory University School of Medicine, Atlanta, GA, USA
- Jason T. Bariteau, MD, Emory University
Department of Orthopaedics, 59 Executive Park S, Atlanta, GA 30324, USA.
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Manz WJ, Nash AE, Novak J, Fink J, Kadakia R, Coleman MM, Bariteau JT. Non-emergent Conditions of the Ankle, Hindfoot, and Midfoot in Elderly Patients Are as Mobility Limiting as Congestive Heart Failure. Foot Ankle Spec 2022:19386400221127836. [PMID: 36210764 DOI: 10.1177/19386400221127836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mobility limitations are well linked to increased morbidity and mortality. Older patients with chronic pathologies of the foot and ankle can suffer from significant mobility limitations; however, the magnitude of limitation experienced by this cohort is not well characterized. Conversely, the effects of congestive heart failure (CHF) on patient mobility are routinely assessed via the New York Heart Association (NYHA) classification. New York Heart Association classification is determined by a patient's physical activity limitation and is strongly correlated to functional status. We hypothesized that non-emergent conditions of the foot and ankle would be as mobility limiting as CHF. METHODS Life-Space Mobility Assessments (LSAs) were prospectively collected from orthopaedic patients at their preoperative visits and from CHF patients at a cardiology clinic. Patients over the age of 50 years were included in this study. Congestive heart failure patients NYHA class II or greater were included. The non-emergent foot and ankle cohort included Achilles tendonitis, ankle joint cartilage defects, ankle arthritis, subtalar arthritis, and midfoot arthritis. Patient demographics and LSA scores were analyzed using Mann-Whitney U and chi-squared tests. RESULTS A total of 96 elderly, non-emergent foot and ankle operative patients and 45 CHF patients met inclusion criteria. All medical comorbidities, except smoking status, were significantly more prevalent in the CHF cohort. No statistical difference was observed between CHF and preoperative foot and ankle LSA scores (56.1 vs 62.4, P = .320). Life-Space Mobility Assessment scores in the foot and ankle cohort were significantly improved relative to CHF patients, at 6-month and 1-year postoperative visits (P = .028, P < .0001, respectively). CONCLUSION Non-emergent ankle, hindfoot, and midfoot pathology is associated with similar mobility limitation to that of NYHA class II and III CHF. Older patients undergoing elective foot and ankle procedures exceeded the mobility of CHF patients at 6 months post-operation, and the mobility gains persisted at 1-year post-operation. LEVELS OF EVIDENCE Level II: Prospective cohort study.
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Affiliation(s)
- Wesley J Manz
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | - Amalie E Nash
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | - Jack Novak
- Emory University School of Medicine, Atlanta, Georgia
| | - Juliet Fink
- Emory University School of Medicine, Atlanta, Georgia
| | - Rishin Kadakia
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | - Michelle M Coleman
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | - Jason T Bariteau
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
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Holmes S, Webb AR, Manz WJ, Jacobson JE, Coleman MM, Kadakia RJ, Bariteau JT. No Association Between Cavovarus Alignment and Risk of Non-Union or Delayed Union in Jones Fractures. Foot & Ankle Orthopaedics 2022. [DOI: 10.1177/2473011421s00691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Category: Midfoot/Forefoot; Other Introduction/Purpose: It has been well documented in the literature that fractures of the base of the fifth metatarsal are often associated with varus hindfoot alignment. Zone two fractures at the metaphyseal-diaphyseal junction, commonly referred to as Jones fractures, have specifically been noted to have a higher incidence of delayed union and nonunion. This has historically been attributed to the tenuous blood supply in this region. Although it is known that hindfoot varus may predispose to these fractures, there is little information on whether a cavovarus alignment may also contribute to the increased risk of nonunion. The purpose of this study is to determine whether cavovarus foot alignment is associated with delayed union or nonunion in Jones fractures. Methods: We identified patients who sustained a proximal fifth metatarsal fracture between the years 2016-2021 at a single academic institution. Weightbearing foot radiographs were then reviewed to identify zone 2 fractures. Talo-first metatarsal, talonavicular coverage, and talocalcaneal angles were then measured on the AP view and calcaneal pitch, talocalcaneal, and talo- first metatarsal angles were measured on the lateral view to assess foot alignment. The primary outcome measure was the presence of a nonunion or delayed union. T-tests, Mann Whitney U tests, and ANOVA analyses were conducted to assess for differences. Results: We identified a total of 117 patients with 118 zone 2 proximal fifth metatarsal fractures. Of those fractures, there were 23 of which were considered either delayed union (n=8) or nonunion (n=15). Similar rates of nonunion and delayed union were observed between patients undergoing nonoperative and operative management of their Jones fractures (p=0.514, p=0.200, respectively). For all patients with a nonunion or delayed union, no differences in anteroposterior (AP) talo-first metatarsal angle, AP talonavicular coverage angle, AP talocalcaneal angle, lateral calcaneal pitch, lateral talo-first metatarsal angle, or lateral talocalcaneal angle from those with expected healing were observed (p = 0.773, p = 0.084, p = 0.874, p = 0.751, p = 0.471, and p = 0.386 - respectively). Conclusion: Overall, no measured foot alignment values (talo-first metatarsal angle, talonavicular coverage, talocalcaneal angle, or calcaneal pitch) were statistically associated with increased risk of delayed union or non-union among patients with Jones fractures undergoing either operative or non-operative treatment. Furthermore, there was no measured difference in these foot alignment parameters between those patients undergoing operative treatment and those undergoing non-operative treatment. In conclusion, cavovarus alignment is not associated with an increased risk of non-union or delayed union in the operative or non-operative treatment of Jones fractures.
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Manz WJ, Novack JC, Fink J, Zaldumbide JA, Jacobson JE, Bariteau JT. Impact of Low Social Support Systems on Post-Operative Outcomes of Ankle, Hindfoot and Midfoot Surgery. Foot & Ankle Orthopaedics 2022. [DOI: 10.1177/2473011421s00774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Category: Other; Hindfoot; Midfoot/Forefoot; Trauma Introduction/Purpose: Degenerative conditions of the ankle, hindfoot and midfoot can markedly limit mobility, and functional disability due to bone and joint pathology has been demonstrated to predict mortality, and in some cases, decrease life expectancy by up to 10 years. Optimizing outcomes in surgical treatment of these conditions is therefore essential and requires analysis of both medical interventions and psychosocial factors. Physicians have only recently begun to identify social support to be a key factor in post-operative functional ability, though our understanding of their impact on surgical outcomes is limited. The purpose of this study was to elucidate the link between low social support and postoperative surgical foot and ankle outcomes. Methods: A single-center, prospective study was conducted on patients who underwent elective or non-elective ankle, hindfoot, or midfoot surgery between 2015 and 2019. Patients who were pre-operatively and post-operatively assessed at 6 month or 1 year follow up using the Short Form Health Survey (SF-36), Life-Space Assessment survey (LSA), and/or visual analog scale (VAS) for pain were administered a social support survey scoring the individuals social support system. Patient reported outcomes were compared between low social support patients (score <= 13) and high social support patients (score > 13). Results: Preoperative baseline and 6 month LSA scores in the low social support group were significantly lower compared to the normal social support group (P = 0.044, P = 0.038), a trend not observed at the 1 year post-operative mark. Low social support pre-operative SF-36 MCS scores (P = 0.015) were significantly lower than the high social support group with no difference detected in pre-operative SF-36 PCS scoring. At 6-month follow-up, the low social support group had significantly lower SF-36 PCS scores (P = 0.031) and SF-36 MCS scores (P = 0.006) compared to the high social support group. At 1 year follow up, these differences in PCS (P = 0.04) and MCS (P= 0.007) persisted. No significant differences in VAS scores were observed. Conclusion: Among adults undergoing foot and ankle surgery, low perceived social support was associated with lower degrees of perceived mental well-being and physical wellbeing up to 1 year postoperatively.
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Novack JC, Manz WJ, Fink J, Jacobson JE, Kadakia RJ, Coleman MM, Bariteau JT. Does the Reduction Matter? Non-Emergent Ankle Fractures and the Effect of Near-Anatomic Reduction. Foot & Ankle Orthopaedics 2022. [DOI: 10.1177/2473011421s00852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Category: Ankle; Other Introduction/Purpose: Ankle fractures are a common orthopedic injury observed in a wide variety of patient populations. Prior to being seen by an orthopedic specialist, patients with ankle fractures may have already undergone several procedures in the field or in the emergency department to stabilize or reduce the injured bone. While a paradigm that near-anatomic reduction improves outcomes in non-urgent ankle fractures exists, no study to date has shown objective evidence of this in postoperative patient- reported outcomes. The present study aims to evaluate whether adequate reduction of non-emergent ankle fractures within 24 hours of inciting injury influenced postoperative outcomes. Methods: All non-emergent ankle fractures treated by a single foot and ankle, fellowship-trained surgeon were queried over a period of 5 years and retrospectively evaluated through the electronic medical record. 97 patients over the age of 18 years with traumatic ankle fracture etiologies were considered. Plain film radiographs from initial presentation to the emergency department or first visit to orthopedics clinic were evaluated by the attending physician for adequate reduction based on AP and lateral tibiotalar congruency. Patient demographics and surgical outcomes data were collected from electronic medical record review. In the cases deemed to be dislocated or subluxated on initial injury films, the days until adequate reduction were calculated along with patient-reported VAS and SF-36 scores. Non-continuous data were compared using chi-squared tests, while continuous, non- normally distributed data were compared utilizing a Mann-Whitney U test. Alpha and beta for this study were assumed to be 0.05 and 0.8, respectively. Results: The average age was 46, with 68.9% of the patient population that was female. 51 patients were found to be adequately reduced within 24 hours, while 39 were not. The average time to final PRO follow-up was 12.6 months +- 1.9. No differences in preoperative VAS, SF-36 physical nor mental scores were noted between adequately and inadequately reduced cohorts (p= 0.654, p=0.262, p=0.760 respectively). Similarly, no differences in final postoperative follow up VAS, SF-36 physical nor mental scores were observed (p=0.503, p=0.252, p=0.296 respectively). VAS pain scores in both cohorts also improved to a similar degree over the preoperative to final postoperative follow up time point (p=0.261). Conclusion: These data show no difference in patient-reported pain or physical and mental functioning scores over 1 year after surgical fixation of the ankle, regardless of whether the ankle joint was adequately reduced within 24 hours of injury. We assert that anatomic reduction of the ankle joint following traumatic, non-emergent ankle fracture does not play a significant role in overall patient outcomes over 1 year following surgical correction.
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Manz WJ, Webb AR, Fuqua A, Novack JC, Coleman MM, Kadakia RJ, Bariteau JT. Impact of BMI on Outcomes after First Metatarsophalangeal Joint Arthrodesis. Foot & Ankle Orthopaedics 2022. [DOI: 10.1177/2473011421s00773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Category: Bunion; Midfoot/Forefoot Introduction/Purpose: First metatarsophalangeal joint (MTPJ) arthrodesis is a commonly performed procedure for patients with various disorders of the first ray including hallux rigidus, severe hallux valgus, failed 1st MTPJ replacement, and failed hallux valgus correction. Outcomes are generally favorable and similar outcomes have been shown in the young and elderly. It is well documented that medical comorbidities have deleterious effects on outcomes in foot and ankle surgery. Obesity - in particular - has been broadly studied among the foot and ankle literature and has been associated with increased complications. Presently, there is a paucity of studies examining obesity's effect on outcomes of 1st MTPJ arthrodesis. This study's purpose was to evaluate outcomes following 1st MTPJ arthrodesis in obese vs 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, Visual Analog Pain scale (VAS), and Short Form 36 (SF-36) surveys were examined and stratified into 2 patient groups: BMI < 30 and 3 30, with sub-analyses conducted between Obesity class I (30-34.9) and Obesity class II (35-39.9) patients. Continueous, normally distributed data were compared with independent sample t-tests, while comparisons of categorical data were made using chi-squared tests. Alpha and beta were assumed to be 0.05 and 0.8, respectively. Results: Average overall VAS and SF-36 physical component scores improved significantly at 6 months (P< 0.0001, 0.006) and 1- year postoperative visits (P <0.0001, 0.007) following 1st MTP fusion in the cohort as a whole. No differences in VAS or SF-36 scores were found between the obese (BMI > 30) or non-obese cohorts. Amongst BMI classified subgroups, significantly greater changes in preoperative to 6-month and 1-year postoperative VAS pain were observed in the Obesity class I patients vs. Obsesity class II or greater (P=0.043, 0.022). Conclusion: Our study showed first MTPJ fusion reliably improves pain and physical quality-of-life in arthritic obese and non- obese patients without differences in nonunion, complications, or patient-reported measures. Additionally, we observed that obese patients experienced comparable improvements in VAS pain and SF-36 physical function scores as their non-obese peers. Our findings asset that first MTPJ fusion is an effective procedure for correction of MPTJ pathology in the obese.
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Weinberg DS, Eoh JH, Manz WJ, Fakunle OP, Dawes AM, Park ET, Rhee JM. Off-label usage of RhBMP-2 in posterior cervical fusion is not associated with early increased complication rate and has similar clinical outcomes. Spine J 2022; 22:1079-1088. [PMID: 35181539 DOI: 10.1016/j.spinee.2022.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Arthrodesis is important for the success of posterior cervical fusion (PCF), however, there exists limited data regarding the safety and efficacy of bone morphogenic protein (BMP) in PCF. PURPOSE The primary objective was to evaluate early postoperative complications associated with BMP in PCF and determine whether BMP leads to adverse early clinical outcomes. A secondary objective was to determine the optimal location for BMP sponge placement, within the facet joint (IF) or elsewhere, and the optimal dosage/level. DESIGN Retrospective, consecutive case-control study. PATIENT SAMPLE Seven hundred sixty-five patients who underwent PCF OUTCOME MEASURES: Patient-reported outcomes (PROs), complications, arthrodesis, optimum dose/level of BMP METHODS: Surgical data, including preoperative diagnosis, levels fused, type of bone graft, BMP dose (when used), and fusion technique were recorded. Complications were assessed by reviewing the medical record encompassing the first 6-weeks postoperative. These included medical, neurological, and wound-related complications and reoperation. Neurological complications were defined as any new weakness, radicular pain, or numbness. PROs were collected, including SF36, VAS, EQ-5D, and NDI scores. To determine the optimal dosage and location for BMP placement, a sub-analysis was performed. RESULTS There were no significant differences between the BMP and no BMP group with regards to wound complications, neurological complications, or reoperation. There were no differences in PROs between BMP and no BMP. Placement of BMP for IF and at a dose of 0.87 mg/level minimized wound-related complications. The BMP group had a higher fusion rate compared to the no BMP group (96% vs. 91%, p=.02) when assessed 1 year post-operatively. CONCLUSION BMP was not associated with a higher rate of early complications after PCF when the dose was minimized. Complications thought to be associated with BMP, such as compressive seroma, radiculitis, and wound-related complications were not seen at a higher rate. PROs at early follow-up were similar. Placement of BMP for IF and at lower doses than previously reported may minimize complications.
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Affiliation(s)
- Douglas S Weinberg
- Department of Orthopedic Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jae Hyung Eoh
- Department of Orthopedics, Pohang Semyeong Christianity Hospital, Pohang, Korea
| | - Wesley J Manz
- Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Eric T Park
- Emory University School of Medicine, Atlanta, GA, USA
| | - John M Rhee
- Department of Orthopedic Surgery and Neurosurgery, The Emory Spine Center, Emory University School of Medicine, 59 Executive Park South, Atlanta, GA, USA.
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Coyle MA, Goss CS, Manz WJ, Greenshields JT, Chapman RF, Stager JM. Nedocromil sodium and diphenhydramine HCl ameliorate exercise-induced arterial hypoxemia in highly trained athletes. Physiol Rep 2022; 10:e15149. [PMID: 35001564 PMCID: PMC8743671 DOI: 10.14814/phy2.15149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 10/25/2021] [Accepted: 11/04/2021] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION Exercise-induced arterial hypoxemia (EIAH) has been observed in highly trained endurance athletes during near maximal exercise, which may be influenced by a histamine-mediated inflammatory response at the pulmonary capillary-alveolar membrane. In order to test this hypothesis, we examined whether the mast cell stabilizer nedocromil sodium (NS) and H1 -receptor antagonist diphenhydramine HCL (DH) would ameliorate EIAH and mitigate the drop in arterial oxyhemoglobin saturation (Sa O2 ) during intensive exercise. METHODS Seven highly trained male cross country runners (age, 21 ± 2 years; V̇O2max , 74.7 ± 3.5 ml·kg-1 ·min-1 ) participated in the study. All subjects completed a maximal exercise treadmill test to exhaustion, followed by three 5-min constant-load exercise bouts at 70%, 80%, and 90% V̇O2max . Prior to testing, subjects received either placebo (PL), NS, or DH. RESULTS Compared to PL, there was a significant treatment effect on Sa O2 (p < 0.001) for both NS and DH during both constant-load exercise and at V̇O2max . Post hoc tests revealed Sa O2 values, compared to PL, were significantly higher at V̇O2max and during DH trials and higher with NS at constant-load intensities except at 70% (p = 0.13). CONCLUSION The findings provide further evidence that histamine contributes directly or indirectly to the development of EIAH during intense exercise in highly trained athletes.
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Affiliation(s)
- Michael A. Coyle
- HH Morris Human Performance Laboratory, Department of Kinesiology, School of Public HealthIndiana UniversityBloomingtonIndianaUSA
| | - Curtis S. Goss
- HH Morris Human Performance Laboratory, Department of Kinesiology, School of Public HealthIndiana UniversityBloomingtonIndianaUSA
| | - Wesley J. Manz
- HH Morris Human Performance Laboratory, Department of Kinesiology, School of Public HealthIndiana UniversityBloomingtonIndianaUSA
- Department of Orthopaedic SurgeryEmory University School of MedicineAtlantaGeorgiaUSA
| | - Joel T. Greenshields
- HH Morris Human Performance Laboratory, Department of Kinesiology, School of Public HealthIndiana UniversityBloomingtonIndianaUSA
- Dr. Lawrence D. Rink Center for Sports Medicine and TechnologyDepartment of Intercollegiate AthletesIndiana UniversityBloomingtonIndianaUSA
| | - Robert F. Chapman
- HH Morris Human Performance Laboratory, Department of Kinesiology, School of Public HealthIndiana UniversityBloomingtonIndianaUSA
| | - Joel M. Stager
- HH Morris Human Performance Laboratory, Department of Kinesiology, School of Public HealthIndiana UniversityBloomingtonIndianaUSA
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11
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Manz WJ, Goel R, Fakunle OP, Labib SA, Bariteau JT. Feasibility of Rapid Development and Deployment of a Telemedicine Program in a Foot and Ankle Orthopedic Practice. Foot Ankle Int 2021; 42:320-328. [PMID: 33040599 DOI: 10.1177/1071100720963059] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A lack of access to care is predictably associated with negative outcomes in foot and ankle surgery. Despite recent advances in telecommunication technologies, the field of orthopedics has been slow to adopt these resources in offsetting barriers to care. The COVID-19 pandemic has forced departments to change their clinical approach, lending unprecedented opportunity to better understand how telehealth may bridge this care gap in foot and ankle practices. The purpose of this study was to assess patient-reported outcomes of telemedicine encounters, including comfort and patient satisfaction. Our hypothesis was that patients would be significantly less satisfied with telemedicine when compared with in-office appointments for all nonemergency visit types. METHODS Telemedicine satisfaction was assessed via phone survey with a modified 1 to 5 Likert scale. Patients who had completed a telemedicine visit between April 13, 2020, and June 19, 2020, were eligible to participate. Patient demographics were recorded, and data were analyzed using paired and independent t tests for parametric continuous data and Fisher's exact and chi-square tests for noncontinuous data. A total of 216 patients completed the telemedicine questionnaire. RESULTS The overall mean satisfaction for telemedicine visits (4.7) was significantly lower than that for in-office visits (4.9) (P < .001). However, the majority (90.3%) of patients reported they would use telemedicine again in the future. When compared, patients seeking fracture care had significantly higher telemedicine satisfaction (4.9, n = 38) than those receiving nonfracture care (4.6, n = 178) (P = .001), and those greater than 50 miles from the clinic had higher satisfaction (5.0, n = 14) than patients living within 50 miles of the clinic (4.7, n = 202) (P < .001). CONCLUSION Patients were more satisfied with their in-office clinic visit than telemedicine, although the vast majority of patients endorsed a willingness to utilize telemedicine in the future. Patients with trauma and greater barriers to foot and ankle care were more satisfied with their telemedicine visits. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Wesley J Manz
- Emory University School of Medicine, Atlanta, GA, USA
| | - Rahul Goel
- Emory University School of Medicine, Atlanta, GA, USA.,Emory Orthopaedics and Spine Center, Atlanta, GA, USA
| | | | - Sameh A Labib
- Emory University School of Medicine, Atlanta, GA, USA.,Emory Orthopaedics and Spine Center, Atlanta, GA, USA
| | - Jason T Bariteau
- Emory University School of Medicine, Atlanta, GA, USA.,Emory Orthopaedics and Spine Center, Atlanta, GA, USA
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12
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Greenfield PT, Manz WJ, DeMaio EL, Duddleston SH, Xerogeanes JW, Scott Maughon T, Spencer CC, Dawes A, Boden SD, Hammond KE, Wagner ER, Gottschalk MB, Daly CA, Pombo MW. Telehealth Can Be Implemented Across a Musculoskeletal Service Line Without Compromising Patient Satisfaction. HSS J 2021; 17:36-45. [PMID: 33967640 PMCID: PMC8077987 DOI: 10.1177/1556331620977171] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/06/2020] [Indexed: 11/29/2022]
Abstract
Background: The COVID-19 pandemic has led to changes to in-office orthopedic care, with a rapid shift to telemedicine. Institutions' lack of established infrastructure for these types of visits has posed challenges requiring attention to confidentiality, safety, and patient satisfaction. Purpose: The aim of this study was to analyze the feasibility of telemedicine in orthopedics during the pandemic and its effect on efficiency and patient satisfaction. Methods: Patients seen by the Emory University Department of Orthopaedics Sports Medicine and Upper Extremity Divisions via telemedicine from March 23 to April 24, 2020, were contacted by telephone. Each patient was asked to respond to questions on satisfaction, ease of use, and potential future use; satisfaction with telemedicine and previous clinical visits were measured using a modified 5-point Likert scale. Results: Of the 762 patients seen, 346 (45.4%) completed the telemedicine questionnaire. Satisfaction varied by visit type, with average scores of 4.88/5 for in-office clinic visits versus 4.61/5 for telemedicine visits. There was no significant difference among age groups for satisfaction ratings. Patients 65 years old or older reported significantly longer visit times and decreased ease of use with the telemedicine platform. Conclusion: Telemedicine in a large orthopedics department was successfully implemented without compromising patient satisfaction. The use of telemedicine allows many patients to be seen quickly and efficiently without diminishing their musculoskeletal clinical experience.
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Affiliation(s)
| | - Wesley J. Manz
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Emily L. DeMaio
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | | | | | - T. Scott Maughon
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Corey C. Spencer
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Alexander Dawes
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Scott D. Boden
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Kyle E. Hammond
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Eric R. Wagner
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | | | - Charles A. Daly
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Mathew W. Pombo
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
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13
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Lunati MP, Manz WJ, Maidman SD, Kukowski NR, Mignemi D, Bariteau JT. Effect of Age on Complication Rates and Outcomes Following First Metatarsophalangeal Arthrodesis for Hallux Rigidus. Foot Ankle Int 2020; 41:1347-1354. [PMID: 32791854 DOI: 10.1177/1071100720942140] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hallux rigidus is one of the most common toe pathologies in patients greater than 50 years old. Although metatarsophalangeal (MTP) arthrodesis is used to improve pain and function, older patients are often considered to be higher-risk operative candidates. There are minimal data on outcomes of MTP fusion and no studies comparing outcomes between geriatric and younger patients. METHODS This is a single-center, prospective study of all patients who underwent MTP fusion between August 1, 2015, and July 1, 2018. Patient-reported outcomes were assessed using the Short Form Health Survey (SF-36), Life-Space Assessment survey (LSA), and visual analog scale (VAS) for pain administered preoperatively as well as 6 months and 1 year postoperatively. Baseline characteristics and operative outcomes were collected from the electronic medical record. Clinical and patient-reported outcomes were compared between patients <65 years old and ≥65 years old. Of 143 included patients, 79 were in the younger group (mean of 56.5 years) and 64 were in the older group (mean of 72.0 years). RESULTS Compared with the younger group, the older group was more predominantly female (95.3% older group, 77.2% younger group, P = .002). More patients in the older group had hypertension (73.4% older group, 50.6% younger group, P = .005) and coronary artery disease (9.4% older group, 0.0% younger group, P = .005). Both age groups had similar rates of postoperative wound complications requiring operative irrigation and debridement, deep vein thrombosis, deformity recurrence, and revision surgery. No differences were detected in SF-36, LSA, and VAS surveys administered at baseline, 6 months postoperation, or 1 year postoperation between younger and older patients. CONCLUSION Despite more comorbidities, older patients had similar rates of postoperative complications and reported similar outcomes for pain, function, and mobility following MTP fusion. These findings support increased implementation of MTP fusion surgery for older patients with hallux rigidus. LEVEL OF EVIDENCE Level II, prospective cohort.
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Affiliation(s)
- Matthew P Lunati
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Wesley J Manz
- Emory University School of Medicine, Atlanta, GA, USA
| | | | - Nathan R Kukowski
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Jason T Bariteau
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
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14
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Maidman SD, Nash AE, Manz WJ, Spencer CC, Fantry A, Tenenbaum S, Brodsky J, Bariteau JT. Comorbidities Associated With Poor Outcomes Following Operative Hammertoe Correction in a Geriatric Population. Foot Ankle Orthop 2020; 5:2473011420946726. [PMID: 35097407 PMCID: PMC8702909 DOI: 10.1177/2473011420946726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Although complications following hammertoe correction surgery are rare, older patients with comorbid conditions are often considered poorer operative candidates compared with younger, healthier patients because of a suspected increased risk of adverse outcomes. The aim of this study was to determine if the presence of multiple comorbidities was associated with increased complications or unsuccessful patient-reported outcomes following operative hammertoe correction in geriatric patients. Methods: Prospectively collected data was reviewed on 78 patients aged 60 years or older who underwent operative correction of hammertoe deformity. Patient demographics, comorbidities, and postoperative complications were recorded. Patient-reported outcomes were assessed using preoperative and postoperative visual analog scale for pain and Short Form Health Survey Physical and Mental Component Summary with 1 year of follow-up. Patients were divided into 2 groups based on number of comorbidities (0 or 1 vs > 2) and then compared. The average age of patients was 69.4 years and the prevalence of comorbidities in the study population was as follows: 11.5% smokers, 25.6% on blood thinners, 15.4% with rheumatoid arthritis, 7.7% with diabetes mellitus, 2.6% with peripheral arterial disease, 6.4% with chronic obstructive pulmonary disease, 11.5% with coronary artery disease, and 23.1% with osteoporosis. Results: Fifty-three patients (67.9%) had 0 or 1 comorbidity and 25 (32.1%) had 2 or more comorbidities. Compared to the 0 or 1 comorbidity group, the presence of multiple comorbidities was associated with an adjusted odds ratio (OR) for superficial wound infection of 4.18 (P = .045) and deformity recurrence requiring surgery OR of 23.15 (P = .032). Patient-reported outcomes were similar between comorbidity groups. Conclusions: This study further informs foot and ankle specialists to maintain increased surveillance for postoperative complications and unsuccessful outcomes in patients with multiple comorbidities. Although geriatric patients still report significant improvements in both pain and function, patients with underlying medical conditions should be counseled about their increased risks when pursuing operative hammertoe correction. Level of Evidence: Level III, retrospective comparative series.
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Affiliation(s)
| | - Amalie E Nash
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Wesley J Manz
- Emory University School of Medicine, Atlanta, GA, USA
| | - Corey C Spencer
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA.,Emory Orthopaedics and Spine Center, Atlanta, GA, USA
| | | | - Shay Tenenbaum
- Chaim Sheba Medical Center at Tel HaShomer, affiliated to Sackler Faculty of Medicine, Tel Aviv University, Israel
| | | | - Jason T Bariteau
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA.,Emory Orthopaedics and Spine Center, Atlanta, GA, USA
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15
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Phen HM, Manz WJ, Mignemi D, Greenshields JT, Bariteau JT. Outcomes of Operative Management of Insertional Achilles Tendinopathy in the Young vs Elderly. Foot & Ankle Orthopaedics 2020; 5:2473011420926101. [PMID: 35097382 PMCID: PMC8564938 DOI: 10.1177/2473011420926101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Insertional Achilles tendinopathy (IAT) is a common cause of chronic posterior heel pain. Surgical intervention reproducibly improves patients’ pain and functional status. We hypothesized that patients older than 60 years would have similar improvements in pain and function and low rates of complications after surgery for IAT when compared to a younger cohort. Methods: Retrospective review of adult case series in patients undergoing surgical management of IAT. Patients were stratified into those 60 years and younger and those older than 60 years. Patients with prior or concomitant surgical procedures and revisions were excluded. Visual analog scale (VAS), Short Form–36 Physical Component Summary and Mental Component Summary (SF-36 PCS/MCS) scores, wound infection, and recurrence, defined as a redevelopment of heel pain in the operative extremity within 6 months, were assessed with a minimum follow-up of 12 months. Statistical analysis was performed using linear regression mixed models and χ2 analysis. Thirty-seven patients were enrolled, with 38 operative heels. The younger cohort had an average age of 49.1 (range, 26-60) years. The older group had an average age of 66.8 (range, 61-76) years. Results: VAS and SF-36 PCS scores for the entire cohort significantly improved at 6 and 12 months postoperatively ( P < .001). Postoperative SF-36 MCS scores for the cohort significantly improved only at 12 months ( P < .001). No significant differences between the young and elderly were seen with regard to improvements in VAS and SF-36 PCS/MCS at 6 or 12 months postoperatively. Multiple linear regression models showed no significant difference between age groups and VAS score, SF-36 PCS/MCS, or change in pain scores after controlling for comorbidities. No significant difference in overall complication rates was seen between the 2 groups (4.9% vs 29.4%, P = .104). There was 1 recurrence of heel pain in the younger group and 4 recurrences of pain in the older group (23.5%) at 6 months, of which 2 resolved at 1 year. There was 1 case of a superficial wound infection requiring antibiotics in the older cohort (5.9%). No patients required surgical revision. Conclusion: Surgical management of IAT in an older population produced similar improvements in clinical results when compared to a younger cohort, with no significant increase in postoperative complications. Level of Evidence: Level III, retrospective comparative series.
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16
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Kurkis G, Erwood A, Maidman SD, Manz WJ, Nazzal E, Bradbury TL, Bariteau JT. Mobility Limitation After Surgery for Degenerative Pathology of the Ankle, Hindfoot, and Midfoot vs Total Hip Arthroplasty. Foot Ankle Int 2020; 41:501-507. [PMID: 32129086 DOI: 10.1177/1071100720907034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Surgery for degenerative foot and ankle conditions often results in a lengthy recovery. Current outcome measures do not accurately assess postoperative mobility, especially in older patients. The Life-Space Assessment (LSA), a questionnaire quantifying patients' mobility after a medical event, was used in this study to assess perioperative mobility in total hip arthroplasty (THA) and foot and ankle surgery patients. We hypothesized that patients undergoing elective foot and ankle surgery would have greater postoperative mobility limitation than THA patients. METHODS Preoperative, 3-month, and 6-month postoperative LSA data were collected from THA and foot and ankle cohorts. Twelve-month postoperative data were obtained for the foot and ankle group as well. Patient demographics were recorded, and data were analyzed using a Mann-Whitney U test. RESULTS Twenty-eight degenerative foot and ankle operative patients and 38 THA patients met inclusion criteria. Only patients aged ≥60 years were included in this study. The mean preoperative LSA score was lower in the foot and ankle group (68.8) compared with THA (74.0), although the difference was not statistically significant (P = .602). THA patients showed a significant increase in LSA score from preoperative (74) to 6 months postoperation (95.9) (P = .003); however, foot and ankle patients showed no significant difference between preoperative (68.8) and 6-month (61.2) scores (P = .468). Twelve months postoperatively, foot and ankle patients showed improvement in LSA score (88.3) compared with preoperation (P = .065). CONCLUSION Compared with THA, recovery of mobility after foot and ankle surgery was slower. THA patients exhibited improved mobility as early as 3 months after surgery, whereas foot and ankle patients did not show full improvement until 12 months. This work will assist the foot and ankle specialist in educating patients about challenges in mobility during their recovery from surgery. LEVEL OF EVIDENCE Level II, prospective cohort study.
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Affiliation(s)
- Gregory Kurkis
- Emory University School of Medicine, Atlanta, GA, USA.,Emory University Orthopaedics and Spine Center, Atlanta, GA, USA
| | - Amalie Erwood
- Emory University School of Medicine, Atlanta, GA, USA.,Emory University Orthopaedics and Spine Center, Atlanta, GA, USA
| | | | - Wesley J Manz
- Emory University School of Medicine, Atlanta, GA, USA
| | | | - Thomas Lane Bradbury
- Emory University School of Medicine, Atlanta, GA, USA.,Emory University Orthopaedics and Spine Center, Atlanta, GA, USA
| | - Jason Tyler Bariteau
- Emory University School of Medicine, Atlanta, GA, USA.,Emory University Orthopaedics and Spine Center, Atlanta, GA, USA
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Wan HY, Stickford JL, Kitano K, Manz WJ, Koceja DM, Chapman RF, Stager JM. Hypercapnia and Voluntary Activation of the Diaphragm in Healthy Humans. Med Sci Sports Exerc 2017. [DOI: 10.1249/01.mss.0000519135.56108.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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18
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Manz WJ, Emery MS, Greenshields JT, Rink LD, Stager JM. Cardiovascular Structure and Function in Lifelong Competitive Swimmers. Med Sci Sports Exerc 2017. [DOI: 10.1249/01.mss.0000518913.46210.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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