Samuel Huntley

Associations between season and surgical site infections in orthopaedic foot and ankle surgery

BACKGROUNDnSurgical site infections (SSI) in orthopaedic surgery are common nosocomial complications that contribute significantly to patient morbidity and increased healthcare costs. While past studies support an increase in the incidence of SSI during the summer months in orthopaedic spine surgery and joint arthroplasty, there has not been any study examining the association between season and SSI in the setting of orthopaedic foot and ankle surgery.nnnMETHODSnA retrospective analysis of data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2011-2015 was conducted. 17,939 patients who received at least one of 218 CPT codes specific to orthopaedic foot and ankle surgery were identfied from the NSQIP database. Descriptive statistics of patient demographics, comorbidities, and complications were stratified by quarter of admission.nnnRESULTSnOf the 17,939 patients, there were 4995 in the 1st quarter (27.8%), 4078 in the 2nd quarter (22.7%), 4333 in the 3rd quarter (24.2%), and 4533 in the 4th quarter (25.3%). The overall rate of surgical complications was 2.3%. The highest incidence of surgical complications was during the summer at 2.7% and the lowest was during the fall at 2.1% (p=0.338). The summer months also demonstrated the highest incidence of medical complications at 5.9% (p=0.524). There were significantly more women undergoing surgery in the winter and summer months (p=0.028).nnnCONCLUSIONnThe surgical site infection rate in the setting of orthopaedic foot and ankle surgery was higher, although not significantly, in the summer months.nnnLEVEL OF EVIDENCEnLevel III retrospective.

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.

Morton’s Neuroma Excision: What Are We Really Doing? Which Retractor Is Superior?

Background: When using a dorsal approach for Morton’s neuroma excision, the most common complication is recurrent Morton’s neuroma. The present cadaveric study demonstrates how far proximally the nerve is resected during a dorsal approach and examines both the laminar spreader and Gelpiretractor to determine which instrument facilitates maximal proximal resection of the nerve. Methods: This study involved 12 fresh-frozen cadaver specimens, each of which underwent a dorsal approach to the interdigital nerve with proximal resection. Either a laminar spreader or a Gelpi retractor was used to improve visualization of the intermetatarsal space. The interdigital nerve was then resected, and the lengths of the cut nerves were compared based on the retractor employed. Results: The mean length of proximal resection in the second intermetatarsal space was 2.42 cm when using the laminar spreader and 1.93 cm when using the Gelpi retractor (P = .252). In the third intermetatarsal space, the mean length of proximal resection was 2.14 cm when using the Laminar spreader and 1.48 cm when using the Gelpi retractor (P = .166). Conclusion: This study demonstrates how far proximal the interdigital nerve is resected during a dorsal approach to Morton’s neuroma and shows no statistically significant difference between the Laminar spreader and the Gelpi retractor. Levels of Evidence: Level V: Cadaver study

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

Incidence of Venous Thromboembolism in Orthopaedic Foot and Ankle Surgeries

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.

Postoperative Tourniquet Pain in Patients Undergoing Foot and Ankle Surgery

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.

Postoperative infection in foot & ankle surgery: does the season matter?

Category: Other Introduction/Purpose: Surgical site infections (SSI) are infections of the incision site, organ, or space at or near the surgical incision within 30 days of the procedure or within 90 days for prosthetic implants. Being the most common nosocomial infection, SSI’s are a burden to the healthcare system as they increase costs, duration of stay, antimicrobial resistance, morbidity, and mortality. While there is limited evidence in the orthopaedic literature suggesting that the incidence of SSI increases during the summer months, this association has not been examined in the setting of foot and ankle surgery. The purpose of this study was to determine whether seasonal variation plays a role in developing SSI’s after orthopaedic foot and ankle surgery. Methods: Data from the National Surgical Quality Improvement Program (NSQIP) years 2011-2015 were used in this study. The pooled and individual incidences of superficial incisional SSI, deep SSI, and organ space SSI were calculated and stratified by quarter of admission. The quarters of admission represent the various seasons (1=winter, 2=spring, 3=summer, 4=fall). Differences in the incidence of SSI as well as various demographic, comorbidity, and complication variables were evaluated using ANOVA for continuous variables and Pearson’s Chi-Square for categorical variables. Results: A total of 17,939 patients were identified. After pooling the superficial, deep, and organ space infections, the overall SSI rate was highest in the summer months (July-September, 3rd quarter) at 2.68% as compared to 2.20%, 2.33%, and 2.14% in the other respective quarters (p=0.338). There was a total of 218 cases of superficial incisional SSI. The summer months had the highest incidence of superficial SSI at 1.38% compared to 1.14%, 1.13%, and 1.21% for 1st, 2nd, and 4th quarters, respectively (p=0.677). There were 145 cases of deep incisional SSI. The third quarter again had the highest rate at 1.02% compared to 0.72%, 0.93%, and 0.60% for 1st, 2nd, and 4th quarter respectively (p=0.105). Conclusion: Our results show that superficial incisional SSI, deep incisional SSI, and open wound infections have increased likelihood during the summer months in the setting of orthopaedic foot and ankle surgery. Some studies have associated the increased temperature and humidity during the summer months with increased rates of infections and our results show similar trends. Additional evidence with larger sample sizes is needed to determine which specific procedures are at highest risk of infection during the summer months.

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

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.

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

Category: Hindfoot Introduction/Purpose: Hindfoot fusion procedures are increasingly being performed in the outpatient setting. However, the cost-effectiveness of hindfoot fusion procedures compared with risk and benefit have not been clearly investigated. The primary objective of this study was to investigate the cost-effectiveness of outpatient versus inpatient hindfoot arthrodesis. Secondary objectives were to compare patient characteristics and short-term complications of patients in each cohort. Methods: This was a retrospective review of all patients who underwent inpatient and outpatient hindfoot fusion procedures at a single institution from 2013-2017. Data collected for each patient included demographic information, operative variables, comorbidities, complications, and any subsequent emergency department visits, readmissions or reoperations. Cost data was collected for each inpatient or outpatient encounter, as well as any subsequent encounters related to the index procedure. Results: Of 151 total hindfoot procedures performed over the study period, 37 were inpatient and 114 were performed in the outpatient setting. There were 3 more readmissions, 22 more ED visits, and 0 more reoperations after outpatient surgery vs inpatient surgery. The average total cost for an outpatient hindfoot fusion procedure was significantly lower than the average total cost for inpatient hindfoot fusion, without a significant increase in complication rate. We are currently in the process of performing the total cost analysis, and will have the completed cost and risk/benefit information within the next two weeks. Conclusion: Outpatient hindfoot fusion surgery may be more cost-effective when compared to inpatient fusion surgery without a significant increase in complications, ED visits, or readmissions.

A Comparative Analysis of Short Term Postoperative Complications in Outpatient vs. Inpatient Total Ankle Arthroplasty

Category: Ankle Introduction/Purpose: Ankle arthritis is a potentially debilitating disease with approximately 50,000 cases diagnosed annually. Once conservative management fails, surgical options for these patients include total ankle arthroplasty (TAA) and ankle arthrodesis. Younger, more active patients may prefer TAA as it may allow better ankle mobility compared to ankle arthrodesis. TAA has historically been performed in the inpatient setting with a one- to two-night postoperative hospital stay. Outpatient surgeries are gaining popularity due to their cost effectiveness, decreased length of hospital stay, and convenience. Therefore, it is important to evaluate the safety of specific procedures in the outpatient setting compared to the inpatient setting. This study evaluates the complication rates in inpatient vs. outpatient TAA. Methods: Our team conducted a retrospective analysis of data from 591 patients receiving inpatient and outpatient TAA from the NSQIP database. This database contains de-identified patient data and allows retrospective analyses to be performed based on data they have extracted from over 400 hospitals. Demographic information was recorded including age, sex, weight, height, and race. Thirty-day postoperative complication rates were compared between 66 outpatients and 535 inpatients. Frequencies of the following complications were analyzed: wound complications, pneumonia, hematologic complications (pulmonary embolism and deep vein thrombosis), renal failure, stroke, and return to the operating room within 30 days. The inpatient and outpatient groups were compared using chi-squared tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. Results: 591 total patients were identified that underwent TAA. 66 patients (11.1%) were treated as outpatients and 525 (88.8%) as inpatients. Inpatient TAA had a significantly higher mean operation time (161 min vs 148 min) and a significant difference in length of total hospital stay (2.3 days vs 1.1 days). Inpatients had higher rates of superficial incisional surgical site infection (SSI) (0.57% vs 0%), deep SSI (0.19 % vs 0%), organ/space SSI (0.19% vs 0%), pneumonia (0.38% vs 0%), and return to the operating room (0.76% to 0%). However, no significant differences were found in complication rates between inpatient and outpatient groups. There were no occurrences of acute renal failure, wound disruption, pulmonary embolism, stroke, or DVT/thrombophlebitis for inpatients or outpatients. Conclusion: We found no significant difference between inpatient vs. outpatient TAA. Incidental differences we found were that inpatients were significantly more likely to be older in age, diagnosed with diabetes, and inpatients had longer operative times. Our results suggest that inpatients are more likely, but not significantly, to have a higher occurrence of complications and return to the OR. Therefore, this study suggests that outpatient TAA is safe and may be a superior option for the correct patient population. Further investigation is warranted to verify these conclusions.