Gowreeson Thevendran

Factors Associated with Longer Length of Hospital Stay After Primary Elective Ankle Surgery for End-Stage Ankle Arthritis

BACKGROUND Longer length of stay in the hospital after elective surgery results in increased use of health-care resources and higher costs. Improved perioperative care permits many foot and ankle surgical procedures to be performed as day surgery. This study determined perioperative factors associated with a longer length of stay after elective total ankle replacement or ankle arthrodesis. METHODS Data were prospectively collected on patients who underwent open or arthroscopic ankle fusion or total ankle replacement for end-stage ankle arthritis at our institution from 2003 to 2010. Univariate and multivariable generalized linear regression models with gamma distribution and log link function were conducted with use of the length of the hospital stay as the dependent variable and preselected risk factors of age, sex, physical and mental functional scores, comorbid factors, American Society of Anesthesiologists grade, body mass index, type of surgery, duration of surgery, and surgery day of the week as the independent variables. RESULTS This study included 343 patients with a median length of stay of seventy-five hours (interquartile range, fifty-two to ninety-seven hours). With use of regression analyses, the variables of age, female sex, higher American Society of Anesthesiologists grade, multiple medical comorbidities, rheumatoid arthritis, lower Short Form-36 Physical Component Summary and General Health domain scores, and open surgery were significantly associated with increased length of stay. Conversely, the variables of obesity, Short Form-36 Mental Component Summary score, surgery day of the week, and surgical duration were not associated with length of stay. Two predictive models of the length of stay were developed: one included only patient-related factors, and the other included patient and surgery-related factors. CONCLUSIONS The patients who are identified with a higher risk of a longer length of stay may warrant better education and more focused perioperative care when designing care pathways and allocating health-care resources.

Nonunion Risk Assessment in Foot and Ankle Surgery Proposing a Predictive Risk Assessment Model

Background: Nonunion risk factor identification and modification are subjective. We describe and validate a predictive nonunion risk factor model to identify foot and ankle operative patients at risk for nonunion. Materials and Methods: One hundred international experts in foot and ankle surgery were surveyed. Nineteen nonunion risk factors were stratified into 3 categories: more significant than, as significant as, and less significant than smoking 1 pack per day. A nonunion risk assessment model was developed by assigning a weighted score to each risk factor, based on its mean score from the survey. A total nonunion risk (TNR) score was calculated for individual patients. It was retrospectively validated in 2 patient cohorts from a single center’s prospectively collected end-stage ankle arthritis patient database: 22 cases of ankle and/or hindfoot fusion nonunion and 40 sex- and procedure-matched controls with bony fusion. Analyses included descriptive statistics, logistic regression, and univariate and multivariate linear regression models. Results: The mean TNR score was 6.6 ± 5.6 in controls and 13.5 ± 8.2 in the nonunion group (P < .001). Data showed excellent intraobserver and interobserver correlation coefficients. In a logistic regression model, the risk of nonunion exceeded 9% with a TNR score greater than or equal to 10. Multivariate linear regression analysis, adjusted for age and sex, suggested that lack of fusion site stability and obesity (body mass index greater than 30) were significantly predictive of nonunion. Conclusion: The nonunion risk assessment model provides a reliable, sensitive, and specific method for predicting nonunion based on objective patient assessment. Orthopaedic patients at risk for nonunion could benefit from targeted intervention. Level of Evidence: Level IV, retrospective observational study.

Deep-vein thrombosis prophylaxis in foot and ankle surgery: what is the current state of practice?

Background. When contemplating thromboprophylaxis for patients undergoing elective foot and ankle surgery the potential for complications secondary to venous thromboembolism (VTE) must be balanced against the cost, risk, and effectiveness of prophylactic treatment. The incidence of pulmonary embolism (PE) following foot and ankle surgery is considerably lower than after hip or knee surgery. The purpose of this study was to assess current trends in practice regarding VTE prophylaxis among expert orthopaedic foot and ankle surgeons. Methods. An e-mail-based survey of active AOFAS (American Orthopaedic Foot and Ankle Society) committee members was conducted (n = 100). Surgeons were questioned as to their use, type, and duration of thromboprophylaxis following elective ankle fusion surgery. Scenarios included the following: (1) A 50-year-old woman with no risk factors; (2) a 50-year-old woman with a history of PE; and (3) a 35-year-old woman actively using birth control pills (BCPs). Results. The response rate for the survey was 80% (80/100). Replies regarding the use of thromboprophylaxis were as follows: (1) in the absence of risk factors, 57% of respondents (45/80) answered, “No prophylaxis required”; (2) for the scenario in which the patient had experienced a previous PE, 97.5% of respondents (78/80) answered, “Yes” to prophylaxis use; (3) for the scenario in which the patient was on BCP, 61.3% of respondents (49/80) stated that they would give some type of thromboprophylaxis. The most commonly recommended methods of prophylaxis were aspirin, 49% (24/49), and low-molecular-weight heparin, 47% (23/49). The recommended length of time for thromboprophylaxis varied widely, from 1 day to more than 6 weeks. Conclusion. There remains wide variation in the practice of deep-vein thrombosis thromboprophylaxis within the foot and ankle community. Because risks for foot and ankle patients differ from those in the well-studied areas of hip and knee, specific guidelines are needed for foot and ankle surgery. Levels of Evidence: Level V: Expert Opinion

Hallux Rigidus: Nonoperative Treatment and Orthotics

Hallux rigidus, the most common degenerative disorder of the foot, is accountable for abnormality of gait and restriction of activity levels and daily function. This article describes and reviews the available literature on nonoperative modalities available in the treatment of hallux rigidus, including manipulation and intra-articular injections, shoe modifications and orthotics, physical therapy, and experimental therapies.

Clinical Outcomes of Nonunions of Hindfoot and Ankle Fusions.

BACKGROUND While nonunion after foot and ankle fusion surgery has been associated with poor outcomes, we are not aware of any longitudinal study on this subject. Thus, we prospectively evaluated the impact of nonunion on clinical outcomes of foot and ankle fusions and identified potential risk factors for nonunion after these procedures. METHODS Using data from a randomized clinical trial on recombinant human platelet-derived growth factor-BB (rhPDGF-BB; Augment Bone Graft, BioMimetic Therapeutics), union was defined either by assessment of computed tomography (CT) scans at 24 weeks by a reviewer blinded to the type of treatment or by the surgeons composite assessment of clinical and radiographic findings at 52 weeks and CT findings at 24 or 36 weeks. The nonunion and union groups (defined with each assessment) were then compared in terms of clinical outcome scores on the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS-AHS), Foot Function Index (FFI), and Short Form-12 (SF-12) as well as age, sex, body mass index (BMI), smoking status, diabetes status, work status, and arthrodesis site. RESULTS Blinded CT assessment identified nonunion in 67 (18%) of 370 patients, and surgeon assessment found nonunion in 21 (5%) of 389 patients. Postoperatively, the nonunion group scored worse than the union group, regardless of the method used to define the nonunion, on the AOFAS-AHS and FFI, with mean differences of 10 and 12 points, respectively, when nonunion was determined by blinded CT assessment and 19 and 20 points when it was assessed by the surgeon. The nonunion group also had worse SF-12 Physical Component Summary scores. Differences between the union and nonunion groups were clinically meaningful for all outcome measures, regardless of the nonunion assessment method. The concept of an asymptomatic nonunion (i.e., imaging indicating nonunion but the patient doing well) was not supported. Patients with nonunion were more likely to be overweight, smokers, and not working. CONCLUSIONS This prospective longitudinal study demonstrated poorer functional outcomes in patients with a nonunion after foot and ankle fusion, regardless of whether the diagnosis of nonunion was based on CT only or on combined clinical, radiographic, and CT assessment. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The role of orthobiologics in foot and ankle surgery

Orthobiologics are biological substances that are used therapeutically for their positive effects on healing skeletal and soft-tissue injuries. The array of orthobiological products currently available to the foot and ankle surgeon is wide, and includes bone allografts, bone substitutes, growth factors, and chondral scaffolds. Nonetheless, despite the surge in interest and usage of orthobiologics, there remains a relative paucity of research addressing their specific applications in foot and ankle surgery. In this review, we attempt to provide an overview of the literature on commonly available allogenic bone grafts and bone substitutes. There is Level II, III and IV evidence addressing allogenic bone grafts in primary arthrodesis and osteotomy procedures in foot and ankle surgery, which compares favourably with autogenic bone grafts in terms of fusion rates and clinical outcomes (often with fewer complications), and supports a Grade B recommendation for its use. Pertaining to bone substitutes, the multiplicity of products, coupled with a lack of large prospective clinical trials, makes firm recommendations difficult. Level II and IV studies of calcium phosphate and calcium sulphate products in displaced intra-articular calcaneal fractures have found favourable results in addressing bone voids, maintaining reduction and promoting union, meriting a Grade B recommendation. Evidence for TCP is limited to level IV studies reporting similarly good outcomes in intra-articular calcaneal fractures, warranting a Grade C recommendation. The use of demineralised bone matrix products in hindfoot and ankle fusions has been described in Level II and III studies, with favourable results in achieving fusion and good clinical outcomes, supporting a Grade B recommendation for these indications. Overall, despite the general lack of high-level evidence in foot and ankle surgery, allogenic bone grafts and bone substitutes continue to hold front-line roles in treating the bone defects encountered in trauma, tumour, and deformity correction surgery. However, more investigation is required before firm recommendations can be made. Cite this article: EFORT Open Rev 2017;2:272–280. DOI: 10.1302/2058-5241.2.160044

Return to physical activity after gastrocnemius recession

AIM To prospectively investigate the time taken and patients’ ability to resume preoperative level of physical activity after gastrocnemius recession. METHODS Endoscopic gastrocnemius recession (EGR) was performed on 48 feet in 46 consecutive sportspersons, with a minimum follow-up of 24 mo. The Halasi Ankle Activity Score was used to quantify the level of physical activity. Time taken to return to work and physical activity was recorded. Functional outcomes were evaluated using the short form 36 (SF-36), American Orthopedic Foot and Ankle Society (AOFAS) Hindfoot score and modified Olerud and Molander (O and M) scores respectively. Patient’s satisfaction and pain experienced were assessed using a modified Likert scale and visual analogue scales. P-value < 0.05 was considered statistically significant. RESULTS Ninety-one percent (n = 42) of all patients returned to their preoperative level of physical activity after EGR. The mean time for return to physical activity was 7.5 (2-24) mo. Ninety-eight percent (n = 45) of all patients were able to return to their preoperative employment status, with a mean time of 3.6 (1-12) mo. Ninety-six percent (n = 23) of all patients with an activity score > 2 were able to resume their preoperative level of physical activity in mean time of 8.8 mo, as compared to 86% (n = 19) of patients whose activity score was ≤ 2, with mean time of 6.1 mo. Significant improvements were noted in SF-36, AOFAS hindfoot and modified O and M scores. Ninety percent of all patients rated good or very good outcomes on the Likert scale. CONCLUSION The majority of patients were able to return to their pre-operative level of sporting activity after EGR.

Tibiotalocalcaneal Arthrodesis With the Hindfoot Arthrodesis Nail: A Prospective Consecutive Series From a Single Institution

ABSTRACT Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure. We report a series of 20 patients who underwent TTCA using an intramedullary nail. Of the 20 patients, 7 (35%) had diabetes mellitus. The patient experiences and outcomes were analyzed. Their mean age was 61.1 (range 39 to 78) years. The minimum follow‐up period was 13 (mean 28, range 13 to 49) months. Surgical indications included diabetic Charcot arthropathy in 7 (35%), hindfoot osteoarthritis in 10 (50%), and severe equinovarus deformity in 3 (15%). A calcaneal spiral blade was used in 2 patients (10%). Significant improvements (p < .05) were observed in 5 of 8 Short‐Form 36‐item Health Survey components, the American Orthopaedic Foot and Ankle Society Ankle‐Hindfoot scale (p < .001), and visual analog scale for pain (p < .001). The mean length of the hospital stay was 6.7 (range 1 to 27) days. Of the 20 patients, 76.9% had improvement in their activity postoperatively. Also, 81.8% were able to resume their preoperative work after a mean of 7.89 (range 3 to 24) months. Overall, 19 patients (95%) reported favorable outcomes. Superficial wound infection (n = 4; 20%) and deep wound infection (n = 3; 15%) were the most common complications (35%), with 1 case (5%) culminating in a below‐the‐knee amputation. Radiographic union was achieved in 16 of the tibiotalar joints (80%), 16 subtalar joints (80%), and 4 tibiocalcaneal fusions (20%). In a subgroup analysis of 7 patients with diabetes mellitus (35%), the incidence of wound complications and fusion was comparable to that of the primary cohort. TTCA performed with an intramedullary nail appears to offer a reliable and safe alternative for patients with severe ankle and hindfoot pathologic entities, including those with diabetes mellitus. Level of Clinical Evidence: 4

Perceived risk factors for nonunion following foot and ankle arthrodesis

Background: A major complication of foot and ankle arthrodesis is nonunion, which occurs in approximately 12% of cases. Various factors influence a patient’s risk for nonunion following foot and ankle arthrodesis. We surveyed international foot and ankle surgeons to determine (1) risk factors perceived most important for nonunion, (2) factors considered absolute contraindications for arthrodesis, and (3) differences among expert groups regarding perceived risk factors and their stratification. Methods: A questionnaire was e-mailed to members of a major foot and ankle journal editorial board and four foot and ankle society executive committees. The relative risk of 18 potential nonunion risk factors was rated from 1 to 10, using smoking 1 pack/day as a benchmark score of 5.00. Results: The response rate was 72% (100/139); 81% declared foot and ankle surgery encompasses >90% of their practice. The highest perceived risk factors (p < 0.001) were smoking 2 packs/day (mean score 8.69), lack of fusion site stability (8.66), and poor local vascularity (7.66). The least important risk factors (p < 0.001) were perceived to be age >60 years (mean score 2.54), rheumatoid arthritis (3.05), and osteoporosis (3.56). The most frequently cited absolute contraindications to arthrodesis surgery were local infection (46%), poor local vascularity (41%), and smoking (32%). Conclusion: To improve arthrodesis outcomes, resource allocation and patient and surgeon education should focus on smoking, construct stability, and local vascularity. Development of an objective nonunion risk assessment tool to identify patients at risk for nonunion using these results could help maximize the efficiency of available resources.

Preoperative Mental Health Score and Postoperative Outcome After Hallux Valgus Surgery

Background: Preoperative mental health status as a predictor of operative outcome has been a growing area of interest. In this paper, the correlation between preoperative mental health status and postoperative functional outcome following scarf osteotomy for hallux valgus correction was explored. Methods: Parameters were tabulated preoperatively and postoperatively at a minimum of 1-year follow-up. They included the Short Form 36 (SF-36), American Orthopaedic Foot & Ankle Society (AOFAS) forefoot score, hallux valgus angle (HVA), and intermetatarsal angle (IMA) measurements and the visual analog score (VAS) to quantify pain. SF-36 mental component summary (MCS) score was used as a surrogate for patient’s mental health status. Seventy-six consecutive cases were analyzed at a minimum of 1-year follow-up. Results: There were significant improvements in all 8 domains of the SF-36, with the mean MCS score increasing from 52.3 ± 7.6 preoperatively to 55.7 ± 6.8 postoperatively. Preoperative MCS scores were not correlated to changes in AOFAS score, PCS score, VAS pain score, HVA or IMA. Preoperative MCS was observed to be correlated to postoperative AOFAS (r = 0.381, P = .001) and PCS score (r = 0.315, P = .006). Patients with a preoperative MCS score ⩾50 had a statistically higher postoperative AOFAS and PCS score than patients with MCS score <50. There was no correlation between preoperative MCS scores and improvements in radiologic parameters. There was also no correlation between the improvements in radiologic parameters and improvements in both the AOFAS and VAS pain scores. Conclusion: Preoperative mental health (as measured by the MCS score) was only correlated to postoperative functional outcome (as measured by the postoperative AOFAS and PCS score), but not other postoperative outcomes (VAS pain score, radiologic parameters). Level of Evidence: Level III, comparative study.