Surgical Outcomes in Charcot Arthropathy.

Treatment of Charcot neuroarthropathy (CN) of the foot and ankle remains challenging for both patients and surgeons. Nonoperative treatment with cast/orthosis immobilization has long been the mainstay of treatment, but surgical intervention has gained interest to improve poor long-term outcomes. A review of existing data on the operative management of CN demonstrates the potential benefits but also the continued risks associated with treatment. Additionally, a retrospective review of cohorts managed with limited surgical interventions (wound debridements, exostectomies, and other surgical procedures) compared to reconstructive procedures provides additional insight into the surgical management of CN.

The Differentiation Between Infection and Acute Charcot.

The differentiation between acute Charcot neuroarthropathy and infection in the foot and ankle should be supported by multiple criteria. A detailed history and physical examination should always be completed. Plain radiographs should be performed, though advanced imaging, currently MRI, is more helpful in diagnosis. Scintigraphy and PET may become the standard imaging modalities once they are more clinically available due to their reported increased accuracy. Laboratory analysis can also act as a helpful diagnostic tool. Histopathology with culturing should be performed if osteomyelitis is suspected. The prompt diagnosis and initiation of treatment is vital to reducing patient morbidity and mortality.

Tibiotalocalcaneal Arthrodesis Using Hybrid Plate-Nail Constructs: A Novel Technique for Treatment of Unstable Ankle and Hindfoot Deformities.

SUMMARY: Tibiotalocalcaneal (TTC) arthrodesis is a treatment option for several pathologies of the ankle and hindfoot, including acute trauma, posttraumatic arthritis, and Charcot neuroarthropathy. Traditional fixation options for TTC arthrodesis include intramedullary hindfoot nailing or internal fixation with plates and/or screws. In certain patients, either due to poor bone quality, impaired sensation, or concern for noncompliance, more robust fixation may be desired. In such patients, we have used a hybrid plate-nail construct with promising results. This article and the accompanying video demonstrate our technique for TTC arthrodesis using a plate-nail construct and review treatment decisions involved with management of these complex cases.

Cost Analysis and Reimbursement of Weightbearing Computed Tomography.

Background: Weightbearing computed tomography (WBCT) is becoming a valuable tool in the evaluation of foot and ankle pathology. Currently, cost analyses of WBCT scanners in private practice are lacking in the literature. This study evaluated the costs of acquisition, utilization, and reimbursements for a WBCT at a tertiary referral center, information of particular interest to practices considering obtaining such equipment. Methods: All WBCT scans performed at a tertiary referral center over the 55-month period (August 2016 to February 2021) were retrospectively evaluated. Patient demographics, pathology location, etiology, subspecialty of the ordering provider, and whether the study was unilateral or bilateral were collected. Reimbursement was calculated based on payor source as a percentage of Medicare reimbursement for lower extremity CT. The number of total scans performed per month was evaluated to determine revenue generated per month. Results: Over the study period, 1903 scans were performed. An average of 34.6 scans were performed each month. Forty-one providers ordered WBCT scans over the study period. Foot and ankle fellowship-trained orthopaedic surgeons ordered 75.5% of all scans. The most common location of pathology was the ankle, and the most common etiology was trauma. The device was cost neutral at 44.2 months, assuming reimbursement for each study was commensurate with Medicare rates. The device became cost neutral at approximately 29.9 months when calculating reimbursement according to mixed-payor source. Conclusion: As WBCT scan becomes more widely used for evaluation of foot and ankle pathology, practices may be interested in understanding the financial implications of such an investment. To the authors' knowledge, this study is the only cost-effectiveness analysis of WBCT based in the United States. We found that in a large, multispecialty orthopaedic group, WBCT can be a financially viable asset and a valuable diagnostic tool for a variety of pathologies. Level of Evidence: Level III, diagnostic.

The chevron bunionectomy for moderate to severe hallux valgus deformity: Effects of procedural factors on hallux valgus correction.

BACKGROUND: Effects of procedural factors on chevron bunionectomy outcomes were studied. METHODS: Included were 109 feet with distal chevron osteotomy and preoperative intermetatarsal angle (IMA) greater than 15 degrees. IMA and hallux valgus angles (HVA), release type, fixation, second-digit procedures, and risk factors were evaluated. RESULTS: Eighty-three percent (91/109 feet) had satisfactory outcomes; nine had moderate pain. From preoperative, IMA improved 7.2 and HVA 20.5 degrees. Risk factors or second-digit procedures had no effect. Lateral release improved IMA (p < 0.01), with no difference between open lateral and transarticular release; 86% percent (64/74) were satisfied with open lateral release compared with 83% (19/23) and 66% (8/12) with no release and transarticular release, respectively. Fixation did not affect outcomes. CONCLUSION: Chevron bunionectomy corrected IMA and HVA to normal with few complications. Lateral release increased IMA correction. Transarticular release had lower satisfaction than open lateral release or no release. LEVEL OF EVIDENCE: Level III, retrospective.

Efficacy of Postoperative Oral Antibiotics in Foot and Ankle Surgery.

BACKGROUND: Preoperative oral antibiotic use in patients undergoing foot and ankle surgery is standard practice, but no consensus has been reached regarding the efficacy of postoperative oral antibiotics. The purpose of this study was to determine whether postoperative oral antibiotics reduce the rate of surgical site infections (SSIs) in patients, with and without comorbidities, undergoing foot and ankle surgery. METHODS: A retrospective chart review was conducted identifying patients who underwent foot and ankle surgery by 4 fellowship-trained, foot and ankle orthopaedic surgeons between January 1, 2015, and January 1, 2019. Patients were divided into 2 groups: those who received postoperative oral antibiotics (group 1) and those who did not (group 2). Two surgeons routinely prescribed postoperative oral antibiotics, and 2 did not. Demographics, comorbidities, and procedure complexity based on surgical site and Current Procedural Terminology code were recorded from the charts. The primary outcome was postoperative infection (superficial or deep) within 6 months after surgery. Patients with antibiotic use prior to surgery, preoperative infection, or lack of follow-up >6 weeks were excluded. Multivariate logistic regression modeling was used to analyze differences in infection rate and severity. RESULTS: Chart review identified 3631 patients, 1227 of whom did not receive postoperative oral antibiotics whereas 2394 patients did. Routine postoperative oral antibiotic use did not significantly affect postoperative infection rates or severity. However, all covariates studied (diabetes, hypertension, obesity, tobacco use, alcohol use, rheumatoid conditions, and age) influenced postoperative infection rates and severity. CONCLUSION: The results of this study indicate that postoperative oral antibiotics are not associated with differences in infection rates or severity. We do not recommend routine use in foot and ankle surgery.

A Direct Posterior Approach for Subtalar Distraction Arthrodesis.

SUMMARY: Because of soft tissue constraints, definitive management of hindfoot trauma occasionally requires a direct posterior approach via a coronal split of the Achilles tendon. This article and the accompanying video demonstrate a direct posterior approach for subtalar distraction arthrodesis and review treatment decisions involved with management of these complex cases.

Early Failure of the Paragon28 Phantom Hindfoot Fusion Nail: A Case Report.

CASE: Tibio-talar-calaneal fusion nails can be used to treat acute ankle fractures in patients with diabetes, Charcot arthropathy, or other comorbidities. Recently, Paragon28 released the Phantom Hindfoot Fusion Nail (Phantom nail) with a unique design feature-a proximal coil. We present a case of an ankle fracture-dislocation in a diabetic patient treated with the Paragon28 nail who experienced early implant failure. CONCLUSION: It is important for surgeons to understand that the proximal coil in the Phantom nail should not be considered part of the working length of the nail and may introduce a stress riser that may lead to early implant failure.

Analysis of Wheeled Knee Walker Use following Foot and Ankle Surgery or Injury.

To determine patient satisfaction and safety with wheeled knee walkers, we performed a retrospective, observational, and descriptive study. Inclusion criteria were age ≥18 years, unilateral foot or ankle surgery, non-weightbearing status, and being given the option of using the knee walker. Surveys were sent to eligible patients, and chart review included only those patients who returned surveys. Primary endpoints were occurrence and frequency of falls. Secondary endpoints were patient demographics, comorbidities, knee walker characteristics, duration of use, and patient satisfaction. We also attempted to identify associations between falls and patient characteristics. Eighty participants, 51 females and 29 males, responded adequately to the survey. The mean age of respondents was 55.6 ± 13.0 years and their mean body mass index (BMI) was 30.2 ± 5.9 kg/m2. Most used a steerable, 4-wheeled knee walker. Almost half (46%) had no prior experience with any type of walking aids, and none had experience using a knee walker. Two thirds (66%) did not receive any instruction on usage of the knee walker. Thirty-four (43%) of the 80 respondents fell while using the knee walker; nearly two thirds (62%) of those who fell reported multiple falls. Sixteen (55%) of 29 males compared to 18 (36%) of 50 females reported falling (p = .097). There was no statistical association between falls and age, BMI, or number of comorbidities. Most respondents (91%) who fell still reported satisfaction with the knee walker. Nearly half (43%) experienced falling, and nearly two thirds (64%) of those who fell had multiple falls.

Race and Insurance Status Association With Receiving Orthopedic Surgeon-Prescribed Foot Orthoses.

BACKGROUND: This study looked at the effect of patient demographics, insurance status, education, and patient opinion on whether various orthotic footwear prescribed for a variety of diagnoses were received by the patient. The study also assessed the effect of the orthoses on relief of symptoms. METHODS: Chart review documented patient demographics, diagnoses, and medical comorbidities. Eligible patients completed a survey either while in the clinic or by phone after their clinic visit. RESULTS: Of the 382 patients prescribed orthoses, 235 (61.5%) received their orthoses; 186 (48.7%) filled out the survey. Race and whether or not the patient received the orthosis were found to be significant predictors of survey completion. Race, type of insurance, and amount of orthotic cost covered by insurance were significant predictors of whether or not patients received their prescribed orthoses. Type of orthosis, diabetes as a comorbidity, education, income, sex, and diagnosis were not significant predictors of whether the patient received the orthosis. Qualitative results from the survey revealed that among those receiving their orthoses, 87% experienced improvement in symptoms: 21% felt completely relieved, 66% felt better, 10% felt no different, and 3% felt worse. CONCLUSION: We found that white patients had almost 3 times the odds of receiving prescribed orthoses as black patients, even after controlling for type of insurance, suggesting race to be the primary driver of discrepancies, raising the question of what can be done to address these inequalities. While large, systematic change will be necessary, some strategies can be employed by those working directly in patient care, such as informing primary care practices of their ability to see patients with limited insurance, limiting blanket refusal policies for government insurance, and educating office staff on how to efficiently work with Medicare and Medicaid. LEVEL OF EVIDENCE: Level III, comparative study.

The Current State of the Residency Match.

This article explores the current state of the residency match in 2020 with a focus on orthopedic surgery, analyzing the utility of current applicant screening methods in producing future generations of competent surgeons. Discussed are anticipated changes to the residency application process considering the COVID-19 pandemic and Step 1 becoming pass/fail in January 2022. Also explored are potential changes to improve the process for applicants and residency programs, such as identifying and using predictive factors of resident success in the applicant screening process, finding better ways to match applicants with programs, and increasing female and underrepresented minorities within orthopedics.

Smoking Effects in Foot and Ankle Surgery: An Evidence-Based Review.

BACKGROUND: The purpose of this article was to review the basic science pertaining to the harmful effects of cigarette smoke, summarize recent clinical outcome studies, and examine the benefits of smoking cessation and the efficacy of current smoking cessation strategies. METHODS: The literature concerning basic science, clinical outcomes, and smoking cessation was reviewed; over half (56%) of the 52 articles reviewed were published in the last 5 years. RESULTS: Smoking is associated with low bone mineral density, delayed fracture union, peri-implant bone loss, and implant failure. Orthopedic surgical patients who smoke have increased pain and lower overall patient satisfaction, along with significantly increased rates of wound healing complications. DISCUSSION/CONCLUSION: Active smoking is a significant modifiable risk factor and should be discontinued before foot and ankle surgery whenever possible. Orthopedic surgeons play an important role in educating patients on the effects of smoking and facilitating access to smoking cessation resources. LEVEL OF EVIDENCE: Level V, expert opinion.

Early Clinical and Radiographic Outcomes of Trabecular Metal Total Ankle Replacement Using a Transfibular Approach.

BACKGROUND: In the last 2 decades, total ankle replacement has gained greater acceptance as a treatment option in patients with end-stage ankle osteoarthritis. However, there is a lack of literature on total ankle replacement using a lateral transfibular approach. Therefore, we sought to report early clinical and radiographic results for a patient cohort treated with total ankle replacement using a lateral transfibular approach, performed by a single surgeon. METHODS: From October 2012 to December 2014, 55 primary total ankle arthroplasties using the Zimmer Trabecular Metal Total Ankle implant were performed in 54 patients (29 male and 25 female; mean age, 67.0 years). Clinical assessment, including pain evaluation and measurement of ankle range of motion, was conducted preoperatively and at the latest follow-up. Weight-bearing radiographs were used to determine angular alignment of the tibial and talar components and to analyze the bone-implant interface. Intraoperative and postoperative complications, revision surgeries, and survivorship were evaluated. RESULTS: Implant survival was 93% at 24 months of follow-up. There were 3 revisions of a tibial component due to aseptic loosening. In 10 of the 55 cases, a secondary procedure was performed during follow-up. The mean follow-up duration was 26.6 ± 4.2 months. No delayed union or nonunion was observed for fibular healing. The average visual analog scale (VAS) pain score decreased significantly, from 7.9 ± 1.3 to 0.8 ± 1.2. The average total range of motion increased significantly, from 22.9° ± 12.7° to 40.2° ± 11.8°. CONCLUSIONS: Early results of total ankle replacement using the Zimmer trabecular metal implant and the lateral transfibular approach demonstrated improved patient-reported outcomes and increased ankle motion at a minimum follow-up of 2 years. In the 55 consecutive cases, the fibular osteotomy required for access to the ankle healed without complications. Painful early loosening due to lack of osseous ingrowth required revision in 3 of 55 cases. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Distal Femoral Replacement for Acute Distal Femoral Fractures in Elderly Patients.

OBJECTIVES: To evaluate outcomes and complications using cemented modular distal femoral replacement in elderly patients with distal femoral fractures. DESIGN: Retrospective chart review, case series. SETTING: A Level 1 and Level 2 trauma center, both tertiary referral hospitals. PATIENTS/PARTICIPANTS: Eighteen patients older than 60 years (average age 77 years) who had cemented distal femoral replacement for distal femoral fractures (comminuted, intraarticular, osteoporotic, arthritic) between 2005 and 2013. Patients with previous knee surgery were excluded. INTERVENTION: Cemented modular distal femoral replacement. MAIN OUTCOME MEASURES: Implant status, complications, Knee Society Score, Musculoskeletal Tumor Society score, and Western Ontario and McMaster Osteoarthritis Index. RESULTS: All patients were extremely or very satisfied with their outcomes. For patients with functional outcome data, Knee Society Score averaged 85.7 with a functional score of 35, Musculoskeletal Tumor Society score averaged 19.2, and Western Ontario and McMaster Osteoarthritis Index score averaged 23.1 at an average follow-up of 2.3 years. Range of motion was 1-99 degrees. Implant-related complications occurred in 2 patients (11%); one required revision to total femoral replacement because of periprosthetic fracture and the other had a deep infection that required exchange of the components. No patient had aseptic loosening or patellar maltracking. There were no perioperative deaths or late amputations. CONCLUSIONS: Cemented modular distal femoral replacement is a viable treatment option in elderly patients that permits immediate full weight-bearing, with most patients returning to preoperative functional status. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effect of Obesity on Outcomes of Forefoot Surgery.

BACKGROUND: Forefoot surgery typically is elective, so it is important to define risk factors to educate patients on potential complications. The purpose of this study was to determine if obesity is an independent risk factor that contributes to increased complication rates after forefoot surgery. METHODS: Through a retrospective review of records, 633 patients were identified who had forefoot surgery at one institution between 2008 and 2010. All patients who currently smoked or smoked in the past were excluded to eliminate a confounding factor, as smoking is known to increase complication rates, leaving 427 patients for inclusion, 299 nonobese (BMI less than 30) and 128 obese (BMI more than 30). Medical records were reviewed for the occurrence of complications, including nonunion, delayed union, delayed wound healing, infection, and persistent pain. RESULTS: The overall complication rate was 9%, with similar rates between obese (10%) and nonobese patients (9%). The only specific complication approaching significance (P = .13) was a higher rate of infection in obese patients (4 % compared to 1%), which could be attributed to the higher percentage of diabetic patients in the obese group. Diabetic patients, regardless of weight, had significantly higher rates of infection (P = .03), with a trend toward higher rates of overall complications and delayed wound healing (P = .08 and P < .06, respectively). CONCLUSION: Obesity was not shown to lead to more frequent complications after forefoot surgery. Diabetes was associated with significantly higher rates of infection, regardless of weight. Though not significant, there was a trend toward higher rates of overall complications and delayed wound healing in diabetic patients as well. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Cigarette smoking increases complication rate in forefoot surgery.

BACKGROUND: Cigarette smoking is known to increase perioperative complication rates, but no study to date has examined its effect specifically in forefoot surgery. The purpose of this study was to determine whether cigarette smoking increased complications after forefoot surgery. METHODS: The records of 602 patients who had forefoot surgery between 2008 and 2010, and for whom smoking status was known, were reviewed. Patients were categorized into 3 groups based on smoking status: active smoker, smoker in the past, or nonsmoker. Medical records were reviewed for occurrence of complications, including nonunion, delayed union, delayed wound healing, infection, and persistent pain. RESULTS: Active smokers were found to have a notably higher complication rate (36.4%) after forefoot surgery than patients who previously (16.5%) or never (8.5%) smoked. Patients who continued to smoke in the perioperative period had the highest percentage of delayed union (3.0%), infection (9.1%), delayed wound healing (10.6%), and persistent pain (15.2%). Active cigarette smokers were 4.3 times more likely to have a complication than nonsmokers. Patients who smoked at any point in the past but quit prior to surgery were 1.9 times more likely than nonsmokers to incur a complication. The average time of smoking cessation for patients who had smoked at any point in the past but had quit prior to surgery was 17 years. For active smokers, those with a complication smoked an average of 18 cigarettes daily, while those without a complication smoked 14 cigarettes daily. CONCLUSIONS: Before forefoot surgery, surgeons should educate patients who smoke about their increased risk of complications and encourage smoking cessation. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Is Gelsolin a Biomarker for Aseptic Loosening After Total Knee Arthroplasty?

Gelsolin (GSN) has been implicated in inflammatory reactions in asthmatic patients and may be a marker for acute or chronic reactions in synovial tissue. Detection of increased levels of GSN in synovial fluid could differentiate between aseptic loosening (low GSN) and hypersensitivity reaction (high GSN). Synovial fluid from both knees of 7 cadaver specimens with unilateral TKA was analyzed using ELISA for GSN levels. Components were explanted after spiral CT scans to determine wear patterns and loosening. Results were compared to synovial fluid from 7 consecutive TKA revisions for aseptic failure. Average GSN levels for cadaver native and well-functioning TKA knees were 24,534±10,437 ng/mL and 38,430±30,907 ng/mL, respectively (p=0.314). Average GSN level for revision patients was 53,294±19,868 ng/mL, significantly higher than cadaver well-functioning TKAs (p=0.006). The patient with the highest level of GSN at time of revision surgery showed significant metallosis at the time of surgery.