Brian S. Winters

The RAM Classification: A Novel, Systematic Approach to the Adult-Acquired Flatfoot

In summary, prior classifications have provided broad guidelines for treating the AAFF without accounting for case-specific variables in determining a treatment plan. The current system breaks down the deformity into three independent levels of involvement: the rearfoot, the ankle, and the midfoot. Via a simple, easy to remember, and reproducible schema based off the original Johnson and Strom classification, each level can be independently evaluated and a patient-specific surgical treatment plan can be formulated based on our most current understanding of the AAFF.

The Use of Allograft in Joint-preserving Surgery for Ankle Osteochondral Lesions and Osteoarthritis

The surgical management of young patients with large osteochondral lesions of the talus or end-stage osteoarthritis of the ankle joint presents a challenge to the orthopedic surgeon because these are well-recognized sources of pain and dysfunction. Procedures designed to address these disorders either have a limited role because of poor success rates or have significant implications, such as with the total ankle arthroplasty. Fresh osteochondral allografts allow defective tissue to be anatomically matched and reconstructed through transplantation. This article presents an overview of fresh osteochondral allografts, as well as potential concerns with their use, and summarizes the current literature.

Midterm Outcome of the Agility Total Ankle Arthroplasty

Background: Ankle arthritis is a debilitating condition that causes severe functional impairment. While arthrodesis has been the gold standard of surgical treatment for this condition, significant improvements in total ankle arthroplasty have made it a viable alternative. The purpose of this study was to look at the midterm follow-up of the Agility total ankle. Methods: A retrospective review of prospectively collected data was conducted on 127 consecutive Agility total ankles implanted between 2002 and 2009. Charts were reviewed to collect patient demographics. In addition, coronal alignment, overall arc of motion, tibiotalar component motion, syndesmotic fusion, zones of osteolysis, and subsidence were determined. A Kaplan-Meier survival and linear regression analysis were used to predict implant failure. A multivariate regression analysis was used to assess whether radiographic measures were predictive of patient satisfaction. Results: Ninety (78.2%) of 115 patients retained their primary implant, of which 105 were available for evaluation, with an average follow-up of 9.1 years. Twenty-five had their implant removed. The average score for the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale was 82.4, FAAM sport subscale 55.3, postoperative visual analog scale (VAS) for pain 12.7, and Short Form-12 (SF-12) Health Survey physical component 45.8 and SF-12 mental component 56.1. Average arc of motion across the implant was 22.3 and 6.3 degrees in adjacent joints. Osteolysis most commonly occurred in zones 1 and 6. No statistical differences were found in the rate or location of subsidence. Linear regression analysis demonstrated that age at the time of surgery was predictive of failure (P = .036). Inflammatory and atraumatic arthritis demonstrated higher likelihoods of revision. No correlation was detected between radiographic parameters and outcomes scores (P > .05; rho >0.2). A significant reduction in mean VAS pain scores by 67.6% was maintained at an average of 8 years. Discussion: Our results were improved over the nondesigner outcomes published in the current literature. Survivorship approached 80% at 9 years, with Kaplan-Meier 14-year survival calculated at 70.4%. Patients with their original implant were functioning with a high level of satisfaction based on statistically validated outcome scores, which was independent of the radiographic appearance of their implant. Age at the time of surgery and inflammatory/atraumatic arthritis were predictive of failure. Level of Evidence: Level IV, case series.

The Influence of Wait Time on Patient Satisfaction in the Orthopedic Clinic

Introduction: Patient satisfaction is of increasing importance in the delivery of quality healthcare and may influence provider reimbursement. The purpose of this study is to examine how patient wait time relates to their level of satisfaction and likelihood to recommend an orthopedic clinic to others. Methods: A retrospective analysis was performed on standardized new patient survey data collected at a single orthopedic clinic from June 2011 through October 2014. Results: A total of 3125 and 3151 responses were collected for satisfaction and likelihood to recommend the practice. The mean wait time was 27.3 ± 11.3 minutes. The likelihood of obtaining an “excellent” (odds ratio [OR]: 0.86, P = .01081) or “excellent/very good” (OR: 0.82, P = .0199) satisfaction demonstrated significant correlation with wait time in 15-minute intervals. The likelihood of obtaining an “agree” (OR: 0.9, P = .10575) and “strongly agree/agree” (OR: 0.85, P = .139) response to recommend the practice demonstrated no correlation during the same interval. Conclusion: Minimizing wait times in the orthopedic clinic may improve patient satisfaction but may not affect their likelihood of recommending the practice to others.

Driving After Hallux Valgus Surgery

Background: The purpose of the study was to determine when patients can safely return to driving after first metatarsal osteotomy for hallux valgus correction. Methods: After institutional review board approval, 60 patients undergoing right first metatarsal osteotomy for hallux valgus correction surgery were recruited prospectively. Patients’ brake reaction time (BRT) was tested at 6 weeks and repeated until patients achieved a passing BRT. A control group of twenty healthy patients was used to establish as passing BRT. Patients were given a novel driver readiness survey to complete. Results: At 6 weeks, 51 of the 60 patients (85%) had BRT less than 0.85 seconds and were considered safe to drive. At 6 weeks, the passing group average was 0.64 seconds. At the 8 weeks, 59 patients (100%) of those who completed the study achieved a passing BRT. Patients that failed at 6 weeks had statistically greater visual analog scale (VAS) pain score and diminished first metatarsophalangeal (MTP) range of motion (ROM). On the novel driver readiness survey, 8 of the 9 patients (89%) who did not pass disagreed or strongly disagreed with the statement, “Based on what I think my braking reaction time is, I think that I am ready to drive.” Conclusion: Most patients may be informed that they can safely return to driving 8 weeks after right metatarsal osteotomy for hallux valgus correction. Some patients may be eligible to return to driving sooner depending on their VAS, first MTP ROM, and driver readiness survey results. Level of Evidence: Level II, comparative study

Metatarsophalangeal Fusion Techniques with First Metatarsal Bone Loss/Defects

First metatarsophalangeal joint disorder is a common cause of chronic forefoot pain that is frequently encountered in the orthopedic clinic. Numerous surgical techniques have been described to improve patient pain and function in this regard, including prosthetic joint replacement, resection arthroplasty, and arthrodesis. When these procedures fail, surgeons can be confronted with significant first metatarsal bone loss/defects. First metatarsophalangeal joint fusion remains the gold standard, and, in the setting of significant bone loss, the use of structural bone graft must be considered in order to restore length to the first ray and the normal biomechanics of the foot.

Radiographic Outcomes of Postoperative Taping Following Hallux Valgus Correction.

Background: Traditionally, hallux valgus operative correction has been accompanied by serial spica taping of the great toe during the postoperative period. Methods: We retrospectively reviewed 187 adult patients who underwent proximal first metatarsal osteotomy with a modified McBride procedure in 2008-2009 (n = 83) and 2011-2012 (n = 104). Postoperatively, to maintain the corrected position of the hallux, patients from 2008 through 2009 underwent weekly spica taping, while patients from 2011 through 2012 utilized a toe separator. The hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured using anteroposterior weight-bearing preoperative, 2-week postoperative non-weight-bearing, and 3-month weight-bearing final follow-up radiographs. A mixed-effects linear regression model identified differences between the treatment groups over time, and a t test compared actual radiographic differences at final follow-up. Results: The mixed-effects model revealed no significant difference in the HVA over time when comparing patients taped to those not taped at the preoperative (33 ± 6 vs 33 ± 6), 2-week postoperative (10 ± 7 vs 9 ± 6), and 3-month follow-up (14 ± 6 vs 11 ± 7) visits (P = .08). At final follow-up, the HVA was lower for the group that was not taped, but the difference (2.5 degrees) was below the minimal clinically important difference (MCID) (P = .015, 95% CI 0.5-4.5). For IMA, there was improved maintenance of correction over time in the patients that were not taped compared to those taped at the preoperative (15 ± 3 vs 15 ± 3), 2-week postoperative (2 ± 2 vs 3 ± 3), and 3-month follow-up (5 ± 4 vs 7 ± 4) visits (P = .002). At final follow-up, the IMA was lower for the group that was not taped, but the difference (1.7 degrees) was below the MCID (P = .004, 95% CI 0.7-2.9). Conclusions: We report no radiographic benefit of postoperative taping after hallux valgus correction. The present study challenges the previous dogma of postoperative spica taping as the protocol is cost and time intensive for the patient and surgeon. Level of Evidence: Level III, comparative series.

Effect of Mitomycin C on recurrence of plantar fibromas: MITOMYCIN C AND PLANTAR FIBROMAS

Although certainly not the first line treatment for plantar fibromas, surgical resection is a treatment option for some patients with have failed exhaustive non‐surgical treatment. The use of topical Mitomycin C has been recently shown to reduce the recurrence rate of other fibrous lesions. The purpose of this study was to determine the impact of topical application of Mitomycin C on recurrence rate of plantar fibromas. A retrospective analysis was done from a prospectively gathered database with a total 50 consecutive patients over a 16‐month study period. The control group (n = 29) consisted of patients who underwent only surgical resection, while the study group (n = 21) consisted of patients who underwent surgical resection with adjuvant therapy using Mitomycin C. The primary endpoint was local recurrence after the procedure. Secondary end points included complications and toxicity associated with this medication. No patients were lost to follow up. Of the 29 patients in the control group, there were 17 patients (17/29, 58.6%) had recurrence of the plantar fibroma at a mean follow‐up of 9.1 months. In contrast, in the experimental study group, all patients were free from local recurrence. No complications or side effects were associated with Mitomycin C use. The results demonstrate that the topical application of Mitomycin C to the tumor bed after surgical resection of plantar fibromas reduced the recurrence rate.

A Prospective Randomized Study Evaluating the Effect of Perioperative NSAIDs on Opioid Consumption and Pain Management After Ankle Fracture Surgery

Category: Trauma Introduction/Purpose: Currently there is an epidemic in the United States regarding opioid abuse. This has resulted in strict government prescribing regulations throughout the country and increasing efforts by orthopaedic surgeons to better manage postoperative narcotic analgesia. Non-steroidal anti-inflammatory drugs (NSAIDs) can serve as a powerful adjunct in managing postoperative pain and in turn minimize the need for opioid medications. It has recently been shown that ketorolac can be used after open reduction and internal fixation (ORIF) of ankle fractures without interfering with bone healing. Therefore, we set out to evaluate whether including ketorolac in the postoperative drug regimen reduces opioid consumption and pain after ORIF of ankle fractures. Methods: 128 patients undergoing ORIF of an ankle fracture were prospectively randomized to treatment with or without ketorolac. Patients also had the option to simultaneously undergo regional anesthesia. Patients assigned to the treatment group were given 30 mg of IV ketorolac intraoperatively; prescribed 20 tablets of ketorolac 10 mg PO Q6 H and 30 tablets of Oxycodone/Acetaminophen 5/325 Q4-6 H PRN. Patients assigned to the control group were given 30 tablets of oxycodone/acetaminophen 5/325 Q4-6 H PRN only. A survey was distributed via Research Electronic Data Capture (REDCap) on postoperative days 1-7. Patients were asked to report their daily opioid consumption, pain level using the Visual Analog Scale (VAS), satisfaction with pain management, and side effects. Intention-to-treat analysis was performed. Normality of data was tested using the Shapiro-Wilk test. Differences between the control and treatment groups were tested using Mann-Whitney U or Student’s t-tests. Results: 105/128 (82%) patients with mean BMI of 29.3 completed all study requirements. 54 received ketorolac with opioid medication and 51 received opioids alone. 43 men (41%) and 62 women (59%) participated with mean age of 48 years. Patients receiving ketorolac required less oxycodone/acetaminophen (p<0.013) and reported less pain (p<0.048) during postoperative days 1 and 2 compared to control patients(Figure 1). While opioid consumption did not significantly differ after day 2, patients treated with ketorolac maintained less pain (days 1-4, p<0.028); better sleep (days 1-5, p<0.037); lower frequency of pain (days 1-3; p<0.017); and greater satisfaction with pain management (days 1-3, p<0.047). Hypersensitivity was significantly less on day 1 (p=0.036) and paresthesias on day 3 (p=0.011). Surprisingly, there was no difference in nausea/constipation between groups (p>0.139). Conclusion: The addition of ketorolac to the postoperative drug regimen significantly reduced pain, while decreasing the use of opioid medication following ORIF of ankle fractures early in the postoperative period. Better pain management during postoperative days 1 and 2 is particularly important because patients on average consume the most opioids during this time. With the assurance that ketorolac does not interfere with bone healing, this NSAID is a valuable tool for helping patients manage postoperative pain with less narcotic analgesia.

A Prospective Evaluation of Opioid Consumption Following Orthopaedic Foot and Ankle Surgery: Utilization Patterns and Prescribing Guidelines

Category: Other Introduction/Purpose: The purpose of our study was to assess opioid consumption patterns following outpatient orthopaedic foot and ankle procedures in order to develop a pragmatic approach to narcotic drug prescription. Methods: Patients undergoing outpatient orthopaedic foot and ankle procedures who met inclusion criteria had the following prospective information collected: patient demographics, preoperative health history and Visual Analog Scale (VAS), anesthesia type, procedural details, and opioid prescription and consumption details. Utilization rates were compared using the Man-Whitney Test or the Kruskall-Wallis analysis of variance test with post-hoc Dunn’s multiple comparison test. Results: A total of 1,009 of 1,027 patients were included in this study (mean age: 49 years). Overall, patients consumed a median of 20 pills whereas the median number of pills prescribed was 40. This resulted in a utilization rate of 51% and nearly 21,196 pills left unused. Patients who received forefoot surgery used 6 pills less than those receiving hindfoot/ankle surgery (p=0.002). Patients between the ages of 60-79 consumed significantly less than those between 18-59 years old (p<0.012). Patients with preoperative VAS score =77 (p=0.002) or self-reported anxiety (p=0.070) a had an increase in opioid consumption compared to those who did not. Conclusion: Our study demonstrates that patients who undergo orthopaedic foot and ankle procedures are overprescribed narcotic medication by nearly twice the amount that is actually consumed. This leads to a significant surplus of narcotics available for potential diversion. We recommend that surgeons judiciously administer opioid prescriptions based on their patients’ consumption patterns and anatomic location of surgery.