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Background: Individuals with limited health literacy often struggle in effectively communicating with their physicians and may lack the skills needed to make informed health decisions. It is therefore important that providers have insight into patients’ baseline medical knowledge, as this can help physicians customize their approach to, and conversations with, each patient. As such, this study evaluated the foot and ankle–specific knowledge of patients seeking care for various foot and ankle ailments. Methods: An unvalidated survey developed by our study group was distributed to 206 patients, assessing their knowledge of foot and ankle anatomy, terminology, conditions, treatment, and perioperative issues. Performance was evaluated as a function of participants’ demographic factors. Results: Participants performed significantly worse on the conditions and treatment questions as compared to the anatomy, terminology, and perioperative considerations subsections. Significantly better performance correlated with education (≥college), visit type (preoperative evaluation), a current or previous health care occupation, and prior orthopedic surgeon evaluation. Conclusions: Patients’ knowledge of foot and ankle anatomy, terminology, conditions, treatment, and perioperative issues correlates with certain patient characteristics and demographics. With enhanced insight into the risk factors for limited knowledge, education campaigns can be designed to target those most in need.

Category: Ankle Arthritis Introduction/Purpose: Ankle arthritis is a debilitating problem, causing significant pain and functional limitations. Previous literature suggests patients treated with ankle arthroplasty (TAA) versus ankle arthrodesis (AA) may have better function and have lower risk for adjacent joint arthritis in the foot. However, there is little research on how these interventions impact proximal joints, such as the knee. The knee adduction moment (KAM) is a surrogate measure for the force experienced at the medial tibiofemoral compartment and is linked with the onset and progression of knee osteoarthritis. We hypothesized that patients with TAA and AA will exhibit altered frontal plane kinematics and kinetics in the affected limb compared to the contralateral unaffected side, and that the AA cohort will have a significantly greater KAM compared to TAA. Methods: Instrumented 3D walking gait was recorded in 10 TAA and 10 AA patients, minimum 2-year post-operatively. Subjects were demographically matched, had unilateral ankle arthritis and lacked complications such as adjacent joint arthritis, neuropathy or significant weight-bearing pain. The TAA patients had either a Salto-Talaris or INBONE prosthesis. Lower limb kinematic and kinetic data were measured with reflective skin surface markers and floor-embedded force plates at self-selected walking speeds. Average first and second peak KAMs [N-m/kg], KAM impulse [N-m-s/kg] and range-of-motion (ROM, [°]) were calculated on both the affected and unaffected limb for each patient. Group differences in KAM, impulse and ROM between TAA and AA interventions and the affected and unaffected limb were analyzed using a 2-sample unpaired t test. P-values less than 0.05 were considered significant. Results: See Table 1 for demographic and statistical analyses summary. Between the affected and unaffected limbs in each surgical cohort there were no significant differences in the KAM’s first and second peak or impulse (p>0.135) and no difference in the knee ROM in any plane (p>0.214). When comparing AA with TAA, the average first peak KAMs generated while walking were 0.07N-m/kg greater in the TAA treatment but that difference was not significant (p=0.429). The second peak KAM was, on average, 0.1N-m/kg greater within TAA patients but was also not statistically different from AA patients (p=0.594). The KAM impulse and ROM in all 3 planes were not different between intervention types (p>0.318). Conclusion: TAA and AA may not significantly affect ipsilateral knee kinetics and KAMs in short term follow-up. This study highlights the importance of continuing to study these parameters in larger cohorts of patients with longer follow-up to determine how our treatment of end-stage ankle arthritis may affect the incidence or progression of ipsilateral knee osteoarthritis.

Category: Other Introduction/Purpose: Neuraxial anesthesia is often viewed as superior to general anesthesia (GA), but there are concerns that it may prolong length of stay (LOS). Most studies comparing the two anesthesias were performed in the absence of peripheral nerve blocks (PNBs), which when used as an analgesic adjunct may overcome the associated negative side effects of GA and allow decreased LOS. We hypothesized that patients given PNBs and GA would be discharged sooner than patients given PNBs and spinal anesthesia plus sedation, without increased incidence of adverse side effects such as pain, opioid administration and nausea. Methods: A single-center triple-blinded randomized controlled trial of 36 consecutive patients receiving elective F&A surgery predicted to take 1-3 hours under planned PNB with either spinal or GA was performed (see table 1. for demographics).The primary outcome was time to meet criteria for home discharge. The a priori clinically relevant difference with 80% power was determined to be 45 minutes. Patients were assessed after admission to the PACU and at 15-minute intervals thereafter. Once an Aldrete score=9 (scale signifying patient no longer needs intensive monitoring) was obtained, patients were transferred to Phase II and assessed until the post anesthesia discharge scoring system, a home readiness scale, was =9. Actual time to discharge was also recorded.Additional outcomes included a series of baseline characterizations which were assessed pre-and post-operatively, and again during Phase II.The primary outcome was compared using multivariable unconditional quantile regression. Various regressions were performed on secondary outcomes. Results: After adjustment for age and surgical duration, patients given GA plus PNB were ready for discharge from PACU 39 minutes prior to patients given neuraxial anesthesia plus PNB, but this difference did not reach the clinically relevant a priori selected difference of 45 minutes (Table 1). However, the adjusted median time to meet ambulation discharge criteria was 52 minutes fewer (p = 0.003) (Table 1). Patients met discharge criteria substantially sooner than their time until actual discharge which was not different between groups (Table 1). Pain scores at rest were higher among GA patients at 1 hour in the PACU (adjusted difference in means [95% CI]: 2.1 [1.0, 3.2], p < 0.001). Subsequent pain scores and all other secondary outcomes were not different. Conclusion: GA with PNB patients were ready for discharge 39 minutes earlier, but that difference may not be clinically significant. Although patients met criteria for discharge sooner due to a significantly more rapid ability to ambulate, they were not discharged sooner because PACU staff was not acclimated to the earlier readiness and so did not push for earlier discharge. These findings suggest that GA plus PNB leads to earlier discharge with similar side effects as spinal plus PNB. Therefore, the use of GA with PNB for foot and ankle surgeries could save the hospital and the patient time and resources.

Category: Pain Management, Anesthetic Advances Introduction/Purpose: The number of opioid prescriptions in the United States has significantly increased over the past 20 years, including those given after low-risk surgery. Unintentional opioid overdoses have also dramatically risen. Excess pills are widely acknowledged as a source of diversion, which accounts for up to 40% of opioid-related overdoses. In the foot and ankle literature, there are no studies looking at the quantity of pain medications that should be prescribed following outpatient surgery. Furthermore, with the increasing use of peripheral nerve blocks, their effect on quantities of narcotics needed after these surgeries have not been explored. This study aims to determine prescribing patterns for common outpatient foot and ankle surgery and whether patients are over or under-prescribed opioids and if so, by how much. Methods: 57 patients undergoing outpatient foot and ankle surgeries were prospectively enrolled. Patients received a spinal neuraxial block and a long-acting popliteal peripheral nerve block, and did not receive ketorolac perioperatively. Patients were excluded if they had a history of chronic pain, or were currently using opioids or muscle relaxers. Enrolled patients received a standard post-operative prescription regimen of 60 tablets of narcotics, 3 days of scheduled ibuprofen, aspirin 81 mg twice a day (or alternate based on risk factors) for DVT prophylaxis, and ondansetron taken as needed. Patients used a pain diary to record when their block wore off and the quantity of narcotic taken. They received surveys at post-operative day (POD) 3, 7, and 14 detailing how many days they took the medication and how many pills were consumed, how their actual pain compared to their expected level of pain, and if they were satisfied with their pain control. Results: At POD 3, compared to their expected level of pain 36 patients had less pain, 15 had the same pain, and 3 had more pain than expected. The mean pain score was 4. Patients first started feeling the block wear off at 0.9 days. Patients averaged 10.3 pills of narcotics in the first 3 days and rated their overall satisfaction with pain control at 8.5. Between days 4-7, patients took an average of 7 pills, and on POD 7, 22 patients were still taking narcotics. At POD 14, patients experienced 74.4% relief of pain compared to their expected pain, and rated their overall satisfaction at 8.2. Patients had an average of 33.5 remaining pills on POD 14 and 13 patients (22.8%) were still taking narcotics. Conclusion: Patients receiving spinal and long-acting popliteal blocks, followed by the prescription regimen described above had excellent pain control after outpatient foot and ankle surgeries. Patients had a high level of satisfaction with their pain control, with many patients describing better pain relief than expected. However, 60 tablets of narcotics were excessive in most cases. We suggest that in patients receiving spinal and long-acting popliteal blocks, 30 tablets of a narcotic would cover the pain needs of most patients. This would provide a small excess in case of need, but would help minimize the risk of narcotic related complications and diversion.

Category: Ankle Introduction/Purpose: Stenosing Peroneal Tenosynovitis is an uncommon entity that is equally difficult to diagnose. In our practice, we have found 14 patients with this diagnosis. They were all successfully treated with release of the peroneal tendon sheath and debridement of the calcaneal exostosis. Further, the ultrasound guided anesthetic injection of the tendon sheath preoperatively essential in confirming this diagnosis and evaluating for successful outcomes after surgical intervention. Methods: 14 patients were diagnosed with Stenosing Peroneal Tenosynovitis. Upon initial presentation, the patients all reported a persistent history of pain along the ankle and had exhausted conservative treatment options. Patients with MRIs had images that appeared normal. In order to confirm the diagnosis as Stenosing Peroneal Tenosynovitis, ultrasound guided injections of anesthetics were administered into the peroneal tendon sheath. If the injection alleviated the pain, this confirmed the diagnosis of Stenosing Peroneal Tenosynovitis. Patients also had neurological consults to rule out possible sural neuritis. In patients with a confirmed diagnosis of stenosing peroneal tenosynovitis, we proceeded with surgical intervention. They underwent surgery between 2006 and 2014 by two fellowship trained orthopedic surgeons at one institution. Retrospective chart review was performed and functional outcomes were assessed pre-and postoperatively using the Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) general health questionnaire. Results: All patients that underwent this procedure were given the Foot and Ankle Outcome Score (FAOS) and Short Form 12 (SF-12) general health questionnaire pre-operatively. Questionnaire results were collected post-operatively and were successfully obtained at one year or greater from 11 patients. Of these 11 patients, all showed significant improvements (student t test used, p

Category: Other Introduction/Purpose: Few authors have investigated patients’ expectations from foot and ankle surgery, and standardized means of assessing expectations are lacking. Managing patients’ preoperative expectations may help improve their ultimate satisfaction with surgery. In a previous study (in press), we developed a valid and reliable patient-derived expectations survey for patients undergoing foot and ankle surgery. In this study, we aimed to examine relationships between patients’ preoperative expectations and their demographic and clinical characteristics. We hypothesized that patients with more disability and those with anxiety or depressive symptoms would have greater expectations. Methods: All adult patients scheduled for elective foot or ankle surgery by one of six orthopaedic foot and ankle surgeons were screened for inclusion over eight months. Preoperatively, patients completed the Foot & Ankle Surgery Expectations Survey in addition to the Foot & Ankle Outcome Score (FAOS), Short Form (SF)-12, Patient Health Questionnaire (PHQ)-8, Generalized Anxiety Disorder 7-item scale (GAD-7), and pain visual analog scale (VAS). The expectations survey contains 23 expectations categories, each with five answer choices ranging from I do not have this expectation to complete improvement expected. It is scored from 0-100; higher scores indicate greater expectations. Differences in expectations score with categorical variables were assessed with t-tests and single factor analysis of variance (ANOVA). Differences in number of expectations and number of expectations with complete improvement expected were assessed with Mann-Whitney U and Kruskal Wallis tests. Relationships between expectations and continuous variables were assessed with linear regression. Results: 352 patients (average age 55 ± 15, range 18 to 86) were enrolled. Expectations were not significantly related to age. Women expected to achieve complete improvement more often than men (p = 0.011). Other factors significantly associated with higher expectations (p < 0.05) included non-Caucasian race, workers’ compensation, use of a cane or other assistive device, diagnosis of ankle instability or osteochondral lesion, and greater medical comorbidity (Table). Patients with a history of prior orthopaedic surgery were less likely to expect complete improvement. Worse function and quality of life (as assessed by all FAOS subscales and SF-12 physical and mental components), more depressive and anxiety symptoms, and higher pain VAS scores were associated with higher expectations scores and more expectations (p < 0.001 for all). Conclusion: The results of this study may help inform surgeons’ preoperative discussions with their patients regarding realistic expectations from surgery. Generally patients with worse function and more disability had higher expectations from surgery. Addressing these patients’ expectations preoperatively may help improve their ultimate satisfaction with surgery.

Background: Individuals with limited health literacy often struggle in effectively communicating with their physicians and may lack the skills needed to make informed health decisions. It is therefore important that providers have insight into patients’ baseline medical knowledge, as this can help physicians customize their approach to, and conversations with, each patient. As such, this study evaluated the foot and ankle–specific knowledge of patients seeking care for various foot and ankle ailments. Methods: An unvalidated survey developed by our study group was distributed to 206 patients, assessing their knowledge of foot and ankle anatomy, terminology, conditions, treatment, and perioperative issues. Performance was evaluated as a function of participants’ demographic factors. Results: Participants performed significantly worse on the conditions and treatment questions as compared to the anatomy, terminology, and perioperative considerations subsections. Significantly better performance correlated with education (≥college), visit type (preoperative evaluation), a current or previous health care occupation, and prior orthopedic surgeon evaluation. Conclusions: Patients’ knowledge of foot and ankle anatomy, terminology, conditions, treatment, and perioperative issues correlates with certain patient characteristics and demographics. With enhanced insight into the risk factors for limited knowledge, education campaigns can be designed to target those most in need.