Elizabeth McDonald

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

Combined Popliteal Catheter With Single-Injection vs Continuous-Infusion Saphenous Nerve Block for Foot and Ankle Surgery:

Background: The increasing scope and complexity of foot and ankle procedures performed in an outpatient setting require more intensive perioperative analgesia. Regional anesthesia (popliteal and saphenous nerve blocks) has been proven to provide satisfactory pain management, decreased postoperative opioid use, and earlier patient discharge. This can be further augmented with the placement of a continuous-flow catheter, typically inserted into the popliteal nerve region. This study investigated the use of a combined popliteal and saphenous continuous-flow catheter nerve block compared to a single popliteal catheter and single-injection saphenous nerve block in postoperative pain management after ambulatory foot and ankle surgery. Methods: A prospective study was conducted using 60 patients who underwent foot and ankle surgery performed in an outpatient setting. Demographic data, degree of medial operative involvement, American Society of Anesthesiologists physical classification system, anesthesia time, and postanesthesia care unit time were recorded. Outcome measures included pain satisfaction, numeric pain scores (NPS) at rest and with activity, and opioid intake. Patients were also classified by degree of saphenous nerve involvement in the operative procedure, by the surgeon who was blinded to the anesthesia randomization. Results: Patients in the dual-catheter group took significantly less opioid medication on the day of surgery and postoperative day 1 (POD 1) compared to the single-catheter group (P = .02). The dual-catheter group reported significantly greater satisfaction with pain at POD 1 and POD 3 and a significantly lower NPS at POD 1, 2, and 3. This trend was observed in all 3 subgroups of medial operative involvement. Conclusion: Patients in the single-catheter group reported more pain, less satisfaction with pain control, and increased opioid use on POD 1, suggesting dual-catheter use was superior to single-injection nerve blocks with regard to managing early postoperative pain in outpatient foot and ankle surgery. Level of Evidence: Level II, prospective cohort study.

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.

Incidence and Risk Factors for Complications of Exposed Kirschner Wires Following Elective Forefoot Surgery

Category: Midfoot/Forefoot Introduction/Purpose: Kirschner wires (K-wires) are commonly utilized for temporary metatarsal and phalangeal fixation following forefoot corrective osteotomies. K-wires can remain in place for up to 6 weeks postoperatively and are at risk for wound complications. Their exposure to the outside environment and direct osseous communication makes infection an important concern for the clinician. Early removal, prophylactic antibiotics, and re-operation are potential sequelae of infected K-wires and can affect outcomes. The purpose of this study is to evaluate the incidence of complications of exposed K-wires after forefoot surgery and identify patient or perioperative risk factors for these complications. Methods: A single surgeon retrospective chart review of forefoot surgeries over the past 10 years was undertaken. Inclusion criteria were any adult undergoing elective forefoot surgery with the use of exposed K-wires. Incidence of wound complication defined as cellulitis, pin site drainage, or migration/loosening of the pin requiring prophylactic antibiotics or early removal was noted. Patient demographic data such as age, BMI, comorbidities, and smoking status were recorded. Perioperative data such as tourniquet time, type of anesthesia, and perioperative antibiotics was also recorded. Univariate analysis was performed via Mann-Whitney test for continuous variables and Chi square test for categorical variables. Multivariate analysis was performed for statistically significant risk factors. Results: 1,217 Patients (2,018 K-wires) were analyzed. There was a 10% complication rate requiring prophylactic antibiotics or early removal (N=123). 40 patients required early pin removal, 54 patients were given oral antibiotics, and 29 patients required both. Female gender (p<0.001), BMI over 28 (p<0.001), general anesthesia (p=0.025), increased tourniquet time (p=0.003) and history of rheumatoid arthritis (p=0.047) were significantly associated with complications. Both male gender [OR 2.62] and tourniquet time [OR 1.01] remained significant on multivariate regression analysis. There was no increased risk of complications with a history of smoking or diabetes. Conclusion: The K-wire is an important modality for providing temporary immobilization of the smaller bones of the forefoot following deformity correction. Male gender, elevated BMI, history of rheumatoid arthritis, general anesthesia, and longer tourniquet time are associated with increased risk of pin infection requiring early removal and/or antibiotics. Further study is needed to determine whether optimizing inflammatory disease, using efficient perioperative technique, and utilizing local anesthesia may limit the risk of wound complications with K-wires in forefoot surgery.

Response to “Letter Regarding: Combined Popliteal Catheter With Single-Injection vs Continuous-Infusion Saphenous Nerve Block for Foot and Ankle Surgery”

Dear Editor: Thank-you to Dr Kendall for reading our study comparing the use of a dual-catheter (continuous popliteal and saphenous) to continuous popliteal catheter and singleinjection saphenous nerve blocks in outpatient foot and ankle surgery. We appreciate the comments and questions and hope the answers provided will help address any concerns. With regard to intraoperative analgesic techniques, both the intraoperative analgesic technique and the anesthetic technique were standardized for both study groups. Analgesic technique relied on perineural catheters and peripheral nerve blocks placed preoperatively. Intravenous narcotic medicines, nonsteroidal anti-inflammatory drugs (NSAIDs), and intravenous acetaminophen (Ofirmev) were not incorporated as part of the intraoperative analgesic technique. Intravenous narcotics and Ofirmev were administered in the postanesthesia care unit (PACU) as described in the manuscript. Anesthetic technique was standardized as well. All patients were managed under standardized general anesthetic with a laryngeal mask airway using sevoflurane as the halogenated anesthetic. The study was performed at a stand-alone outpatient surgery center in Pennsylvania, which restricts ASA IV patients as per state regulations. The task of standardizing the anesthetic was uncomplicated mostly as a result of the study patients’ having limited comorbidities. Additionally, no patients in the study were given any NSAIDs during the first 2 weeks following surgery, including during the study immediate postoperative period. In regard to the statistical analysis, No adjustments were made. However, the raw P values and summary statistics were reported, allowing readers to infer statistical and practical significance at their discretion. Considering pain and satisfaction were each measured at 5 time points, readers could adjust the threshold for significance. Notably, the differences in reported pain and satisfaction at postoperative day 1 were strongly significant (P < .001); even after adjusting for multiple comparisons at different timepoints, the conclusions remain unchanged. Thank you again for your inquiry. Regards Steven M. Raikin, MD Rothman Institute, Philadelphia, PA, USA steven.raikin@rothmaninstitute.com

Influence of Depressive Symptoms on Hallux Valgus Surgical Outcomes

Background: The relationship between depressive symptoms and patient outcomes after hallux valgus surgery has not been well-studied. We hypothesized that patients with depressive symptoms would have greater subjective dysfunction preoperatively and less functional improvement and satisfaction after surgery when compared with patients without depressive symptoms. Methods: A total of 239 adult patients who had surgical hallux valgus correction over a 2-year period were retrospectively enrolled. A telephone survey was administered prospectively at least 11 months postoperatively inquiring about overall satisfaction level with surgery and satisfaction with postoperative pain level. A scale of 0 to 6 was used, with 0 indicating complete dissatisfaction and 6 indicating complete satisfaction. Patients were divided into 2 groups based on depressive symptoms; a Short Form–12 mental component score (SF-12 MCS) of less than 45.6 points was considered indicative of active depressive symptoms based on literature correlating SF-12 scores with Patient Health Questionnaire–9 for depression. Given the great variability of depressive symptoms in patients with or without self-reported depression and medicated or unmedicated status, we elected to use the MCS classification of depressive symptoms for our analysis. Data from 239 patients were available for analysis, with an average age of 51.6 years and 207 women (87%). Two hundred eighteen patients (91%) completed preoperative functional scores, 160 patients (67%) completed the satisfaction survey at an average of 23 months postoperatively (range 11 to 43 months), and 154 patients (64%) completed postoperative functional scores an average of 21 months postoperatively (range, 11-44 months). Results Thirty-six of 239 patients (15%) with baseline functional scores exhibited depressive symptoms. There was no significant difference in baseline functional scores and pain levels between groups with the exception of the SF-12 MCS (P < .001). Most outcomes improved significantly over time, including the SF-12 physical component score (P = .013), Foot and Ankle Ability Measure (FAAM; P = .013), and FAAM Activities of Daily Living (P = .046). The patients with depressive symptoms generally had lower scores at baseline and final follow-up in all functional scores, with the exception of visual analog scale (VAS). VAS pain scores started higher in the group of patients with depressive symptoms and ended lower. Satisfaction with postoperative pain was lower in the group with depressive symptoms when compared with patients without depressive symptoms (3.6 vs 4.5, P = .042). There was no significant difference in satisfaction after surgery between groups (P = .251). Conclusion: Patients with depressive symptoms had greater pain at baseline and less pain postoperatively when compared with patients without depressive symptoms; however, satisfaction levels with postoperative pain were lower in these patients. Furthermore, most functional scores were lower in patients with depressive symptoms, with the exception of the MCS. Reported history of depression was not associated with any significant difference in functional outcome scores or satisfaction. Further study is warranted to determine why patients with depressive symptoms fare worse after surgical hallux valgus correction by most subjective measures. Level of Evidence: Level III, comparative study.

Prospective Evaluation of Utilization Patterns and Prescribing Guidelines of Opioid Consumption Following Orthopedic Foot and Ankle Surgery

Background: Overprescription of narcotic pain medication is a major culprit in the present opioid epidemic plaguing the United States. The current literature on lower extremity opioid usage has limitations and would benefit from additional study. The purpose of our study was to prospectively assess opioid consumption patterns following outpatient orthopedic foot and ankle procedures. Methods: Patients undergoing outpatient orthopedic foot and ankle procedures who met inclusion criteria had the following prospective information collected: patient demographics, preoperative health history, patient-reported outcomes, anesthesia type, procedure type, opioid prescription and consumption details. The morphine equivalent dose was calculated for each prescription and then converted to the equivalent of a 5-mg oxycodone “pill.” Univariable analyses were performed to identify variables with a statistically robust association with opioid consumption for inclusion in a multivariable linear regression. A stepwise backward regression was then performed to identify independent predictors of opioid consumption. Postoperative opioid utilization was reported for 988 patients (mean age: 49 years). Results: Overall, patients consumed a median of 20 pills whereas the median number of pills prescribed was 40. This resulted in a utilization rate of 50% and 20 631 pills left unused. Independent factors associated with higher opioid consumption were anesthesia type (P < .004), age <60 years (P < .001), preoperative visual analog scale (VAS) pain report of >6 (P = .008), and bony procedures (P = .008); residual standard error 16.73 (F7,844=14.3, P < .001). Conclusion: Our study found that patients who underwent orthopedic foot and ankle procedures were overprescribed narcotic medication by nearly twice the amount that was actually consumed. Although we identified 4 independent factors associated with opioid consumption, the large residual standard error suggests that there remains a substantial degree of unexplained variance of opioid consumption observed in the patient population. Physicians face a challenging task of setting appropriate protocols when balancing pain relief and generalizable guidelines. Level of Evidence: Level II, prospective observational cohort study.

Effect of Postoperative Ketorolac Administration on Bone Healing in Ankle Fracture Surgery

Background: In an effort to minimize narcotic analgesia and its potential side effects, anti-inflammatory agents offer great potential provided they do not interfere with bone healing. The safety of ketorolac administration after foot and ankle surgery has not been well defined in the current literature. The purpose of this study was to report clinical healing and radiographic outcomes for patients treated with a perioperative ketorolac regimen after open reduction and internal fixation (ORIF) of ankle fractures. Methods: A retrospective review was performed on all patients that received perioperative ketorolac at the time of lateral malleolar, bimalleolar, and trimalleolar ankle ORIF by a single surgeon between 2010 and 2016 with minimum 4 months follow-up. Patients received 20 tablets of 10 mg ketorolac Q6 hours. Radiographs were evaluated independently by 2 blinded fellowship-trained orthopedic foot and ankle surgeons to assess for radiographic healing. A total of 281 patients were included, with a median age of 51 years and 138 males (47%). Statistical analysis consisted of a linear mixed-effects regression. Results: In all, 265/281 (94%) were clinically healed within 12 weeks and 261/281 (92%) were radiographically healed within 12 weeks. Within the group of patients that did not heal within 12 weeks, mean time to clinical healing was 16.9 weeks (range = 14-25 weeks), and mean time to radiographic healing was 17.1 weeks (range = 14-25 weeks). In patients taking ketorolac, there were no cases of nonunion in our series (n = 281) and no significant difference found between fracture patterns and healing or complications (P = .500). Conclusions: Perioperative ketorolac use was associated with a high rate of fracture union by 12 weeks. This is the first study to examine the effect of ketorolac on radiographic time to union of ankle fractures. Additional studies are necessary to determine whether ketorolac helps reduce opioid consumption and improve pain following ORIF of ankle fractures. Level of Evidence: Level IV, case series.

Correction of Severe Flexible Pes Planovalgus Deformity Using Trabecular Metallic Wedges

Category: Hindfoot, Midfoot/Forefoot Introduction/Purpose: Lateral column lengthening and a medial cuneiform plantarflexion (Cotton) osteotomy are procedures commonly used in the treatment of symptomatic flexible pes planovalgus. Traditionally, structural autograft or allograft have been used for both osteotomies. While union rates for both types of graft have been shown to be comparably high, the use of allograft or autograft each come with their own set of inherent risks and/or potential complications. A trabecular titanium wedge implant provides an attractive alternative that avoids the concerns associated with autograft and allograft use, and has previously been shown in the literature to demonstrate similar union rates. The purpose of this study was to retrospectively review the radiographic outcomes of corrective osteotomies utilizing trabecular metal wedges to address severe flexible pes planovalgus deformity. Methods: 115 feet in 109 patients who were treated with corrective osteotomies using a trabecular titanium wedges performed by one surgeon were retrospectively reviewed. All patients had symptomatic flexible pes planovalgus, mostly secondary to stage IIB posterior tibialis tendon dysfunction. Other diagnoses included pes planovalgus secondary to the adolescent idiopathic flexible subtype, traumatic posterior tibialis tendon rupture, coalition, or an accessory navicular. Preoperative radiographic parameters assessing severity of deformity were recorded and compared to the postoperative measurements taken at the time of most recent follow up visit to assess for correction. The radiographic measurements included the (1) AP talo-1st metatarsal angle (2) Lateral talo-1st metatarsal angle (3) Calcaneal pitch (4) Lateral talo-calcaneal angle and (5) Talonavicular uncoverage angle. All angles were measured off standard weight-bearing radiographs by one author using our institution’s picture archiving and communication system (PACS) software. All complications were also recorded. Results: At an average follow up time of 40 weeks, there were statistically significant corrective changes in the AP-talo-1st metatarsal angle (-12.56), lateral talo-1st metatarsal angle (+14.15), calcaneal pitch (+5.23), lateral talo-calcaneal angle (-3.87) and talonavicular uncoverage angle (-17.76). There were 3 nonunions (2.6%) confirmed by CT, 2 of which were eventually revised. There were a total of 9 complications (7.8%). Other than the nonunion revisions, none of these complications required a return to the operating room. There were no cases of collapse or loss of correction at the time of followup, as compared to the initial post-operative radiographs. Conclusion: In our study population corrective osteotomies using a trabecular titanium wedge was effective in improving radiographic parameters associated with flexible pes planovalgus deformity. The nonunion and overall complication rates using a trabecular titanium wedge were shown to be comparable or superior to what has previously been reported in the literature using allograft or autograft.