Anesthesia for the Patient Undergoing Foot and Ankle Surgery

Modern anesthetic management for foot and ankle surgery includes a variety of anesthesia techniques including general anesthesia, neuraxial anesthesia, or MAC in combination with peripheral nerve blocks and/or multimodal analgesic agents. The choice of techniques should be tailored to the nature of the procedure, patient comorbidities, anesthesiologist skill level, intensity of anticipated postoperative pain, and surgeon preference.

Ligament Insufficiency with Flatfoot: Spring Ligament and Deltoid Ligament

The objective of this article was to review the deltoid ligament and spring ligament specifically as they pertain to ligament insufficiency and adult-acquired flatfoot deformity. Discussion includes the normal and abnormal biomechanical forces that extend through these ligaments in normal and flatfoot deformity. Current literature related to spring ligament repair as part of the flatfoot deformity reconstruction is also reviewed.

To wedge or not to wedge; A cadaveric comparison study of two medial malleolar osteotomy modalities

OBJECTIVE

To quantify the surface area of the talus accessible with a uniplanar and a biplanar medial malleolus osteotomy. Our secondary purpose study is to quantify the amount of weightbearing area that each osteotomy effects on the tibial articular surface.

PATIENTS AND METHODS

Eight ankle joint specimens were dissected for this study. The uniplanar osteotomy was performed first. A K-wire marked the limits of access at two different angles: 90° and 30°. The boundaries were marked with a skin marker. Wedges were then created on the tibia plafond, and the osteotomy was converted into a biplanar one. Measurements were repeated again for this osteotomy. The talus, the tibial plafond, and the medial malleolus were then excised. Images were taken and then electronically calibrated for two-dimensional digital measurement of accessible areas. Areas of perpendicular and 30-degree access were recorded for both osteotomies. The articular surface of the tibia was also measured, and an area analysis was performed to calculate the amount of weightbearing cartilage removed by each osteotomy.

RESULTS

Almost the entire sagittal plane was accessible with both osteotomies. At a 30° angle, bone purchase was achieved for 67.7 % of the talar articular surface with the uniplanar osteotomy and for 74.8 % with the biplanar osteotomy. At a 90° angle, uniplanar osteotomy provided access to 32.7 % of the talar articular area, whereas the biplanar osteotomy achieved an average coverage of 52.8 %. The difference was statistically significant. On average, 25.3 % of the weightbearing area of the tibial plafond is affected when a biplanar osteotomy is performed.

CONCLUSION

Medial malleolar osteotomy provides varying degrees of access to the talar dome depending on how it is performed. A wedge-shaped biplanar osteotomy provides greater access and is therefore more suitable for defects located deeper on the talar dome. Despite providing wider access, it results in greater disruption of the weightbearing cartilage of the tibial plafond.

LEVEL OF EVIDENCE

Level V.

"High ankle block" for surgery at the ankle joint

BACKGROUND

Surgery around the ankle is increasingly embedded in outpatient treatment concepts. Unfortunately, the classic "ankle block" as a concept of regional anesthesia is inappropriate for surgery around the ankle because the injection sites are too distal to block this specific region.

METHODS

The "high ankle block" avoids this disadvantage by dislocating the injection points 15 cm proximal to the malleoli. Three of five peripheral nerves necessary to perform the block can be reached by a circumferential subcutaneous wall. The Posterior Tibial Nerve and the Deep Peroneal Nerve are addressed by an ultrasound guided approach.

RESULTS

The efficacy of the technique is highlighted by a case series (3 cases) in which the new blockade was used as a stand-alone procedure, i.e. without additional general anesthesia.

CONCLUSIONS

The "high ankle block" may serve as an ultrasound guided expansion to the classic techniques, extending the operative spectrum to the ankle region.

The role of the posterior malleolus in the treatment of unstable upper ankle joint injuries - A biomechanical study

BACKGROUND

This biomechanical study aimed to test if the fixation of the posterior malleolus (PM) only with screws inserted from posterior to anterior (PA) restores stability comparable with the natural condition. The extent of stability was also compared with that of anterior to posterior (AP) screw osteosynthesis (OS) with an additional syndesmotic screw (SS).

METHODS

First, the stability of the upper ankle joint in seven pairs of intact lower legs were examined. Subsequently, half of the lower legs were treated with PA screw fixation of a PM fracture without SS and the other half with AP screw fixation with additional tricortical SS.

RESULTS

PA OS without SS showed significantly more diastasis (p = 0.027). The AP OS with an SS revealed a diastasis that was comparable with the intact condition (p = 0.797). The use of SS led to significantly higher stability compared to OS without SS (p = 0.019).

CONCLUSIONS

The Fixation of the PM alone without an additional syndesmotic screw cannot achieve intact upper ankle stability. Fixation of a PM fracture with an SS helps in nearly achieving the natural condition.

Anesthesia for the Patient Undergoing Foot and Ankle Surgery

Modern anesthetic management for foot and ankle surgery includes a variety of anesthesia techniques including general anesthesia, neuraxial anesthesia, or MAC in combination with peripheral nerve blocks and/or multimodal analgesic agents. The choice of techniques should be tailored to the nature of the procedure, patient comorbidities, anesthesiologist skill level, intensity of anticipated postoperative pain, and surgeon preference.

Comparison of EQ-5D-3L and 5L versions following operative fixation of closed ankle fractures

Purpose

To undertake the first testing and comparison of measurement properties for the EuroQol EQ-5D-3L and 5L in patients with ankle problems.

Methods

The cross-sectional postal survey of 959 patients aged ≥ 18 years, who underwent surgical treatment (ORIF) for unstable and closed ankle fractures in Eastern Norway. Both the EQ-5D-3L and 5L were included in a postal questionnaire in 2015, 3–6 years post surgery. Missing data, floor and ceiling effects, and response consistency were assessed. Tests of validity included comparisons with scores for the SF-36 and widely used ankle-specific instruments. The 5L version was assessed for test–retest reliability.

Results

There were 567 (59%) respondents; 501 completed both versions and 182 (61%) the 5L retest questionnaire. The 5L outperformed the 3L in tests of data quality and classification efficiency. Correlations with scores for other instruments largely met expectations, those for the 5L being slightly higher. All 5L scores had acceptable levels of reliability. For the 5L index, the smallest detectable differences for group and individual comparisons were 0.02 and 0.20, respectively.

Conclusion

The 5L outperformed the 3L in terms of data quality, number of health states assessed and tests of validity. The 5L is recommended in research and other applications following surgery for ankle fracture but further testing including responsiveness to change is recommended at clinically relevant follow-up periods.

Higher preoperative range of motion is predictive of good mid-term results in the surgical management of osteochondral lesions of the talus: a prospective multicentric study

INTRODUCTION

Osteochondral lesions of the talus (OLT) are a frequent cause of pain in young patients and a new CT arthrographic classification system of OLT was recently proposed to help guide the choices of and standardize the indications for surgical treatment. The primary hypothesis was that this algorithm would result in a postoperative AOFAS score of ≥ 80/100. The secondary hypothesis was to identify the preoperative factors of successful surgery.

METHODS

This was a prospective observational multicenter study. Eighty-six patients who underwent surgery for OLT after at least 6 months of unsuccessful conservative management were included for a mean follow-up of 15 months (12-36). Forty-nine patients with stage 1 OLT underwent microperforation, 2 patients with stage 2 OLT underwent a lift, drill, fill, and fix graft procedure with screw fixation, and 35 patients with stage 3 OLT were treated with mosaicplasty.

RESULTS

After a follow-up of at least 1 year, 56 patients (65%) had an AOFAS score > 80 and the mean AOFAS score was 82 (16-100). A lower BMI (p = 0.038), a higher preoperative range of motion in the ankle (p = 0.033), higher preoperative AOFAS and FAOS scores (p = 0.001 and p = 0.011), and the presence of a preoperative bone bruise on MRI (p = 0.020) were good prognostic factors on univariate analysis. The presence of grade 1 osteoarthritis on the Van Dijk classification was predictive of a poor prognosis (p = 0.044). Multivariate analysis showed that a good preoperative range of motion (OR = 1.080 [1.020-1.150] p = 0.01) was predictive of a positive outcome, while grade 1 osteoarthritis was predictive of a poor outcome (OR = 0.147 [0.036-0.603] p = 0.008). The postoperative AOFAS decreased in six patients and 17 patients had at least one complication: six dysthesias of the superficial fibular nerve, two of the sural nerve, and nine stage 1 complex regional pain syndromes.

CONCLUSION

The new algorithm for OLT resulted in a postoperative AOFAS score of ≥ 80/100 in 65% of cases. The positive predictive factors of a successful postoperative outcome were the presence of a good preoperative range of motion and the absence of preoperative osteoarthritis.

LEVEL OF EVIDENCE

Level II.

Design and psychometric testing of a new patient-reported outcome measure for ankle treatment

BACKGROUND

Several outcome scores are used to assess the outcome of ankle surgery, but many are not validated and there is currently no 'gold-standard'. Consequently, there is demand to develop a new 'gold-standard' score to assess ankle surgery. The study aim was to review existing scores to develop and validate a new patient-reported outcome measure (PROM) to assess the outcome of operative ankle surgery.

METHODS

The questionnaire items covered three areas: pain, symptoms and activity. The scale was reviewed by a patient group, resulting in the Oswestry Ankle score (Os-Ankle). The Os-Ankle was validated using a cohort of 206 patients at both pre-operative and post-operative stages of ankle surgery. Patients provided two other outcome scores, the scores currently used at our centre: the Manchester-Oxford Foot Questionnaire (MOxFQ) and the Veterans Rand-12 (VR-12). Factor analysis and Rasch were determined to assess the psychometric testing and design of the Os-Ankle score. A follow up paper assesses the validity of the Os-Ankle against two existing scores.

RESULTS

Results of the factor and Rasch analysis suggested that 12-items should be removed. The remaining 18-items fitted the Rasch model well, suggesting good internal consistency.

CONCLUSION

A new ankle PROM, the Os-Ankle, was successfully developed and demonstrated good psychometric testing. The Os-Ankle evaluates pain, symptoms and activities and results in a single score. The Os-Ankle has been validated in our follow up paper, and is ready to be implemented by ankle clinicians to monitor clinical outcomes. With the publication of two back to back papers, it will allow for further engage with other clinicians and other centres.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Factors affecting emergency department visits, readmissions, and reoperations within 30 days of ankle fracture surgery- an institutional retrospective study

INTRODUCTION

With the U.S. healthcare system focused on value of care, providers and hospitals are increasingly measured by factors that increase patient care and decrease healthcare cost. Early postoperative adverse events not only increase healthcare cost, but also illuminate areas of potential improvement in patient care. This large single institution study aims to delineate factors that may influence emergency department visits, admissions, and reoperations within 30 days of ankle fracture surgery.

METHODS

This retrospective review of patients at a Level 1 trauma center evaluated 30-day outcomes after ankle fracture surgery over a 4-year period (2015-2018). A total of 596 patients were included in final analysis. The primary outcome measures assessed were emergency department (ED) visits within 30 days, unplanned readmissions within 30 days and unplanned return to the operating room (OR) within 30 days. Patient and injury characteristics were investigated as potential factors related to these 30-day outcomes. Multiple linear regression was used for outcomes.

RESULTS

Forty-three (7.2%) patients visited the ED within thirty days, 30 (5.0%) patients were readmitted within thirty days, and 10 (1.7%) patients requiring reoperation within thirty days. Sex, insurance status, several comorbidities, smoking status, and fracture type/location were not found to be significantly related to 30-day events. Age less than 45 was a significant risk factor for returning to the ED within 30 days (RR 2.1, p = 0.016). Open fractures were more likely to require unplanned reoperation than closed fractures (RR 5.7, p<0.01). Fifty-four percent of ED visits were for postoperative pain, while 37% of ED visits and 60% of readmissions within 30 days were for issues unrelated to the ankle fracture.

CONCLUSIONS

Age less than 45 years old was a risk factor for early ED visits, highlighting a potential "at-risk" population after ankle fracture surgery. Furthermore, many of the ED visits (37%) and readmissions (60%) were unrelated to the ankle fracture suggesting unnecessary healthcare utilization may be avoided with protocols that increase emphasis on reconditioning and optimization of comorbidities.

Computer-assisted intra-operative verification of surgical outcome for the treatment of syndesmotic injuries through contralateral side comparison

PURPOSE

Fracture reduction and fixation of syndesmotic injuries is a common procedure in trauma surgery. An intra-operative evaluation of the surgical outcome is challenging due to high inter-individual anatomical variation. A comparison to the contralateral uninjured ankle would be highly beneficial but would also incur additional radiation and time consumption. In this work, we pioneer automatic contralateral side comparison while avoiding an additional 3D scan.

METHODS

We reconstruct an accurate 3D surface of the uninjured ankle joint from three low-dose 2D fluoroscopic projections. Through CNN complemented 3D shape model segmentation, we create a reference model of the injured ankle while addressing the issues of metal artifacts and initialization. Following 2D-3D multiple bone reconstruction, a final reference contour can be created and matched to the uninjured ankle for contralateral side comparison without any user interaction.

RESULTS

The accuracy and robustness of individual workflow steps were assessed using 81 C-arm datasets, with 2D and 3D images available for injured and uninjured ankles. Furthermore, the entire workflow was tested on eleven clinical cases. These experiments showed an overall average Hausdorff distance of [Formula: see text] mm measured at clinical evaluation level.

CONCLUSION

Reference contours of the contralateral side reconstructed from three projection images can assist surgeons in optimizing reduction results, reducing the duration of radiation exposure and potentially improving postoperative outcomes in the long term.

Revision Total Ankle Arthroplasty

With total ankle arthroplasty, documented complications can be categorized chronologically into intraoperative, postoperative, and late complications. Factors such as patient selection, surgeon experience, implant features, and prosthetic device selection can influence functional outcomes as well as incidence of complications. Even with impeccable surgical technique and optimal patient selection, complications that require revision may still arise and the most common complications with revision solutions are discussed in this article.

Peripheral Nerve Blocks in Foot and Ankle Surgery

Postoperative pain is one of the most important factors in regard to patient outcomes. It has been linked with patient satisfaction, length of stay, and overall hospital costs. Peripheral nerve blocks have provided a safe, effective method to control early postoperative pain when symptoms are most severe. Peripheral nerve blocks, whether used intraoperatively or postoperatively, provide an alternative or adjunct to conventional pain management methods for patients who may not tolerate heavy narcotics or general anesthesia, in particular the elderly and those with cardiopulmonary disease.

Postoperative Foot and Ankle MR Imaging

MR imaging has an important role in the evaluation of the postoperative foot and ankle. In this article, a variety of operative techniques and postoperative findings in the foot and ankle are described, including tendon and ligament reconstruction, as well as the treatment of tarsal coalition and Morton neuroma. The role of MR imaging in the assessment of complications of foot and ankle surgery is also detailed.

Can platelet-rich plasma have a role in Achilles tendon surgical repair?

PURPOSE

Our hypothesis was that the Achilles tendon healing process after surgical treatment would be promoted by PRP with a faster return to sports activities.

METHODS

Thirty patients with Achilles tendon rupture and surgically treated with a combined mini-open and percutaneous technique were prospectively enroled in the study. Patients were alternately case-by-case assigned to Group A (control group; 15 patients) or Group B (study group; 15 patients). In Group B, PRP was locally infiltrated both during surgery and 14 days after surgery. Patients in both groups were followed up at 1, 3, 6 and 24 months post-operatively via physical examination, VAS, FAOS and VISA-A scales; ultrasonography (US) and MRI were also conducted at one and 6 months; at the 6-month follow-up, isokinetic and jumping capacity tests were also performed.

RESULTS

The VAS, FAOS and VISA-A scale showed no difference between the two groups at 1, 3, 6 and 24 months post-operatively. Isokinetic evaluation showed no differences at both angular speeds. Jumping evaluation showed no difference at 6 months. Also US evaluation showed no differences. MRI data analysis before administration of gadolinium did not reveal significant differences between the two groups. Moreover, after intravenous injection of gadolinium, patients in Group B showed signal enhancement in 30 % of patients compared to 80 % in Group A at 6 months, as indirect evidence of better tendon remodelling (P < 0.05).

CONCLUSIONS

A substantial equivalence in structural and functional results in Achilles tendon ruptures surgically treated with and without addition of PRP is shown by present study. Clinical results, morphological features and jumping capability were similar in both groups. The addition of PRP to the surgical treatment of Achilles tendon rupture does not appear to offer superior clinical and functional results.

LEVEL OF EVIDENCE

IV.

Females report higher postoperative pain scores than males after ankle surgery

OBJECTIVES

The majority of patients experience moderate-to-intense pain following ankle surgery. Early, adequate treatment of postoperative pain is desirable for optimal pain relief, which in turn may facilitate optimal pulmonary function, normal respiration pattern, rehabilitation and prevention of a chronic pain condition. In this retrospective study, we aimed to identify possible predictors of moderate-to-intense postoperative pain while in the Post Anaesthesia Care Unit (PACU) in patients operated for ankle fractures.

MATERIALS AND METHODS

Social demographics and clinical characteristics from admission throughout the stay in the PACU were collected from the hospital patient record system in retrospect. Pain was assessed using a Visual Analogue Scale (VAS) or a verbal Numeric Rating Scale (vNRS). A VAS/vNRS score 4-6 was classified as moderate and 7-10 as intense pain. Other factors which were investigated were time from ankle fracture to surgery, anaesthetic procedure, pre-, per- and postoperative medical treatment, radiological classification, complexity of fracture, operative technique, and time using tourniquet procedure.

RESULTS

Data from 336 patients who underwent surgery to repair an ankle fracture between January 2009 and December 2010 were analysed. None of the following variables had a statistically significant effect on pain; age, weight, smoking, timeframe from fracture to operation, type of anaesthesia, opioids given peroperatively, complexity of the fracture, operation technique or tourniquet inflation procedure. Female sex predicted moderate-to-intense postoperative pain in the PACU with odds ratio 2.31 (95% confidence interval 1.39-3.86), P=0.001. As far as we know, this is the first study to show a sex difference in reporting pain in the first hours after surgery for ankle fracture.

CONCLUSION

Female patients operated for ankle fracture report higher pain-intensity-score than male patients while in the PACU.

IMPLICATIONS

Our findings suggest that treatment strategies to prevent high peaks of pain should particularly target women operated for an ankle fracture.

The anterior talofibular ligament: A detailed morphological study

The anterior talofibular ligament (ATFL) is commonly injured and may result in ankle instability. Good results from ATFL reconstruction have been reported; however complications and movement restrictions have also been observed. ATFL differences have been reported; however details of its precise bony attachment are lacking. This study provides a detailed morphology of the ATFL with respect to surgical and clinical applications. ATFL morphology, number of bands and the exact insertion points were studied in 50 formaldehyde embalmed feet. ATFL length was measured in different joint positions to assess its functional role: ATFL length varied from 18.81 mm in dorsiflexion to 21.06 mm in plantarflexion: mid-length width and thickness were 4.97 mm and 1.01 mm respectively. The bony attachment lengths were also measured: mean proximal and distal bony attachment lengths were 4.68 mm and 3.1mm respectively, while 13.04 mm had no bony attachment. One (22.9%), two (56.3%) and three (20.8%) band morphologies were observed originating 10.37 mm anterosuperior to the lateral malleolar tip and inserting 3.92 mm anterior to the anterior lateral malleolar line (ALML). Detailed morphology of the ATFL may help in restoring injured ATFL function by appropriate ligament reconstruction, as well as aid the understanding of the mechanism of ligament injury.

Wound management with vacuum assisted closure in surgical site infection after ankle surgery

OBJECTIVE

The aim of this study was to compare the efficacy of vacuum assisted closure (VAC) with standard moist wound care (SMWC) in surgical site infection after ankle surgery.

METHODS

A prospective cohort was performed among patients with surgical site infection after ankle surgery between 2012 and 2013. The follow-up period was three month, and the efficacy end point was complete wound closure rate.

RESULTS

Ninety-four patients were analyzed, with 61 patients in the VAC group and 33 in the SMWC group. The complete wound closure rate in the VAC group was higher than that in the SMWC group at 3 month follow up (90.2% Vs. 72.7%, p = 0.028). The median time to complete wound closure was 31 days (95% CI 20.2-41.8) for VAC, and 63 days (95% CI 46.9-79.1) for SMWC (χ(2) = 4.023, p = 0.045). In the superficial infection subgroup, the median times to complete wound closure were 20 days (95% CI 14.2-35.1) in the VAC group and 42 days (95% CI 35.4-69.4) in SMWC group (χ(2) = 4.331, p = 0.041). In the deep subgroup, the median times to complete wound closure were 46 days (95% CI 28.2-65.9) in the VAC group and 75 days (95% CI 43.2-79.6) in SMWC group (χ(2) = 6.475, p = 0.026).

CONCLUSION

Our result showed that vacuum assisted closure was more effective than standard moist wound care in surgical site infection after ankle surgery.