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.

Implementation of a Service-Specific Template Integrating Objective Structured Clinical Examination and Accreditation Council for Graduate Medical Education Milestones: One Institution's Experience.

The Accreditation Council for Graduate Medical Education (ACGME) orthopaedic milestones require detailed, frequent resident evaluations. This institution desired a cost-effective objective structured clinical examination (OSCE) to facilitate these evaluations. Data were collected as a prospective, uncontrolled observational study. The OSCE was completed by residents entering and exiting the foot and ankle rotation during postgraduate years 2 and 4. Physician assistants functioned as standardized patients. Statistical analyses were performed using paired and independent t tests. The OSCE was implemented using reliable, low-cost modalities and has facilitated milestones evaluations. Preliminary data show 4th-year residents performed higher in prerotation global assessment with a standardized patient and written exam (p < .03). Second-year residents showed improvement in the written exam on rotation completion (p = .03). Using this methodology, institutions may establish similar cost-effective OSCEs as feasible evaluative solutions to satisfy milestone requirements. The authors believe this tool may be modified for any specialty. (Journal of Surgical Orthopaedic Advances 26(4):257-261, 2017).

What are the patterns of prophylactic postoperative oral antibiotic use after foot and ankle surgery?

BACKGROUND: The CDC estimates 23% of healthcare-associated infections to be surgical site infections, with alarming prevalence of antibiotic-resistant organisms. While there is consensus regarding preoperative prophylaxis, orthopaedic surgeons' use of prophylactic postoperative oral antibiotics is less defined. QUESTIONS/PURPOSES: We investigated surgeons' use of prophylactic postoperative oral antibiotics after elective outpatient foot or ankle procedures, identifying (1) frequency of use, (2) regimen preferences, (3) personal indications, and (4) associated experience and demographics. METHODS: Using a cross-sectional survey design, a questionnaire was emailed to all active and candidate members of the American Orthopaedic Foot and Ankle Society. Supplementary questions captured demographic information. We invited 1136 members to participate; 22 addresses produced delivery failure messages, leaving 1114 members as potential participants. After nonresponses and exclusions, 312 (28%) responses were analyzed. Statistical analysis used Pearson's chi-square test, Fisher's exact test, and multivariate regression. RESULTS: The majority (75%) of respondents reported use of prophylactic postoperative oral antibiotics. Most users (69%) prescribed to fewer than 25% of patients, although 16% prescribed for all elective cases. The most frequent regimen was cephalexin 500 mg four times a day (63%) and the most common duration was 5 to 7 days (50%). Surgeons' most common indications were previous infection (71%), medical comorbidities (65%), and previous wound-healing difficulties (56%). Those who do and do not prescribe prophylactic postoperative oral antibiotics showed no difference in surgical site infection rate or any demographic category. CONCLUSIONS: Surgeons' reported use of prophylactic postoperative oral antibiotics after elective foot or ankle surgery was common, without demographic association. Commonalities were identified in antibiotic regimen and personal indications for this practice. Comparative clinical studies are warranted to elucidate the efficacy of prophylactic postoperative oral antibiotics and establish evidence-based guidelines for their use.

Arcus venosus dorsalis pedis: morphological considerations for use in superficial palmar arch reconstruction.

PURPOSE: To report the branching patterns, vessel diameters, and location of the valves in the arcus venosus dorsalis pedis (AVDP) as a graft option for use in superficial palmar arch reconstruction after mutilating hand injuries. METHODS: We dissected 10 cadaveric feet and measured vessel diameters, recorded number of branches, and located valves within the tibial, middle, and fibular thirds of the system. We used retrograde india ink injection to locate valves. RESULTS: The AVDP branching pattern was grossly different from side to side in the 4 cadavers with bilateral feet available. Mean flat diameters were 4.7, 2.9, and 2.1 mm in the tibial, middle, and fibular thirds of the arch, respectively. There was a mean of 1.7 valves (range, 1-4 valves) in the tibial third, 1.5 valves (range 0-4 valves) in the middle third, and 0 valves in the fibular third. There was an average of 3.4 branches off the middle third with a mean branch diameter of 2.1 mm. In 65% of these branches, valves were within 1 cm distal to the main arch. The direction of flow within the middle third was from fibular to tibial. CONCLUSIONS: Valves were commonly found within the middle and tibial thirds of the AVDP and within branches just distal to bifurcations. By contrast, the fibular third of the AVDP contained no valves. Valvular anatomy suggests that the direction of flow within the middle third was from fibular to tibial direction. CLINICAL RELEVANCE: The AVDP is morphologically similar to the palmar arch. When rendering valves within the AVDP incompetent, attention should be paid not just to the main arch itself, but also to branches off the AVDP. The fibular and middle thirds of the AVDP can safely be used for palmar arch reconstruction without blockage of flow owing to valves. The branches off the middle third must be used within a few millimeters of their takeoff to avoid valves.

Jones Fracture Management in Athletes.

Jones fractures in both elite and recreational athletes are best treated with surgical fixation, given superior results as compared to nonoperative management. While screw specifics remain controversial, intramedullary screw fixation is established as the standard surgical technique. Plate fixation also has shown excellent outcomes. Complications of refracture, nonunion, and delayed union require careful evaluation for contributions of early return to play, implant characteristics, and anatomic/metabolic abnormality. Revision fixation with autograft and biologic augmentation is supported in the literature, with ongoing inquiry to optimizing specific implants and adjuvants.

Orthopedic Surgical Options for Joint Cartilage Repair and Restoration.

The limited natural capacity for articular cartilage to regenerate has led to a continuously broadening array of surgical interventions. Used once patients' symptoms are not relieved by nonoperative management, these share the goals of joint preservation and restoration. Techniques include bone marrow stimulation, whole-tissue transplantation, and cell-based strategies, each with its own variations. Many of these interventions are performed arthroscopically or with extended-portal techniques. Indications, operative techniques, unique benefits, and limitations are presented.

Spastic foot and ankle deformities: evaluation and treatment.

Spastic foot and ankle deformities can occur from various causes and have profound effects on individuals and society. Presentations can vary clinically and a thorough clinical evaluation, potentially with a dynamic electromyogram, is essential to selecting the most appropriate treatment. Nonoperative treatments, such as orthotics, casting, oral medications, and nerve blocks, can be effective but surgery is indicated if they are no longer effective. Of the various operative procedures to treat this condition, split anterior tibialis tendon transfer and tendo Achilles lengthening are the most commonly performed. Multiple surgical options have been shown to be effective.