Harshadkumar Patel

Staple Versus Suture Closure for Ankle Fracture Fixation: Retrospective Chart Review for Safety and Outcomes

INTRODUCTION/AIMnRecent comparisons of suture versus metal staple skin closure on the rates of wound complications in orthopaedic surgeries have yielded conflicting results. Several studies have since started to approach this question based on anatomic location, comparing suture versus staple closure in total hip and knee arthroplasty and acetabulum fracture surgery. Ankle fractures are one of the most commonly treated fractures by orthopaedic surgeons with unique challenges to skin closure due to the lack of subcutaneous support. However, to date there are no studies comparing superficial skin closure methods specifically in ankle surgery. The objective of this study was to evaluate the safety of staple versus suture closure for open fixation of acute traumatic ankle fractures.nnnMETHODSnThe medical records of patients treated at one institution by a single surgeon with open surgical fixation of an acute traumatic ankle fracture between 2011 and 2017 were retrospectively reviewed. Patients with less than 6 months of follow-up, polytrauma patients, diabetic patients, and patients with more than 3 medical comorbidities were excluded. Skin closure technique was determined by the presence or absence of metallic staples on postoperative imaging. Demographic variables, surgical characteristics, and postoperative outcomes up to one year were compared between patients who received superficial skin closure using staple versus suture techniques. Statistical analysis was performed using chi-squared tests and Fishers exact tests, with p=0.05 used to denote statistical significance.nnnRESULTSnThis study included 94 patients aged 18 to 75: two groups of 47 patients (Staple group and Suture group) that were demographically similar at baseline. Overweight and obese patients constituted the majority of the sample, 34% and 46% of patients, respectively. Current tobacco use was reported by 45% of patients. Fractures tended to be right-sided (63%), low energy (64%), and closed (98%), and the most common fracture types were bimalleolar (30%), lateral malleolar (24%), and pilon (19%) fractures. Ten patients (10.6%) developed local wound related complications within 4 months postoperatively, including five incidences of wound dehiscence, four superficial wound infections, and one deep infection. Eight patients (8.5%) required revision surgery due to wound related complications. There was no difference in the incidence of surgical site infections (p=0.361), local wound related complications (p=0.316), or revision surgeries (p=0.267) between wound closure techniques. Suture group patients required more staff in the operating room compared with staple group patients (p=0.001).nnnCONCLUSIONnThese results suggest that staples are a safe alternative to sutures for superficial skin closure in healthy, non-diabetic patients following open surgical fixation of acute traumatic ankle fractures. However, this retrospective, single-institution study was limited by the low number of available patients relative to the rare outcomes of interest. Larger, prospective studies are needed to validate the accuracy and generalizability of these results.

The surgical anatomy of the dorsal scapular nerve: a triple-tendon transfer perspective

BACKGROUNDnIatrogenic or traumatic injury to the spinal accessory nerve is a rare but debilitating injury. An effective treatment, known as the Eden-Lange modification triple-tendon transfer procedure, involves the transfer of the rhomboid major (RM), rhomboid minor (Rm), and levator scapulae (LS). Careful detachment of their insertions is necessary to avoid injury of the dorsal scapular nerve (DSN). This study evaluated the surgical anatomy and safety of the DSN relative to this procedure.nnnMETHODSnThe study used 12 cadavers (22 shoulders). The RM, Rm, and LS were detached from their insertions, and the DSN was dissected. Measurements were taken to evaluate the anatomy of each relative to the triple-tendon transfer procedure. Additional measurements were taken to identify danger zones for DSN injury, regarding detachment of RM, Rm, and LS from their respective insertions.nnnRESULTSnMeasurements of the 22 shoulders included in the study showed wide variation in anatomy. The minimum distance between the scapula and the DSN at the vertebral scapular border was 0.7u2009cm, suggesting that care and precision are needed to perform this technique. The region where the DSN crosses the superior border of the Rm was shown to be the greatest danger zone of this technique, with a mean distance to the scapula of 1.61u2009±u20090.53u2009cm CONCLUSIONS: This study provides insight into the surgical anatomy of the DSN relative to a rare but successful procedure used to treat trapezius paralysis. The results of this study can inform the surgeon regarding potential anatomic considerations when performing the triple-tendon transfer.

Is interposition arthroplasty a viable option for treatment of moderate to severe hallux rigidus? — A systematic review and meta-analysis

INTRODUCTIONnWhen conservative therapy for hallux rigidus fails, surgical options such as arthrodesis and interposition arthroplasty can be considered. Although arthrodesis of MTP joint is the gold standard treatment. However patients desiring MTP joint movement may opt for either interposition arthroplasty or implant arthroplasty to avoid the movement restrictions of arthrodesis. The purpose of this systematic review was to investigate clinical outcomes and complications following interposition arthroplasty for moderate to severe hallux rigidus, for patietns who would prefer to maintain range of motion in the MTP joint.nnnMETHODSnA systematic search on MEDLINE, EMBASE and Cochrane library database was performed during February 2018. Demographics, surgical techniques, clinical outcomes, radiological outcomes and complications were recorded from each included study. Pooled statistics performed for variables with homogenous data across the studies. A linear regression model used to compare the clinical outcomes between autogenous vs allogenous material interposition arthroplasty.nnnRESULTSnFifteen articles were included in the systematic review. Mean AOFAS scores improved from preoperative 41.35 to postoperative 83.17. Mean pain, function, and alignment score improved from preoperative values of 14.9, 24.9, and 10 to postoperative values of 33.3, 35.8, and 14.5. Mean dorsiflexion increased from 21.27° (5-30) to 42.03° (25-71). Mean ROM improved from 21.06° to 46.43°. Joint space increased from 0.8mm to 2.5mm. The most common postoperative complications included metatarsalgia (13.9%), loss of ground contact (9.7%), osteonecrosis (5.4%), great toe weakness (4.8%), hypoesthesia (4.2%), decreased push off power (4.2%), and callous formation (4.2%).nnnCONCLUSIONnInterposition arthroplasty is an effective treatment option with acceptable clinical outcomes in patients with moderate-severe hallux rigidus who prefer to maintain range of motion and accept the risk of future complications.nnnLEVEL OF EVIDENCEnIV.

Incidence of and Risk Factors for Venous Thromboembolism After Foot and Ankle Surgery

Background: Venous thromboembolism (VTE) is a rare but potentially lethal complication after orthopaedic foot and ankle surgery. The true incidence of VTE after orthopaedic foot and ankle surgery stratified by specific procedure has yet to be examined. The purpose of this study is to report the incidence of and identify risk factors for VTE in a large sample of patients receiving orthopaedic foot and ankle surgery. Methods: In this study, we retrospectively analyzed data from the National Surgical Quality Improvement Program 2006 to 2015 data files. The incidence of VTE was calculated for 30 specific orthopaedic foot and ankle surgeries and for 4 broad types of foot and ankle surgery. Demographic, comorbidity, and complication variables were analyzed to determine associations with development of VTE. Results: The overall incidence of VTE in our sample was 0.6%. The types of procedures with the highest frequency of VTE were ankle fractures (105/15 302 cases, 0.7%), foot pathologies (28/5466, 0.6%), and arthroscopy (2/398, 0.5%). Female gender, increasing age, obesity, inpatient status, and nonelective surgery were all significantly associated with VTE. Conclusion: Although VTE after orthopaedic foot and ankle surgery is a rare occurrence, several high-risk groups and procedures may be especially indicated for chemical thromboprophylaxis. Levels of Evidence: Level III: Retrospective, comparative study

A Safety and Cost Analysis of Outpatient Versus Inpatient Hindfoot Fusion Surgery

Background. Hindfoot fusion procedures are increasingly being performed in the outpatient setting. However, the cost savings of these procedures compared with the risks and benefits has not been clearly investigated. The objective of this study was to compare patient characteristics, costs, and short-term complications between inpatient and outpatient procedures. Methods. This was a retrospective review of all patients who underwent inpatient and outpatient hindfoot fusion procedures by a single surgeon, at 1 academic institution, from 2013 to 2017. Data collected included demographics, operative variables, comorbidities, complications, costs, and subsequent reencounters. Results. Of 124 procedures, 34 were inpatient and 90 were outpatient. Between procedural settings, with the numbers available, there was no significant increase in complication rate or frequency of reencounters within 90 days. There were no significant differences in the number of patients with reencounters related to the index procedure within 90 days (P = .43). There were 30 reencounters within 90 days after outpatient surgery versus 4 after inpatient surgery (P = .05). The total number of emergency room visits in the outpatient group within 90 days was significantly higher compared with the inpatient group (P = .04). The average cost for outpatient procedures was US

Syndesmotic Fixation With Suture Button. Neurovascular Structures at Risk. A Cadaver Study

4159 less than inpatient procedures (P < .0001). Conclusion. Outpatient hindfoot fusion may be a safe alternative to inpatient surgery, with significant overall cost savings and similar rate of short-term complications. On the basis of these findings, we believe that outpatient management is preferable for the majority of patients, but further investigation is warranted. Levels of Evidence: Level III

Incidence of Venous Thromboembolism in Orthopaedic Foot and Ankle Surgeries

Category: Trauma Introduction/Purpose: Damage to distal tibiofibular syndesmosis occurs in 25% of operative ankle fractures. Syndesmotic stabilization is crucial to prevent significant pain, instability and degeneration of the joint. One operative method is insertion of suture buttons. Though effective, this method can result in entrapment and damage of the saphenous neurovasculature of the medial tibia. The purpose of this study was to describe the anatomic risk of direct injury to the saphenous nerve and greater saphenous vein during syndesmotic suture button fixation. Methods: This study was performed on 10 below knee cadaveric leg specimens. Under fluoroscopic guidance, syndesmotic suture buttons were placed from lateral to medial at 1cm, 2cm, and 3cm above the tibial plafond at an anterior angle of 30 degrees to the coronal plane. Dissection was performed through medial tibial incision to record the distance and position of each button from the greater saphenous vein and saphenous nerve. Statistical measurement and analysis was performed with SPSS. Results: The mean age of cadavers was 78.2 ± 6.9 years and mean BMI was 21.6 ± 2.2. The mean distance of the saphenous nerve to the suture buttons at 1cm, 2cm, and 3cm were 7.1 ± 5.6mm, 6.5 ± 4.6mm, and 6.1 ± 4.2mm, respectively. The saphenous nerve was compressed in 2 cadavers (20%) at 1cm, 2 cadavers (20%) at 2cm and 1 cadaver (10%) at 3cm by suture buttons. Mean distance of the greater saphenous vein from the suture buttons at 1cm, 2cm and 3cm were 8.6 ± 7.1, 9.1 ± 5.3, and 7.9 ± 4.9mm respectively. The great saphenous vein was compressed in 2 cadavers (20%) at 1cm, 1 cadaver (10%) at 2cm and 1 cadaver (10%) at 3cm by suture buttons. Conclusion: There was at least one case of injury to both the saphenous vein and nerve at every level of button insertion at a rate of 10-20%. The close proximity of the suture button to neurovasculature combined with significant anatomic variation in saphenous nerve anatomy suggest that neurovascular injury may be best avoided by direct visualization prior to suture button placement. Great care should be taken to avoid injury to saphenous neurovascular structures during suture button insertion. Keeping an eye on close proximity of neurovasculatures, we recommend medial incision for during syndesmotic suture button fixation.

Postoperative Tourniquet Pain in Patients Undergoing Foot and Ankle Surgery

Category: Other Introduction/Purpose: Venous thromboembolism (VTE) is a rare but potentially lethal complication following orthopaedic foot and ankle surgery. Surgeons continue to debate the types of patients and procedures in which it is appropriate to use chemical thromboprophylaxis. A recent meta-analysis concluded that patients at high risk for VTE after foot and ankle surgery should receive prophylaxis, but there remains a paucity of data to elucidate which demographic or comorbidity variables are most strongly associated with development of VTE. The incidence of VTE after orthopaedic foot and ankle surgery stratified by specific procedure has yet to be examined. The purpose of this study is to report the incidence of and identify risk factors for VTE in a large sample of patients receiving orthopaedic foot and ankle surgery. Methods: In this study, we retrospectively analyzed prospectively-collected data from the National Surgical Quality Improvement Program (NSQIP) 2006 to 2015 data files. The incidence of VTE was calculated for 30 specific orthopaedic foot and ankle surgeries and for four broad types of foot and ankle surgery. A total of 23,212 patients were identified and grouped by current procedures terminology (CPT) codes. Demographic, comorbidity, and complication variables were analyzed to determine associations with development of VTE. Pearson’s chi-squared test was used to compare categorical variables and Student t test was used to compare continuous variables. P-values of p<0.05 were considered statistically significant. Multivariable modelling was not possible due to the very low number of VTE cases relative to non-VTE cases. Results: The mean age at the time of surgery was 52.7±17.8 years. VTE events were documented 142 times in our sample, yielding an overall sample VTE incidence of 0.6%. The types of procedures with the highest frequency of VTE were ankle fractures (105/15,302 cases, 0.7%), foot pathologies (28/5,466, 0.6%), and arthroscopy (2/398, 0.5%). Female sex, increasing age, obesity level, inpatient status, and non-elective surgery were all significantly associated with VTE events. Postoperative pneumonia was significantly associated with VTE development. Patients who developed a VTE stayed at the hospital after surgery significantly longer than patients without VTE (6.2 vs. 3.1 days). Patients who developed VTE also had significantly higher estimated probability of morbidity (8.0% vs. 6.0%) and mortality (2.0% vs. 1.0%) when compared to patients without VTE. Conclusion: The present study confirms that VTE events after foot and ankle procedures are rare. The data presented suggest that female sex, increasing age, higher BMI, inpatient status, and non-elective procedures are associated with increased risk for VTE after orthopaedic foot and ankle surgery. Prospective, randomized, controlled trials are necessary to definitively determine the efficacy of chemoprophylaxis and to develop evidence-based clinical practice guidelines to minimize VTE after foot and ankle procedures.

Hemi vs. Total joint arthroplasty for hallux rigidus: a systematic review and a Meta-analysis

Category: Other Introduction/Purpose: The tourniquet is commonly used in orthopedic surgeries on the upper and lower extremities to reduce blood loss, improve visualization, and expedite the surgical procedure. However, tourniquets have been associated with multiple local and systemic complications, including postoperative pain. Guidelines vary regarding ideal tourniquet pressure and duration, while the practice of fixed, high tourniquet pressures remains common. The relationship between tourniquet pressure, duration, and postoperative pain has been studied in various orthopaedic procedures, but these relationships remain unknown in foot and ankle surgery. The purpose of this study was to assess for correlation between excessive tourniquet pressure and duration and the increased incidence of tourniquet pain in foot and ankle surgery patients. Methods: Retrospective chart review was performed for 132 adult patients who underwent foot and ankle surgery with concomitant use of intraoperative tourniquet at a single institution between August and December of 2015. Patients with history of daily opioid use of 30 or more morphine oral equivalents for greater than 30 days, patients who underwent foot and ankle surgery without regional nerve block, patients deemed to have failed regional nerve block, and patients who underwent foot and ankle surgery without tourniquet use were excluded. Patient’s baseline systolic blood pressure, tourniquet pressure and duration, tourniquet deflation time, tourniquet reinflation pressure and duration, intraoperative blood pressure and heart rate changes, intra-operative opioid consumption, PACU pain scores, PACU opioid consumption, and PACU length of stay were collected. Statistical correlation between tourniquet pressure and duration and postoperative pain scores, pain location, narcotic use, and length of stay in PACU was assessed using linear regression in SPSS. Results: Average age of patients was 47.6 years (Range: 16 - 79). Tourniquet pressure was 280 mmHg in 90.6% of patients (Range: 250-300 mmHg). Only 3.8% percent of patients had tourniquet pressures 100-150 mmHg above systolic blood pressure. Mean tourniquet time was 106.2 ± 40.1 min. Tourniquet time showed significant positive correlation with morphine equivalents used in the perioperative period (N = 121; r = 0.406; p < 0.001). Long tourniquet times (= 90 minutes) were associated with greater intraoperative opioid use than short tourniquet times (= 90 minutes) (19 mg ± 22 mg vs. 5 mg ± 11.6 mg; p <0.001). Tourniquet duration and PACU length of stay had a positive association (R2 = 0.4). Conclusion: The majority of cases of foot and ankle surgery at our institution did not adhere to current tourniquet use guidelines, which recommend tourniquet pressure between 100 and 150 mmHg above patient’s systolic blood pressure. Prolonged tourniquet times at high pressures not based on limb occlusion pressure, as observed in our study, lead to increased pain and opioid use and prolonged time in PACU. Basing tourniquet pressures on limb occlusion pressures could likely improve the safety margin of tourniquets, however randomized studies need to be completed to confirm this.

A Comparative Analysis of Risk and Cost-effectiveness of Outpatient versus Inpatient Hindfoot Fusion

Category: Midfoot/Forefoot Introduction/Purpose: Advanced-stage arthritis of the first metatarsophalangeal joint (MTPJ), or “Hallux Rigidus” (HR) is a common forefoot pathology. When surgery is indicated, arthroplasty is an alternative to arthrodesis, which aims to preserve MTPJ dorsiflexion. Since it is unclear whether total-toe or hemi-toe devices are preferred implants in MTPJ arthroplasty, we completed a systematic review of the literature and did a meta analysis to test which type of implants clinically outperform in hallux rigidus. Methods: A systematic review of MTPJ arthroplasty was performed using Pubmed, EMBASE, SCOPUS, and Cochrane library for the years 2000 to 2017. Data was extracted from articles containing both preoperative and postoperative endpoints for either hemi or total MTPJ arthroplasty cases. To be eligible for inclusion, studies must have had a mean follow-up window of at least 24 months and standard deviation of outcome. Total eleven studies were included for review, seven studies with hemi replacement and six studies with total arthroplasty. Pooled mean values were calculated, and a forest plot was created comparing pre-and post-operative American Orthopedic Foot and Ankle Score (AOFAS), visual analogue scale (VAS), and range of motion (ROM) results for both hemi-toe and total-toe arthroplasty. Statistical analysis was performed using SPSS. Results: Mean postoperative AOFAS scores in patients undergoing hemiarthroplasty improved by 50.7 points (95%CI: 48.5, 52.8), which was higher than the mean postoperative AOFAS improvement of 40.6 points (95%CI: 38.5, 42.8) seen in total-toe patients. Mean postoperative VAS improvement in hemiarthroplasty was 6.05 points (95%CI: 5.92, 6.18), which was comparable to the mean VAS improvement of 6.29 points (95%CI: 6.02, 6.55) seen in total arthroplasty. Mean postoperative MTPJ ROM improved by 43.0 degrees (95%CI: 39.3, 46.6) in hemi-toe patients, which exceeded the mean ROM improvement of 32.5 degrees (95%CI: 29.9, 35.1) found in total-toe cases. A meta-analysis of the data revealed non-significant statistical trends for AOFAS and ROM in favor of hemiarthroplasty. Conclusion: Hemi-surface implants in MTPJ arthroplasty may improve postoperative AOFAS and ROM results to a greater extent than total-toe devices. High-quality randomized controlled studies are needed to confirm long-term surgical outcomes in these patients.