Andrew P. Matson

Determining the Cost-Savings Threshold and Alignment Accuracy of Patient-Specific Instrumentation in Total Ankle Replacements

Background: Traditional intraoperative referencing for total ankle replacements (TARs) involves multiple steps and fluoroscopic guidance to determine mechanical alignment. Recent adoption of patient-specific instrumentation (PSI) allows for referencing to be determined preoperatively, resulting in less steps and potentially decreased operative time. We hypothesized that usage of PSI would result in decreased operating room time that would offset the additional cost of PSI compared with standard referencing (SR). In addition, we aimed to compare postoperative radiographic alignment between PSI and SR. Methods: Between August 2014 and September 2015, 87 patients undergoing TAR were enrolled in a prospectively collected TAR database. Patients were divided into cohorts based on PSI vs SR, and operative times were reviewed. Radiographic alignment parameters were retrospectively measured at 6 weeks postoperatively. Time-driven activity-based costing (TDABC) was used to derive direct costs. Cost vs operative time-savings were examined via 2-way sensitivity analysis to determine cost-saving thresholds for PSI applicable to a range of institution types. Cost-saving thresholds defined the price of PSI below which PSI would be cost-saving. A total of 35 PSI and 52 SR cases were evaluated with no significant differences identified in patient characteristics. Results: Operative time from incision to completion of casting in cases without adjunct procedures was 127 minutes with PSI and 161 minutes with SR (P < .05). PSI demonstrated similar postoperative accuracy to SR in coronal tibial-plafond alignment (1.1 vs 0.3 degrees varus, P = .06), tibial-plafond alignment (0.3 ± 2.1 vs 1.1 ± 2.1 degrees varus, P = .06), and tibial component sagittal alignment (0.7 vs 0.9 degrees plantarflexion, P = .14). The TDABC method estimated a PSI cost-savings threshold range at our institution of

Predictors of Time to Union After Operative Fixation of Closed Ankle Fractures.

863 below which PSI pricing would provide net cost-savings. Two-way sensitivity analysis generated a globally applicable cost-savings threshold model based on institution-specific costs and surgeon-specific time-savings. Conclusions: This study demonstrated equivalent postoperative TAR alignment with PSI and SR referencing systems but with a significant decrease in operative time with PSI. Based on TDABC and associated sensitivity analysis, a cost-savings threshold of

Single-Stage Bipedicle Local Tissue Transfer and Skin Graft for Achilles Tendon Surgery Wound Complications

863 was identified for PSI pricing at our institution below which PSI was less costly than SR. Similar internal cost accounting may benefit health care systems for identifying cost drivers and obtaining leverage during price negotiations. Level of Evidence: Level III, therapeutic study.

Management of the Essex-Lopresti Injury.

Background. Ankle fractures are common and represent a significant burden to society. We aim to report the rate of union as determined by clinical and radiographic data, and to identify factors that predict time to union. Methods. A cohort of 112 consecutive patients with isolated, closed, operative malleolar ankle fractures treated with open reduction and internal fixation was retrospectively reviewed for time to clinical union. Clinical union was defined based on radiographic and clinical parameters, and delayed union was defined by time to union >12 weeks. Injury characteristics, patient factors and treatment variables were recorded, and statistical techniques employed included the Chi-square test, the Student’s T-test, and multivariate linear regression modeling. Results. Forty-two (37.5%) of patients who achieved union did so in less than 12 weeks, and 69 (61.6%) of these patients demonstrated delayed union at a mean of 16.7 weeks (range, 12.1-26.7 weeks), and the remaining patient required revision surgery. Factors associated with higher rates of delayed union or increased time to union included tobacco use, bimalleolar fixation, and high energy mechanism (all p<0.05). In regression analysis, statistically significant negative predictors of time to union were BMI, dislocation of the tibiotalar joint, external fixation for initial stabilization and delay of definitive management (all p<0.05). Conclusion. Patient characteristics, injury factors and treatment variables are predictive of time to union following open reduction and internal fixation of closed ankle fractures. These findings should assist with patient counseling, and help guide the provider when considering adjunctive therapies that promote bone healing. Levels of Evidence: Prognostic, Level IV: Case series

Surgical Management of Proximal Tibiofibular Joint Instability Using an Adjustable Loop, Cortical Fixation Device

Introduction. Achilles tendon and posterior heel wound complications are difficult to treat. These typically require soft tissue coverage via microvascular free tissue transfer at a tertiary referral center. Here, we describe coverage of a series of posterior heel and Achilles wounds via simple, local tissue transfer, called a bipedicle fasciocutaneous flap. This flap can be performed by an orthopaedic foot and ankle surgeon, without resources of tertiary/specialized care or microvascular support. Methods. Three patients with separate pathologies were treated with a single-stage bipedicle fasciocutaneous local tissue transfer. Case 1 was a patient with insertional wound breakdown after Achilles debridement and repair to the calcaneus. Case 2 was a heel venous stasis ulcer with calcaneal exposure in a diabetic patient with vasculopathy. Case 3 was a patient with wound breakdown following midsubstance Achilles tendon repair. All three cases were treated with a single-stage bipedicle local tissue transfer for posterior ankle and heel wound complications. Results. All 3 patients demonstrated complete healing of the posterior defect, lateral ankle skin graft recipient site, and the skin graft donor site after surgery. Case 3 had a subsequent recurrent ulceration after initial healing. This was superficial and healed with local wound care. All patients regained full preoperative range of motion and were able to ambulate independently without modified footwear. Conclusions. The bipedicled fasciocutaneous flap described here offers a predictable single stage procedure that can be accomplished by an orthopaedic foot and ankle surgeon without resources of a tertiary care center for posterior foot and ankle defects. This flap can be performed with short operative times and can be customized to facilitate defect coverage. The flap is durable to withstand local tissue stresses required for early ambulation. Despite its reliability, patients require careful follow-up to manage underlying comorbid conditions that may complicate wound healing. Levels of Evidence: Level IV: Case series

Predictors of Time to Clinical Union in Ankle Fractures

Essex-Lopresti injuries (ELIs) are characterized by fracture of the radial head, disruption of the forearm interosseous membrane, and dislocation of the distal radioulnar joint. This injury pattern results in axial and longitudinal instability of the forearm. Initial radiographs may fail to reveal the full extent of the injury, and therefore diagnosis in the acute setting requires a high index of suspicion. Early recognition and treatment are preferred as failure to fully treat the problem may result in chronic wrist pain from ulnar abutment or chronic elbow pain from radiocapitellar arthrosis. In this article the presentation, relevant anatomy, and management options for ELIs are overviewed, and a summary of outcomes reported in the literature is provided. Additionally, the preferred surgical technique of the senior author is presented, which involves reconstruction of the interosseous membrane with a local pronator rerouting autograft.

Ulnar Nerve Transection in an Orthopaedic Surgeon Sustained During Surgery: A Case Report and Commentary.

A technique for proximal tibiofibular joint stabilization using an adjustable loop, cortical fixation device is presented. A standard diagnostic arthroscopy is performed to exclude intra-articular pathology. After arthroscopy, a 5-cm posterior-based curvilinear incision is made over the fibular head with dissection of the fascia and decompression of the common peroneal nerve ensuring adequate exposure of the fibular head. A guidewire is placed across 4 cortices using fluoroscopic guidance from the fibular head to the anteromedial tibia. A cannulated drill bit is guided through the 4 cortices. A shuttle wire carrying the adjustable loop, cortical fixation device is fed from lateral to medial and through the skin until the medial cortical button is deployed. The device is tightened until the lateral circular cortical button is secured on the fibula. Fluoroscopy is performed to confirm the button position. The device is secured after tensioning by tying the sutures. To confirm joint stabilization, a shuck test can be performed. If a second fixation device is necessary, this procedure can be repeated distally to the first.

Simultaneous Intraoperative Measurement of Cadaver Ankle and Subtalar Joint Compression During Arthrodesis With Intramedullary Nail, Screws, and Tibiotalocalcaneal Plate

Category: Ankle Introduction/Purpose: Ankle fractures are an increasingly common musculoskeletal injury and represent a substantial source of societal economic loss due to missed days of work and utilization of healthcare resources. While common protocols exist for postoperative management of these fractures, predictors of time to union have not been analyzed. We aim to evaluate patient characteristics, injury features and perioperative factors that predict time to union and may allow for optimized postoperative protocols and improved patient counseling. Methods: A cohort of consecutive patients with isolated, closed operative ankle fractures treated by multiple surgeons at a tertiary care academic medical center from 2008-2012 was retrospectively reviewed for time to clinical union. Clinical union was defined as plain film radiographic evidence of bony healing and minimal to no pain clinically. Patients with pilon fractures, open injuries, additional fractures and incomplete outcomes data were excluded from analysis. Means and standard deviations were calculated and multivariate linear regression modeling was utilized to identify predictors of time to clinical union. Results: A total of 108 isolated, closed operative ankle fractures met inclusion criteria. Of these, 99.1% achieved clinical union in less than 6 months and the remaining one patient completed union in a delayed fashion with the use of non-operative adjuncts. Mean time to union was 14.1 weeks (SD 5.3 weeks). Statistically significant negative predictors of time to union were BMI, dislocation of the tibiotalar joint, external fixation for initial stabilization and delay of definitive management (all p < 0.05). Sex, age, diabetes mellitus, tobacco usage and high-energy mechanism were not significant after adjustment (Table 1). Fracture pattern and definitive operative fixation technique did not contribute to a parsimonious regression model and were excluded from final analysis. Conclusion: Time to clinical union after ankle fracture is significantly correlated with BMI, tibiotalar dislocation, external fixation for initial stabilization and delay of definitive management. In these instances, it is important to counsel patients about the potential for nonunion and consideration should be given to healing adjuncts such as prolonged non-weightbearing immobilization, bone stimulation and vitamin D.

Risks and Benefits of the Different Types of Gloves used in the Perioperative Setting

Case Report The first scheduled case of the day was a left knee arthroscopy, medial meniscal repair, and allograft anterior cruciate ligament (ACL) reconstruction. The patient and the surgeon had decided on using a patellar tendon allograft, but the case initially had been posted as a hamstring ACL reconstruction. The posting discrepancy was resolved prior to the patient leaving the preoperative area, but the necessary OR equipment needed to be rectified. My surgical team that day included a physician assistant (PA) as well as the OR team, which consisted of a nurse anesthetist, a circulating nurse, and a scrub nurse who had worked together for many years. A second-year resident would perform the diagnostic arthroscopy; then, I would repair the meniscal tear and reconstruct the ACL with a patellar tendon allograft while concurrently teaching the resident. The setup of the OR is shown in Figure 1. A time-out was performed per standard practice. Afterward, the circulating nurse noted that the safety strap was still on the base of the operating table. She and the nurse anesthetist went under the drapes to pass the strap from one side of the patient to the other side. The procedure began with the resident marking the location for each portal. The resident established the anterolateral portal with a #11-blade scalpel, and returned the scalpel to a basin in the safe zone on the back table using a “no-hands” technique, per routine. The resident inserted the arthroscope into the knee through the portal. As the resident introduced the arthroscope into the joint, I mentioned that he had not made the superomedial incision for the outflow cannula, which was my normal routine. The resident requested the scalpel, but the scrub nurse was setting up instruments and was turned away from the operative field. To assist, the PA passed the scalpel to the resident from the back table, and the resident made the appropriate incision. Using this teachable moment, I noted that making both incisions at the same time saves steps and reduces the number of exchanges of the scalpel. Once the outflow portal had been established, the resident turned to hand the scalpel to the scrub nurse, who was still organizing the arthroscopic equipment. The resident set the scalpel down on the Mayo stand and turned back to the patient to start the diagnostic arthroscopy, but no one saw him place the scalpel on the Mayo stand, and its placement had not been

Highlights in Spine Care during the Last One Hundred Years

Background: Suboptimal tibiotalocalcaneal arthrodesis (TTCA) fusion rates may result from inadequate compression that increases motion and interferes with bony bridging. The aim of this study was to evaluate compressive forces at the ankle and subtalar joints with 3 contemporary TTCA constructs. Methods: Thirty fresh-frozen cadaveric lower extremity specimens were divided into 3 groups of 10 each: 3 partially threaded cannulated screws, hindfoot nail, and lateral plate. Specimens were mounted to a testing apparatus, and compression was independently measured at the tibiotalar and talocalcaneal interfaces. Statistical analysis included paired Student t tests, analysis of variance, and Tukey post hoc tests. Results: Mean forces at the ankle joint for the screws, nail, and plate constructs were 331 ± 86, 479 ± 137, and 548 ± 199 N, respectively, with plates providing significantly more compression than screws (P < .01). Similarly, subtalar compressive forces demonstrated 319 ± 105 N in the screws group, 466 ± 125 N, in the nail group, and 513 ± 181 N in the plate group, with plate compression greater than that achieved with screws (P < .01). No differences were identified in compression between ankle and subtalar joints within specimens in any group. Conclusions: Lateral TTCA plates provided increased compressive forces at the ankle and subtalar joint compared with screws-only constructs. Hindfoot nails did not demonstrate significant differences in either of these parameters compared with plates or screws in this study. Clinical Relevance: Hindfoot nail and lateral plate options should be strongly considered when aiming to maximize compression in patients undergoing TTCA.