Zachariah Pinter

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.

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.

Vascular supply at risk during lateral release of the patella during total knee arthroplasty: A cadaveric study

Introduction Lateral release to improve patellar tracking is commonly performed during total knee arthroplasty. Blood is supplied to the lateral patella by two main arteries: the superior and inferior lateral genicular arteries. The transverse infrapatellar artery also branches off the lateral inferior genicular artery to supply the inferior half of the patella. Severance of any of these arteries during lateral release can lead to avascular necrosis of the patella. This cadaveric study investigates the lateral vasculature to the patella and whether it can be visualized and preserved during lateral release of the patella. Materials and methods This study involved ten cadavers, each of which underwent lateral release of the patella. One senior joint surgeon performed and supervised the incisions and attempted to locate and preserve these vessels. We then quantified the number of cadavers with visualized blood vessels and analysed their location and course to determine whether they could be preserved during lateral release of the patella. Results In our study, three of the ten cadavers had an artery that was visible within the incisional plane and preserved. Two were the inferior lateral genicular artery, and one was the superior lateral genicular artery. In the other seven cadavers, no vessels were visualized during the lateral dissection. Conclusions These results demonstrate that it is difficult to visualize blood supply to the patella during lateral release. Every attempt should be made to preserve these blood vessels to avoid devascularization to patella in the setting of an already severed medial vascularity due to standard approach to knee replacement.

A Retrospective Case Series of Carbon Fiber Plate Fixation of Ankle Fractures

Distal fibula fractures represent a common problem in orthopaedics. When fibula fractures require operative fixation, implants are typically made from stainless steel or titanium alloys. Carbon fiber implants have been used elsewhere in orthopaedics for years, and their advantages include a modulus of elasticity similar to that of bone, biocompatibility, increased fatigue strength, and radiolucency. This study hypothesized that carbon fiber plates would provide similar outcomes for ankle fracture fixation as titanium and steel implants. A retrospective chart review was performed of 30 patients who underwent fibular open reduction and internal fixation (ORIF). The main outcomes assessed were postoperative union rate and complication rate. The nonunion or failure rate for carbon fiber plates was 4% (1/24), and the union rate was 96% (23/24). The mean follow-up time was 20 months, and the complication rate was 8% (2/24). Carbon fiber plates are a viable alternative to metal plates in ankle fracture fixation, demonstrating union and complication rates comparable to those of traditional fixation techniques. Their theoretical advantages and similar cost make them an attractive implant choice for ORIF of the fibula. However, further studies are needed for extended follow-up and inclusion of larger patient cohorts. Levels of Evidence: Level IV: Retrospective Case series

Outcomes of First Metatarsophalangeal Joint Fusion in Patients with Greater Than Fifteen Percent Intermetatarsal Angle. Is Lag Screw Essential

Category: Midfoot/Forefoot Introduction/Purpose: Metatarsophalangeal arthrodesis has usually been performed using a dorsal plate to immobilize the MTP joint with or without lag screw fixation. Data in the literature is sparse on outcomes of dorsal plate plus lag screw fixation, especially in patients with IMA greater than 15 percent. Our objective was to compare IMA correction outcomes and union rates between dorsal plate only fusions and dorsal plate plus lag screw fixation in patients with IMA greater than 15 percent. Methods: We retrospectively reviewed the charts of 36 patients (39 feet) who underwent first MTP joint arthrodesis for moderate to severe HV deformity between 2011 and 2015. Average age was 61 (range, 39 to 84) years. There were 24 females and 12 males. A single surgeon performed all operations. Joints were immobilized postoperatively using either dorsal locking plate alone or dorsal locking plate with a lag screw. Union (at least 3 bridging cortices) was determined radiographically at 6 weeks, 3 months, 6 months and yearly. All suspect nonunions were examined with CT. Other radiographic parameters examined included preoperative and postoperative hallux valgus, intermetatarsal, and dorsiflexion angles (HVA, IMA, and DFA respectively). Student’s t test was used to compare group means while Pearson’s Chi square test was used to compare group rates. Results: Overall union rate was 82.1% (32/39). There was no significant difference in union rates between the two groups (dorsal plate only = 81.5% (22/27), dorsal plate plus lag screw group = 83.3% (10/12)) (P > 0.05). Average follow-up was 9 (range 7 to 35) months. Overall, the average IMA correction was 4.7 (preoperative = 17.8, postoperative = 13.1) degrees. Average IMA corrections were 4.7 and 4.54 degrees in the dorsal plate only group and dorsal plate plus lag screw groups respectively. Overall, average HVA correction was 21 (preoperative = 39.5, postoperative = 18.5) degrees. Conclusion: Our findings indicate that there is no difference in the fusion rates between both patient groups with IMA greater than fifteen percent. Because other published studies have a wide range of IMAs preoperatively, our study represents more attainable goals in patients with severe (IMA greater than 15%) deformities. In addition, our findings suggest that in such patients, MTP arthrodesis may not be sufficient as a standalone procedure for correction of IMA. Additional proximal osteotomy may be required for correction of the IMA.

Calcaneal Osteotomies in the treatment of Hindfoot Deformities: Comparison between One Screw vs Two Screws fixation technique

Category: Hindfoot Introduction/Purpose: Calcaneal osteotomy is a common procedure for hindfoot deformities correction. Screw fixation is the most common technique used to stabilize these osteotomies. The clinical decision regarding the number of screws used is frequently based on the surgeon’s experience without sufficient data regarding outcomes and complications. The aim of this study was to compare the outcomes and complications of one versus two screws fixation technique of sliding calcaneal osteotomies. Methods: We reviewed 190 patients (112 female, 78 male) who underwent corrective calcaneal osteotomy for hind-foot angular deformity between 2010-2016. The average age was 48.4 years (18-83), and mean follow-up was 28 weeks (4-150). We divided patients into two groups, according to the number of screws used in the osteotomy fixation (one or two). 85 osteotomies were fixed by one screw and 105 by two screws. We compared both groups regarding incision type, positioning and type of the screws (headed or headless) and complications (non-union, infection, hardware related heel pain). Results: The average time for radiographic union was similar between the groups, around 5.6 weeks (4-10 weeks). Non-unions were not found. The overall Incidence of complications was not significant different in the one screw group compare two screw group (12.7% x 8%, p-value 0.465). Infection rate was similar in both groups (4.7% vs 3.5%, p-value 0.674). There was not significant difference of hardware related heel pain between two groups (15.2% vs 8.5%, p-value 0.149). Similarly, no difference in incidence of hardware related symptoms between patients who used headed screw when comparing with headless screws. Conclusion: Our study compared results in the use of one screw versus two screws fixation technique for sliding calcaneal osteotomies. We found similar time for union. Base of date there was no significant difference of complications, infection, and hardware related heel pain between patients who used one screw when comparing two screws fixation technique for corrective calcaneal osteotomy.

Lateral Ankle Instability Surgical Treatment: A Comparison Between Primary Repair and Revision Surgery

Category: Ankle, Sports Introduction/Purpose: Lateral ankle instability is a common cause of disability in the active population. Although the majority of patients can be treated conservatively, surgical repair of the ligaments, with or without reinforcement, represents an excellent option for refractory cases. Failed primary surgical repair, recurrence of the ankle instability and need for revision surgery can rarely happen and is probably affected by multiple variables. That includes patient’s characteristics such as BMI and comorbidities and surgical aspects such as the use of suture anchors and soft-tissue reinforcement. The purpose of this study was to compare patient’s characteristics and complication rates of primary repair and revision procedures. Methods: We retrospectively reviewed 231 patients (160 Female, 71 Male) who underwent surgical treatment for lateral ankle instability between 2010-2016. Thirty-two were revision cases (14.2%), including 24 females and 8 males, and 199 were primary direct repairs (85.8%). The mean age at the time of the surgery was 39 (19-65)years, and average follow-up was 9 (2-55) months. The procedures were performed by four different surgeons. All cases were reviewed based on age, gender, BMI, procedure type and number of incisions, comorbidities, and complications. Data found was compared between the two groups (primary repair and revision surgery) by T-test. A p-value <0.05 was considered significant. Results: The Brostrom-Gould procedure was used in 69.5% of the primary repairs and 63.6% of the revision cases. The use of suture anchors was also similar in both groups (51%). Repair of the calcaneofibular ligament was performed in 68% of primary repairs and 81.8% of the revisions. We didn’t find significant differences regarding comorbidities between two groups: smoking (23.4% x 27.2%, p-value 0.371); diabetes (6.8% x 6%, p-value 0.951) and body mass index above 30 (28.5% x 24.2%, p-value 0.347). We found significant difference in the complication rate of the procedures, with a higher incidence in the revision group (48.4%) when compared to the primary repair group (24%). That included: sural neuritis (15.1% x 3.4%), superficial peroneal neuritis (12.1% x 4.5%), skin problems (9% x 7.4%). Conclusion: Our study of 231 patients that underwent surgical treatment for lateral ankle instability found significant higher incidence of complications in patients who had revision procedures when compared to primary repair. No differences regarding smoking status, diabetes and BMI were found.

Revisiting the Prevalence of Associated Co-Pathologies in Chronic Lateral Ankle Instability

Category: Ankle, Hindfoot, Sports Introduction/Purpose: Ankle sprains are the most common athletic injury with an estimated 30% risk of developing chronic lateral ankle instability. Up to 20% of these patients will require surgical management after trial of conservative treatment for chronic disease. Current literature suggests that the presence and type of co-pathologies associated with chronic lateral ankle instability can serve as important predictors of surgical outcomes. As the occurrence of these co-pathologies varies in the literature, providers may underestimate their presence which may lead to suboptimal surgical approach. The purpose of this study is to re-examine the prevalence of common associated lesions in patients who underwent surgical treatment for chronic lateral ankle instability. Methods: We retrospectively reviewed medical charts for 389 cases of lateral ankle instability repair surgery at our institution between June 2006 and November 2016. All patients had undergone at least 6 months of conservative therapy such as ankle stabilizing orthosis or physical therapy with no improvement. All operations were performed by senior orthopaedic surgeons. Exclusion criteria included age less than 18 at time of surgery, gross traumatic event, and history of ipsilateral subtalar arthrodesis. Demographic information such as age, gender, body mass index, and race/ethnicity were collected. 166 surgical notes accessible through the electronic medical record were reviewed for specific intra-operative findings including presence of peroneal pathology (including tendon split lesion), talar osteochondral defects, anterior or posterior ankle impingement, low lying muscle belly of the peroneus brevis and surgical approach. Simple descriptive statistics were used to examine means and frequencies of the collected data. Results: 166 cases (48 males, 118 females) were included (mean age = 39 ±13.4 years, mean body mass index = 31.41 ± 7.5 kg/m2, mean follow-up = 44 ± 46 weeks). 95 cases involved the left foot while 71 cases involved the right foot. Two senior surgeons accounted for 87% (145/166) of the cases. 20 cases were revisions. 72.3% (120/166) of all cases had associated peroneal pathology (36.6% (44/120) peroneus brevis split lesion and 5.8% (7/120) with peroneus longus split lesion). 41% (69/166) of the patients had ankle impingement (anterior = 32; posterior = 19. combined = 17), 37% (62/166) had a low lying muscle belly of the peroneus brevis and 19% (32/166) had osteochondral lesions of the talus. Conclusion: Surgical approach and long-term outcomes can be affected by the knowledge and proper diagnosis of chronic lateral ankle instability associated lesions. Our study reinforces the need for vigilant exploration of chronic ankle instability patients who require surgical treatment. More specifically, surgical exploration for peroneal pathology and ankle impingement may be crucial as our findings reveal a high intraoperative rate of their occurrence. While the role of a low-lying peroneus brevis muscle belly in the development or course of chronic lateral ankle instability remains to be elucidated, we report a significant percentage of its occurrence.

Calcaneal Osteotomy Safe-Zone to Prevent Neurological Damage: Fact or Fiction?

Category: Ankle, Hindfoot Introduction/Purpose: Calcaneal osteotomy is a relatively common procedure used to address hindfoot deformities with a lateral calcaneal slide being utilized in the treatment of varus deformities and a medial slide for valgus deformities. This procedure does put neurological structures at risk. Specifically, a lateral approach jeopardizes the sural and lateral calcaneal nerves, while a medial approach endangers the medial plantar, lateral plantar, and calcaneal nerves. A previous cadaveric study described a neurological “safe zone” 11.2 mm anteriorly from “line A” which was described as extending from the posterior-superior aspect of the calcaneal tuberosity to the origin of the plantar fascia. We performed a retrospective chart review to correlate the positioning of the calcaneal osteotomy and the presence of neurological injuries. Methods: In this retrospective study, we reviewed charts of patients who underwent calcaneal osteotomy at our institution in the past 5 years (January 1, 2011 to December 31, 2015). All immediate postoperative radiographs were examined and the distance between the calcaneal osteotomy line and line A was measured. If this distance was less than 11.2 mm the osteotomy was defined as “inside the safe zone”, over 11.2 mm was defined as “anterior to safe zone”, and osteotomies posterior to line A were defined as “posterior to the safe zone”. We correlated the positioning of the osteotomy with the presence of postoperative neurological findings, including damage to the sural, calcaneal, or plantar nerves, presenting as paresthesias or numbness in the nerves’ distributions. Results: Overall, we identified 179 calcaneal osteotomy cases with adequate radiographs and follow-up for inclusion in our analysis. Seven patients experienced postoperative neurological deficits consistent with iatrogenic nerve injury. Of these patients, 28.6% (2/7) had osteotomies anterior to the safe zone with an average distance of 18.40 mm anterior to line A. The remaining 5 (71.4%) received osteotomies inside the safe zone, an average of 7.12 mm anterior to line A. Of the patients who did not sustain nerve injuries 36.0% (62/172) had osteotomies anterior to the safe zone with an average distance of 15.40 mm anterior to line A, 66.2% (107/172) were inside the safe zone with an average distance of 7.84 mm, and 1.7% (3/172) were posterior to the safe zone. Conclusion: Our findings suggest a clinical safe zone in calcaneal osteotomies may not actually exist. Although not statistically significant due to the low prevalence of nerve injury overall, a greater percent (71.4%) of patients with nerve injuries had their osteotomies performed within the safe zone when compared to neurologically intact postoperative patients (66.2%). This data may indicate the lack of a true safe zone, likely due to wide anatomical variation of the implicated nerves, as described in prior studies. Patients should be properly counseled preoperatively on the low, but seemingly fixed risk of nerve injury before undergoing calcaneal osteotomy.

The Role of MRI in the Assessment of Chronic Lateral Ankle Instability: Are Reports Underestimating Peroneal Tendon Pathology?

Category: Ankle, Arthroscopy, Sports Introduction/Purpose: Chronic lateral ankle instability is a common problem in foot and ankle surgery, especially in patients with neutral or varus alignment of the hindfoot. Peroneal tendinopathy is a common associated condition with reported incidence as high as 77%. Not all surgical approaches allow for assessment of the peroneal tendons intraoperatively, and so physical exam and imaging, by either ultrasound or MRI, often plays an important role in pre-operative planning. We evaluated the usefulness of MRI reports in identifying peroneal tendon pathology in patients with lateral ankle instability. Specifically, we aimed to identify the most commonly missed lesions, as well as the sensitivity of an MRI report at detecting any peroneal pathology, as we reason this finding to have the great effect on preoperative planning. Methods: We performed a retrospective chart review of all patients who had undergone surgery for lateral ankle instability at our institution in the past 7 years (January 1, 2009 to December 31, 2015). We used intraoperative peroneal pathology as our gold standard for diagnosis, and identified cases via the operative report. We defined peroneal pathology as peroneal brevis/longus rupture, split lesion, tenosynovitis, or tendinopathy not otherwise specified. Additionally, we assessed for low insertion of the peroneus brevis muscle belly. Then we examined all cases of intraoperative peroneal pathology that had a preoperative MRI report. We correlated MRI reports to intraoperative peroneal findings aiming to assess the accuracy of MRI reports in diagnosing peroneal pathology in patients undergoing surgical treatment for chronic lateral ankle instability. Results: We identified 76 patients with intraoperative peroneal pathology and preoperative MRI reports. Forty-six had some form of peroneal pathology noted on their MRI report (60.5% sensitivity, 39.5% false negatives). MRI report had a 53.3% (16/30) sensitivity for detecting peroneus brevis split lesions, and a 46.2% (30/65) sensitivity for peroneal tenosynovitis or tendinopathy not otherwise specified. Additionally, 41 cases of low insertion of the peroneus brevis muscle belly were found intraoperatively, but MRI report failed to identify any of these specifically. Of the 30 patients who had intraoperative peroneal pathology without such findings on their MRI report, 93.3% (28/30) had peroneal tenosynovitis or tendinopathy not otherwise specified, while 26.7% (8/30) had a peroneus brevis split lesion and 6.7% (2/30) had a peroneus longus split lesion. Conclusion: Our findings suggest that MRI reports may not be accurate in describing the presence of peroneal tendons pathology in patients with chronic lateral ankle instability. With a false-negative rate of nearly 40%, it is likely that MR imaging underestimates peroneal pathology in these patients. This is clinically significant as certain limited surgical approaches such as the “smile” incision, do not allow intraoperative assessment of the peroneal tendons. Our study findings encourage surgeons to review MR images preoperatively and to use a surgical approach that allows peroneal tendon assessment when repairing the lateral ankle ligaments.