Search

Category: Trauma; Ankle Introduction/Purpose: Pilon fractures are difficult injuries to manage as they are typically associated with extensive soft tissue damage. Although staged management of external fixation followed by open reduction and internal fixation is often used to prevent additional soft tissue damage and its associated complications, rates of nonunion remain high in this patient population. The purpose of this study is to evaluate and identify factors associated with increased rates of nonunion following operative fixation of pilon fractures. Methods: A retrospective review of all operatively managed pilon fractures at a single level 1 trauma center from 2014 to 2019 was performed. Minimum six-month follow-up was required for inclusion. Patients with skeletal immaturity or amputation prior to definitive fixation were excluded. Patients were grouped based on presence or absence of nonunion, which was defined as lack of bridging bone in at least 3 of 4 cortices and the presence of pain with ambulation at six-month follow-up. Demographics, injury and operative characteristics, and surgical outcomes were compared between the two groups. Results: Among the 279 patients meeting inclusion criteria, 48 developed nonunion at 6-month follow-up (17.2%). Average follow-up was 3.2 years. Patients with nonunion had significantly higher rates of open fractures (50.0% vs. 22.1%, p

Category: Hindfoot; Trauma Introduction/Purpose: Calcaneus fractures are common injuries to the hindfoot. The safety of in-patient versus outpatient treatment in patients with calcaneus fractures remains unclear. The aim of the present study was to assess differences in wound complications and readmissions in operative calcaneus fractures treated with open reduction and internal fixation (ORIF) in an in- patient versus outpatient setting. Methods: Patients undergoing ORIF for calcaneus fractures from 2012 to 2020 were reviewed. Inclusion criteria were age greater than 18 years and an operative calcaneus fracture treated with the sinus tarsi approach (STA). Exclusion criteria consisted of a minimum of three months follow-up, open calcaneal fractures or fracture dislocations, inpatients with polytrauma, and patients without a preoperative computed tomography (CT) scan. A total of 113 patients met inclusion criteria with 24 (21%) managed inpatient and 89 (79%) managed as outpatient. The primary outcomes were deep infection defined as return to the operating room for debridement with positive cultures and readmissions. Secondary outcomes included implant related pain and unplanned return to the operating room. Results: Inpatients had a higher percentage of ASA classification 3&4 patients (58.3% vs 29.2%, p=0.008). Outpatients had a longer delay in days between injury and definitive fixation (mean 8 (8.9 SD, 0-31 range) vs. 14 (12.4 SD, 0-91 range) days, p=0.009). There were no statistically significant differences in the incidence of deep infections (8.3% vs. 4.5%, p=.606), implant related pain (8.3% vs. 15.7%, p=.516), return to the operating room (16.7% vs. 15.7%, p=1.0) or readmissions (4.2% vs. 3.4%, p=1.0) between inpatient and outpatient groups including in binary logistic regression models (p>.3 for all). In our retrospective study of patients undergoing operative repair of isolated calcaneus fractures with STA, there was no increased risk of wound complications or readmissions when calcaneus fractures were treated in an outpatient setting. Conclusion: In our retrospective study of patients undergoing operative repair of isolated calcaneus fractures with STA, there was no increased risk of wound complications or readmissions when calcaneus fractures were treated in an outpatient setting.

Category: Midfoot/Forefoot Introduction/Purpose: The Modified Lapidus arthrodesis is a historically established surgical technique for treatment of hallux valgus, providing quality patient outcomes and reproducible results. Addition of a transverse first to second intermetatarsal screw spanning the base of the metatarsals in this procedure can increase stability. However, no study evaluates the radiographical parameters following application of this intermetatarsal screw fixation to procedures without first to second intermetatarsal screw fixation. The purpose of this study was to assess the quality of radiographic parameters between individuals receiving a first to second intertarsal screw fixation to those that did not receive intermetatarsal screw fixation following a non-saw cut Modified Lapidus procedure. Methods: A retrospective review was performed on 74 patients that underwent a Modified Lapidus arthrodesis between 2016- 2020 at a single institution. Preoperative indications for the procedure included first ray instability, first ray hypermobility, hallux abductovalgus, and metatarsal primus elevatus. Inclusion criteria consisted of skeletally mature patients undergoing non sawcut Modified Lapidus procedure. Patients that received the procedure due to a traumatic event or patients with concomitant second metatarsal arthrodesis were excluded. Review of patient's charts was performed. Basic demographics data, implant type, and radiographic parameters including intermetatarsal angle (IMA) and first metatarsal length were obtained from preoperative as well as postoperative films. Results: A total of 74 patients who underwent a Modified Lapidus arthrodesis were included in the study. A group of 43 patients received the Modified Lapidus arthrodesis with the addition of a first to second intermetatarsal screw fixation compared to a group of 31 patients who only received the Modified Lapidus arthrodesis procedure. The average IMA in all patients prior to surgery was 13°. The patients who received intermetatarsal screw fixation had significantly higher IMA reductions between preoperative and postoperative films than those who did not receive the intermetatarsal screw (-8.41° vs. -5.78°, p=.005). The difference in first metatarsal length on preoperative and postoperative films was less in patients who received the screw fixation but this was not statistically significant. Conclusion: The Modified Lapidus procedure is a commonly used procedure to treat hallux valgus. The results of this study found that the addition of a first to second intermetatarsal significantly reduced the IMA when compared to individuals who did not receive the screw construct. These findings will help surgeons further delineate if an intermetatarsal screw is required and how it will contribute to the radiographic parameters of interest.

Category: Hindfoot; Trauma Introduction/Purpose: The sinus tarsi (ST) approach for calcaneus fractures has gained popularity in recent years; however, the literature surrounding early complications rates based on age differences for this specific approach is lacking. The objective of this study was to determine if rates of early complications based on age varied for patients undergoing open reduction and internal fixation (ORIF) of calcaneus fractures using the ST approach. Methods: A retrospective review of patients undergoing ORIF for closed calcaneus fractures from 2012 to 2020 was performed. Inclusion criteria was based on an age greater than 18 years old, surgical management of a closed calcaneus fracture using a ST approach, requirement of a preoperative CT scan, and a minimum of 90 days follow-up. Patients were divided into two groups: those under the age of 50 and those over the age of 50. Measurement outcomes included wound dehiscence, superficial surgical site infection, deep infection, and implant removal. Results: A total of 175 patients (186 fractures) were included with 108 patients in the 50 age group. Mean age was 34.8 and 58.7 years in the younger and older groups, respectively. The older group had similar rates of wound dehiscence (1.3% vs. 1.9%, P=0.761), superficial surgical site infection (1.3% vs. 0.9%, P=0.816), and deep infection (5.1% vs. 4.6%, P=0.876) as compared to the younger group. Eleven (10.2%) fractures in 50 age group (P=0.193). Postoperative Gissane and Bohler angles were not significantly differnet between the two groups. Conclusion: Calcaneal fractures can be debilitating injuries, especially in the older patient population. The present study found that patients with intraarticular calcaneus fractures treated via the ST approach maintain similar early complication rates as compared to younger individuals.

Category: Trauma; Ankle Introduction/Purpose: Pilon fractures are complex injuries that most commonly result from high-energy trauma. The extensive soft tissue damage and high rates of associated infection seen in these injuries remains a challenging concern for surgeons. The purpose of this study is to identify risk factors associated with surgical site infection (SSI) following operative management of pilon fractures. Methods: A retrospective review of all operatively managed pilon fractures at a single level 1 trauma center from 2014 to 2019 was performed. Minimum six-month follow-up and skeletal maturity was required for inclusion. Patients with amputation prior to definitive fixation were excluded. SSI consisted of superficial (defined as infection resolving with oral antibiotics) and/or deep infections (defined as return to the operating room for debridement with positive cultures). Patients were grouped based on presence or absence of SSI. Demographics, injury and operative characteristics, and surgical outcomes were compared between the two groups. Results: A total of 279 patients met inclusion criteria for the study, with 40 patients developing SSI (14.3%). Average follow-up was 3.2 years. Patients that developed SSI had a significantly higher proportion of open fractures (47.5% vs 23.4%, p=0.003); however, there were no significant differences in Gustilo-Anderson classification or open wound location compared to controls. The SSI group required significantly higher rates of skin grafts (25.0% vs 4.2%, p

Background: The sinus tarsi (ST) approach for calcaneus fractures has gained popularity in recent years with an increased interest in shifting to less invasive approaches for calcaneal fracture fixation allowing for adequate fixation if complications do not arise. Although the ST approach has gained acceptance as standard for calcaneus fracture fixation, the literature surrounding early complications rates based on age differences for this specific approach and pathology is lacking. The objective of this study was to determine if rates of complications based on age varied for patients undergoing open reduction and internal fixation (ORIF) of closed calcaneus fractures using the ST approach. Methods: A retrospective review of patients undergoing ORIF for closed calcaneus fractures from 2012 to 2020 was performed. Inclusion criteria were based on an age greater than 18 years, surgical management of a closed calcaneus fracture using a ST approach, requirement of a preoperative computed tomographic scan, and a minimum of 180 days’ follow-up. Patients were divided into 2 groups: those aged 50 years. Results: A total of 196 fractures were included with 114 fractures in the 50-year age group. Mean age was 34.2 and 59.7 years in the younger and older groups, respectively. The older group had similar rates of wound dehiscence (1.2% vs 4.4%, P = .204), superficial surgical site infection (1.2% vs 2.6%, P = .490), deep infection (9.8% vs 7.9%, P = .648), and nonunion (4.9% vs 3.5%, P = .633) compared with the younger group. Rates of 30-day readmission, unplanned reoperation, and symptomatic hardware were not significantly different. Postoperative Bohler and Gissane angles were not significantly different between both groups. Conclusion: Older patients with intraarticular calcaneus fractures treated via the ST approach maintain complication rates similar to those in younger individuals. Level of Evidence: Level III, retrospective study.

Background: The National COVID Cohort Collaborative (N3C) is an innovative approach to integrate real-world clinical observations into a harmonized database during the time of the COVID-19 pandemic when clinical research on ankle fracture surgery is otherwise mostly limited to expert opinion and research letters. The purpose of this manuscript is to introduce the largest cohort of US ankle fracture surgery patients to date with a comparison between lab-confirmed COVID-19–positive and COVID-19–negative. Methods: A retrospective cohort of adults with ankle fracture surgery using data from the N3C database with patients undergoing surgery between March 2020 and June 2021. The database is an NIH-funded platform through which the harmonized clinical data from 46 sites is stored. Patient characteristics included body mass index, Charlson Comorbidity Index, and smoking status. Outcomes included 30-day mortality, overall mortality, surgical site infection (SSI), deep SSI, acute kidney injury, pulmonary embolism, deep vein thrombosis, sepsis, time to surgery, and length of stay. COVID-19–positive patients were compared to COVID-19–negative controls to investigate perioperative outcomes during the pandemic. Results: A total population of 8.4 million patient records was queried, identifying 4735 adults with ankle fracture surgery. The COVID-19–positive group (n=158, 3.3%) had significantly longer times to surgery (6.5 ± 6.6 vs 5.1 ± 5.5 days, P = .001) and longer lengths of stay (8.3 ± 23.5 vs 4.3 ± 7.4 days, P < .001), compared to the COVID-19–negative group. The COVID-19–positive group also had a higher rate of 30-day mortality. Conclusion: Patients with ankle fracture surgery had longer time to surgery and prolonged hospitalizations in COVID-19–positive patients compared to those who tested negative (average delay was about 1 day and increased length of hospitalization was about 4 days). Few perioperative events were observed in either group. Overall, the risks associated with COVID-19 were measurable but not substantial. Level of Evidence : Level III, retrospective cohort study.

Category: Trauma Introduction/Purpose: The purpose of this study was to evaluate union of talar neck fractures with critical bone defects treated acutely with autologous tibial bone graft during primary osteosynthesis. We hypothesized that acute autografting leads to reliable union rates. Methods: A case series at a Level I trauma center was performed to identify patients who underwent open reduction and internal fixation of talar neck fracture with proximal tibial autograft between 2015 and 2018. Inclusion criteria were age greater than 18 years and displaced talar neck fracture with critical bone defect treated with tibial autograft. Critical bone defect was defined as a gap greater than 5mm in the sagittal plane and greater than 1/3 of the width of the talar neck in the coronal plane. Post-operative foot CT scans were obtained for all patients to assess for union. Primary outcome was union and secondary outcomes were malunion, avascular necrosis, post-traumatic arthritis, and patient-reported outcomes (PRO) including PROMIS (Patient Reported Outcomes Measurement Information System), Foot and Ankle Measurements: Activity of Daily Living and Sports (FAAM ADL/Sports), Visual Analogue Scale for feet (VAS), Foot Function Index (FFI), and Short Form-36 (SF-36). Results: Twelve patients were included in the series. The average age was 34 years (17-59). The Hawkins classification of the fractures were four type II (33%) and eight type III (67%). Five fractures (42%) were extruded tali. Four fractures (33%) were open fractures, all being type III fractures. Union was achieved in eleven patients (92%). Nonunion occurred in one patient (8%), who had an open, extruded talus fracture and was a heavy smoker. Avascular necrosis occurred in 11 patients (92%). Ten patients (83%) had radiographic tibiotalar post-traumatic arthritis (PTA), and 12 patients (100%) developed subtalar PTA. Average PROMIS score was 37 (32-45) and average FAAM ADL and Sports was 61 (31-87) and 31 (0-71), respectively. Average VAS was 5 (0-10) and average FFI was 49 (7-89). SF-36 scores showed fair to poor outcomes in the majority of patients. Conclusion: Tibial autograft in primary osteosynthesis of comminuted talar neck fractures with critical bone defects leads to reliable union rates and is an operative strategy that should be considered when treating these difficult fractures. Despite high union rates, secondary outcomes of AVN, PTA, and below-average PRO still occurred in the majority of patients.

Category: Ankle; Trauma Introduction/Purpose: Coronavirus (COVID-19) is an emerging, rapidly evolving situation. The National COVID Cohort Collaborative (N3C) is an innovative approach to integrate real-world clinical observations into a harmonized database. To investigate the outcomes of adults with ankle fracture surgery during the (COVID-19) pandemic, we had the following research question: What are the outcomes of ankle fracture patients with COVID-19 (invasive ventilation, length of stay, death)? The purpose of this abstract is to introduce the largest cohort of ankle fracture patients to date with a comparison between lab- confirmed COVID-19-positive and COVID-19-negative. Methods: A retrospective cohort of adults with ankle fracture surgery in the N3C Data Enclave. The N3C Data Enclave is an NIH-funded, secure platform through which the harmonized clinical data from electronic health records is stored ( https://covid.cd2h.org/ ). COVID-19 status was determined using a set of 55 SARS-CoV-2 polymerase chain reaction and antigen lab tests. Ankle fracture surgery was defined using SNOMED codes for 'fracture of bone' and one of the following CPT codes '27766, 27769, 27792, 27814, 27822, 27823, 27829' for 'ankle fracture surgery.' Results: A total population of 3.4 million patient records was queried in the National COVID Cohort, identifying 2,032 participants with ankle fracture surgery. The age range of the overall group was 18-98 years. Comparing COVID-19-positive to COVID-19-negative, the age (48.9 years vs 47.7 years) and gender (66.7% female vs 55.1% female) distribution of each group were comparable (both p>0.05). COVID-19-positive comprised 2.4% of the group (n=48). The length of stay was 4.7 days longer in the COVID-19-positive group (8.7 days vs 4.0 days, p

Category: Hindfoot; Trauma Introduction/Purpose: Pilon fractures are often associated with severe bone comminution and soft tissue compromise. As a result, surgical salvage procedures such as hindfoot nailing may be indicated for patients who are not candidates for standard fixation techniques such as open reduction and internal fixation (ORIF). The purpose of this review was to access outcomes associated with complex hindfoot trauma acutely treated with hindfoot nailing. Methods: A case series at a Level I trauma center was performed to identify trauma patients with complex hindfoot fractures who underwent hindfoot nailing as definitive treatment after initial external fixation between 2012 and 2020. Indications included a combination of patient comorbidities, fracture severity, and soft tissue injury. Exclusion criteria included follow-up less than 3 months. Post-operative radiographs were interpreted by a fellowship-trained foot and ankle surgeon. Primary outcome measures included unplanned reoperation/revision and deep infection. Deep infection was defined as any patient requiring surgical debridement after definitive fixation with positive cultures or the presence of positive cultures at the time of planned surgery. Fractures were classified using the AO/OTA classification and injury characteristics and postoperative complications were recorded via chart review. Results: Twenty-six of 29 of identified patients met inclusion criteria. The most common AO/OTA classification was 43C (62%). The average age was 55 years (range, 31-94) and the most common mechanism of injury was motor vehicle crash (38%). Thirteen fractures (50%) were open with Gustilo Anderson grade IIIA fractures being the most common (38%). The overall deep infection rate was 15% with fifty percent of cases positive for a history of diabetes mellitus or smoking. Unplanned reoperations occurred in seven (27%) cases. Among these, a total of four (57%) occurred due to the development of deep infection, two (29%) were nonunions, and one (14%) was indicated for hardware failure. Below the knee amputation occurred in one patient with nonunion (4%), which was a grade IIIA open pilon fracture with significant bone loss. Union was achieved in the majority of patients (92%). Conclusion: Treatment of complex hindfoot trauma with intramedullary nailing has a high union rate as a salvage procedure in a poor host. Surgeons should consider this treatment in patients that are not candidates for standard open reduction and internal fixation techniques.

Category: Ankle; Trauma Introduction/Purpose: Subtalar fracture dislocations are a rare hindfoot injury with relatively little evidence to inform surgeons about outcomes and risk factors for complications. Some previously documented poor prognostic factors include lateral and complicated dislocations, total talar extrusions, and concomitant fractures. The mechanism of injury often results from high energy trauma and has been reported as severe inversion (medial dislocation) or eversion (lateral dislocation) of the foot. The purpose of this study was to assess the risk factors associated with deep infection after operative treatment of subtalar fracture dislocations. Methods: A retrospective cohort study at a single level 1 trauma center was performed to identify patients who had operative treatment of a subtalar fracture dislocation over an 11 year period (2008-2019). Patients were identified by review of the electronic health record and data collected included patient demographics, injury characteristics, and treatment choices. Deep infection was defined as return to the operating room for debridement. Minimum follow-up for inclusion was 3 months. Descriptive analyses (means, medians, standard deviations, ranges, frequency distributions) were used to assess and describe the group. Chi-square tests of association and independent-sample t tests were used to assess differences between the infected group and those without infection. Results: A total of 154 met criteria for this study. The most common associated fractures were talus (47%) and calcaneus (33%). Approximately every 1 in 8 patients (12.3%) patients developed a deep infection. The infected group was older (47.2 vs 39.5 years, p=0.03). Tobacco users were found to have a significantly higher rate of postoperative deep infection (74 vs 34%, aOR=7.4, 95% CI, 2.3-24.1, p=0.001). There was a significantly higher proportion of infection in patients with Gustilo-Anderson type 3 open fractures (32 vs 12%, aOR=5.7, 95% CI, 1.6-20.3, p=0.007). The infected group had a higher proportion of below the knee amputation (47 vs 1%, p

Category: Ankle; Hindfoot Introduction/Purpose: Flexor Hallucis Longus (FHL) tendon transfer to the calcaneus is a common adjuvant procedure in the treatment of Achilles pathology. The FHL tendon can be harvested using a posterior incision where the tendon is dissected along its course into the fibroosseous tunnel. Alternatively, the FHL may be harvested through a separate plantar medial incision as it crosses the flexor digitorium longus at the Knot of Henry. This study aims to quantify FHL tendon lengths achieved through the two common approaches utilizing pair matched cadavers. Methods: Seven pair matched fresh-frozen cadaver legs without signs of musculoskeletal abnormalities were used for this assessment. One leg in each pairing underwent a single incision harvest while the contralateral leg underwent an accessory medial plantar harvest. After dissecting the tendon, a calcaneus tunnel was prepared from dorsal to plantar in both calcanei in standard fashion. Two measurements were obtained. The first measurement was taken from the distal aspect of the muscle belly to the distal end of the tendon. The tendon was then pulled through the calcaneus, and the foot was held in tension at 20 degrees of plantar flexion. The second measurement was taken from site where tendon entered the calcaneous to the distal end of the tendon graft. The measurements were analyzed using Wilcoxon Signed Ranks Test and Fischer Exact Test. Results: Using a posterior incision, the mean tendon measurement from calcaneous tunnel to the distal end of the tendon was 4.0 cm. Using an accessory plantar medial incision, the mean tendon measurement from the calcaneous tunnel to the distal end of the tendon was 7.2 cm. The average tunnel length obtained using an accessory medial incision was significantly greater than the length obtained using the single incision approach (p= 0.0003, p=0.0022, and p=0.0016). The accessory plantar medial incision obtained an FHL tendon tunnel length that was an average of 2.9 cm greater than the posterior incision. Conclusion: The single incision approach provided sufficient length to safely anchor the FHL into the calcaneus which suggests that the accessory plantar medial approach is not necessary for routine FHL transfers to the calcaneus with interference screw fixation. However, if additional length is needed for other applications such as posterior tibialis tendon dysfunction or peritoneal tendon tears, the accessory incision does provide an average of 2.9 cm of additional length.

Category: Hindfoot; Trauma Introduction/Purpose: The lateral extensile approach (LEA) to the calcaneus has long been a popular surgical approach to treat calcaneal fractures. However, high rates of wound complications have led surgeons to investigate alternative approaches. As a result, the sinus tarsi approach has grown in popularity. The lateral extensile approach affords substantial visualization of the calcaneus. However, this visualization has never been compared in a quantitative manner to the sinus tarsi approach (STA). The objective of this cadaveric study is to compare calcaneal visualization afforded by a sinus tarsi approach and a lateral extensile approach. Methods: Seven pair-matched, fresh-frozen, below-knee cadaver specimens were obtained. For each pair, one side received an LEA and the other side received a STA. To identify areas of the calcaneus accessible by instrument, a curette was used to mark the visualized calcaneal surfaces. The calcaneus was then disarticulated and cleared of all soft tissue. The curette markings were then identified and marked with blue surgical marker. Photos were taken of each calcaneus, and visualized surface areas were calculated using Image J software. Results: There were no statistically significant differences in the articular surfaces accessible between the two approaches (831.99 mm2 for LEA vs. 903.41 mm2 for STA, p=0.53) including the anterior, middle, and posterior facets. The total calcaneal surface area accessible was 3107.08 mm2 for LEA and 1444.19 mm2 for STA (p=0.02). The LEA allowed better exposure to the lateral wall (p

Category: Ankle; Trauma Introduction/Purpose: Treatment of geriatric fractures are unique in their perioperative and postsurgical complications. Increased age, increased number of comorbidities, and decreased bone quality present a significant challenge when treating geriatric fractures, including ankle fractures. Recent studies have hypothesized using locking plates will lead to better outcomes compared to non-locking plates in geriatric ankle fractures. Conventional non-locking plates depend on the bone quality and screw-plate friction in order to achieve proper fixation and stability whereas locking plates do not. Locking plates are common in this patient population due to greater rigidity and biomechanical stability while not relying on bone quality to maintain fixation. This study aims to determine if locking plates are necessary to maintain reduction in geriatric ankle fractures. Methods: After approval from the Institutional Review Board, a retrospective chart review was performed on all patients 60 years or older sustaining an ankle fracture between 2012-2018. Patients with less than 3 months follow-up at the time of injury were excluded. Each patient underwent surgical fixation at the discretion of the attending surgeon for bimalleolar or trimalleolar ankle fractures. The following patient information was collected from the charts: age, mechanism of injury, and comorbidities. Radiographic review was performed to determine open or closed fracture status, the type of fracture pattern and presence or absence of a syndesmotic injury. Patient radiographs from the most recent follow-up were analyzed for maintenance of reduction and use of a locking or non-locking plate. Statistical analysis was performed using the Chi Square Test for significance and the Fisher’s Exact Test when necessary. Results: Out of 218 patients, 143 received locking plates (L) and 75 received non-locking plates (NL). There were 99 bimalleolar fractures (69.2%) and 44 trimalleolar fractures (30.8%) in the L group. The NL group had a higher percentage of trimalleolar fractures, 50.7% (38), with 37 bimalleolar fractures (49.3%) (p=0.004). The two groups did not differ in terms of mechanism of injury (p=0.906), high energy (39.2% in L and 41.3% in NL, p=0.773), and open fractures (24.5% in L and 17.3% in NL, p=0.227). Upon radiographic review, 142 patients in the L group (0.7%) and 72 patients in the NL group (4.0%) maintained reduction (p=0.119). Loss of reduction in the L group was a trimalleolar fracture whereas 2 bimalleolar and 1 trimalleolar fractures in the NL group. Conclusion: Our study demonstrates that there is not a greater loss of reduction when utilizing locking plates. Surgeons should keep this in mind when choosing constructs for fixation of geriatric ankle fractures.

Category: Ankle; Hindfoot; Midfoot/Forefoot Introduction/Purpose: Prescription opioids are commonly used to control postoperative pain in foot and ankle surgery, but present potentially detrimental side effects including sedation, respiratory depression, and addiction. In foot and ankle surgery, pain is a common cause of delayed hospital discharge and decreased willingness to move, thereby slowing recovery. Gabapentin acts by decreasing lesion-induced hyperexcitability of posterior horn neurons and central sensitization, and has been explored as a potential addition to patients’ pain regimen. Although studies have previously assessed the effect of gabapentin on pain relief, to our knowledge none have evaluated whether gabapentin is effective in opioid consumption reduction beyond the immediate postoperative period. The purpose of this study is to assess whether gabapentin acts synergistically to improve postoperative pain among patients undergoing foot and ankle surgery. Methods: Patients from a single institution who underwent elective foot and ankle surgery were identified using CPT codes 27700, 27702, 27870, 28705, 28715, 28725, 28730, and 28740. All patients prescribed opioids postoperatively were included. A retrospective chart review was conducted for each patient to identify prescription dose, number of pills, date in which prescription was filled, and dates of refills for oxycodone, hydrocodone, oxycodone-acetaminophen, hydrocodone-acetaminophen, tramadol, and gabapentin. Medication information was collected only for prescriptions by the operating surgeon, nurse practitioner, physician assistant, resident, or fellow which were pertinent to the foot/ankle surgery performed; prescriptions from other services or providers were not included in order to ensure that the medications prescribed were specific to postoperative pain. Opioid quantities were converted to morphine equivalents and compared at various time intervals between patients who were prescribed only opioids, and patients who were prescribed opioids and gabapentin. Results: Among patients not taking opioids or gabapentin preoperatively, total morphine equivalents prescribed was significantly less among patients prescribed postoperative gabapentin (177.3 OME) in comparison to those prescribed only opioids (442.2 OME) (p=0.0018) in the 3-6 week postoperative interval. When all patients were analyzed, including those taking preoperative opioids or gabapentin, patients who received postoperative gabapentin were also prescribed significantly fewer OME at weeks 1-2 (p= 0.0270), weeks 3-6 (p = 0.0006), and weeks 7 - 12 (p = 0.0149). Conclusion: Gabapentin may be effective in reducing postoperative opioid consumption beyond the immediate postoperative period among elective foot and ankle surgery patients. Prospective clinical trials are warranted to further validate these results.

Category: Foot & Ankle Surgery Introduction/Purpose: Prescription opioids are commonly used to control postoperative pain in foot and ankle surgery, but present potentially detrimental side effects including sedation, respiratory depression, and addiction. In foot and ankle surgery, pain is a common cause of delayed hospital discharge and decreased willingness to move, thereby slowing recovery. Gabapentin acts by decreasing lesion-induced hyperexcitability of posterior horn neurons and central sensitization, and has been explored as a potential addition to patients’ pain regimen. Although studies have previously assessed the effect of gabapentin on pain relief, to our knowledge none have evaluated whether gabapentin is effective in opioid consumption reduction beyond the immediate postoperative period. This study aims to assess whether gabapentin acts synergistically to improve postoperative pain among patients undergoing foot and ankle surgery. Methods: Patients from a single institution who underwent elective foot and ankle surgery were identified using CPT codes 27700, 27702, 27870, 28705, 28715, 28725, 28730, and 28740. Those prescribed opioids postoperatively were included. A retrospective chart review was conducted for each patient to identify prescription dose, number of pills, date in which prescription was filled, and dates of refills for oxycodone, hydrocodone, oxycodone-acetaminophen, hydrocodone-acetaminophen, tramadol, and gabapentin. Medication information was collected only for prescriptions by the operating surgeon, nurse practitioner, physician assistant, resident, or fellow which were pertinent to the foot/ankle surgery performed; prescriptions from other services or providers were not included in order to ensure that the medications prescribed were specific to postoperative pain. Opioid quantities were converted to morphine equivalents and compared at various time intervals between patients who were prescribed only opioids, and patients who were prescribed opioids and gabapentin. Results: Among patients prescribed gabapentin plus opioids, total opioids prescribed (in morphine equivalents, OME) was 68.33, 221.25, 87.50, and 400.83 at weeks 1-2, 3-6, 7-12, and greater than 12, respectively. Although not statistically significantly different, patients prescribed only opioids had greater average amounts of opioids prescribed at all time intervals, equaling 98.34 OME, 553.52 OME, 540.53 OME, and 766.25 OME at weeks 1-2, 3-6, 7-12, and greater than 12, respectively. When excluding patients taking opioids preoperatively, total morphine equivalents prescribed was significantly less among patients prescribed gabapentin (196.94 OME) in comparison to those prescribed only opioids (457.41 OME) (p=0.0255). Conclusion: The findings of this study suggest that gabapentin may be effective in reducing postoperative opioid consumption beyond the immediate postoperative period among elective foot and ankle surgery patients. Gabapentin may be particularly beneficial within the three to six week postoperative period. Prospective clinical trials are warranted to further validate these results.

Category: Post-operative Driving Introduction/Purpose: For many patients, returning to driving after right foot and ankle surgery is a concern, and it is not uncommon for patients to ask if driving may be performed with their left foot. A paucity of literature exists to guide physician recommendations for return to driving. The purpose of this study is to describe the driving habits of patients after right-sided foot surgery and assess the safety of left foot driving using a driving simulator. Methods: Patients who underwent right foot or ankle operations between January 2015 and December 2015 were retrospectively identified. A survey assessing driving habits prior to surgery and during the recovery period was administered via REDCap database through email or telephone. Additionally, simulated driving scenarios were conducted using a driving simulator in 20 patients to compare characteristics of left versus right foot driving. Results: Thirty six of 96 (37%) patients who responded to the survey reported driving with the left foot postoperatively. No trends were found associating left foot driving prevalence and socioeconomic status. In driving simulations, patients exceeded the speed limit significantly more (p

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) is an effective treatment for end-stage ankle arthritis and is increasing in utilization. Need for blood transfusion is one potential complication of TAA. While numerous studies have associated blood transfusions with increased complications in hip and knee arthroplasty, little is known of its effect in TAA. This study aims to use a large nationally representative database to determine the effect of blood transfusion on inpatient complications and total hospital costs following TAA. Methods: Using the Nationwide Inpatient Sample (NIS) database from 2002-2012, 19,190 patients undergoing TAA were identified, with 294 (1.5%) receiving a blood transfusion. Univariate analysis was performed to determine patient and hospital factors associated with blood transfusion during inpatient stay following TAA. Multivariate analysis was performed to determine if blood transfusion was associated with other inpatient complications after controlling for age, race, gender, and comorbidities. Results: Patients receiving a blood transfusion were more likely to be older, female, African American race, on Medicaid insurance, and in a non-teaching hospital. The average length of stay for patients undergoing blood transfusion was 5.4 days compared to 2.5 days for those who did not (P < 0.001), while the average inpatient cost was $101,214.77 vs. $58,076.23. Blood transfusion was associated (P < 0.001) with acute renal failure, acute myocardial infarction, pneumonia, length of stay and inpatient cost greater than 75th percentile. After controlling for age, race, gender, and comorbidities, blood transfusion was determined to be an independent risk factor for acute renal failure (P=0.001, OR=3.17), acute myocardial infarction (P < 0.001, OR=66.76), extended length of stay (P < 0.001, OR=5.82), and increased inpatient cost (P < 0.001, OR=2.68). Conclusion: Peri-operative blood transfusions are associated with increased inpatient complications and increased hospital costs following total ankle arthroplasty. Careful preoperative assessment and medical optimization of these patients should be performed in order minimize the risk of peri-operative blood transfusion.

Background:. Few evidence-based suggestions are available to help applicants and mentors improve reapplication outcomes. We sought to provide program directors' (PDs) perspectives on actionable steps to improve reapplicants' chances for a match. Methods:. The PDs were asked to rank positions unmatched applicants can pursue, steps these applicants can take for the next application cycle, and reasons why reapplicants do not match. Results:. Responses from 66 of 123 PDs were received (53.6% response rate). Obtaining new recommendation letters and rotating with orthopaedics were the highest 20 ranked steps unmatched applicants can take. No curriculum vitae (CV) improvement, poor interview, and poor letters of recommendation were the most important reasons hindering applicants from matching when reapplying. Conclusions:. Steps reapplicants could prioritize include obtaining new recommendation letters, rotating in orthopaedics, and producing new research items. CV strengthening and improving interview skills address the 2 main reasons why unmatched applicants failed in subsequent attempts. Level of Evidence:. Level IV

Background:. To maintain the integrity of the match, postinterview communication (PIC) from programs to applicants is monitored and discouraged. The most recent report on the prevalence of PIC in orthopaedics found that 64% of surveyed applicants in 2014 and 2015 had received some form of PIC during their match cycle. In July 2019, the American Orthopaedic Association’s Council of Orthopaedic Residency Directors (AOA/CORD) released a guideline recommending the elimination of all PIC in any form. The goal of this follow-up study was to determine the current prevalence of PIC with orthopaedic surgery applicants and assess the perspectives of medical students who recently applied for orthopaedic surgery residency positions. Methods:. A 35-question survey was e-mailed to all orthopaedic surgery residency applicants of 4 geographically diverse residency programs in postmatch March 2020. The survey was open for 1 month, and the responses were reported using descriptive statistics. Results:. Of the 229 respondents (21% response rate), 91 (39.7%) received PIC during the 2019 to 2020 residency match cycle. The program director was most commonly identified (80.2%) as the person who communicated with the applicants. At the interview day, 198 respondents (86.5%) were told that programs would not be contacting the applicants with PIC. However, over a quarter of respondents (25.3%) who received PIC answered that those programs contacted applicants after announcing they would not. Nearly half of the respondents (48.5%) agreed or strongly agreed that PIC causes added stress on applicants, and over half (52.9%) agreed or strongly agreed that all programs should stop participating in any form of PIC. Conclusions:. Although the prevalence of PIC seems to have decreased since the 2014 and 2015 match, there is still room for improvement toward eliminating PIC. The AOA/CORD position statement from July 2019 should be disseminated to all members of the residency selection team to ensure consistency from all programs. The primary limitation of this study was the 21% response rate. Level of Evidence:. Level IV (survey study)