Association Between Fulfillment of Preoperative Expectations and Diagnosis in Foot and Ankle Surgery.

BACKGROUND: There has been growing interest in patient-reported outcomes in foot and ankle surgery, and the fulfillment of patient expectations is a potentially powerful tool that compares preoperative expectations and perceived postoperative improvement. Prior work has validated the use of expectation fulfillment in foot and ankle surgery. However, given the wide spectrum of pathologies and treatments in foot and ankle, no study has examined the association between expectation fulfillment and specific diagnosis. METHODS: This is a retrospective cohort study consisting of 266 patients who completed the Foot & Ankle Expectations Survey and the Foot and Ankle Outcome Survey (FAOS) preoperatively and 2 years postoperatively. A fulfillment proportion (FP) was calculated using the pre- and postoperative Foot & Ankle Expectations Survey scores. An estimated mean fulfillment proportion for each diagnosis was calculated using a multivariable linear regression model, and pairwise comparisons were used to compare the FP between diagnoses. RESULTS: All diagnoses had an FP less than 1, indicating partially fulfilled expectations. Ankle arthritis had the highest FP (0.95, 95% CI 0.81-1.08), whereas neuromas and mid/hindfoot diagnoses had the lowest FPs (0.46, 95% CI 0.23-0.68; 0.62, 95% CI 0.45-0.80). Higher preoperative expectations were correlated with lower fulfillment proportions. CONCLUSION: FP varied with diagnosis and preoperative expectations. An understanding of current expectation fulfillment among different diagnoses in foot and ankle surgery helps highlight areas for improvement in the management of expectations for presumed diagnoses. LEVEL OF EVIDENCE: Level III, retrospective review of prospective cohort study.

Distal Tibia Apex Posterior Angulation: A Normal Anatomic Variant Related to Hindfoot Alignment With Side-to-Side Symmetry.

OBJECTIVES: The sagittal plane of the distal tibia has not been well-described. This study sought to characterize sagittal plane morphology, determine symmetry from side to side, and identify differences based on hindfoot alignment. METHODS: One hundred twelve bilateral lateral weight-bearing ankle radiographs were retrospectively evaluated (224 ankles). Hindfoot alignment was classified as neutral, planus, or cavus using the Meary angle. The angle between the diaphyseal and distal tibia axes was measured, and the apex location relative to the plafond was recorded. RESULTS: A mean distal tibia apex posterior angulation (DTAPA) of 2.0° (range -2° to 7°, SD = 2.06°) was located 8.0 cm proximal to the plafond. No difference was observed from side to side in DTAPA magnitude (P = 0.36) or location (P = 0.90). Planus alignment was associated with a significantly greater DTAPA (3.05°) as compared with neutral (1.89°) (P = 0.002) and cavus (1.25°) (P < 0.001) alignment. CONCLUSION: The distal tibia has an apex posterior angulation, suggesting that the true anatomic axis of the tibia terminates just posterior to the plafond center. Hindfoot alignment is related to distal tibia morphology. DTAPA symmetry indicates that contralateral imaging can be used to guide reconstruction of patient-specific anatomy and alignment. Knowledge of the DTAPA may help mitigate sagittal malalignment during distal tibia fracture surgery.

A cross-sport comparison of performance-based outcomes of professional athletes following primary microfracture of the knee.

BACKGROUND: The purpose of this study was to compare performance-based outcomes among professional athletes in four major North American sports following microfracture to treat symptomatic chondral defects of the knee. METHODS: Major League Baseball (MLB), National Basketball Association (NBA), National Football League (NFL), and National Hockey League (NHL) athletes who underwent primary unilateral microfracture of the knee were identified through a previously reported protocol based on public sources. Successful return-to-play was defined as returning for at least one professional regular season game after surgery. Regular season player statistics and sport-specific performance scores were compiled for each player. Each player served as his own control, with the season prior to surgery defined as baseline. Comparisons across sports were enabled by adjusting for expected season and career length differences between sports and by calculating percent changes in performance. RESULTS: One hundred thirty one professional athletes who underwent microfracture were included. One hundred three athletes (78.6%) successfully returned to play. The ratio of games started-to-games played before surgery was found to be a significant positive independent predictor of returning (p = 0.002). Compared with their preoperative season, basketball and baseball players demonstrated significantly decreased performance one season after surgery (-14.8%, p = 0.029 and -12.9%, p = 0.002, respectively) that was recoverable to baseline by postoperative seasons 2-3 for baseball players but not for basketball players (-9.7%, p = 0.024). CONCLUSION: Knee microfracture surgery is associated with a high rate of return to the professional level. However, the impact of this procedure on postoperative performance varied significantly depending on sport.

Can Surgeon Demographic Factors Predict Postoperative Complication Rates After Elective Spinal Fusion?

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Determine whether surgeon demographic factors influence postoperative complication rates after elective spine fusion procedures. BACKGROUND: Surgeon demographic factors have been shown to impact decision making in the management of degenerative disease of the lumbar spine. Complication rates are frequently reported outcome measurements used to evaluate surgical treatments, quality-of-care, and determine health care reimbursements. However, there are few studies investigating the association between surgeon demographic factors and complication outcomes after elective spine fusions. METHODS: A database of US spine surgeons with corresponding postoperative complications data after elective spine fusions was compiled utilizing public data provided by the Centers for Medicare and Medicaid Services (2011-2013) and ProPublica Surgeon Scorecard (2009-2013). Demographic data for each surgeon was collected and consisted of: surgical specialty (orthopedic vs. neurosurgery), years in practice, practice setting (private vs. academic), type of medical degree (MD vs. DO), medical school location (United States vs. foreign), sex, and geographic region of practice. General linear mixed models using a Beta distribution with a logit link and pairwise comparison with post hoc Tukey-Kramer were used to assess the relationship between surgeon demographics and complication rates. RESULTS: 2110 US-practicing spine surgeons who performed spine fusions on 125,787 Medicare patients from 2011 to 2013 met inclusion criteria for this study. None of the surgeon demographic factors analyzed were found to significantly affect overall complication rates in lumbar (posterior approach) or cervical spine fusion. CONCLUSIONS: Publicly available complication rates for individual spine surgeons are being utilized by hospital systems and patients to assess aptitude and gauge expectations. The increasing demand for transparency will likely lead to emphasis of these statistics to improve outcomes. We conclude that none of the surgeon demographic factors analyzed in this study are associated with differences in overall complications rates in patients undergoing elective spine fusion as published by the ProPublica Surgeon Scorecard. LEVEL OF EVIDENCE: Level 3.

Effects of Conflicts of Interest on Practice Patterns and Complication Rates in Spine Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: We sought to determine whether financial relationships with industry had any impact on operative and/or complication rates of spine surgeons performing fusion surgeries. SUMMARY OF BACKGROUND DATA: Recent actions from Congress and the Institute of Medicine have highlighted the importance of conflicts of interest among physicians. Orthopedic surgeons and neurosurgeons have been identified as receiving the highest amount of industry payments among all specialties. No study has yet investigated the potential effects of disclosed industry payments with quality and choices of patient care. METHODS: A comprehensive database of spine surgeons in the United States with compiled data of industry payments, operative fusion rates, and complication rates was created. Practice pattern data were derived from a publicly available Medicare-based database generated from selected CPT codes from 2011 to 2012. Complication rate data from 2009 to 2013 were extracted from the ProPublica-Surgeon-Scorecard database, which utilizes postoperative inhospital mortality and 30-day-readmission for designated conditions as complications of surgery. Data regarding industry payments from 2013 to 2014 were derived from the Open Payments website. Surgeons performing <10 fusions, those without complication data, and those whose identity could not be verified through public records were excluded. Pearson correlation coefficients and multivariate regression analyses were used to determine the relationship between industry payments, operative fusion rate, and/or complication rate. RESULTS: A total of 2110 surgeons met the inclusion criteria for our database. The average operative fusion rate was 8.8% (SD 4.8%), whereas the average complication rate for lumbar and cervical fusion was 4.1% and 1.9%, respectively. Pearson correlation analysis revealed a statistically significant but negligible relationship between disclosed payments/transactions and both operative fusion and complication rates. CONCLUSION: Our findings do not support a strong correlation between the payments a surgeon receives from industry and their decisions to perform spine fusion or associated complication rates. Large variability in the rate of fusions performed suggests a poor consensus for indications for spine fusion surgery. LEVEL OF EVIDENCE: 3.