Enhancing precision in osteochondral lesions of the talus measurements and improving agreement in surgical decision-making using weight-bearing computed tomography and distance mapping

PURPOSE

Weight-bearing computed tomography (WBCT) enables the creation of a three-dimensional (3D) model that represents the ankle morphology in a standing position. Distance mapping (DM) is a complementary feature that uses color coding to represent the relative intraarticular distance and can be used to outline intraarticular defects. Consequently, DM offers a novel approach to delineating osteochondral lesions of the talus (OLT), allowing for the quantification of its surface, volume and depth. The reliability of DM for OLT measurements has yet to be thoroughly evaluated. This study primarily aims to determine the reliability of DM in measuring the surface, depth and volume of OLT. A secondary objective is to ascertain whether measurements obtained through DM, when integrated with a predefined treatment algorithm, can facilitate consensus among surgeons regarding the optimal surgical intervention.

METHODS

This cohort comprised 36 patients with 40 OLTs evaluated using WBCT and DM. Two raters used DM to determine the lesion boundary (LB) and lesion fundus (LF) and calculate the lesion depth, surface and volume. The raters were asked to choose between bone marrow stimulation, autologous matrix-induced chondrogenesis and osteochondral transposition based on the measurement. Inter-rater and intra-rater agreement was measured.

RESULTS

Interclass correlation of the lesion's depth surface produced an excellent inter-rater and intra-rater agreement of 0.90-0.94 p < 0.001. Cohen's κ agreement analysis of the preferable preoperative plan produced a κ = 0.834, p < 0.001, indicating a near-perfect agreement.

CONCLUSION

WBCT-based 3D modules and DM can be used to measure the lesion's surface, depth and volume with excellent inter-rater and inter-rater agreement; using this measurement and a predetermined treatment algorithm, a near-perfect inter-rater agreement for the preoperative planning was reached. WBCT in conjunction with AI capabilities could help determine the type of surgery needed preoperatively, evaluate the hindfoot alignment and assess if additional surgeries are needed.

LEVEL OF EVIDENCE

Level III.

Evidence-Based Opioid Education That Reduces Prescribing: The 10 Principles of Opioid Prescribing in Foot and Ankle Surgery

Over half of opioid misusers last obtained access to opioids via a friend or relative, a problematic reflection of the opioid reservoir phenomenon, which results from an unused backlog of excess prescription opioids that are typically stored in the American home. We aim to determine if a voluntary educational intervention containing standard opioid and nonopioid analgesic prescribing ranges for common surgeries is effective in altering postoperative prescribing practice. We utilized a mixed methods approach and sent out a questionnaire to American podiatric physicians, including residents (baseline group A), via email in early 2020 for baseline data; then, we interviewed foot and ankle surgeons and the primary themes of these semistructured interviews informed us to target residents for an educational intervention. We repeated the survey 3 years later in summer 2022 (preintervention group B). We created an opioid guide and emailed it to residents in fall 2022. Another repeat survey was done in spring 2023 (postintervention group C). We used the Mann-Whitney U test to examine differences between the groups among their reported postoperative opioid quantities for a first metatarsal osteotomy surgical scenario. Groups A, B, and C had 60, 100, and 99 residents, respectively. There was no significant difference (p = .9873) between baseline group A and preintervention group B. There was a difference (p < .0001; -5 median) between preintervention group B and postintervention group C (same residency year). In postintervention group C, a majority (91/99) reported viewing the guide at least once, and the number of residents that reported supplementing with NSAIDs also doubled compared to preintervention group B. This novel opioid educational intervention resulted in meaningful change in self-reported postoperative prescribing behavior among residents.

Analysis of Gender Diversity Within Foot and Ankle Surgery Fellowship Programs

BACKGROUND

Women continue to be underrepresented in orthopaedic surgery. This study seeks to evaluate gender diversity of faculty and trainees at foot and ankle surgery fellowship programs.

METHODS

In this cross-sectional analysis of 49 US foot and ankle fellowship programs, all publicly available data on program faculty (as of July 2023) were collected, as well as data on current and past fellows between 2018 and 2024.

RESULTS

Of 49 programs with 195 foot and ankle surgery faculty, 26.5% (n = 13) had at least 1 female on faculty, with only 8.2% (n = 4) having female fellowship directors. Female faculty made up 9.7% (n = 19) of foot and ankle surgery faculty overall. Of 307 total fellows identified within the 6-year period, 19.5% (n = 60) were female. Geographic distribution of programs was as follows: 29% (n = 14) Northeast, 31% (n = 15) South, 19% (n = 9) Midwest, and 21% (n = 10) West. Northeast programs made up 62% of all programs with female faculty, whereas Midwest programs made up the least at 8% (P = .048). Programs with female faculty had more female fellows from 2018 to 2024 than programs without female faculty (33.7% vs 14%, P < .001).

CONCLUSION

Our findings suggest that females remain underrepresented in foot and ankle surgery fellowship director positions, despite an increasing proportion of females entering orthopaedic surgery. Foot and ankle surgery fellowship programs with female faculty had a higher number of female trainees; as such, diversification of foot and ankle fellowship departments may be an important factor in ongoing efforts to promote gender diversity within the specialty.

LEVEL OF EVIDENCE

Level IV, observational cross-sectional analysis.

Fix or Replace? Patient Preferences for the Treatment of Geriatric Lower Extremity Fractures: A Discrete Choice Experiment

Introduction

When considering treatment options for geriatric patients with lower extremity fractures, little is known about which outcomes are prioritized by patients. This study aimed to determine the patient preferences for outcomes after a geriatric lower extremity fracture.

Materials and Methods

We administered a discrete choice experiment survey to 150 patients who were at least 60 years of age and treated for a lower extremity fracture at a Level I trauma center. The discrete choice experiment presented study participants with 8 sets of hypothetical outcome comparisons, including joint preservation (yes or no), risk of reoperation at 6 months and 24 months, postoperative weightbearing status, disposition, and function as measured by return to baseline walking distance. We estimated the relative importance of these potential outcomes using multinomial logit modeling.

Results

The strongest patient preference was for maintained function after treatment (59%, P < .001), followed by reoperation within 6 months (12%, P < .001). Although patients generally favored joint preservation, patients were willing to change their preference in favor of joint replacement if it increased function (walking distance) by 13% (SE, 66%). Reducing the short-term reoperation risk (12%, P < .001) was more important to patients than reducing long-term reoperation risk (4%, P = .33). Disposition and weightbearing status were lesser priorities to patients (9%, P < .001 and 7%, P < .001, respectively).

Discussion

After a lower extremity fracture, geriatric patients prioritized maintained walking function. Avoiding short-term reoperation was more important than avoiding long-term reoperation. Joint preservation through fracture fixation was the preferred treatment of geriatric patients unless arthroplasty or arthrodesis provides a meaningful functional benefit. Hospital disposition and postoperative weightbearing status were less important to patients than the other included outcomes.

Conclusions

Geriatric patients strongly prioritize function over other outcomes after a lower extremity fracture.

The Radiological Anatomy of the Distal Tibiofibular Joint: A Retrospective Computed Tomography Study

Introduction Distal tibiofibular joint (DTFJ) injuries are commonly encountered in patients with ankle fractures. Achieving optimal fixation is mandatory, but it requires a thorough understanding of the local anatomical relationships. For this reason, we performed a retrospective CT study in healthy ankles to radiologically describe the normal anatomy of the DTFJ and the anatomical relationship of the fibula within the ankle joint. Materials and methods For this study, we retrospectively examined 60 CT scans of healthy, non-injured ankles in a plantigrade position. Patients with prior ankle surgery or systemic diseases with ankle involvement were excluded because we needed to describe the normal anatomy of the joint. The radiological evaluation included the position of the fibula in the fibular notch and the rotational relationship of the fibula with the talus and the medial malleolus. Results Our study included 60 healthy ankles. Thirty-three were right ankles, and 27 were left. The cohort included 36 females and 24 males with a mean age of 48.3 years old. We found that the fibular notch was retroverted on the transverse plane, with the tibiofibular engagement being 0.11 mm (SD=1.57 mm, SE=0.2 mm), at 1 cm proximally to the tibial plafond. Additionally, we observed that the fibula was internally rotated against the lateral talar facet, while the medial and lateral malleolus facets were externally rotated in between. Moreover, we found a strong positive correlation between the incisura retroversion and fibular engagement at 1 cm above the tibial plafond line (Pearson correlation=0.273, p=0.03). Conclusion Our study highlights the importance of gaining a comprehensive understanding of the inherent anatomy of the DTFJ to achieve reduction goals in ankle fractures. According to our results, in ankle fracture treatment, surgeons should aim for anatomical fracture and syndesmotic fixation, with the fibula in internal rotation against the lateral talar facet. Additionally, as normal tibiofibular engagement is borderline, we do not suggest that over-tightening the syndesmotic screws is essential. This study's findings can aid surgeons in reducing the malreduction rates in patients with ankle fractures.

Carbon Footprint of Minor Foot and Ankle Surgery: A Randomized Controlled Trial

Background

Climate change poses a substantial threat to human health, and operating rooms (ORs) have an outsized environmental impact. The Program for Research in Sustainable Medicine (PRiSM) designed a protocol for minor foot and ankle surgery intended to reduce waste, streamline instrument trays, and minimize laundry. We conducted a randomized controlled trial to compare the carbon footprint of procedures performed using the PRiSM protocol vs a traditional protocol.

Methods

Forty adult patients undergoing foreign body removal, hammertoe correction, toe amputation, hardware removal, mass excision, or gastrocnemius recession were randomized to the PRiSM or our "Traditional" protocol. The PRiSM protocol used a smaller instrument tray, fewer drapes and towels, and minimal positioning blankets. No changes were made to surgical site preparation or operative techniques. Environmental impact was estimated using the carbon footprint, measured in kilograms of carbon dioxide equivalents (CO2e). Emissions associated with OR waste, instrument processing, and laundry were calculated.

Results

On average, PRiSM cases had a smaller carbon footprint than Traditional cases (17.3 kg CO2e [SD = 3.2] vs 20.6 kg CO2e [SD = 2.0], P < .001). Waste-associated emissions from PRiSM cases were reduced (16.0 kg CO2e [SD = 2.7] vs 18.4 kg CO2e [SD = 1.8], P = .002), as were modeled instrument processing-related emissions (0.34 vs 0.91 kg CO2e). One superficial surgical site infection occurred in each group.

Conclusion

We found a small but statistically significant reduction in the environmental impact of minor foot and ankle surgery when using the PRiSM vs Traditional protocol. The environmental impact of these cases was dominated by plastic waste-related emissions. Orthopaedic surgeons should think critically about what components of their surgical setup are truly necessary for patient care, as minor changes in product utilization can have significant impacts on waste and greenhouse gas emissions.

Level of Evidence

Level I, randomized controlled trial.

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

Background

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

Methods

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

Results

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

Conclusion

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

Level of Evidence

Level III, case-control study.

Venous Thromboembolism Prophylaxis in Foot and Ankle Surgery: A Worldwide Survey

Current recommendations on thromboprophylaxis for foot and ankle (FA) surgery are often inconsistent and generally based on weak evidence. The aim of this survey study was to evaluate the current practice among orthopedic surgeons regarding venous thromboembolism (VTE) prophylaxis following FA surgery. From February 2019 to March 2020, an online questionnaire was sent by e-mail to orthopedic societies across the world. The questionnaire was hosted by the International Society of Thrombosis and Haemostais RedCAP platform. Topics of interest were VTE rates following FA surgery, duration and type of thromboprophylaxis, bleeding complications, VTE risk factors for prophylaxis and use of risk assessment. A total of 693 FA orthopedic surgeons from all continents completed the survey of whom 392 (57%) performed more than 200 FA procedures per year. A total of 669/693 (97%) respondents stated that thromboprophylaxis is necessary in FA surgeries. When thromboprophylaxis was prescribed, half of surgeons prescribed it for the duration of immobilization. Acetylsalicylic acid, low molecular weight heparin and direct-oral anticoagulants were, in this order, the preferred choice. Acetylsalicylic acid and low molecular weight heparin were predominantly prescribed in North America and Europe, respectively. Previous deep vein thrombosis, immobility, obesity and inherited thrombophilia were considered the main risk factors indicative of thromboprophylaxis use. In this survey, most surgeons agree that thromboprophylaxis is indicated for FA surgery, but the prescription, type and duration of prophylaxis differs greatly with a large intercontinental discrepancy. These survey results could be a foundation for developing uniform guidelines to optimize thromboprophylactic strategies in FA procedures around the world.

Accuracy of a Patient-Specific Total Ankle Arthroplasty Instrumentation

BACKGROUND

Total ankle arthroplasty (TAA) is a preferred surgical option for end-stage ankle osteoarthritis; however, it is a demanding procedure with a higher historical rate of revision compared with ankle fusion. Patient-specific instrumentation (PSI) has been introduced to optimize prosthesis alignment and theoretically overall improve TAA outcomes. The goal of this study is to report on the experience and surgical outcomes of one implant with specific evaluation of the accuracy and reproducibility of the system with respect to prosthesis alignment and prediction of implant size.

METHODS

A retrospective, multicentered study involving 4 foot and ankle fellowship-trained orthopaedic surgeon's patients undergoing TAA between January 1, 2015, and December 31, 2018, using the PROPHECY PSI system.

RESULTS

80 TAA procedures were performed. On average the postoperative tibial component alignment was 89.9 (range, 86.1-96.5) degrees in the coronal plane, with a mean sagittal alignment of 88.1 (range, 81.3-96.7) degrees. The mean deviation from neutral sagittal alignment improved from 4.9 ± 3.9 degrees preoperatively to 2.7 ± 1.7 degrees postoperatively, whereas the mean coronal alignment improved from 3.3 ± 2.5 degrees to 1.3 ± 1.1 degrees. The PSI software correctly determined the tibial implant size in 70 patients (89%). Prediction of talar implant sizing was less accurate than the tibial component, with 56 patients (71%) using the predicted sized implant. The overall implant survival at a mean follow-up of 45 months (range, 27-76) was 97.5%.

CONCLUSION

We found that this PSI system accurately and reliably assisted in implant total ankle prosthesis positioning within a clinically acceptable margin and without significant outliers. Prediction of implant size was not as accurate as component orientation.

LEVEL OF EVIDENCE

Level III, retrospective study.

Three-Dimensional Distance Mapping to Identify Safe Zones for Lateral Column Lengthening

BACKGROUND

Evans (E-LCL) and Hintermann LCL (H-LCL) lateral column lengthening osteotomies are standard surgical solutions for flexible, progressive collapsing feet. E-LCL is performed between the anterior and middle facets and endangers specific os calcis subtalar joint (OCST) subtypes without distinct facets. H-LCL is oriented between the posterior and middle facets and should be suitable for all OCSTs. Both osteotomies are associated with increased subtalar osteoarthritis, indicating iatrogenic damage. Distance mapping (DM) enables visualization of the relative distance between 2 articular surfaces represented by color patterns. This study aims to measure the safe zones for LCL using 3-dimensional (3D) models and DM; we hypothesize that it could be measured with high reproducibility.

METHODS

Two raters categorized 200 feet across 134 patients into OCSTs based on the Bruckner classification. Four angles were measured independently. The proximal and distal extents of the posterior safe zone (PSZ) angles were determined for H-LCL osteotomies; similarly, the proximal and distal extents of the anterior safe zone (ASZ) angles were identified for E-LCL osteotomies. Consequently, the surface available for safe osteotomies were calculated. An interclass correlation was used to assess the agreement between the 2 raters. Additionally, analysis of variance and Mann-Whitney U test were used to compare the safe zones between OCSTs.

RESULTS

The mean proximal and distal extents of the PSZ angles were 68 ± 7 and 75 ± 5 degrees from a line parallel to the lateral border of the calcaneus, respectively, and the proximal and distal extent of the ASZ angles were 89 ± 6 and 95 ± 5 degrees, respectively. There were no statistically significant differences between the OCSTs. Two raters measured the angles with good to excellent interrater and intrarater agreement. In 18 cases, we were unable to plan for H-LCL or E-LCL osteotomies.

CONCLUSION

Distance mapping could be used to measure the safe zone, tailor a preoperative plan, and potentially reduce the risk for iatrogenic damage in LCL. 3D models and DM can increase the reliability of preoperative plans in bones with complex 3D structures.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Time and State Legislation Have Decreased Opioid Prescribing in Elective Foot and Ankle Surgery in the United States

BACKGROUND

Legislation in the United States has been enacted to reduce opioid overuse and abuse in the setting of the opioid epidemic, and a notable target has been opioid overprescription. However, the impact of this legislation on elective foot and ankle surgery is largely unknown. The purpose of this study was to evaluate the impact of opioid-limiting legislation on opioid prescribing in elective foot and ankle surgery.

METHODS

The 90-day perioperative opioid prescription filling in oxycodone 5-mg equivalents was identified in all patients 18 years of age and older undergoing nontrauma, nonarthroplasty foot and ankle surgery from 2010 to 2019 using a commercial database. States with and without legislation were identified, and opioid prescription filling before and after the legislation were tabulated. Unadjusted and adjusted analyses were performed to evaluate the impact of time and state legislation on perioperative opioid prescribing in this patient population.

RESULTS

Initial and cumulative opioid prescribing decreased significantly from 2010 to 2019 (39 vs 35.7 initial and 98.1 vs 55.7 cumulative). States with legislation had larger and more significant reductions in initial and cumulative opioid prescribing compared with states without legislation over similar time frames (41.6 to 35.1 with legislation vs 40.6 to 39.1 without legislation initial prescription filling volume and 87.7 to 62.8 vs 88.6 to 74.1 cumulative prescription filling volume).

CONCLUSION

State legislation and time have been associated with large, clinically relevant reductions in 90-day perioperative cumulative opioid prescription filling, although reductions in initial opioid prescription filing have remained low. These results encourage states without legislation to enact restraints to reduce the opioid epidemic.

LEVELS OF EVIDENCE

Level III: Retrospective, prognostic cohort study.

The Classic Three-Month Post-Operative Adaptation Phase in Foot and Ankle Surgery-An Expert Perspective

Foot and ankle disorders are a common reason for orthopedic surgical intervention. After surgery, specific precautions such as partial weight bearing or complete unloading, and the use of walking aids, coupled with a period of rest, are usually implemented to ensure the surgical outcome. However, when these aids are discontinued and the patients resume load increase and normal daily activities, they may enter a transitional phase characterized by inflammation, swelling, and pain. We call this phenomenon the "classic three-month post-operative adaptation phase" (POAP). It is essential to differentiate this physiological transition phase from other conditions, such as from the immediate post-surgical inflammation, complex pain regional syndrome, or an infection. The objective of this expert opinion is to describe and raise medical awareness of this evidence-based phenomenon, which we commonly observe in our daily practice.

Quick Transposition of ReBOSSIS-J® to the Host Bone Trabeculae Within One Month After Supplementing to the Harvest Site on the Calcaneus for Autologous Bone Grafting in a Rheumatoid Arthritis Case

We present the case of a patient with rheumatoid arthritis who underwent talonavicular joint fusion using an autologous calcaneal bone graft. At the same time, the bony defect at the harvest site was supplemented with ReBOSSIS-J® [70% β-TCP and 30% poly(L-lactide-co-glycolide)](ORTHOREBIRTH Co. Ltd., Kanagawa, Japan), a synthetic bioresorbable bone void filler for the repair of bony defects with handling characteristics similar to a cotton ball. Material resorption and new bone formation had already started one week postoperatively. Transposition to host bone trabeculae was almost completed by 26 days postoperatively. Very rapid reactive graft resorption, repair with new bone formation, and subsequently, most of the transformation to host bone trabeculae were confirmed. ReBOSSIS-J® appears feasible to contribute to early heel weight-bearing exercise after foot or ankle surgery. In addition, preventing the fracture at the harvesting site of the calcaneal bone graft can also be expected.

Use of a Hindfoot Nail Without Separate Subtalar and Tibiotalar Joint Preparation to Treat Geriatric Ankle and Distal Tibia Fractures: A Case Series

Introduction

Ankle fractures in geriatric patients can be devastating injuries, as they limit an individual's mobility, autonomy, and quality of life. This study examines the functional outcomes and complications related to hindfoot nails (HFN) in geriatric patients who have suffered an ankle malleolar or distal tibia fracture.

Materials and Methods

This is a single-surgeon case-series of patients who underwent HFN for acute fixation or delayed reconstruction after an ankle or distal tibia fracture. Demographic information, comorbidities, baseline functional status, AO/OTA classification, surgical indications, need for external fixation, total operative time, length of stay (LOS), ambulation at discharge, and discharge disposition were recorded. Primary outcomes included 30-day complications, ambulation at follow-up, and time to fracture union and fusion.

Results

There were 22 patients, with average age 80.8 years. Mean LOS was 7.0 days, and 68.2% were discharged to subacute rehabilitation. Within 30 days, 1 patient developed a deep vein thrombosis and bilateral pulmonary emboli, and 2 experienced wound dehiscence requiring antibiotics. At 6-weeks, 1 patient sustained a fall with periprosthetic fracture requiring HFN revision, and another developed cellulitis necessitating hardware removal. Fracture healing was seen in 72.7% at 19.4 weeks, while radiographic fusion occurred in 18.2% at 43.0 weeks. 72.7% were ambulating with an assistive device at discharge, and 100.0% at 12-weeks post-operatively or last follow-up. Upon final examination, all patients were ambulating without pain.

Discussion

HFNs provide a reliable alternative to traditional open reduction internal fixation and have the ability to improve quality of life for geriatric patients through a faster return to weight-bearing. Additionally, radiographic fusion rates show that patients have favorable functional outcomes even without formal arthrodesis.

Conclusion

HFN is beneficial for elderly patients with low functional demand and complex medical comorbidities, as it allows for early mobility after sustaining an ankle or distal tibia fracture.

Elective Foot and Ankle Procedures in the Patients Greater than 65 Years of Age: Worth the Mobility Gains

Chronic, non-traumatic pathologies of the foot and ankle can be mobility-limiting for patients of all ages. The objective of this study was to compare postoperative changes in LifeSpace Mobility Assessment (LSA) scores of adult and elderly patients following elective foot and ankle surgery. A prospective study of 184 patients undergoing elective ankle, hindfoot, and midfoot procedures conducted by one surgeon between 2015 and 2019 was undertaken. Patient-reported LSA scores were collected at preoperative, 6-month, and 12-month follow-up. Patient data was compared using an independent sample t-test for continuous, normally distributed data and a chi-squared or Fischer's exact test for categorical data. Alpha and beta were .05 and .8. Patients were divided based on age. 140 patients were observed in the younger (<65) group, 44 patients were observed in the elderly (≥65) group. The average LSA score of elderly patients at the preoperative visit was 58.3 (SD 38.0) vs 79.3 (SD 38.8) in the younger cohort (P = .041). Both patient cohorts saw decreased mobility at 3-month postoperative visits but surpassed preoperative mobility scores by 6 months and 1 year postop. No difference in average mobility score was observed between young (85.6, SD 36.1) and elderly (90.1, SD 34.3) cohorts at 1-year follow up. Given the increased rates of perioperative comorbidities and the heightened risks of intraoperative complications, physicians may be more inclined to manage elderly patients with longer periods of conservative treatment for similar pathologies. However, these results imply that elderly patients experience similar improvements after surgery to younger cohorts and should not be excluded from surgical consideration. Our results, in tandem with literature showing the deleterious effects of decreased mobility in the elderly, suggest that the discussion to pursue or hold surgical correction of chronic foot and ankle disease in patients over age 65 must consider the mobility benefits of surgery.

Republication of "Postoperative Narcotic Prescription Practice in Orthopedic Foot and Ankle Surgery"

Background

The misuse and abuse of opioid pain medications have become a public health crisis. Because orthopedic surgeons are the third highest prescribers of opioids, understanding their postoperative pain medication prescribing practices is key to solving the opioid crisis. To this end, we conducted a study of the variability in orthopedic foot and ankle surgery postoperative opioid prescribing practice patterns.

Methods

Three hundred fifty orthopedic foot and ankle surgeons were contacted; respondents completed a survey with 4 common patient scenarios and surgical procedures followed by questions regarding typical postoperative pain medication prescriptions. The scenarios ranged from minimally painful procedures to those that would be expected to be significantly more painful. Summaries were calculated as percentages and chi-square or Fisher exact tests were used to compare survey responses between groups stratified by years in practice and type of practice.

Results

Sixty-four surgeons responded to the survey (92.8% male), 31% were in practice less than 5 years, 34% 6 to 15 years and 34% more than 15 years. For each scenario, there was variation in the type of pain medication prescribed (scenario 1: 17% 5 mg hydrocodone, 22% 10 mg hydrocodone, 52% oxycodone, and 3% oxycodone sustained release [SR]; scenario 2: 15% 5 mg hydrocodone, 13% 10 mg hydrocodone, 58% oxycodone, and 9% oxycodone SR; scenario 3: 11% 5 mg hydrocodone, 13% 10 mg hydrocodone, 56% oxycodone, and 14.1% oxycodone SR; scenario 4: 3% 5 mg hydrocodone, 5% 10 mg hydrocodone, 44% oxycodone, and 45% oxycodone SR) and the number of pills dispensed. Use of multimodal pain management was variable but most physicians use regional nerve blocks for each scenario (76%, 87%, 69%, 94%). Less experienced surgeons (less than 5 years in practice) supplement with tramadol more for scenario 1 (P = .034) as well as use regional nerve blocks for scenario 2 (P = .039) more than experienced surgeons (more than 15 years in practice).

Conclusion

It is evident that variation exists in narcotic prescription practices for postoperative pain management by orthopedic foot and ankle surgeons. With new AAOS guidelines, it is important to try to create some standardization in opioid prescription protocols.

Improving Randomized-Controlled Trials in Foot and Ankle Orthopaedics: The Need to Include Sociodemographic Patient Data

BACKGROUND

The representation of sociodemographic data within randomized-controlled trials (RCT) regarding foot and ankle surgery is undefined. The purpose of this study was to determine the incidence of sociodemographic data being reported in contemporary foot and ankle RCTs.

METHODS

Randomized-controlled trials within the PubMed database from 2016 to 2021 were searched and the full text of 40 articles was reviewed to identify sociodemographic variables reported in the manuscript. Data regarding race, ethnicity, insurance status, income, work status, and education were collected.

RESULTS

Race was reported in the results in 4 studies (10.0%), ethnicity in 1 (2.5%), insurance status in 0 (0%), income in 1 (2.5%), work status in 3 (7.5%) and education in 2 (5.0%). In any section other than the results, race was reported in 6 studies (15.0%), ethnicity in 1 (2.5%), insurance status in 3 (7.5%), income in 6 (15.0%), work status in 6 (15.0%), and education in 3 (7.5%). There was no difference in sociodemographic data by journal (P = .212), year of publication (P = .216), or outcome study (P = .604).

CONCLUSION

The overall rate of sociodemographic data reported in foot and ankle RCTs is low. There was no difference in the reporting of sociodemographic data between journal, year of publication, or outcome study.

LEVEL OF EVIDENCE

Level II.

Biomechanical Comparison of Cannulated Screw Osteosynthesis With Tension-Band Wiring for Proximal Fractures of the Fifth Metatarsal (Jones Fracture)

Jones fractures, which lie at the junction of the diaphysis to the metaphysis of the fifth metatarsal, are a well-described clinical issue. There are various surgical approaches, including the commonly performed cannulated screw osteosyntheses, and the less frequently used tension-band approach. The aim is to compare the biomechanical stability of these osteosyntheses. We performed an osteotomy on 16 fresh frozen fifth metatarsal bones from body donors representing a Jones fracture. The fractures were treated pairwise with screw osteosynthesis or tension-band wiring. This was followed by cyclic axial bending until osteosynthesis failure. Stability under axial bending force was higher in the screw osteosynthesis (mean: 70.0 ± 66.5 N) compared to the tension-band wiring (mean: 35.7 ± 23.3 N) group although not reaching statistical significance (p = .116). The study shows no statistically significant difference in biomechanical stability under axial loading between screw osteosynthesis and tension band wiring. Based on the data obtained, no differences can be observed from a biomechanical point of view. The study supports the established method of treating Jones fractures primarily with screw osteosynthesis. In addition, the data suggest that tension band wiring may be a good alternative osteosynthesis, for example, after failed casting treatment or failure of primary osteosynthesis.

A rare case of mobile diplopodia mistaken for polydactyly

We present a rare case of a mobile diplopodia in an infant with disorganization syndrome. This was initially mistaken for polydactyly due to the more typical association between these conditions. The resulting corrective surgery was more extensive and complicated than anticipated, with the removal of a partial foot duplication and reconstruction of residual hindfoot structures, rather than the planned digit amputation. We highlight the association of diplopodia with disorganization syndrome, discuss differentiating diplopodia from polydactyly and describe the surgical management of an unusual case.

Incidence of Venous Thromboembolism in Patients Receiving Anticoagulation for Foot and Ankle Surgery

Venous thromboembolism (VTE) is a serious medical condition that can be an unfortunate complication arising from foot and ankle surgery. Many factors may predispose a patient to a VTE event including prolonged postoperative immobilization, comorbidities, extended length of tourniquet time, and higher risk surgeries. Unfortunately, there is no clinical consensus for guidelines on VTE prophylaxis following foot and ankle surgery. In this retrospective cohort study, we present our patient population who were prophylactically anticoagulated following foot and ankle surgery along with their incidence of deep vein thrombosis and pulmonary embolism (PE). Included in the study were patients who had undergone elective and traumatic foot and ankle surgery from June 2017 to December 2018. Using retrospective data obtained we compared patient demographics, surgery type, length of tourniquet time, postoperative immobilization, type of VTE prophylaxis, and comorbidities including history of smoking, peripheral vascular disease, bleeding disorders, and patients undergoing dialysis. Five of 425 (1.2%) patients were diagnosed with a deep vein thrombosis and 1 of 425 (0.2%) patients was diagnosed with a pulmonary embolism. Risks factors statistically significant for developing a VTE in our patient population included extended periods of immobilization and an increasing patient age. We were able to conclude that routine prophylaxis for elective and traumatic foot and ankle surgery is both effective and safe for especially in older patients requiring extended immobilization. It's also important to take into consideration comorbidities, smoking history, tourniquet time, and the type of surgery that is being performed.

How international are the editorial boards in the field of foot and ankle surgery?: A STROBE-compliant cross-sectional study

Very low proportions of publications from low- and middle-income countries (LAMIC) have been proved in multiple fields. Some researchers from these countries believe that there is a biased attitude of editors against their studies. Under-representation of editorial board members from LAMIC were revealed in many research fields. However, it has not been investigated in the field of foot and ankle surgery. The current study aimed to analyze the composition of the editorial board members in leading foot and ankle journals, and to provide the international representation of editorial boards in the field of foot and ankle surgery. Five leading journals in the field of foot and ankle surgery were included. The editorial board members were collected from the official websites of these journals. The countries of board members were classified based on World Bank. The board compositions of the journals were analyzed. In total, 229 editorial board members were identified. These editors were from 29 countries. The United States (29.69%) had the greatest number of editors, followed by the United Kingdom (20.52%), Australia (8.30%), Italy (6.11%), and Germany (5.68%). When the editors were classified by regions, 49.34% of board members were from Europe & Central Asia, followed by North America (31.44%), East Asia & Pacific (14.41%), Latin America & Caribbean (2.62%), and Middle East & North Africa (2.18%). No editors were from South Asia and Sub-Saharan Africa. A total of 217 editors (94.76%) were from high-income countries, followed by upper-middle-income countries (3.06%), and lower-middle-income countries (2.18%). No members were from low-income countries. There is a lack of international representation on editorial boards of leading foot and ankle journals. Editorial board members in the field of foot and ankle surgery are largely composed by editors from high-income countries with sever under-representation of LAMIC.

Computed Tomography Scan Architectural Measurements in Adult Foot and Ankle Surgery: A Narrative Review for Orthopaedic Trainees

CT scan plays an important role in adult foot and ankle surgery. Plain radiographs are usually the first-line imaging modality for assessing foot and ankle bone and joint architectural abnormalities. However, despite the fact that a CT scan is more expensive and associated with higher radiation exposure, it offers better imaging quality for the assessment of bony lesions in orthopaedics and trauma. Evidence has shown that more accurate measurements can be obtained from a CT scan compared to plain radiographs. Weight-bearing multi-detection CT scanning goes the extra mile by providing a more detailed assessment, especially for intra-articular fractures, and mirrors the real-life foot and ankle dynamics compared to conventional non-weight-bearing CT scans. It also has a relatively lower radiation dose compared to conventional CT scans. CT scan is the best modality for assessing bony lesions whereas MRI is better for soft tissue pathology. An understanding of the role of CT scan in the anatomical assessment of the foot and ankle will help improve communication between orthopaedic surgeons, radiologists, and radiographers. A thorough understanding of when to use a CT scan compared to the other imaging modalities will also lead to better surgical outcomes, reduced cost, and reduced risk from radiation exposure. This review article analyzes the role of CT in assessing relevant radiographic architectural measurements for diagnosis and surgical planning in adult foot and ankle surgery.

An Evaluation of Basic Demographic Characteristics in Foot and Ankle Surgery From the American College of Surgeons National Surgical Quality Improvement Program

It has become increasingly prevalent in the foot and ankle surgical literature to evaluate outcomes and trends obtained from large databases. The objective of this investigation was to provide a broad descriptive analysis and compare basic demographic characteristics relating to foot and ankle surgery within the American College of Surgeons National Surgical Quality Improvement Program database. The 16 Current Procedural Terminology® (CPT) codes available within this database pertaining to foot and ankle surgery were studied. Several CPT codes were observed to be more frequently associated with male gender: 27650 (Achilles tendon repair), 27698 (Lateral ankle reconstruction), 27702 (Total ankle arthroplasty), 27766 (ORIF medial malleolus fracture), 27792 (ORIF lateral malleolus fracture), and 28805 (Metatarsal amputation). Several other CPT codes were observed to be more frequently associated with female gender: 27658 (Primary peroneal tendon repair), 27814 (ORIF bimalleolar fracture), 27822 (ORIF trimalleolar ankle fracture without posterior lip fracture), and 27823 (ORIF trimalleolar ankle fracture with posterior lip fracture). The elective case designation was observed to be more frequently associated with male gender (65.4 vs 58.7%; p < .001). These data have potential use in the development and interpretation of quality improvement/performance improvement protocols at individual health care delivery centers, as well as the interpretation of other published investigations utilizing this database.

Efficacy of Postoperative Oral Antibiotics in Foot and Ankle Surgery

BACKGROUND

Preoperative oral antibiotic use in patients undergoing foot and ankle surgery is standard practice, but no consensus has been reached regarding the efficacy of postoperative oral antibiotics. The purpose of this study was to determine whether postoperative oral antibiotics reduce the rate of surgical site infections (SSIs) in patients, with and without comorbidities, undergoing foot and ankle surgery.

METHODS

A retrospective chart review was conducted identifying patients who underwent foot and ankle surgery by 4 fellowship-trained, foot and ankle orthopaedic surgeons between January 1, 2015, and January 1, 2019. Patients were divided into 2 groups: those who received postoperative oral antibiotics (group 1) and those who did not (group 2). Two surgeons routinely prescribed postoperative oral antibiotics, and 2 did not. Demographics, comorbidities, and procedure complexity based on surgical site and Current Procedural Terminology code were recorded from the charts. The primary outcome was postoperative infection (superficial or deep) within 6 months after surgery. Patients with antibiotic use prior to surgery, preoperative infection, or lack of follow-up >6 weeks were excluded. Multivariate logistic regression modeling was used to analyze differences in infection rate and severity.

RESULTS

Chart review identified 3631 patients, 1227 of whom did not receive postoperative oral antibiotics whereas 2394 patients did. Routine postoperative oral antibiotic use did not significantly affect postoperative infection rates or severity. However, all covariates studied (diabetes, hypertension, obesity, tobacco use, alcohol use, rheumatoid conditions, and age) influenced postoperative infection rates and severity.

CONCLUSION

The results of this study indicate that postoperative oral antibiotics are not associated with differences in infection rates or severity. We do not recommend routine use in foot and ankle surgery.

Tranexamic Acid in Foot and Ankle Surgery: A Topical Review and Value Analysis

Tranexamic acid (TXA) has become a commonly used perioperative intervention in total joint arthroplasty, shoulder and knee arthroscopy, and spinal procedures in order to minimize blood loss, hematoma formation, hemarthrosis, and wound healing complications. There is a potential role for TXA use in foot and ankle procedures, with limited studies suggesting a potential benefit in minimizing postoperative wound complications and blood loss without an increased risk of thromboembolic events. In light of the profound clinical and financial impact of TXA use in other orthopaedic subspecialties and the early successes in foot and ankle surgery, we aim to provide more information about TXA and its use in foot and ankle surgery. Therefore, the purpose of this review is to perform a comprehensive literature review on the topic of TXA use in foot and ankle procedures in order to describe the pertinent available literature on the use of TXA in orthopaedic surgery and its implications specifically in foot and ankle surgery. It is our aim to identify potential benefits and shortcomings in the available evidence on TXA use for foot and ankle surgery in hopes to (1) best inform foot and ankle surgeons where beneficial and safe and (2) inspire further research on this topic as it relates to clinical management for foot and ankle patients.Levels of Evidence: Level IV.

Orthopaedic Foot and Ankle Surgery Leadership Trends: A Cross-Sectional Study of Fellowship Directors and Division Chiefs

Background: In orthopaedic surgery departments, foot and ankle fellowship directors are tasked to create a robust clinical curriculum for trainees, while division chiefs manage the division's delivery of patient care. The primary aim of this study was to describe characteristics of foot and ankle surgery fellowship directors and division chiefs in an effort to recognize trends or disparities in leadership traits. Methods: The American Orthopaedic Foot and Ankle Society (AOFAS) fellowship directory for 2021 to 2022 was reviewed for AOFAS-recognized fellowship programs in the United States. Between March 2021 and June 2021, 48 fellowship directors and 23 publicly recognized division chiefs were administered an electronic survey to collect demographic, educational, and professional data. Univariate and bivariate statistical analyses were performed. Results: A total of 42 of the 48 (87.5%) fellowship directors and 18 of the 23 (78.3%) division chiefs responded to the questionnaire. Of the 48 fellowship directors, 45 (93.8%) were male, 43 (89.6%) identified as Caucasian, their average age at leadership appointment was 42.6 ± 7.5 (range, 32-70) years, and the average time between fellowship graduation and leadership appointment was 9.9 ± 7.8 (range, 0-36) years. Of the 23 chiefs, 22 (95.7%) were male, 20 (87.0%) identified as Caucasians, their average age at leadership appointment was 41.7 ± 7.8 (range, 32-53) years, and the average time between fellowship graduation and leadership appointment was 9.8 ± 6.8 (range, 2-21) years. The average H-index for the chiefs was greater than that of the fellowship directors (18.4 vs 13.4, P = .0373) when controlling for years of training>. Conclusion: The majority of current leaders identify as middle-age Caucasian males, demonstrate high research productivity, and have attended a select number of the same residency and fellowship training programs. By demonstrating the lack of diversity within foot and ankle surgery leadership, this study serves as a call to action for making inclusivity a priority.Levels of Evidence: Level IV: Cross-sectional study.

Prevalence and Risk Factors of Postoperative Falls Following Foot and Ankle Surgery

BACKGROUND

No study has examined the incidence of risk factors for postoperative falls following foot and ankle surgery. We investigated the incidence and risk factors for postoperative falls in foot and ankle surgery using inpatient and outpatient population.

METHODS

A single fellowship-trained foot and ankle surgeon instituted collection of a postoperative fall questionnaire at 2 and 6 weeks postoperatively. A retrospective review of 135 patients with complete prospectively collected fall questionnaire data was performed. Patient demographic information, injury characteristics, comorbidities, baseline medications, length of hospital stay, visual analog scale (VAS) pain scores were collected. After univariable analysis, a multivariable binary logistic regression was conducted to assess independent risk factors for postoperative falls.

RESULTS

The median (interquartile range) age was 52 (21) and body mass index was 32.7 (11.1). A total of 108 patients (80%) underwent outpatient procedures. Thirty-nine of the 135 patients (28.9%) reported experiencing a fall in the first 6 weeks after surgery. In multivariable analysis, antidepressant use (adjusted odds ratio 3.41, 95% CI 1.19-9.81) and higher VAS pain scores at 2 weeks postoperatively (adjusted odds ratio 1.27, 95% CI 1.08-1.50) were found to be independent risk factors for postoperative falls.

CONCLUSION

This study found a high incidence of postoperative falls in the first 6 weeks after foot and ankle surgery. Baseline antidepressant use and higher 2-week VAS pain scores were associated with postoperative falls. Foot and ankle surgeons should discuss the risk of falling with patients especially those with risk factors.

LEVEL OF EVIDENCE

Level III, retrospective cohort study at a single institution.

Outcomes of Surgical Reconstruction Using Custom 3D-Printed Porous Titanium Implants for Critical-Sized Bone Defects of the Foot and Ankle

BACKGROUND

Treating critically sized defects (CSDs) of bone remains a significant challenge in foot and ankle surgery. Custom 3D-printed implants are being offered to a small but growing subset of patients as a salvage procedure in lieu of traditional alternates such as structural allografts after the patient has failed prior procedures. The long-term outcomes of 3D-printed implants are still unknown and understudied because of the limited number of cases and short follow-up durations. The purpose of this study was to evaluate the outcomes of patients who received custom 3D-printed implants to treat CSDs of the foot and ankle in an attempt to aid surgeons in selecting appropriate surgical candidates.

METHODS

This was a retrospective study to assess surgical outcomes of patients who underwent implantation of a custom 3D-printed implant made with medical-grade titanium alloy powder (Ti-6Al-4V) to treat CSDs of the foot and ankle between June 1, 2014, and September 30, 2019. All patients had failed previous nonoperative or operative management before proceeding with treatment with a custom 3D-printed implant. Univariate and multivariate odds ratios (ORs) of a secondary surgery and implant removal were calculated for perioperative variables.

RESULTS

There were 39 cases of patients who received a custom 3D-printed implant with at least 1 year of follow-up. The mean follow-up time was 27.0 (12-74) months. Thirteen of 39 cases (33.3%) required a secondary surgery and 10 of 39 (25.6%) required removal of the implant because of septic nonunion (6/10) or aseptic nonunion (4/10). The mean time to secondary surgery was 10 months (1-22). Multivariate logistic regression revealed that patients with neuropathy were more likely to require a secondary surgery with an OR of 5.76 (P = .03).

CONCLUSION

This study demonstrated that 74% of patients who received a custom 3D-printed implant for CSDs did not require as subsequent surgery (minimum of 1-year follow-up). Neuropathy was significantly associated with the need for a secondary surgery. This is the largest series to date demonstrating the efficacy of 3D-printed custom titanium implants. As the number of cases using patient-specific 3D-printed titanium implant increases, larger cohorts of patients should be studied to identify other high-risk groups and possible interventions to improve surgical outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Are Transmetatarsal Amputations a Durable Limb Salvage Option? A Single-Institution Descriptive Analysis

In limb and life-threatening diabetic foot infections, transmetatarsal amputations are often indicated as a limb salvage procedure. The aim of this study is to analyze the long-term durability of initially successful transmetatarsal amputations in the diabetic population. We defined a successful transmetatarsal amputation as one which had clinical healing 1 year after surgery. A retrospective review of transmetatarsal amputations completed at our institution over an 11-year period was performed. We identified 83 amputations that met inclusion criteria. The mean follow-up was 4 years. The mean time to surgical healing was 109.8 days. After successfully healing the transmetatarsal amputation the long-term outcomes were analyzed. Re-ulcerations occurred in 44% of the transmetatarsal amputations a mean of 15 months after surgical healing. Patients who re-ulcerated were noted to be significantly younger (p value 0.02) with a significantly higher preprocedure hemoglobin A1c (p value < .001). Additional procedures after successful healing included 13 (15.66%) revision surgeries and 12 (14.46%) more proximal amputations. While transmetatarsal amputations remain a viable and durable limb preserving surgery, all patients who have undergone a transmetatarsal amputation should be monitored lifelong as they remain at risk for re-ulceration and more proximal amputation.

Development and internal validation of a multivariable risk prediction model for severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block

BACKGROUND

Rebound pain occurs after up to 50% of ambulatory surgeries involving regional anaesthesia. To assist with risk stratification, we developed a model to predict severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block.

METHODS

After ethics approval, we performed a single-centre retrospective cohort study. Patients undergoing lower limb surgery with popliteal sciatic nerve block from January 2016 to November 2019 were included. Exclusion criteria were uncontrolled pain in the PACU, use of a perineural catheter, or loss to follow-up. We developed and internally validated a multivariable logistic regression model for severe rebound pain, defined as transition from well-controlled pain in the PACU (numerical rating scale [NRS] 3 or less) to severe pain (NRS ≥7) within 48 h. A priori predictors were age, sex, surgery type, planned admission, local anaesthetic type, dexamethasone use, and intraoperative anaesthesia type. Model performance was evaluated using area under the receiver operating characteristic curve (AUROC), Nagelkerke's R², scaled Brier score, and calibration slope.

RESULTS

The cohort included 1365 patients (mean [standard deviation] age: 50 [16] yr). The primary outcome was abstracted in 1311 (96%) patients, with severe rebound pain in 652 (50%). Internal validation revealed poor model performance, with AUROC 0.632 (95% confidence interval [CI]: 0.602-0.661; bootstrap optimisation 0.021), Nagelkerke's R² 0.063, and scaled Brier score 0.047. Calibration slope was 0.832 (95% CI: 0.623-1.041).

CONCLUSIONS

We show that a multivariable risk prediction model developed using routinely collected clinical data had poor predictive performance for severe rebound pain after foot and ankle surgery. Prospective studies involving other patient-related predictors are needed.

CLINICAL TRIAL REGISTRATION

NCT05018104.

Are Hindfoot Procedures More Painful than Forefoot Procedures? A Prospective Observational Study in Elective Foot and Ankle Surgery

Pain after lower limb orthopedic surgery can be severe. Poorly controlled pain is associated with adverse outcomes. Peripheral nerve blocks (PNB) have become popular in foot and ankle surgery for their effective pain control and low complication rates. It has always been assumed that hindfoot procedures are more painful than midfoot/forefoot procedures often requiring inpatient stay for pain relief. There are no published studies evaluating this assumption. To investigate whether hindfoot procedures are more painful than forefoot/midfoot procedures by measuring pain scores, assessing effectiveness of PNBs and patient satisfaction. One hundred forty patients undergoing elective foot and ankle surgery were prospectively studied. Inclusion criteria: Adults undergoing elective foot and ankle surgery. Exclusion criteria: Patients 16 years or under, those with alternate sources of pain, peripheral neuropathy, known substance abuse, psychiatric illness and incomplete pain scores. Pain was measured via the Visual Analog Scale at 3 time intervals: immediately, 6 hours and at 24 hours postoperatively. Analysis was via t-test. A p value of <.05 demonstrated a statistical significance. Forefoot/midfoot versus hindfoot surgery pain scores showed that there was no significant difference at any postoperative interval. PNB versus no PNB pain scores showed there was no significant difference, except at 24 hours postoperatively (p value .024). Patients who had a PNB experienced rebound pain at 24 hours. Hindfoot surgery is not more painful than forefoot/midfoot surgery. Patients who had a PNB experienced rebound pain at 24 hours postoperatively, a finding that requires further research.

The safe resumption of elective orthopaedic services following the first wave of the COVID-19 pandemic : a review of 2,316 consecutive cases and implications for recovery following further waves

Aims

There is little published on the outcomes after restarting elective orthopaedic procedures following cessation of surgery due to the COVID-19 pandemic. During the pandemic, the reported perioperative mortality in patients who acquired SARS-CoV-2 infection while undergoing elective orthopaedic surgery was 18% to 20%. The aim of this study is to report the surgical outcomes, complications, and risk of developing COVID-19 in 2,316 consecutive patients who underwent elective orthopaedic surgery in the latter part of 2020 and comparing it to the same, pre-pandemic, period in 2019.

Methods

A retrospective service evaluation of patients who underwent elective surgical procedures between 16 June 2020 and 12 December 2020 was undertaken. The number and type of cases, demographic details, American society of Anesthesiologists (ASA) grade, BMI, 30-day readmission rates, mortality, and complications at one- and six-week intervals were obtained and compared with patients who underwent surgery during the same six-month period in 2019.

Results

A total of 2,316 patients underwent surgery in 2020 compared to 2,552 in the same period in 2019. There were no statistical differences in sex distribution, BMI, or ASA grade. The 30-day readmission rate and six-week validated complication rates were significantly lower for the 2020 patients compared to those in 2019 (p < 0.05). No deaths were reported at 30 days in the 2020 group as opposed to three in the 2019 group (p < 0.05). In 2020 one patient developed COVID-19 symptoms five days following foot and ankle surgery. This was possibly due to a family contact immediately following discharge from hospital, and the patient subsequently made a full recovery.

Conclusion

Elective surgery was safely resumed following the cessation of operating during the COVID-19 pandemic in 2020. Strict adherence to protocols resulted in 2,316 elective surgical procedures being performed with lower complications, readmissions, and mortality compared to 2019. Furthermore, only one patient developed COVID-19 with no evidence that this was a direct result of undergoing surgery.

Level of evidence: III

Cite this article: Bone Jt Open 2022;3(1):42–53.

30-Day Outcomes for Total Ankle Arthroplasty in Patients With Anemia

BACKGROUND

While anemia has been associated with poor surgical outcomes in total knee arthroplasty and total hip arthroplasty, the effects of anemia on total ankle arthroplasty remain unknown. This study examines how preoperative anemia affects postoperative outcomes in total ankle arthroplasty.

METHODS

A retrospective analysis was performed using the American College of Surgeons National Surgery Quality Improvement Project database from 2011 to 2018 for total ankle arthroplasty procedures. Hematocrit (HCT) levels were used to determine preoperative anemia.

RESULTS

Of the 1028 patients included in this study, 114 patients were found to be anemic. Univariate analysis demonstrated anemia was significantly associated with an increased average hospital length of stay (2.2 vs 1.8 days, P < .008), increased rate of 30-day readmission (3.5% vs 1.1%, P = .036), increased 30-day reoperation (2.6% vs 0.4%, P = .007), extended length of stay (64% vs 49.9%, P = .004), wound complication (1.75% vs 0.11%, P = .002), and surgical site infection (2.6% vs 0.6%, P = .017). Multivariate logistic regression analysis found anemia to be significantly associated with extended hospital length of stay (odds ratio [OR], 1.62; 95% CI, 1.07-2.45; P = .023) and increased reoperation rates (OR, 5.47; 95% CI, 1.15-26.00; P = .033). Anemia was not found to be a predictor of increased readmission rates (OR, 3.13; 95% CI, 0.93-10.56; P = .066) or postoperative complications (OR, 1.27; 95% CI, 0.35-4.56; P = .71).

CONCLUSION

This study found increasing severity of anemia to be associated with extended hospital length of stay and increased reoperation rates. Providers and patients should be aware of the increased risks of total ankle arthroplasty with preoperative anemia.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Analysis of Wheeled Knee Walker Use following Foot and Ankle Surgery or Injury

To determine patient satisfaction and safety with wheeled knee walkers, we performed a retrospective, observational, and descriptive study. Inclusion criteria were age ≥18 years, unilateral foot or ankle surgery, non-weightbearing status, and being given the option of using the knee walker. Surveys were sent to eligible patients, and chart review included only those patients who returned surveys. Primary endpoints were occurrence and frequency of falls. Secondary endpoints were patient demographics, comorbidities, knee walker characteristics, duration of use, and patient satisfaction. We also attempted to identify associations between falls and patient characteristics. Eighty participants, 51 females and 29 males, responded adequately to the survey. The mean age of respondents was 55.6 ± 13.0 years and their mean body mass index (BMI) was 30.2 ± 5.9 kg/m². Most used a steerable, 4-wheeled knee walker. Almost half (46%) had no prior experience with any type of walking aids, and none had experience using a knee walker. Two thirds (66%) did not receive any instruction on usage of the knee walker. Thirty-four (43%) of the 80 respondents fell while using the knee walker; nearly two thirds (62%) of those who fell reported multiple falls. Sixteen (55%) of 29 males compared to 18 (36%) of 50 females reported falling (p = .097). There was no statistical association between falls and age, BMI, or number of comorbidities. Most respondents (91%) who fell still reported satisfaction with the knee walker. Nearly half (43%) experienced falling, and nearly two thirds (64%) of those who fell had multiple falls.

Computer-assisted surgery and navigation in foot and ankle: state of the art and fields of application

Computer-assisted orthopaedic surgery (CAOS) is a real-time navigation guidance system that supports surgeons intraoperatively.Its use is reported to increase precision and facilitate less-invasive surgery.Advanced intraoperative imaging helps confirm that the initial aim of surgery has been achieved and allows for immediate adjustment when required.The complex anatomy of the foot and ankle, and the associated wide range of challenging procedures should benefit from the use of CAOS; however, reports on the topic are scarce.This article explores the fields of applications of real-time navigation and CAOS in foot and ankle surgery. Cite this article: EFORT Open Rev 2021;6:531-538. DOI: 10.1302/2058-5241.6.200024.

Influence of Complications and Revision Surgery on Fulfillment of Expectations in Foot and Ankle Surgery

BACKGROUND

Fulfillment of patients' expectations following foot and ankle surgery has been previously studied, and shown to be an effective modality in assessing patient-reported outcomes (PROs). Although this assessment has been shown to correlate well with patient satisfaction and other validated PROs, the impact of postoperative complications on fulfillment of expectations is unknown. The aim of this study is to therefore investigate the impact of postoperative complications on fulfillment of patients' expectations.

METHODS

Preoperatively, patients completed a validated Foot and Ankle Expectations Survey consisting of 23 questions encompassing domains including pain, ambulation, daily function, exercise, and shoe wear. At 2 years postoperatively, patients answered how much improvement they received for each item cited preoperatively. A fulfillment proportion (FP) was calculated as the amount of improvement received versus the amount of improvement expected. Chart review was performed to identify patient demographics, comorbidities, pain management, and postoperative complications, which were classified as minor (infection requiring antibiotics) or major (return to operating room for revision, deep infection). FP in patients with a complication was compared to patients who did not experience a complication. In addition, the Foot and Ankle Outcomes Score (FAOS), satisfaction, and Delighted-Terrible scale (how they would feel if asked to spend the rest of their life with their current foot/ankle symptom) were collected at final follow-up. Of the 271 patients (mean age 55.4 years, 65% female), 31 (11.4%, mean age 53.6, 58% female) had a postoperative complication: 25 major (19 revisions, 6 deep infections requiring irrigation and debridement), 4 minor (4 superficial infections requiring antibiotics), and 2 major and minor (revision and superficial infection). Average time from complication to completion of fulfillment survey was 15 (±3.6) months. The groups were similar in diagnoses.

RESULTS

Complications were associated with significantly worse FP (0.69 ± 0.45 vs 0.86 ± 0.40, P = .02). Having a complication significantly correlated with worse satisfaction, Delighted-Terrible scale, and FP (P < .001). FAOS domains were similar between groups preoperatively; postoperatively, patients without complications had significantly higher Activities of Daily Living and Quality of Life scores (P < .05). Demographically, there was no difference in age, sex, body mass index, Charlson Comorbidity Index, depression/anxiety, or pain management between the 2 groups.

CONCLUSION

Our data suggests that postoperative complications following foot and ankle surgery were associated with worse patient-reported fulfillment of their operative expectations even after recovery from the initial surgery and complication. This finding is independent of preoperative expectations, and correlates with patient satisfaction with their procedure. Therefore, while patient-perceived fulfillment following foot and ankle surgery is multifactorial, the incidence of a postoperative complication negatively impacts fulfillment as well as satisfaction following surgery.

LEVEL OF EVIDENCE

Level II, prospective comparative series.

Long-term Follow-up of Lisfranc Injuries Treated With Open Reduction Internal Fixation Patient-Reported Outcomes

Background:

There remains a paucity of data regarding long-term patient-reported outcomes following Lisfranc injuries. We sought to collect long-term clinical outcome data following Lisfranc injuries using PROMIS Physical Function (PROMIS-PF) and visual analog scale–foot and ankle (VAS-FA).

Methods:

A chart review was performed to identify all patients who had surgical treatment of an acute Lisfranc injury at our institution from 2005 to 2014. Of the 45 patients identified, we were able to recruit 19 for a follow-up clinic visit consisting of physical examination, administration of questionnaires addressing pain and medication usage, radiographs, and completion of outcome surveys including PROMIS-Physical Function and visual analog scale–foot and ankle.

Results:

There were 14 female and 5 male patients enrolled in the study with a mean time of 6.25 years from the time of injury. Within this cohort, the mean PROMIS-PF score was 52.4±8.2 and the mean VAS–foot and ankle score was 76.6±22.3.

Conclusion:

We report satisfactory long-term patient-reported outcomes using PROMIS-PF and VAS-FA.

Level of Evidence:

Level III, retrospective cohort study.

Does Insurance Status Affect Access to Care Among Ankle Fracture Patients? An Institutional Retrospective Study

Delayed access to care for patients with ankle fractures may increase risk of complications, particularly if surgical management is warranted. Medicaid is a state and federal insurance program in place for those with low income, which has previously been associated with delayed access to care among patients with ACL tears and total hip arthroplasties. The purpose of this study is to assess whether patient insurance status affects access to care for ankle fracture patients, using data from a single institution. A retrospective cohort study (N = 311 patients)was performed on individuals that underwent open reduction and internal fixation for an ankle fracture between years 01/2008 and 12/2018. Patients with polytraumatic injuries, open injuries, Medicare, no insurance, indigent/charity insurance, self-pay, or whose insurance information was not available were excluded. Time from date of injury to date of surgery, injury to first visit, and first visit to surgery was compared between patients with private insurance and Medicaid. Average time from injury to first appointment was 1.2 days and 6.2 days for privately insured and Medicaid patients, respectively (p < .001). Average time from injury to surgery was 8.3 days and 16.1 days for privately insured and Medicaid patients, respectively (p < .001). Patients enrolled in Medicaid have significantly delayed access to care compared to those with private insurance. For ankle fracture patients this is a critical healing time, and delayed care may result in increased costs, increased utilization of healthcare resources, higher complication rates, and poorer patient outcomes.

Podiatric Medicine and Surgery Resident-Authored Publications in The Journal of Foot and Ankle Surgery: A Systematic Review

Since its introduction into the medical community, the Podiatric Medicine and Surgery residency has strived to graduate the most advanced and learned foot and ankle surgeons. From increasing length of training, to assuring didactics and education are sufficiently incorporated into the residency, the Council on Podiatric Medical Education has overseen this transition. One area of interest, podiatric medicine and research, remains central to this training and contributes to the field of foot and ankle surgery through journal publications. The purpose of this review was to identify Podiatric Medicine and Surgery resident-authored publication rates, trends, and geographic distribution. All published case reports, original research articles, review articles, and tips, quips, and pearls in The Journal of Foot and Ankle Surgery from January 2009 to December 2018 were reviewed. Podiatric Medicine and Surgery residents comprised 8% of all authors. Residents contributed to and published as first authors in 22% and 11% of all manuscripts, respectively. An increasing trend in resident authors, resident-authored manuscripts, and resident-first-authored manuscripts was observed. From before the mandated 3-year residency to after, the proportion of resident-authored manuscripts to all manuscripts declined from 9.99% to 7.21%; however, among these resident-authored publications, the rate of first-authorship increased from 45.32% to 51.36%. To the best of our knowledge, this is the first and only study to examine publication rates among foot and ankle surgery residents.

A prospective study on surgical management of foot deformities in Charcot Marie tooth disease

Foot deformities are frequently observed in patients with Charcot Marie tooth disease (CMT) and orthopaedic surgery is often required. Currently there is no evidence-based guideline on surgical management and only a few studies which have evaluated long-term outcomes of surgical procedures. The aim of the study was to evaluate longitudinally the effect of foot surgery in a cohort of CMT patients. Twenty-five CMT adult patients were assessed using a comprehensive group of validated scales and questionnaires before and after surgery. A wide range of surgical procedures was performed by one team of dedicated foot ankle orthopaedic surgeons. Foot alignment as measured by the foot posture index, pain, quality of life and callosities significantly improved after one year and the improvement was maintained up to 4 years after surgery. There was a trend towards a reduction in the number of falls post-operatively. Surgery had no effect on fatigue, balance and CMT examination score. Our findings showed significant improvement of pain, foot alignment, callosities and quality of life after surgery and suggested that foot deformity correction in adults with CMT performed in a specialised foot and ankle unit is beneficial.

Feasibility of Rapid Development and Deployment of a Telemedicine Program in a Foot and Ankle Orthopedic Practice

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.

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.

Association Between Baseline PROMIS Scores, Patient-Provider Communication Factors, and Musculoskeletal Health Literacy on Patient and Surgeon Expectations in Foot and Ankle Surgery

BACKGROUND

Various factors may affect differences between patient and surgeon expectations. This study aimed to assess associations between patient-reported physical and mental status, patient-surgeon communication, and musculoskeletal health literacy with differences in patient and surgeon expectations of foot and ankle surgery.

METHODS

Two hundred two patients scheduled to undergo foot or ankle surgery at an academic hospital were enrolled. Preoperatively, patients and surgeons completed the Hospital for Special Surgery Foot & Ankle Surgery Expectations Survey. Patients also completed Patient-Reported Outcomes Measurement Information System (PROMIS) scores in Physical Function, Pain Interference, Pain Intensity, Depression, and Global Health. Patient-surgeon communication and musculoskeletal health literacy were assessed via the modified Patients' Perceived Involvement in Care Scale (PICS) and Literacy in Musculoskeletal Problems (LiMP) questionnaire, respectively.

RESULTS

Greater differences in patient and surgeon overall expectations scores were associated with worse scores in Physical Function (P = .003), Pain Interference (P = .001), Pain Intensity (P = .009), Global Physical Health (P < .001), and Depression (P = .009). A greater difference in the number of expectations between patients and surgeons was associated with all of the above (P ≤ .003) and with worse Global Mental Health (P = .003). Patient perceptions of higher surgeons' partnership building were associated with a greater number of patient than surgeon expectations (P = .017). There were no associations found between musculoskeletal health literacy and differences in expectations.

CONCLUSION

Worse baseline patient physical and mental status and higher patient perceptions of provider partnership building were associated with higher patient than surgeon expectations. It may be beneficial for surgeons to set more realistic expectations with patients who have greater disability and in those whom they have stronger partnerships with. Further studies are warranted to understand how modifications in patient and surgeon interactions and patient health literacy affect agreement in expectations of foot and ankle surgery.

LEVEL OF EVIDENCE

Level II, prospective comparative series.

A Solution to After-Hours Fatigue and Surgical Backlog

After-hours surgery represents a novel solution that can effectively combat surgical fatigue of care teams in addition to addressing the high volume of surgical backlog associated with the repercussions of the COVID-19 pandemic. This commentary seeks to rationalize how successful employment of a dedicated after-hours surgical team and protocol has tremendous potential for increased efficiency while maintaining good surgical outcomes in patients.

Publication Characteristics of Foot and Ankle Trauma Publications: A Review of Articles From 1997 to 2017

Background

The purpose of this study is to evaluate and compare publishing characteristics in foot and ankle trauma articles published in two subspecialty journals and two general orthopedic journals.

Methods

All trauma articles related to foot and ankle surgery published from five different time intervals over a 20-year period were collected and the following was analyzed: authorship, level of evidence, type of study, citations, and geographic region.

Results

Foot and Ankle International (FAI) had the highest percentage of last and corresponding authors that were fellowship-trained in foot and ankle. The Journal of Bone and Joint Surgery American and British volumes (JBJS(A) and JBJS(B), respectively) and the Journal of Orthopaedic Trauma (JOT) articles had a higher percentage of last and corresponding authors that were fellowship-trained in trauma.

Conclusion

Foot and ankle-trained authors are currently under-represented in foot and ankle trauma literature. As the field of foot and ankle continues to grow, it is important that the experts in the field are well represented in the literature.

Relevance of SPECT-CT in Complex Cases of Foot and Ankle Surgery: A Comparison With MRI

BACKGROUND

Finding the right diagnoses in patients with complex foot and ankle disorders can be challenging. Single-photon emission computed tomography and computed tomography (SPECT-CT) has shown to be feasible in foot and ankle surgery. The aim of this study was to evaluate the reliability and accuracy of SPECT-CT and thereby its impact on final treatment decision compared with magnetic resonance imaging (MRI).

METHODS

A retrospective study was performed on 49 patients treated at our institution. Experienced foot and ankle surgeons independently, and blinded, analyzed clinical data and radiographs together with MRI, SPECT-CT, or a combination of both. Based on the determined final treatment decision Cohen's kappa values were calculated to illustrate interrater and intrarater reliability.

RESULTS

The kappa values for interrater reliability were higher for SPECT-CT at .68 and MRI + SPECT-CT at .71 compared to 0.38 for MRI alone (P < .05). The kappa values for intrarater reliability of MRI + SPECT-CT were higher at .75 compared with SPECT-CT alone at .67 (P < .05) and MRI at .35 (P < .01).

CONCLUSION

We found a higher interrater and intrarater reliability for SPECT-CT compared with MRI alone for diagnosing complex foot and ankle pathologies. SPECT-CT has a high impact on final treatment decision. The main indications are bony pathologies with diagnostic uncertainty especially in closely adjacent structures as the joints of the midfoot, occult coalitio, stress fractures, verification or exclusion of nonfusion, periprosthetic disorders after total ankle replacement and osteochondral lesion in cases of combined pathologies.Levels of Evidence: Level IV: Retrospective study.

Effect of Postoperative Oral Antibiotics on Infections and Wound Healing Following Foot and Ankle Surgery

BACKGROUND

There is controversy regarding the effectiveness of postoperative antibiotics to prevent wound infection. Some surgeons still use a routine postoperative oral antibiotic regimen. The purpose of this study was to review a series of cases and document statistically any difference in infection rates and whether routine postoperative antibiotics in foot and ankle surgery are justified.

METHODS

A retrospective chart review of 649 patients was performed who underwent elective foot and ankle surgery. Six hundred thirty-one patient charts were included in the final analysis. Evaluated were patients who did and did not receive postoperative oral antibiotics in order to identify whether a difference in infection rate or wound healing occurred. The study also evaluated risk factors for developing infection following foot and ankle surgery.

RESULTS

The number of infections in patients receiving postoperative oral antibiotics was 6 (3%), while the number of infections in those who did not receive postoperative oral antibiotics was 10 (2%) (P = .597). The difference of deep versus superficial infections and delays in wound healing between the 2 groups was not statistically significant. Patients who developed infections were older and had a higher prevalence of hypertension, a history of neoplasm, and a greater American Society of Anesthesiologists Classification of Physical Health.

CONCLUSION

This study suggests that routine use of postoperative antibiotics in foot and ankle surgery does not affect wound complications or infection rates. Additionally, patients who are older and those with multiple medical problems may be at higher risk for developing postoperative infection following foot and ankle surgeries.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Comparison of Patients' and Surgeons' Expectations in Foot and Ankle Surgery

BACKGROUND

Aligning patient and surgeon expectations may improve patient satisfaction and outcomes. This study aimed to assess differences in expectations of foot and ankle surgery between patients and their surgeons.

METHODS

Two hundred two patients scheduled to undergo foot or ankle surgery by one of 7 fellowship-trained foot and ankle surgeons were enrolled. Preoperatively, patients and surgeons completed the Hospital for Special Surgery Foot & Ankle Surgery Expectations Survey independently. Differences between patient and surgeon overall expectations scores, number of expectations, and number of expectations with complete improvement expected were assessed. A difference of ≥10 points was considered a clinically important difference in expectations score. Associations between patient demographic and clinical characteristics, major/minor surgery, and individual surgeon with differences in expectations were also assessed.

RESULTS

Overall, 66.3% of patients had higher expectations, 21.3% had concordant expectations, and 12.4% had lower expectations compared with their surgeons. On average, patients had higher expectations scores than their surgeons (70 ± 20 vs 52 ± 20 points, P < .001). Patients expected complete improvement in a greater number of expectations than surgeons (mean 11 ± 7 vs 1 ± 3, P < .001). Patients had higher expectations than surgeons for 18 of 23 items (78%). Items that had the greatest number of patients with higher expectations than surgeons were "improve confidence in foot/ankle," "prevent foot/ankle from getting worse," and "improve pain at rest." Higher body mass index (BMI) (P = .027) and individual surgeon (P < .001) were associated with greater differences between patient-surgeon expectations. Major/minor surgery was not associated with differences in expectations (P ≥ .142).

CONCLUSION

More than two-thirds of patients had significantly higher expectations than their surgeons. Higher BMI was associated with higher patient than surgeon expectations. These results emphasize the importance for foot and ankle surgeons to adequately educate patients preoperatively.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Arthroscopically Assisted Treatment of Complex Ankle Fractures: Intra-articular Findings and 1-Year Follow-Up

Especially after complex ankle fractures, patients regularly suffer from residual symptoms, presumably due to occult intra-articular injuries. The aim of this study was to evaluate the intra-articular lesions, identify fractures specifically at risk for these, and assess the results after arthroscopically assisted open reduction and internal fixation of complex ankle fractures after 1 year. The primary outcome was the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score. Secondary outcome parameters were the Olerud and Molander Ankle Score (OMAS), Tegner activity scale, arthroscopic findings, functional assessment, and complications. Thirty-two patients (56% female) were enrolled. Chondral lesions were detected in 91%. Full-thickness lesions treated by microfracturing were observed in 0% of unimalleolar, 43% of bimalleolar, and 40% of trimalleolar fractures. After 1 year, the median (interquartile range) AOFAS was 94 (9) and OMAS was 90 (10) for all patients. When analyzing factors possibly influencing the outcome, age, sex, smoking, grading for surgical procedures according to the American Society of Anesthesiologists, fracture type (uni-, bi-, or trimalleolar), severity of chondral lesions graded according to the International Cartilage Repair Society (grade <4 versus grade 4), and syndesmotic instability had no significant influence on the outcome. The only variable significantly influencing the AOFAS (p = .004) and OMAS (p < .001) was body mass index (BMI; r_s = -0.522 and -0.606, respectively), with a higher BMI resulting in inferior outcome scores. Complications were observed in 3 patients, 2 with superficial skin necrosis at the posterolateral incision and 1 nonunion of the medial malleolus. Taken together, these data show that intra-articular injuries were common in ankle fractures. Bi- and trimalleolar fractures were particularly at risk for full-thickness lesions. A higher BMI tended to result in inferior outcome scores. Arthroscopically assisted open reduction and internal fixation led to good to excellent results in all but 1 patient.

Relationship of Preoperative Patient-Reported Outcome Measures (PROMs) to Postoperative Success in End-Stage Ankle Arthritis

BACKGROUND

Ankle osteoarthritis is a significant cause of pain and disability. Despite the effectiveness of treatments, a subset of patients remains with persistent pain and functional limitations. The purpose of this study was to use preoperative patient-reported outcome measures to predict which ankle osteoarthritis patients would be most likely to experience postoperative improvements in functional outcomes.

METHODS

A retrospective analysis of prospectively collected data was used to evaluate 427 patients with end-stage ankle arthritis with 5-year follow-up. Demographics, comorbidities, Ankle Osteoarthritis Scale (AOS), Ankle Arthritis Score (AAS), and the physical and mental component scores of the Short Form-36 (SF-36 Physical Components Score [PCS] and Mental Components Score [MCS]) were collected. The minimal clinically important difference (MCID) was then calculated. Receiver operating characteristic (ROC) analysis was used to choose the optimal threshold values of preoperative patient-reported outcome measure and assess the prediction performance.

RESULTS

Patients who scored worst at preoperative baseline made the greatest gains in function and pain relief, and they had a high chance of achieving MCID following surgical treatment. ROC curves demonstrated that preoperative AOS, AAS, and SF-36 PCS and MCS scores were predictive of postoperative improvements in physical and mental function. Patients with preoperative AOS score above 45.7 had an 83% probability of achieving an MCID (AUC = 0.67). Similarly, patients with a preoperative AAS score above 25.7 had a 78% probability of achieving an MCID (AUC = 0.63). Patients with a preoperative SF-36 PCS score below 31 had a 62% probability of achieving an MCID (AUC = 0.64). Patients with a preoperative SF-36 MCS below 52.7 had a 47% probability of achieving an MCID (AUC = 0.89). MCIDs for AOS, AAS, SF3-36 PCS, and SF-36 MCS score changes were 12.4, 10.0, 6.43, and 8.1, respectively.

CONCLUSION

Preoperative patient-reported outcomes measures could predict postoperative improvement in ankle arthritis patients. The results of this study may be used to facilitate discussion between physicians and patients regarding the expected benefit of surgery.

LEVEL OF EVIDENCE

Level III, prognostic comparative study.