Peter C. Noback

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.

Arthroscopic Wrist Debridement and Radial Styloidectomy for Advanced Scapholunate Advanced Collapse Wrist: Long-term Follow-up

Background: Symptomatic stage 2 or 3 scapholunate advanced collapse (SLAC) wrist is aggressively treated with salvage procedures, such as proximal row carpectomy or partial wrist fusion with resultant pain relief but limited motion. We hypothesize that arthroscopic synovectomy, radial styloidectomy, and neurectomy will preserve wrist motion, relieve pain, and delay or avoid salvage procedures. Methods: We evaluated outcomes in 13 wrists through questionnaires and 11 of these through additional physical examination at a mean follow-up of 5.0 years. Eight wrists were stage 2 and 5 were stage 3. Data at final follow-up included mobility/strength measurements, subjective outcome scores (Disabilities of the Arm, Shoulder, and Hand [DASH] and visual analog scale [VAS] pain), patient satisfaction, and return to work statistics. Results: Patients had an average flexion-extension arc of 88.0° in the treated wrist and an average grip strength that was 95.0% of the contralateral side. No patients required revision surgery at follow-up. The 13 wrists reported an average DASH score of 16.4 and mean VAS pain score at rest and with activity of 17.9 and 31.6, respectively. All patients working prior to the procedure (n = 8) were able to immediately return to work. In all, 84.6% of patients were satisfied. Conclusions: The procedure studied may have advantages in relieving pain, while preserving wrist motion for SLAC stage 2 or 3 disease. This procedure does not preclude future salvage procedures in those patients with severe disease who prefer to maintain wrist motion for the short term. Patients experience good functional outcomes with the majority experiencing a reduction in pain with the ability to return to work.

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

Prevalence of Asymptomatic Achilles Tendinosis

Background: Most patients who sustain Achilles tendon ruptures (ATRs) have no clinical symptoms prior to ATR. The objective of this study was to define the prevalence of ultrasound-detectable Achilles tendinopathy in asymptomatic patients in an at-risk group. Methods: This was a cross-sectional study that collected data from a group of volunteers. All participants were given IPAQ questionnaires to gauge daily activity level, in addition to a demographic form. Participants underwent a physical examination, Silfverskiold test, and an ultrasonographic examination to evaluate for presence of Achilles tendinopathy. Fifty-one volunteers (30 female, 21 male) and 102 Achilles tendons were assessed in this study. The mean age was 27.4±6.3, with an average BMI of 23.5±3.9. Ninety-two percent of participants were categorized as having moderate or high activity levels per the iPAQ questionnaire. Results: Sixteen tendons had at least 1 abnormality: 10 (9.8%) had hypoechoic foci, 9 (8.8%) had calcifications, 1 (0.9%) had increased vascularity, and 1 (0.9%) had a low-grade interstitial tear. Approximately 40% of patients were noted to have a gastroc equinus contracture on Silfverskiold testing. In addition, 14.7% of patients with a gastroc equinus had a hypoechoic focus compared to 8.6% of patients without gastroc equinus (P = .5003). Logistic regression analysis demonstrated that an increased BMI was a significant risk factor for having an Achilles tendon abnormality on ultrasonography (P < .01, odds ratio = 1.41). Conclusion: In this study, 16% of the Achilles tendons were abnormal and had at least 1 abnormality on ultrasonography. This group of patients was generally young, healthy, and active, thus a group at risk for ATRs. Only 40% of patients had gastrocnemius equinus, although a slightly higher non-significant percentage of those with hypoechoic foci had gastrocnemius equinus. It may be advantageous to prophylactically treat these patients with rehabilitation exercises to minimize the risk of ATR. Level of Evidence: Level II, comparative prognostic study.

Anatomy of the ankle capsule: A cadaveric study: Anatomy of Ankle Capsule

Although bony and ligamentous injuries of the ankle are well understood, little is known about the degree to which injury of the ankle capsule can be a component of such injuries. The purpose of this study was to determine the dimensions of the ankle capsule and its relationship to adjacent structures. Thirteen fresh‐frozen ankle specimens were systematically dissected. Methylene blue solution was injected to identify the dimensions of the ankle capsule. External dimensions were measured as the distance from the capsular reflection to the bony margin of the ankle. Internal dimensions were measured as the distance from the capsular attachment of the distal tibia, fibula, and talus to the cartilage margin. The anterior aspect of the capsule demonstrated the most proximal capsular reflection in all specimens. The most proximal reflections of the anteromedial, anterior middle and anterolateral capsule were 10.3, 13.5, and 9.8 mm, respectively. The most proximal reflections of the posteromedial, posterior middle and posterolateral region were 8.7, 6.2, and 3.5 mm, respectively. There was no capsular reflection over the medial malleolus and less than 1 mm over the posterior lateral malleolus. There was a confluence of the capsule and ligamentous complex on the medial side, and also with the transverse tibiofibular ligament about the posterolateral ankle. The most proximal attachment of the ankle capsule was located at the anterior aspect of the distal tibia. The medial and posterolateral capsules were confluent with the ligamentous complexes of the ankle in those regions. Clin. Anat. 31:1018–1023, 2018.

Time to Diagnosis and Treatment of Superficial versus Deep Incisional Surgical Site Infections in Foot and Ankle Surgery

Category: Ankle Introduction/Purpose: Surgical site infections (SSI) are among the most expensive healthcare-associated infections and result in a substantial psychosocial and financial burden for both patients and the healthcare system. A majority of SSIs are estimated to be preventable. Previous literature has focused on antibiotic prophylaxis as the primary intervention to reduce the incidence of SSI. However, little work in the foot and ankle literature has been done on the characterization and risk stratification of patients who will go on to develop superficial versus deep incisional SSIs. Moreover, the time at which patients typically present with an SSI has not been characterized. The primary aim of this study was to quantify the time from surgical intervention to the onset of superficial versus deep SSI. 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 of surgery, subsequent diagnosis of superficial or deep incisional SSI, as well as amount and timing of antibiotic administration, incision, tourniquet and closure time were recorded. Superficial incisional SSIs were defined as those successfully treated with antibiotic therapy alone. Deep incisional SSIs were defined as those requiring subsequent wound irrigation and debridement (I&D). Time to treatment, outcomes and demographic variables were compared between patients that were treated with antibiotics alone and those that required I&D for definitive management. Results: 1569 procedures with complete data met inclusion criteria. There were 17 deep incisional SSIs (1.1%) that required I&D as part of definitive management. There were 63 superficial incisional SSIs (4.0%) that were treated successfully with antibiotics alone. The time interval between surgery and the initial treatment of deep incisional SSI (range: 11 to 42 days) was significantly greater than the time interval between surgery and initial treatment of superficial incisional SSI (range: 4 to 38 days) (28.18 ± 9.11 vs. 13.40 ± 4.65 days, p=<0.001). A total of 11 of 17 (64.7%) infections ultimately diagnosed as deep incisional SSIs failed a trial of antibiotics prior to I&D, in the remaining 6 of 17 (35.3%) infections antibiotics were held until intra-operative wound cultures were obtained. Conclusion: In our cohort of patients undergoing foot and ankle surgery the time to initial diagnosis and treatment of deep incisional SSI was longer than the time to diagnosis and treatment of superficial incisional SSI. Moreover, deep infections did not present until four weeks after surgery on average; this data is of some benefit in trying to define and understand SSIs.

Predictive Factors of Poor Health Literacy in Orthopedics: A Multivariate Analysis

Category: Ankle Introduction/Purpose: Evidence shows that patients with limited health literacy (HL) are susceptible to inferior outcomes. By identifying characteristics associated with these poor traits, healthcare policy aimed at improving HL could be more efficiently implemented. The Literacy in Musculoskeletal Problems (LiMP) survey is a validated nine-item orthopedic HL questionnaire. The purpose of this study was to assess predictors of orthopedic HL using the LiMP survey through a large patient sample at an urban academic medical center. Methods: 245 patients presenting with chief complaints previously untreated were approached in the clinic of one foot and ankle surgeon and three hand and wrist surgeons. Inclusion criteria required age greater than 18 and English proficiency. Enrolled patients completed the LiMP questionnaire in addition to a demographic form. Clinical history was retrospectively reviewed. The following information was collected: age, gender, BMI, duration of symptoms, number of children living at home, past surgical history, visit type (trauma/non-trauma), smoking status (current/non-smoker), diabetes status (yes/no), history of psychiatric disorder (yes/no), race (white/non-white), education level (more/less than bachelor’s degree), and insurance type (public/private). Pearson correlation coefficients (PCC) were calculated between LiMP score, demographic data, and medical history data. Based on results of the correlational analysis, variables that were significantly correlated with LiMP score were entered into multivariate regression analysis to assess their effect on HL. A p value less than 0.05 was considered significant. Results: 231 patients (131 hand/wrist, 100 foot/ankle) were enrolled and fully completed questionnaires. Mean age was 45.6 (±16.8, range 18 – 82), and mean score on the LiMP was 5.40 (±1.8, range 1 – 9). The following variables significantly correlated with LiMP score: race (PCC=0.23), age (PCC=0.16), education (PCC=0.22), past surgical history (SCC=0.18), and insurance type (SCC=-0.16). Multivariate regression analysis was conducted with LiMP score as the dependent variable, and the factors race, age, education, past surgical history, and insurance type as the independent variables. Results of this analysis can be found in Table 1. The final model significantly accounted for 15.0% of variation in LiMP score. Coefficients that significantly contributed to the final model were those of past surgical history, race, and education level. Conclusion: Race, past surgical history, and education level all contribute significantly to a patient’s HL. When controlling for age and past surgical history, the latter of which was significantly associated with elevated HL, race significantly increased ability to predict LiMP score. Similarly, the inclusion of education level also significantly added to our model’s ability to predict LiMP score. In conclusion, our results indicate that when designing healthcare policy aimed at improving HL, efforts should be focused on lower educated persons and minorities regardless of past experience with medical care, and that age and gender are by no means markers for HL.

Sleep Quality, Pain Catastrophization, and Orthopedic Health Literacy: Are These Factors Correlated to Functional Outcome Scores?

Category: Ankle Introduction/Purpose: Evidence increasingly indicates the importance of orthopedic health literacy, sleep quality, and a propensity for pain catastrophization in orthopedic patient outcomes. Using previously validated questionnaires including the Literacy in Musculoskeletal Problems (LiMP), Pain Catastrophization Scale (PCS), and the Pittsburgh Sleep Quality Index (PSQI), this study investigated the relationship between these factors and common functional outcome instruments including the Disability of Arm, Shoulder, and Hand (DASH) and the Foot and Ankle Outcome Score (FAOS). Methods: 245 patients in outpatient clinics of one foot and ankle surgeon and three hand surgeons were approached. Inclusion criteria required age greater than 18, English proficiency, and a newly presenting chief complaint. Enrolled patients completed a demographics form, LiMP, PCS, PSQI, and the DASH or FAOS based on extremity. Clinical history was reviewed retrospectively. DASH and FAOS scores were normalized to the same scale (0 – 100, best to worst) and termed “functional survey” (FS). Correlations were calculated between FS scores, subjective questionnaires, and demographic/clinical information. For the variables of race and education level, one-way ANOVA analysis was conducted to determine if FS scores differed based on these variables. Variables that were significantly correlated with FS score were entered into a multivariate linear regression analysis to assess their effect on FS score. Results: 231 patients (131 hand/wrist, 100 foot/ankle) were enrolled and completed all questionnaires. ANOVA analysis found that there were no significant differences in FS scores based on education or race (p > 0.05). Multivariate regression analysis was conducted with FS score as the dependent variable, and factors that were significantly correlated with FS score, including PCS, PSQI Global Score, visit type (trauma vs. non-trauma), and insurance type (private vs. public) as the independent variables. Health literacy was not significantly correlated with OS score. Results from this analysis can be found in Table 1. The model significantly (p < 0.05) accounted for 19.2% of variation in OS score. Conclusion: There is a strong correlation between tendency to catastrophize pain, sleep quality, and FS score. Every 1 unit increase in the PSQI/PCS corresponds with a 1.8/0.38 point increase in FS score; indicating higher functional disability. Given the strong correlation at baseline, such factors as poorly controlled tendency to catastrophize pain may confound functional outcomes. No significant correlation was noted between health literacy and FS scores. This suggests that an increased level of orthopedic knowledge does not affect perception of functional disability. However, our results show that sleep quality and catastrophic thinking may confound functional outcome scores.

Development and Validation of a Disease-Specific Questionnaire for Basal Joint Arthritis

Background The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire is the most commonly used instrument to assess outcomes of basal joint arthritis (BJA). However, the DASH is subject to influence by the entire upper extremity. Purpose This study aims to develop and validate a disease‐specific questionnaire for BJA that would be more sensitive to changes in thumb function and pain, and correlate better with objective and subjective metrics. Patients and Methods The thumb disability examination (TDX) was developed and 80 patients presenting with BJA at one of the two hospital‐based hand clinics were enrolled in the validation study. At enrollment, subjects were given the TDX, DASH, and visual analog pain scale with activity (A‐VAS) surveys. The strength was assessed. Patients receiving corticosteroid injection were seen for follow‐up at 6 weeks and those who underwent surgery were seen between 3 and 6 months postoperatively. Both the groups were given the TDX, DASH, and A‐VAS scales at follow‐up. Results In total, 65 subjects were included in the analysis. Average TDX completion time was 134.3 seconds. The TDX correlated more strongly with A‐VAS scores at baseline than the DASH, but less strongly with tip‐pinch measures. The TDX was more responsive to injection and surgical treatments for BJA than the DASH, yielding a larger effect size and standardized response mean, and was the only instrument to significantly correlate with changes in A‐VAS. Conclusion The TDX is a reliable instrument for assessing BJA treatment outcomes. It bears less of a burden on patients, is more responsive to symptomatic changes, and correlates better with most objective and subjective measures than the DASH. Level of Evidence II, diagnostic.