New Persistent Opioid Use After Orthopaedic Foot and Ankle Surgery: A Study of 348 Patients.

INTRODUCTION: The opioid epidemic is a devastating public health issue to which orthopaedic surgery is inextricably linked. The purpose of this study was to identify risk factors for new persistent opioid use after orthopaedic foot and ankle surgery among patients who were opioid naive preoperatively. METHODS: Patients undergoing orthopaedic foot or ankle surgery at a single institution were identified. Our state's prescription monitoring program was used to track opioid prescriptions filled in the preoperative (6 months to 30 days before surgery), perioperative (30 days before to 14 days after), and postoperative (2 to 6 months after) periods. Patients filling a prescription during the preoperative period were excluded. Baseline characteristics, surgical characteristics, and perioperative morphine milligram equivalents were tested for association with new persistent use during the postoperative period. RESULTS: A total of 348 opioid-naive patients met the inclusion criteria. Overall, the rate of new persistent postoperative opioid use was 8.9%. Patients reporting recreational drug use had the highest risk, at 26.7% (relative risk [RR] = 3.3, 95% confidence interval, 1.3 to 8.2, P = 0.0141). In addition, patients who had perioperative opioid prescription >160 morphine milligram equivalents were at increased risk (RR = 2.2, 95% confidence interval, 1.1 to 4.5, P = 0.021). Other risk factors included age ≥40 years (RR = 2.2, P = 0.049) and consumption of ≥6 alcoholic beverages per week (RR = 2.1, P = 0.040). New persistent use was not associated with ankle/hindfoot surgery (versus midfoot/forefoot), bone surgery (versus soft-tissue), or chronic condition (versus acute; P > 0.05). CONCLUSION: The rate of new persistent postoperative opioid use after orthopaedic foot and ankle surgery is high, at 8.9%. Greater perioperative opioid prescription is a risk factor for new persistent use and is modifiable. Other risk factors include recreational drug use, greater alcohol use, and greater age. Orthopaedic foot and ankle surgeons should limit perioperative prescriptions and be cognizant of these other risk factors to limit the negative effects of opioid prescriptions on their patients and communities. LEVEL OF EVIDENCE: Level III.

Patient Knowledge Regarding Radiation Exposure From Foot and Ankle Imaging.

Foot and ankle surgeons routinely prescribe diagnostic imaging that exposes patients to potentially harmful ionizing radiation. It is unclear how well patients understand the radiation to which they are exposed. In this study, 946 consecutive new patients were surveyed regarding medical imaging and radiation exposure prior to their first appointment. Respondents compared the amount of radiation associated with chest X-rays (CXRs) with various types of foot and ankle imaging. Results were compared with actual values of radiation exposure from the published literature. Of 946 patients surveyed, 841 (88.9%) participated. Most had private insurance (82.8%) and a bachelor's degree or higher (60.6%). Most believed that foot X-ray, ankle X-ray, "low dose" foot and ankle computed tomography (CT) scan (alluding to cone-beam CT), and traditional foot and ankle CT scan contain similar amounts of ionizing radiation to CXR. This contradicts the published literature that suggests that the actual exposure to patients is 0.006, 0.006, 0.127, and 0.833 CXR equivalents of radiation, respectively. Of patients who had undergone an X-ray, 55.9% thought about the issue of radiation prior to the study, whereas 46.1% of those undergoing a CT scan considered radiation prior to the exam. Similarly, 35.2% and 27.6% reported their doctor having discussed radiation with them prior to obtaining an X-ray and CT scan, respectively. Patients greatly overestimate the radiation exposure associated with plain film X-rays and cone-beam CT scans of the foot and ankle, and may benefit from increased counseling regarding the relatively low radiation exposure associated with these imaging modalities.Level of Evidence: Level III: Prospective questionnaire.

Trends in the Management of Achilles Tendon Ruptures in the United States Medicare Population, 2005-2011.

BACKGROUND: Achilles tendon ruptures are one of the most commonly treated injuries by orthopaedic surgeons and general practitioners. Achilles tendon ruptures have classically been thought to affect the middle-aged "weekend warrior" participating in basketball, volleyball, soccer, or any other ground sport that requires speed and agility; however, with a more active elderly population, these tears are becoming more common in older patients. PURPOSE: To report trends in nonoperative and operative treatment of Achilles tendon tears in the United States from 2005 to 2011 in patients registered with a large Medicare database. STUDY DESIGN: Descriptive epidemiological study. METHODS: Patients who underwent nonoperative and operative treatment of Achilles tendon ruptures by either primary repair or primary repair with graft (International Classification of Diseases 9 [ICD-9] diagnosis code 727.67, Current Procedural Terminology [CPT] codes 27650 and 27652) for the years 2005 to 2011 were identified using the PearlDiver Medicare Database. Demographic and utilization data available within the database were extracted for patients who underwent nonoperative as well as operative treatment for Achilles tendon ruptures. Statistical analysis involved Student t tests, chi-square tests, and linear regression analyses, with statistical significance set at P < .05. RESULTS: From 2005 to 2011, there were a total of 14,127 Achilles tendon ruptures. Of these, 9814 were managed nonoperatively, 3531 were treated with primary repair, and 782 were treated with primary repair with graft. The incidence of Achilles tendon increased from 0.67 per 10,000 in 2005 to 1.08 per 10,000 in 2011 (P < .01). There was no significant difference in the number of Achilles ruptures between males (6636) and females (7582) (P > .05). There was an increase in the overall number of Achilles tendon ruptures over time (1689 in 2005 compared with 2788 in 2011; P < .001) but no difference in the percentage of Achilles ruptures treated operatively (P > .05). Older patients were more likely to be treated nonoperatively (P < .05). No differences in operative versus nonoperative treatment were seen between yearly quarter (P > .05), sex (P > .05), or region (P > .05). CONCLUSION: The incidence of Achilles tendon ruptures is increasing with time, but the trend in operative and nonoperative treatment has not changed between 2005 and 2011. Older patients, especially those older than 85 years, are more likely to be treated nonoperatively. No differences in treatment patterns were seen based on sex, region, or yearly quarter.

Bilateral hallux varus deformity correction with a suture button construct.

Hallux varus deformity typically results from soft-tissue overcorrection at the metatarsophalangeal joint during surgery for hallux valgus. There are several soft-tissue procedures available for flexible hallux varus deformity including transfer of the extensor hallucis longus or abductor hallucis. To our knowledge, there have not been any previous reports in the literature of bilateral hallux varus deformities in the setting of potential pregnancy-related ligamentous laxity combined with iatrogenic injury. We present the case of an isolated bilateral hallux varus deformity occurring after pregnancy and prior bunion surgery. The simultaneous operations using the Mini TightRope device (Arthrex Inc, Naples, Florida) were considered a success with the patient having pain relief and return to regular activities with normal shoewear.

Tendon transfers for Achilles reconstruction.

Tendon transfers are commonly used in the foot and ankle to restore function in neglected ruptures, reconstruct degenerated tendons, and correct deformity. The Achilles tendon is commonly afflicted by these problems because of the dominant role it plays in the mechanics of gait and running and its inherently poor blood supply. This article discusses the general principles of tendon transfers with regard to Achilles tendon function, the surgical techniques involved, and published results using these techniques. The goal is to provide the orthopedic foot and ankle surgeon with a wide variety of techniques to solve both the straightforward Achilles tendon problem as well as the difficult revision case.

Results of non-surgical treatment of stage II posterior tibial tendon dysfunction: a 7- to 10-year followup.

BACKGROUND: There are few long-term studies on the non-operative treatment of Stage II Posterior Tibial Tendon Dysfunction (PTTD). The purpose of this study is to describe the natural history and determine the efficacy of non-operative treatment of Stage II PTTD using clinical outcome scores. MATERIALS AND METHODS: Patients with Stage II PTTD treated with a Double Upright Ankle Foot Orthosis (DUAFO) with a minimum followup of 7 years were identified retrospectively. Patients were evaluated with the AOFAS Ankle/Hindfoot Score, SF-36, Foot Function Index (FFI), Visual Analog Scale (VAS) for pain, and a custom questionnaire in addition to a comprehensive physical examination. RESULTS: Thirty-three feet in 32 patients were included with an average followup of 8.6 years. Success defined as being brace-free and avoiding surgery was 69.7%. Five patients (15.2%) were unable to completely wean from a brace. Five patients went on to surgery. The mean AOFAS and FFI score was 78.4 and 18.4, respectively. Compared to national norms, SF-36 subscores for each age sub-category showed no significant difference in any of the age groups (p<0.05). Average VAS pain scale score was 1.9. Satisfaction was rated as "satisfied" in 20 patients (60.6%), "satisfied with minor reservations" in 11 patients (33.3%), partially satisfied in one (3.0%), and "unsatisfied" in one (3.0%). None of the patients rated as "satisfied with major reservations". CONCLUSION: Treatment of Stage II PTTD with a DUAFO has been shown to be a viable alternative to surgery with a high likelihood of adequate function, avoidance of surgery, and being brace-free at 7- to 10-year followup.

Use of bipolar radiofrequency energy in delayed repair of acute supraspinatus tears in rats.

The purpose of this study is to determine if bipolar radiofrequency energy (bRFE) can enhance delayed surgical repair of acute supraspinatus tendon tears. Bilateral supraspinatus tendon tears were created in 42 Sprague-Dawley rats and repaired at 6 weeks either with or without bRFE augmentation. There were 8 control (sham) rats. Treatment rats were euthanized at 4, 8, and 12 weeks after repair. All specimens underwent biomechanical and histologic evaluation. Compared with standard repair, bRFE-treated repairs showed a greater average maximum stress (8.475 N/m2 versus 3.95 N/m2) at 12 weeks, which was not significant (P < .11). The mode of failure was by humeral fracture in 57.14% > with bRFE versus 14.29% without bRFE. Histologically, both standard and bRFE-treated repairs were indistinguishable from controls at 12 weeks. The use of bRFE showed no definitive effect on delayed repair of acute rat rotator cuff tears.