J. Turner Vosseller

How long should patients be kept non-weight bearing after ankle fracture fixation? A survey of OTA and AOFAS members

BACKGROUND Ankle fractures are common injuries treated routinely by orthopaedic surgeons. A variety of different post-operative protocols have been described with differing periods of non-weight bearing after surgery. The aim of this study was to identify how patient injury characteristics and medical comorbidities contribute to the period of non-weight bearing chosen by orthopaedic surgeons after open reduction and internal fixation of rotational ankle fractures. METHODS A cross sectional expert opinion survey was administered to members of the AOFAS as well as OTA to determine how long they would instruct patients to be non-weight bearing after open reduction and internal fixation of ankle fractures. Three different injury characteristics were described: supination external rotation type 4 equivalents, bimalleolar, and trimalleolar patterns. These patterns were combined with three different medical statuses: young and healthy, older and healthy, and older with significant medical comorbidity. Respondents selected how long they would keep the patient non-weight bearing after surgery for each of the potential scenarios. Finally, they were directly asked which factors they felt affected their decision about length of time to keep patients non-weight bearing. RESULTS Seven hundred and two surgeons (31%) responded to the survey. The average time of non-weight bearing selected varied from 4.9 (± 3.1) weeks for in young, healthy patients with SER4 equivalent injuries to 7.6 (± 6.0) weeks for older patients with medical comorbidities with trimalleolar fractures. Responses had a high degree of heterogeneity, but both injury pattern and medical status were significant predictors of non-weight bearing period (p<0.01), with medical status the stronger determinant. CONCLUSIONS There is significant variation among orthopaedic surgeons when selecting period of non-weight bearing after fixation of ankle fractures, with both injury pattern and medical comorbidity playing a role in decision of time to keep patient non-weight bearing. Further research further evaluating the relationship between these factors and safe periods of non-weight bearing could help identify patients that may benefit from earlier mobilization, and improve surgeons comfort with early mobilization. LEVEL OF EVIDENCE Therapeutic Level V.

Posterolateral Approach for Open Reduction and Internal Fixation of a Posterior Malleolus Fracture—Hinging on an Intact PITFL to Disimpact the Tibial Plafond: A Technical Note

Level of Evidence: Level V, expert opinion.

Incidence of Syndesmotic Injury

Injury to the tibiofibular syndesmosis can occur with ankle sprain or fracture. The incidence of syndesmotic injury has not been specifically studied at a population level. Data on syndesmotic injury were obtained from the Healthcare Cost and Utilization Project (HCUP), a federal-state-private partnership. It is administered by the Agency for Healthcare Research and Quality, a division of the US Department of Health and Human Services. Two HCUP databases were queried for 8 states: the State Inpatient Database and the State Emergency Department Database. The first 6 International Classification of Diseases, Ninth Edition (ICD-9) code diagnoses were searched for codes that are used for syndesmotic injury (ie, 845.03). These data, along with data from the 2010 US census, were used to yield incidence rates for syndesmosis injury, as well as for various demographic groups. National estimates of injury totals were also calculated. In the 8 states, there were a total of 1821 syndesmotic injuries. Given the population of these states, the incidence rate of syndesmotic injury was 2.09 syndesmotic injuries per 100,000 person-years. This incidence correlates to an estimated 6445 syndesmotic injuries per year in the United States. These data provide some baseline numbers as to the incidence of syndesmotic injury in the United States. Although the incidence was low relative to some other injuries, the fact that syndesmotic injuries tend to occur in younger patients may have a greater effect in terms of productive years of life lost.

Professional Athletes' Return to Play and Performance After Operative Repair of an Achilles Tendon Rupture.

Background: Most Achilles tendon ruptures are sports related. However, few studies have examined and compared the effect of surgical repair for complete ruptures on return to play (RTP), play time, and performance across multiple sports. Purpose: To examine RTP and performance among professional athletes after Achilles tendon repair and compare pre- versus postoperative functional outcomes of professional athletes from different major leagues in the United States. Study Design: Cohort study; Level of evidence, 3. Methods: National Basketball Association (NBA), National Football League (NFL), Major League Baseball (MLB), and National Hockey League (NHL) athletes who sustained a primary complete Achilles tendon rupture treated surgically between 1989 and 2013 were identified via public injury reports and press releases. Demographic information and performance-related statistics were recorded for 2 seasons before and after surgery and compared with matched controls. Statistical analyses were used to assess differences in recorded metrics. Results: Of 86 athletes screened, 62 met inclusion criteria including 25 NBA, 32 NFL, and 5 MLB players. Nineteen (30.6%) professional athletes with an isolated Achilles tendon rupture treated surgically were unable to return to play. Among athletes who successfully returned to play, game participation averaged 75.4% (P < .001) and 81.9% (P = .002) of the total games played the season before injury at 1 and 2 years postoperatively, respectively. Play time was significantly decreased and athletes performed significantly worse compared with preoperative levels at 1 and 2 years after injury (P < .001). When players were compared with matched controls, an Achilles tendon rupture resulted in fewer games played (P < .001), decreased play time (P = .025), and worse performance statistics (P < .001) at 1 year but not 2 years postoperatively (P > .05). When individual sports were compared, NBA players were most significantly affected, experiencing significant decreases in games played, play time, and performance. Conclusion: An Achilles tendon rupture is a devastating injury that prevents RTP for 30.6% of professional players. Athletes who do return play in fewer games, have less play time, and perform at a lower level than their preinjury status. However, these functional deficits are seen only at 1 year after surgery compared with matched controls, such that players who return to play can expect to perform at a level commensurate with uninjured controls 2 years postoperatively.

Increasing age in Achilles rupture patients over time

BACKGROUND The changing demographics of Achilles tendon rupture (ATR) patients have not fully been investigated. However, there has been a general suspicion that this injury is occurring in an increasingly older population, in terms of mean age. The aim of this study was to objectively show an increase in age in Achilles tendon rupture patients over time. METHODS Published literature on Achilles tendon ruptures was searched for descriptive statistics on the demographics of patients in the studies, specifically mean and median age of Achilles tendon rupture patients, gender ratio, percentage of athletics-related injuries, percentage of smokers, and BMI. Linear regression analyses were performed to determine the trend of patient demographics over time. A Welch one-way ANOVA was carried out to identify any possible differences in data obtained from different types of studies. RESULTS The patient demographics from 142 studies were recorded, with all ATR injuries occurring between the years 1953 and 2014. There was no significant difference in the mean age data reported by varying study types, i.e. randomized controlled trial, cohort study, case series, etc. (P=0.182). There was a statistically significant rise in mean age of ATR patients over time (P<0.0005). There was also a statistically significant drop in percentage of male ATR patients (P=0.02). There is no significant trend for percentage of athletics-related injuries, smoking or BMI. CONCLUSION Since 1953 to present day, the mean age at which ATR occurs has been increasing by at least 0.721 years every five years. In the same time period, the percentage of female study patients with ATR injuries has also been increasing by at least 0.6% every five years. LEVEL OF EVIDENCE Level III; Retrospective cohort study.

Timing of Antibiotic Prophylaxis for Preventing Surgical Site Infections in Foot and Ankle Surgery

Background: Surgical site infections (SSIs) are one of the most troublesome complications after foot and ankle surgery. Previous literature has emphasized the significance of appropriate timing of antibiotic prophylaxis. However, the optimal timing of antibiotic prophylaxis for SSI prevention is still inconclusive. Our study aimed to investigate the optimal timing of antibiotic administration and to elucidate the risk factors for SSIs in foot and ankle surgery. Methods: A retrospective review of 1933 foot and ankle procedures in 1632 patients from January 1, 2011, through August 31, 2015, was performed. Demographic data; type, amount, and timing of antibiotic administration; incision; and closure time were recorded. Subsequent wound infection and incision and drainage procedure (I&D) within 30 days and 90 days were documented. Outcomes and demographic variables were compared between procedures in which antibiotics were administered less than 15 minutes and between 15 to 60 minutes prior to incision. A total of 1569 procedures met inclusion criteria. Results: There were 17 cases (1.1%) of subsequent wound infection, of which 6 required a subsequent I&D within 30 days. There were 63 additional cases (4%) of wound complications, which did not meet SSI criteria. When comparing SSI and non-SSI groups, the only significant independent predictors were longer surgeries and nonambulatory surgeries (both P < .05). Stepwise multivariate logistic regression analysis demonstrated that 91.8% of the risk of an SSI could be predicted by ASA score and length of surgery alone. Conclusion: In foot and ankle surgeries, the timing of intravenous antibiotic prophylaxis did not appear to play a significant role in the risk of SSI. Host factors and duration of surgery appear to have played a much larger role in SSI than the timing of antibiotic prophylaxis. Level of Evidence: Level III, retrospective comparative study.

Risk factors for achilles tendon rupture: A matched case control study

PURPOSE The purpose of this study was to elucidate whether body mass index (BMI), activity level, and other risk factors predispose patients to Achilles tendon ruptures. MATERIALS AND METHODS A retrospective review of 279 subjects was performed (93 with Achilles tendon rupture, matched 1:2 with 186 age/sex matched controls with ankle sprains). Demographic variables and risk factors for rupture were tabulated and compared. RESULTS The rupture group mean BMI was 27.77 (95% CI, 26.94-28.49), and the control group mean BMI was 26.66 (95% CI, 26.06-27.27). These populations were found to be statistically equivalent (p=0.047 and p<0.001 by two one-sided t-test). A significantly higher proportion of those suffering ruptures reported regular athletic activity at baseline (74%) versus controls (59%, p=0.013). CONCLUSION There was no clinically significant difference found in BMI between patients with ruptures and controls. Furthermore, it was found that patients who sustained ruptures were also more likely to be active at baseline than their ankle sprain counterparts.

A new method for achieving compression in hindfoot arthrodesis

BackgroundWhen performing hindfoot arthodeses, one goal of fixation is often to achieve compression across the joint. Traditional lag screws are applied eccentrically, providing compression more on the edge of the fusion. A new technique, using a post in one bone and a lag screw through the post to the other bone, may offer better compression across more of the joint.MethodsThere are three parts to this study comparing a post-and-screw construct to traditional lag screws. Synthetic bone models, representative of the talonavicular joint, were created and assessed for biomechanical measures of compression. Next, the post-and-screw construct was tested in cadavers, under conditions representing early weight bearing after arthrodesis surgery. Finally, 18 patients who had a talonavicular fusion with a post-and-screw construct with one surgeon were compared to the previous 18 patients fixed with traditional screws.ResultsIn the synthetic bone model, the post-and-screw construct brought the centre of compression closer to the centre of the joint, suggesting compression was less eccentric. Neither traditional screws nor the post-and-screw construct were sufficiently strong to resist early weight bearing forces in cadaver specimens. In the clinical comparison, four patients had a painful nonunion when fixed with traditional screws, compared to none in the post-and-screw construct.ConclusionsA post-and-screw construct spreads the forces of compression more uniformly across an arthrodesis, even when placed eccentrically. Although not all the biomechanical measures were superior, the post-and-screw construct achieved higher levels of successful fusion in patients. This technology may offer improved outcomes in some clinical scenarios and deserves further study.Level of Evidence: Level 3

Online Physical Therapy Protocol Quality, Variability, and Availability in Achilles Tendon Repair

Background: Substantial progress has been made in characterizing the benefit of early functional rehabilitation following Achilles tendon repair (ATR). However, standardized ATR rehabilitation guidelines have yet to be produced. Furthermore, as patients increasingly use the Internet to independently retrieve health care content, access to standardized, clinically effective rehabilitation protocols is necessary. Methods: Online ATR physical therapy protocols from US academic orthopaedic programs were reviewed. A comprehensive scoring rubric was designed after reviewing all identified protocols and was used to assess each protocol for both the presence of various rehabilitation components as well as when those components were introduced. Results: Twenty-two of 155 US academic orthopaedic programs published postoperative Achilles rehabilitation protocols online, with a total of 27 individual protocols available for review. Twenty-one protocols (78%) recommended immediate postoperative splinting. Only one protocol recommended short-leg casting. Twenty-six protocols (96%) advised immediate nonweightbearing with progression to weightbearing as tolerated at an average of 3.0 weeks (range, 1-8 weeks) and to full weightbearing at an average of 7.3 weeks (range, 2-12 weeks). Active plantarflexion and dorsiflexion to neutral were included by most protocols (93%) at an average of 3.9 (range, 0-9) weeks and 3.4 (range, 0-8) weeks, respectively. There was considerable variability in the inclusion and timing of strengthening, stretching, proprioception, and basic cardiovascular exercises. Fourteen protocols (52%) recommended return to training after meeting certain athletic activity criteria. Conclusion: The purpose of this investigation was to evaluate the quality, variability, and patient accessibility of publicly available rehabilitation protocols for ATR provided by US orthoapedic teaching programs. To this end, we found that a minority of US academic orthopaedic programs publish ATR rehabilitation protocols online. While a trend away from traditional ankle casting is apparent, many programs have not adopted the accelerated weightbearing and controlled mobilization techniques that have been shown to produce better functional outcomes and greater patient satisfaction. There is also a substantial degree of variability in both the composition and timing of rehabilitation components across physical therapy protocols. Levels of Evidence: Level III: Retrospective comparative study

Time to Diagnosis and Treatment of Surgical Site Infections in Foot and Ankle Surgery

Background: The time at which patients typically present with surgical site infections (SSI) following foot and ankle surgery has not been characterized. The primary aim of this study was to quantify the time to definitive treatment of SSIs. Methods: We performed a retrospective review of 1933 foot and ankle procedures in 1632 patients from 2011 through 2015. Demographic and surgical data were collected. Time to presentation in cases diagnosed with postoperative wound complications or SSIs was analyzed. Wound complications were defined as any case with concerning wound appearance that subsequently resolved with antibiotic therapy alone. SSIs were defined as cases requiring operative irrigation and debridement (I&D) for successful definitive management. Results: A total of 1569 procedures met inclusion criteria, with 17 SSIs (1.1%) and 63 wound complications (4.0%). Time between surgery and definitive treatment in the SSI group was significantly greater than in the wound complication group (28.2 ± 9.1 vs 13.4 ± 4.7 days, P < .00001). Eleven (64.7%) cases in the SSI group failed a trial of antibiotics prior to I&D, and 6 (35.3%) cases did not receive antibiotics prior to I&D. Antibiotic treatment prior to I&D did not significantly decrease the yield of intraoperative wound cultures (70% vs 100%, P = .51). Conclusion: In our cohort of patients, the time to diagnosis and treatment of SSIs was longer than that of wound complications. SSIs requiring operative intervention did not present until an average of 4 weeks after surgery. These data are of some benefit in trying to define and understand SSI. Level of Evidence: Level III, retrospective cohort study.