Mixed-reality improves execution of templated glenoid component positioning in shoulder arthroplasty: a CT imaging analysis.

INTRODUCTION: Glenoid placement is critical for successful outcomes in total shoulder arthroplasty (TSA). Preoperative templating with three-dimensional imaging has improved implant positioning, but deviations from the planned inclination and version still occur. Mixed-Reality (MR) is a novel technology that allows surgeons intra-operative access to three-dimensional imaging and templates, capable of overlaying the surgical field to help guide component positioning. The purpose of this study was to compare the execution of preoperative templates using MR vs.standard instruments (SIs). METHODS: Retrospective review of 97 total shoulder arthroplasties (18 anatomic, 79 reverse) from a single high-volume shoulder surgeon between January 2021 and February 2023, including only primary diagnoses of osteoarthritis, rotator cuff arthropathy, or a massive irreparable rotator cuff tear. To be included, patients needed a templated preoperative plan and then a postoperative computed tomography scan. Allocation to MR vs. SI was based on availability of the MR headset, industry technical personnel, and the templated preoperative plan loaded into the software, but preoperative or intraoperative patient factors did not contribute to the allocation decision. Postoperative inclination and version were measured by two independent, blinded physicians and compared to the preoperative template. From these measurements, we calculated the mean difference, standard deviation (SD), and variance to compare MR and SI. RESULTS: Comparing 25 MR to 72 SI cases, MR significantly improved both inclination (P < .001) and version (P < .001). Specifically, MR improved the mean difference from preoperative templates (by 1.9° inclination, 2.4° version), narrowed the SD (by 1.7° inclination, 1.8° version), and decreased the variance (11.7-3.0 inclination, 14.9-4.3 version). A scatterplot of the data demonstrates a concentration of MR cases within 5° of plan relative to SI cases typically within 10° of plan. There was no difference in operative time. CONCLUSION: MR improved the accuracy and precision of glenoid positioning. Although it is unlikely that 2° makes a detectable clinical difference, our results demonstrate the potential ability for technology like MR to narrow the bell curve and decrease the outliers in glenoid placement. This will be particularly relevant as MR and other similar technologies continue to evolve into more effective methods in guiding surgical execution.

Does Insurance Status Affect Access to Care Among Ankle Fracture Patients? An Institutional Retrospective Study.

Delayed access to care for patients with ankle fractures may increase risk of complications, particularly if surgical management is warranted. Medicaid is a state and federal insurance program in place for those with low income, which has previously been associated with delayed access to care among patients with ACL tears and total hip arthroplasties. The purpose of this study is to assess whether patient insurance status affects access to care for ankle fracture patients, using data from a single institution. A retrospective cohort study (N = 311 patients)was performed on individuals that underwent open reduction and internal fixation for an ankle fracture between years 01/2008 and 12/2018. Patients with polytraumatic injuries, open injuries, Medicare, no insurance, indigent/charity insurance, self-pay, or whose insurance information was not available were excluded. Time from date of injury to date of surgery, injury to first visit, and first visit to surgery was compared between patients with private insurance and Medicaid. Average time from injury to first appointment was 1.2 days and 6.2 days for privately insured and Medicaid patients, respectively (p < .001). Average time from injury to surgery was 8.3 days and 16.1 days for privately insured and Medicaid patients, respectively (p < .001). Patients enrolled in Medicaid have significantly delayed access to care compared to those with private insurance. For ankle fracture patients this is a critical healing time, and delayed care may result in increased costs, increased utilization of healthcare resources, higher complication rates, and poorer patient outcomes.

Applications of the transfibular approach to the hindfoot: A systematic review and description of a preferred technique.

BACKGROUND: The indications and technique for the transfibular approach to the tibiotalar joint have evolved since its initial popularization in 1942. The purpose of this systematic review is to assess the indications, techniques, and postoperative outcomes among procedures performed with the transfibular approach. METHODS: A comprehensive search of PubMed, Medline, and Embase databases from 1942 to 2018 was performed in accordance with PRISMA guidelines. After an initial broad search of transfibular approach indications, articles were stratified into 4 major surgical categories for assessment: (1) tibiotalar arthrodesis (2) tibiotalocalcaneal arthrodesis (3) total ankle replacement and (4) distal tibial tumor excision. Data was analyzed according to these 4 categories. RESULTS: A total of 32 studies (874 ankles) were included. Fibular non-union rates were 0.7 % (5 of 672) across all studies, 0.6% (2 of 329) for tibiotalar arthrodesis, 0.0% (0 of 12) for tibiotalocalcaneal arthrodesis, 1.0 % (3 of 296) for total ankle arthroplasty and 0.0% (0 of 15) for other procedures. Rates of deep infection were 2.5% (23 of 903) across all studies, 3.2% (15 of 466) for tibiotalar arthrodesis, 3.7% (4 of 106) for tibiotalocalcaneal arthrodesis, 1.3% (4 of 296) for total ankle arthroplasty, and 0.0% (0 of 15) for other procedures. CONCLUSIONS: The transfibular approach is useful for cases requiring extensile exposure of the tibiotalar joint. This study provides evidence that the transfibular approach yields satisfactory results, with low complication and infection rates. LEVEL OF EVIDENCE: IV.

Anatomical structures at risk in the arthroscopic Broström-Gould procedure: A cadaver study.

BACKGROUND: The Broström Gould procedure is the gold standard for repair of lateral ankle ligament injury and ankle instability. This procedure has demonstrated excellent short- and long-term outcomes in the orthopedic literature. Arthroscopic Broström Gould techniques have become increasingly popular among some foot and ankle orthopedic surgeons. Typically, this technique requires standard anteromedial and anterolateral portals along with an accessory lateral working portal. The exact location of this portal is variable within the available described surgical techniques. The objective of this cadaveric study is to establish a standard entry point for and to assess the safety of the accessory lateral portal with respect to nearby anatomical structures. METHODS: Ten fresh-frozen below-knee cadaver specimens were used. The location of the accessory lateral portal was created 1.5 cm anterior to the distal tip of the fibula. A small vertical incision was made at this point, followed by insertion of a Kirschner wire into the joint. The wire was then gently impacted into the fibula. Superficial dissection was subsequently carried out around the entry point to identify the peroneal tendons, superficial peroneal nerve branches, and sural nerve branches. Structures were marked with colored push pins, and distance was measured between the nearest edge of the Kirschner wire and each of the three anatomic structures listed. Any instances of structural contact or damage were documented. RESULTS: The average distance from the Kirschner wire to the peroneal tendon was 16.1 (±4.41) mm. The average distance from the wire to the superficial peroneal nerve and sural nerve was 13.11 (±6.79) mm and 12.33 (±4.08) mm, respectively. There were no instances of injury to any of the studied structures. However, there was a notable amount of variability in the proximity of structures in question for each cadaver. A branch of the superficial peroneal nerve was measured as close as 2 mm and as far as 24 mm in separate cadaver specimens. CONCLUSION: Arthroscopic Broström Gould procedures are a safe and effective method for lateral ankle ligamentous repair but are not without risk. Accessory lateral portal placement is relatively safe but should be meticulously executed to avoid damage to nearby anatomical structures.

Do Geographic Region, Medicaid Status, and Academic Affiliation Affect Access to Care Among Medicaid and Privately Insured Total Hip Arthroplasty Patients?

BACKGROUND: Medicaid provides health coverage to those beneath the federal poverty line. The literature shows that patients with Medicaid experience barriers to scheduling initial and follow-up visits, although this has not been studied in patients undergoing total hip arthroplasty (THA). The purpose of this study is to assess whether insurance type, geographic location, Medicaid expansion, or academic affiliation affect access to evaluation for THA. METHODS: The American Academy of Orthopedic Surgeons directory was used to call a total of 100 practices. Five random private and 5 random academic medical facilities were called from each of 5 Medicaid-expanded and 5 non-expanded states representing different US geographic regions. Calls were made by an investigator requesting the earliest available appointment for their fictitious parent to be evaluated for a THA. Half of the calls were made with the investigator reporting private insurance of Blue Cross Blue Shield (BCBS), and half reporting Medicaid. Appointment success rate and average time to appointment were compared. Further comparisons were drawn among Medicaid-expanded vs non-expanded states, geographic regions, and private vs academic affiliation. RESULTS: Appointments were successful for 99 of 100 (99%) calls made with BCBS, and 72 of 100 (72%) with Medicaid (P < .001). Success rates were significantly higher for BCBS, regardless of academic vs private affiliation. In all geographic regions, appointment success rate was significantly lower with Medicaid than with BCBS (P ≤ .01). Average time to appointment was also significantly longer for Medicaid (26 days) than private (13 days) insurance (P = .020). In the Medicaid group, appointment success rate was significantly greater for academically affiliated practices compared to private practices (84.0% vs 60.0%, respectively; P = .008). CONCLUSION: Patients with Medicaid seeking consultation for THA experience limits in access to evaluation for THA when compared to patients with private insurance, regardless of geographic region or affiliation of the practice.

Anomalous Flexor Carpi Radialis Tendons Giving Rise to a Novel Surgical Technique in the Treatment of Thumb Carpometacarpal Joint Arthritis: A Case Report.

Introduction: Incidental discovery of anomalous muscles and anatomical variants within the forearm and wrist through surgical exposure and advanced imaging techniques is relatively common. Case Report: The patient presented with pain and swelling in her hand that was refractory to rest and anti-inflammatory medications. Here, we describe the intraoperative discovery of an anatomical variant of the flexor carpi radialis (FCR), as well as an anomalous flexor carpi radialis brevis (FCRB) in a 58-year-old patient being treated for thumb carpometacarpal joint (CMCJ) arthritis. Conclusion: To the best of our knowledge, this is the first description of both anomalies within a single patient and the first use of the surgical technique, described here, in treating the patient's thumb CMCJ arthritis. This report reinforces the importance of meticulous dissection and identification of individual anatomy to optimize patient outcomes.

Mini-open vs. Transfibular Approach for Ankle Arthrodesis, Which Approach is Superior in Joint Preparation: A Cadaver Study.

BACKGROUND: Arthrodesis is considered the gold standard for end-stage ankle arthritis in patients who fail conservative management. Achieving union is paramount while minimizing complications. An essential item for successful union is preparation of the articular surface. Our study aims to evaluate the difference in joint preparation between direct lateral and dual mini-open approaches. MATERIALS AND METHODS: Ten below knee fresh-frozen specimens were used for this study. Five were prepared through lateral approach, and five using dual mini-incisions. After preparation, all ankles were dissected and images of tibial plafond and talar articular surfaces were taken. Surface areas of articulating facets and unprepared cartilage of talus, distal tibia, and distal fibula were measured and analyzed. RESULTS: A greater amount of total surface area was prepared with the mini-open approach in comparison to the transfibular approach. Percentage of prepared surface area of total articulating surface (including talus and tibia/fibula), talus, tibia, and fibula with the transfibular approach were 76.9%, 77.7%, and 75%, respectively. Percentages were 90.9%, 92.9%, and 88.6% with the mini-open approach. When excluding medial gutter, there was no significant difference between techniques (83.94% vs. 90.85%, p = 0.1412). CONCLUSION: Joint preparation with the mini-open approach is equally efficacious as the transfibular approach for the tibiotalar joint. The mini-open approach does provide superior preparation of the medial gutter and inferior tibial surface which may help to increase union rates and decreased complications. LEVEL OF EVIDENCE: V.

Risk factors for readmission within thirty days following revision total hip arthroplasty.

BACKGROUND: The number of total hip arthroplasties (THA) being performed has been steadily increasing for decades. With increased primary THA surgical volume, revision THA numbers are also increasing at a steady pace. With the aging, increasingly comorbid patient populations and newly imposed financial penalties for hospitals with high readmission rates, refining understanding of factors influencing readmission following THA is a research priority. We hypothesize that numerous preoperative medical comorbidities and postoperative medical complications will emerge as significant positive risk factors for 30-day readmission. METHODS: ACS-NSQIP database identified patients who underwent revision THA from 2005 to 2015. The primary outcome assessed was hospital readmission within 30 days. Patient demographics, preoperative comorbidities, laboratory studies, operative characteristics, and postsurgical complications were compared between readmitted and non-readmitted patients. Logistic regression identified significant independent risk factors for 30-day readmission among these variables. RESULTS: 10,032 patients underwent revision THA in the ACS-NSQIP from 2005 to 2015; 855 (8.5%) were readmitted within 30-days. Increasing age, the presence of preoperative comorbidities, high ASA class, and increased operative time were significant positively associated independent risk factors for 30-day readmission. Several postoperative medical and surgical complications such as myocardial infarction, stroke, pneumonia, and sepsis demonstrated significant positive associations with readmission. CONCLUSION: Identifying and understanding risk factors associated with readmission allows for the implementation of evidence-based interventions aimed at minimizing risk and reducing 30-day readmission rates following revision THA.

Subtalar Fusion Preparation: What Are We Really Doing? A Cadaver Study.

Introduction. The open, lateral sinus tarsi approach is the most commonly used technique for subtalar arthrodesis. In this cadaver study, we measured the maximum joint surface area that could be denuded of cartilage and subchondral bone through this approach. Methods. Nine fresh frozen above-knee specimens were used. The subtalar joint was accessed through a lateral incision from the fibular malleolus distally over the sinus tarsi area to the level of the calcaneocuboid joint. Cartilage was removed from the anterior, middle, and posterior facets of the calcaneus and talus using an osteotome and/or curette. ImageJ was used to calculate the surface areas of undenuded cartilage. Results. No specimens were 100% denuded of cartilage on all 6 measured surfaces. The greatest percentages of unprepared surface area remained on the middle facet of the talus (18.66%) and the middle facet of the calcaneus (14.51%). The anterior facet of the talus was 100% denuded in 6 specimens, while the middle and posterior facets were 100% denuded in 3 specimens. The anterior facet of the calcaneus was also 100% denuded in 6 specimens, while the middle and posterior facets were 100% denuded in 3 and 4 specimens, respectively. The average total unprepared surface area per specimen was 8.67%. Conclusion. The lateral sinus tarsi approach provides adequate denudation of cartilage of the subtalar joint in most cases. Total percentage of unprepared joint surface may range from approximately 2% to 18%. Future clinical studies are warranted to assess whether this technique results in optimal union rates. Levels of Evidence:V, Cadaveric Study.

Hip external rotation and extension angles for exposure and preparation of the proximal femur in direct anterior total hip arthroplasty: A cadaveric study.

INTRODUCTION: The direct anterior approach (DAA) to total hip arthroplasty (THA) has a known learning curve, largely due to difficulty achieving exposure and visualization of the acetabulum and proximal femur for joint preparation. There is paucity of information on limb positioning and the degree of angulation at which the limb is positioned for adequate visualization. This study aimed to identify the mean angles of limb positioning necessary for adequate exposure when using two Mueller retractors for femoral preparation using traditional table. MATERIALS & METHODS: A surgeon performed a DAA THA on 11 cadaveric hemipelves, exposing the femoral canal with two simple, robust Mueller retractors. The degree of external rotation and extension of the hip was measured. RESULTS: Of the 11, the mean age was 77.6 years and mean BMI was 27.95. The mean external rotation angle was 56.5 ±â€¯13.5°. The mean extension angle was 19.9 ±â€¯6.6°. DISCUSSION & CONCLUSION: The key technical step in this study incorporated a second robust Mueller retractor on the posterior aspect of the greater trochanter, providing maximum leverage to deliver the femur and achieve visibility while reducing angles of limb positioning thereby reducing complications, and ultimately lessening the learning curve.

The utility of electrocautery for suture passage through bone: A biomechanical study.

Electrosurgical devices are routinely employed during surgery. The use of a Bovie Electrosurgical Unit (ESU) to facilitate the passage of a suture needle through bone has not been studied in the literature. This study aimed to identify force reduction with the application of Bovie ESU to the suture needle through the bone. Peak and the average axial force required for a suture needle to penetrate cadaveric proximal humeri were measured using a custom setup. Twenty-four trials were conducted without electricity, and 72 trials were conducted with a Bovie ESU applying current. Needle size and Bovie ESU power settings were varied. t Tests and analysis of variance were used with p ≤ 0.05 denoting statistical significance. The application of electricity reduced the peak and average axial force needed for a needle to pierce bone, regardless of the Bovie ESU power setting (p < 0.001). The average peak force with the Bovie ESU was 65.7 N, compared with 126.0 N without (p < 0.001), a 47.9% reduction. The average axial force with the Bovie ESU was 38.2 N compared with 81.8 N without (p < 0.001), a 53.3% reduction. There was no significant difference in peak or average axial forces between power settings. At 30 and 90 W of power, larger needle size was associated with significantly lower peak (p = 0.001 and p < 0.001, respectively) and axial (p = 0.002 and p = 0.004, respectively) force. The Bovie ESU reduces the axial force required to pass a suture needle through bone. The use of this technique may allow for the avoidance of drilling for soft tissue repair. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:954-960, 2020.

Does the Cage Position in Transforaminal Lumbar Interbody Fusion Determine Unilateral versus Bilateral Screw Placement?: A Review of the Literature.

This literature review examines the relative placement of the interbody cage with respect to the unilateral screw construct to address the need for bilateral screw placement versus unilateral screw placement. Transforaminal lumbar interbody fusion (TLIF) has become a widely used technique for correcting lumbar intervertebral pathologies. This review addresses the necessity for further study on the effects of the relative position of intervertebral cage placement on the outcome of lumbar spine surgery after TLIF with unilateral pedicle screw fixation. Previous studies have addressed various factors, including posterior screw fixation, cage size, cage shape, and number of levels fused, that impact the biomechanics of the lumbar spine following TLIF. A simple survey of the literature was conducted. A search of the English literature was conducted using the keywords 'TLIF,' 'transforaminal lumbar interbody fusion,' 'graft placement,' 'graft position,' 'cage position,' 'cage placement,' 'unilateral pedicle screw,' 'unilateral TLIF cage placement,' 'lumbar biomechanics,' 'lumbar stability,' 'lumbar fusion,' and 'lumbar intervertebral cage' with various combinations of the operators 'AND' and 'OR' and no date restrictions. Seventeen articles in the English literature that were most relevant to this research question were identified. To the best of our knowledge, there are no published data addressing the effects of cage placement relative to the unilateral screw on lumbar stability in TLIF with unilateral pedicle screw fixation. Investigation of the effects of cage placement is, thus, warranted to achieve optimal clinical outcomes in patients undergoing TLIF with unilateral pedicle screw fixation.

Neurovascular structures at risk with percutaneous fixation in tarsometatarsal fusion: A cadaveric study.

INTRODUCTION: First tarsometatarsal (TMT) joint fusion is routinely used for arthritis and deformities. Common fixation methods include a locking plate construct, cross-screws, or combinations of the two. Cross screws have proven effective for union and stability; however, there is a potential for harm to nearby neurovascular structures due to the nature of percutaneous insertion technique. This study assessed risk of damage to the superficial peroneal nerve with percutaneous TMT fusion. METHODS: Nine fresh-frozen cadaver specimens were included. A medial incision in the internervous plane was made for TMT joint preparation. Two crossed percutaneous wires followed by 4.0 cc screws were placed in the dorsal aspect of the proximal aspect of first metatarsal and in the medial cuneiform. Both were 10-15 mm from the TMT joint line. The dorsal aspect of the foot was dissected and examined for neurovascular interruptions, particularly branches of the superficial peroneal nerve. RESULTS: Results showed a mean distance of 4.33 mm from the proximal pin to the medial branch of the superficial peroneal nerve. The distal pin had a mean distance of 6.44 mm from the medial branch, with one pin 9 mm from the lateral branch. One incident of direct injury to the neurovascular bundle was observed. CONCLUSION: Preparing the joint from the medial side using a percutaneous approach is less invasive, but presents a relative risk for neuritis. Care should be taken during insertion of the percutaneous screw after TMT joint preparation for fusion. LEVEL OF EVIDENCE: Level V, cadaver study.

Comparison of risk factors for postoperative complications across age groups in patients undergoing ORIF of the ankle.

INTRODUCTION: Risk factors associated with various adverse outcomes for patients undergoing open reduction and internal fixation (ORIF) of the ankle, and how these risks differ between younger and older patient populations, has not been clearly established. Objective quantitative data may aid physicians in surgical decision making, individualizing postoperative management, and targeting interventions for reducing postoperative comorbidity. The purpose of this study is to compare the incidence of and risk factors for adverse postoperative outcomes following ORIF of ankle fractures across patient age groups. MATERIALS AND METHODS: Charts of patients age 18 years and older who underwent open reduction and internal fixation (ORIF) for any closed, non-polytraumatic, non-pilon ankle fracture at a single institution between the years 2008 and 2018 were reviewed. Demographic information, comorbidities, and postoperative outcomes were collected. Relative risks for adverse outcomes were calculated and compared between patients younger than 50 and patients 50 years and older. RESULTS: A total of 886 patients were included, 375 (42.3%) of which were over age 50. In both age groups, risk of infection was significantly increased among patients with hypertension, although risk among older patients (RR = 3.52, p = 0.004) was greater than that among younger patients (RR = 2.46, p = 0.017). In patients younger than 50, significant risk of wound dehiscence was associated with tobacco use (RR = 3.39, p = 0.022), substance use (RR = 3.07, p = 0.020), and CHF (RR = 12.77, p < 0.001). Risk of implant failure was significantly increased among younger patients with HIV (RR = 4.33, p = 0.026), CHF (RR = 10.54, p < 0.001), and CKD (RR = 10.54, p < 0.001), and among older patients with HTN (RR = 4.51, p = 0.006), CHF (RR = 5.83, p < 0.001), and tobacco use (RR = 3.82, P = 0.001). CONCLUSION: Patients undergoing ORIF of the ankle should be well-informed of the potential risks of surgery as they pertain to specific comorbidities. Multidisciplinary approaches are warranted for appropriate management of patients with multiple comorbidities.

Is Fibular Sesamoidectomy a Viable Option for Sesamoiditis? A Retrospective Study.

Background Pathologic conditions of the sesamoids can be a source of disabling pain for patients, particularly during toe-off. Some underlying causes include osteonecrosis, inflammation, arthritis, and fracture. Nonoperative treatment is the initial standard of care, and has demonstrated satisfactory outcomes overall; however, operative management may be indicated in cases of pain refractory to conservative management. Sesamoidectomy is an uncommon procedure with risk of potential complications, but may be warranted in select cases of failed nonoperative treatment. Methods A retrospective chart review was conducted at one institution from 2009 to 2018. Twelve patients diagnosed with fibular sesamoiditis were treated with sesamoidectomy. Baseline patient demographics as well as postoperative outcomes were recorded. Results All 12 patients underwent fibular sesamoidectomy using the plantar approach following which their symptom (pain) resolved. Average follow-up for this cohort was 35 months. Of the sample, two patients experienced transient neuritis, one patient developed a superficial infection, and one had painful postoperative scarring. Hallux varus deformity was not observed in any patients. Conclusion Fibular sesamoidectomy may be a safe, viable procedure for patients with sesamoiditis who fail conservative measures.

Prevalence and Safety of Left-Footed Driving Following Right Foot Surgery Patients Including a Driving Simulation.

BACKGROUND: For many patients, returning to driving after right foot and ankle surgery is a concern, and it is not uncommon for patients to ask if driving may be performed with their left foot. A paucity of literature exists to guide physician recommendations for return to driving. The purpose of this study was to describe the driving habits of patients after right-sided foot surgery and assess the safety of left-footed driving using a driving simulator. METHODS: Patients who underwent right foot or ankle operations between January 2015 and December 2015 were retrospectively identified. A survey assessing driving habits prior to surgery and during the recovery period was administered via a REDCap database through email or telephone. Additionally, simulated driving scenarios were conducted using a driving simulator in 20 volunteer subjects to compare characteristics of left- versus right-footed driving. RESULTS: Thirty-six of 96 (37%) patients who responded to the survey reported driving with the left foot postoperatively. No trends were found associating left-footed driving prevalence and socioeconomic status. In driving simulations, patients exceeded the speed limit significantly more (P < .001) and hit other vehicles more (P < .026) when driving with the right foot than the left. The time to fully brake and fully release the throttle in response to vehicular hazards was significantly prolonged in left-footed driving compared with right (P = .019 and P = .034, respectively). CONCLUSION: A significant proportion of right foot ankle surgery patients engaged in left-footed driving during postoperative recovery. Driving with both the right and left foot presents a risk of compromised safety. This study provides novel objective data regarding the potential risks of unipedal left-footed driving using a standard right-footed console, which indicates that driving with the left foot may prolong brake and throttle release times. Further studies are warranted for physicians to be able to appropriately advise patients about driving after foot and ankle surgery. LEVEL OF EVIDENCE: Level IV, case series.

Outcomes of Inpatient Versus Outpatient Elective Foot and Ankle Surgery.

Background Complications following orthopedic surgeries are undesirable and costly. A potential method to reduce these costs is to perform traditionally inpatient surgical procedures in the outpatient setting. The purpose of this study is to compare outcomes between inpatient and outpatient settings for elective foot and ankle surgeries using the National Surgical Quality Improvement Program (NSQIP) database. Methods Patients with Current Procedural Terminology (CPT) codes specific to orthopedic foot and ankle surgery were identified from the 2011-2015 American College of Surgeons NSQIP database. Demographics, comorbidities, and complications were compared between patients undergoing inpatient and outpatient procedures. Results Patients receiving inpatient surgery were significantly older and more frequently male. Black patients were significantly more likely to undergo inpatient surgery than outpatient surgery while white patients were significantly more likely to undergo outpatient surgery. Outpatients had a significantly higher mean body mass index (BMI) than inpatients. Smokers were at a significantly greater risk of undergoing inpatient surgery than outpatient surgery. Outpatients had significantly longer operative times, were more likely to receive general anesthesia, had a lower American Society of Anesthesiologists (ASA) class, were more likely to be functionally independent, and were less likely to expire postoperatively. Patients who received surgery as an inpatient were significantly more likely to have comorbidities as compared to outpatients. The overall risk of surgical complications was significant between groups with 8.6% in the inpatient group and 2.0% in the outpatient group. The overall risk of medical complications was 16.9% in the inpatient group and 1.7% in the outpatient group. Similar to the surgical complications, inpatients were significantly more likely to sustain each of the individual medical complications except for stroke/CVA and venous thromboembolism. Conclusions Outpatient management is associated with decreased postoperative complications in select patients. Performing more operations in the outpatient setting in select patients may be beneficial for cost reduction and patient satisfaction.

Outcomes of Staged Treatment for Complex Distal Radius Fractures.

Introduction Distal radius fractures are common, but the results and complications of treatment with early external fixation and staged open reduction internal fixation have not been previously reported. Materials and methods Patients who received staged distal radius fracture treatment from 1/1/2008 to 12/31/2015 at the University of Alabama at Birmingham were identified. Patient, injury, and treatment characteristics, as well as complications, were collected from the medical record. Results There were 50 fractures in 47 patients, with mean follow-up of 9.3 months. Thirty-eight were open and 45 were intra-articular. For definitive treatment, 41 received a volar approach and nine a dorsal approach. Twenty wrists experienced one or more complications, including two non-unions. Five patients developed infections - one Kirschner wire site infection, one external fixator (ex-fix) pin site infection, and three deep infections. All deep infections occurred in tobacco users. The rate of deep infection with volar approach was 2.4%, compared to 22.2% with dorsal approach. Ex-fix pin sites overlapped radiographically with the plate in 20 fractures, with three deep infections in this group (15%) and no deep infections in the group without overlap. None of these differences reached statistical significance. Conclusions This protocol results in reliable healing of complex fractures, with a 96% union rate. However, 40% sustained complications. We conclude that this protocol is useful for temporizing complex fractures but caution that the complication rate is high. Since recent literature indicates that low-grade open distal radius fractures do not require emergent debridement and that immediate internal fixation is safe, complications might be avoided by restricting this protocol to complex or physiologically unstable patients.

Postoperative Tourniquet Pain in Patients Undergoing Foot and Ankle Surgery.

Background  Tourniquets are commonly used to reduce bleeding intraoperatively during orthopedic surgery. There are variable guidelines for ideal tourniquet pressure and duration; the practice of fixed, high tourniquet pressures remains common. The purpose of this study was to assess the correlation between excessive tourniquet pressure and duration and the incidence of tourniquet pain in foot and ankle surgery patients. Methods  A retrospective cohort study was conducted on 128 patients who underwent foot and ankle surgery with tourniquet use. Baseline systolic blood pressure (SBP), tourniquet pressure and duration, intraoperative opioid consumption, post-anesthesia care unit (PACU) pain scores, PACU opioid consumption, and PACU length of stay (LOS) were collected. Linear regression analysis was used to test for the statistical correlation between the tourniquet pressure and duration and postoperative pain scores, narcotic use, and PACU LOS. Results A tourniquet pressure of 280 mmHg was used in 90% of the cases (N = 128). Only 2.5% of the patients had tourniquet pressures 100-150 mmHg above SBP. The mean tourniquet time was 107.5 minutes ± 39.8. Linear regression showed a significant positive correlation between tourniquet time and morphine equivalents used in the perioperative period (r = 0.410; p < 0.001) and the length of PACU stay (r = 0.250; p = 0.012). Conclusion  Prolonged tourniquet times at high pressures, not based on limb occlusion pressure LOP, lead to increased pain and opioid use and prolonged PACU LOS. Basing tourniquet pressures on LOPs could likely improve the safety margin of the tourniquets; however, randomized clinical trials are needed.