Efficiency of Foot and Ankle Surgeries Completed on the Preoperative Stretcher vs Operating Room Table: A Randomized Controlled Trial.

Background: Extremity surgeons frequently operate on the preoperative stretcher rather than the operating room (OR) table. This study sought to identify differences between stretcher-based (SB) and OR table-based (TB) procedures with regard to time efficiency and OR team member preferences. Methods: We conducted a prospective randomized controlled trial comparing the efficiency of SB vs OR TB foot and ankle procedures. Fifty-two patients undergoing a hardware removal, isolated gastrocnemius recession, soft tissue procedure, or foreign body removal at our day surgery unit were included. Start time and exit time were recorded. "Start time" was the number of minutes between the patient entering the OR and first incision. "Exit time" was the number of minutes between the procedure ending and the patient exiting the OR. Surveys were disseminated to OR staff who participated in the included cases. Results: The total measured time in the OR was an average 6 minutes shorter in the Stretcher group compared to the OR Table group (10 minutes vs 16 minutes, P < .001). SB procedures were associated with a significantly shorter start time (median difference = 4 minutes, P = .001), but not exit time (median difference = 1 minute, P = .058). No difference was found in actual surgical time. Thirty (96.8%) OR team members perceived SB procedures as enhancing OR efficiency, and 30 (96.8%) respondents considered SB procedures to be equal or superior to OR TB procedures in terms of patient safety. All would recommend or strongly recommend SB procedures. Conclusion: We found SB foot and ankle procedures to require less room time than OR TB procedures. Particularly for high-volume specialties, an average 6 minutes saved per case may meaningfully improve overall OR efficiency. Most OR team members believed that SB surgery improves OR efficiency and is the safer option for OR team members. Level of Evidence: Level II, randomized controlled trial, survey.

Carbon Footprint of Minor Foot and Ankle Surgery: A Randomized Controlled Trial.

Background: Climate change poses a substantial threat to human health, and operating rooms (ORs) have an outsized environmental impact. The Program for Research in Sustainable Medicine (PRiSM) designed a protocol for minor foot and ankle surgery intended to reduce waste, streamline instrument trays, and minimize laundry. We conducted a randomized controlled trial to compare the carbon footprint of procedures performed using the PRiSM protocol vs a traditional protocol. Methods: Forty adult patients undergoing foreign body removal, hammertoe correction, toe amputation, hardware removal, mass excision, or gastrocnemius recession were randomized to the PRiSM or our "Traditional" protocol. The PRiSM protocol used a smaller instrument tray, fewer drapes and towels, and minimal positioning blankets. No changes were made to surgical site preparation or operative techniques. Environmental impact was estimated using the carbon footprint, measured in kilograms of carbon dioxide equivalents (CO2e). Emissions associated with OR waste, instrument processing, and laundry were calculated. Results: On average, PRiSM cases had a smaller carbon footprint than Traditional cases (17.3 kg CO2e [SD = 3.2] vs 20.6 kg CO2e [SD = 2.0], P < .001). Waste-associated emissions from PRiSM cases were reduced (16.0 kg CO2e [SD = 2.7] vs 18.4 kg CO2e [SD = 1.8], P = .002), as were modeled instrument processing-related emissions (0.34 vs 0.91 kg CO2e). One superficial surgical site infection occurred in each group. Conclusion: We found a small but statistically significant reduction in the environmental impact of minor foot and ankle surgery when using the PRiSM vs Traditional protocol. The environmental impact of these cases was dominated by plastic waste-related emissions. Orthopaedic surgeons should think critically about what components of their surgical setup are truly necessary for patient care, as minor changes in product utilization can have significant impacts on waste and greenhouse gas emissions. Level of Evidence: Level I, randomized controlled trial.

Primary Care Physician Preferences Regarding Communication from Orthopaedic Surgeons.

BACKGROUND: Musculoskeletal consultations constitute a growing portion of primary care physician (PCP) referrals. Optimizing communication between PCPs and orthopaedists can potentially reduce time spent in the electronic medical record (EMR) as well as physician burnout. Little is known about the preferences of PCPs regarding communication from orthopaedic surgeons. Hence, the present study investigated, across a large health network, the preferences of PCPs regarding communication from orthopaedists. METHODS: A total of 175 PCPs across 15 practices within our health network were surveyed. These providers universally utilized Epic as their EMR platform. Five-point, labeled Likert scales were utilized to assess the PCP-perceived importance of communication from orthopaedists in specific clinical scenarios. PCPs were further asked to report their preferred method of communication in each scenario and their overall interest in communication from orthopaedists. Logistic regression analyses were performed to determine whether any PCP characteristics were associated with the preferred method of communication and the overall PCP interest in communication from orthopaedists. RESULTS: A total of 107 PCPs (61.1%) responded to the survey. PCPs most commonly rated communication from orthopaedists as highly important in the scenario of an orthopaedist needing information from the PCP. In this scenario, PCPs preferred to receive an Epic Staff Message. Scenarios involving a recommendation for surgery, hospitalization, or a major clinical change were also rated as highly important. In these scenarios, an Epic CC'd Chart rather than a Staff Message was preferred. Increased after-hours EMR use was associated with diminished odds of having a high interest in communication from orthopaedists (odds ratio, 0.65; 95% confidence interval, 0.48 to 0.88; p = 0.005). Ninety-three PCPs (86.9%) reported spending 1 to 1.5 hours or more per day in Epic after normal clinical hours, and 27 (25.2%) spent >3 hours per day. Forty-six PCPs (43.0%) reported experiencing ≥1 symptom of burnout. CONCLUSIONS: There were distinct preferences among PCPs regarding clinical communication from orthopaedic surgeons. There was also evidence of substantial burnout and after-hours work effort by PCPs. These results may help to optimize communication between PCPs and orthopaedists while reducing the amount of time that PCPs spend in the EMR.

Efficiency and perceived safety of foot and ankle procedures performed on the preoperative stretcher versus operating room table.

BACKGROUND: Foot and ankle surgeons often perform minor surgeries on the preoperative stretcher instead of the operating room table. We examined whether stretcher-based and operating room table-based procedures differed with respect to operating room efficiency and staff perceptions. METHODS: We retrospectively reviewed medical records of patients undergoing minor foot and ankle surgery at an ambulatory surgery centre. We collected 'time to start', the duration between patient arrival in the operating room and incision time, and 'time to exit', the duration between procedure end time and patient exit from the operating room. Staff were surveyed regarding their perceptions of stretcher-based and operating room table-based procedures. RESULTS: 'Time to start' was significantly shorter for stretcher-based procedures, but 'time to exit' was not. Seventeen (81%) staff members thought stretcher-based procedures increased operating room efficiency. Thirteen (62%) thought stretcher-based procedures bettered staff safety. Nineteen (91%) thought stretcher-based procedures were equivalent to or better than operating room table-based procedures for patient safety. Most (67%) would recommend stretcher-based procedures. CONCLUSION: We found small but significant time savings associated with stretcher-based procedures. Without adapting surgical scheduling practices, the impact of stretcher-based procedures on overall operating room efficiency is questionable. Nevertheless, the majority of OR staff think stretcher-based procedures increase OR efficiency and are safer for staff. LEVEL OF EVIDENCE: Level IV, Retrospective case series.

American Orthopaedic Foot and Ankle Society Annual Meeting All-in-person Attendance Results in Immense Carbon Expenditure.

BACKGROUND: Professional society conferences are integral to the medical profession. However, airline travel is a major contributor to greenhouse gas production, and the environmental impact of in-person attendance at an orthopaedic conference has yet to be described. With growing concern about the climate crisis, we sought to quantify the carbon footprint of in-person attendance to help potential attendees more consciously consider in-person attendance, inform strategies to minimize greenhouse gas emissions during travel to annual meetings, and increase awareness about and momentum for efforts in orthopaedic surgery to reduce the carbon footprint of society conferences. QUESTIONS/PURPOSES: (1) What was the magnitude of greenhouse gas production resulting from all-in-person 2019 American Orthopaedic Foot and Ankle Society (AOFAS) annual meeting attendance in Chicago, IL, USA? (2) What was the magnitude of greenhouse gas production resulting from the all-virtual 2020 AOFAS annual meeting, and how does it compare with the 2019 AOFAS annual meeting carbon footprint? (3) To what extent could an alternative in-person meeting model with four or seven hubs decrease greenhouse gas production resulting from round-trip air travel compared with the 2019 AOFAS annual meeting? METHODS: A list of the postal codes and countries of all 1271 registered participants attending the four-day 2019 AOFAS annual meeting in Chicago, IL, USA, was obtained from AOFAS headquarters. The 2019 conference was chosen because it was the last pre-COVID meeting and thus attendance was more likely to resemble that at prepandemic in-person conferences than more recent meetings because of pandemic travel restrictions. We estimated carbon dioxide-equivalent (CO 2 e) production from round-trip air travel using a publicly available internet-based calculator (Myclimate: https://co2.myclimate.org/en/flight_calculators/new ). Emissions produced by the conference venue, car travel, and hotel stays were estimated using published Environmental Protection Agency emission factors. To estimate emissions produced by the all-virtual 2020 AOFAS annual meeting (assuming an equal number of attendees as in 2019), we used the framework published by Faber and summed estimated network data transfer emissions, personal computer and monitor emissions, and server-related emissions. Using the 2019 registrant list, we modeled four-hub and seven-hub in-person meeting alternatives to determine potential decreased round-trip air travel greenhouse gas production. Meeting hub locations were selected by visualizing the geographic distribution of the 2019 registrants and selecting reasonable meeting locations that would minimize air travel for the greatest number of attendees. Registrants were assigned to the nearest hub location. Myclimate was again used to estimate CO 2 e production for round-trip air travel for the hub meeting models. RESULTS: The total estimated emissions of the all-in-person 2019 AOFAS annual meeting (when accounting for travel, conference space, and hotel stays) was 1565 tons CO 2 e (median 0.61 tons per attendee, range 0.02 to 7.7 tons). The total estimated emissions of the all-virtual 2020 meeting (when accounting for network data transfer emissions, personal computer and monitor emissions, and server-related emissions) was 34 tons CO 2 e (median 0.03 tons per attendee). This corresponds to a 97.8% decrease in CO 2 e emissions compared with the in-person conference. The model of a four-hub in-person meeting alternative with meetings in Chicago, Santiago, London, and Tokyo predicted an estimated 54% decrease in CO 2 e emissions from round-trip air travel. The seven-hub meeting model with meetings in Chicago; Washington, DC; Dallas; Los Angeles; Santiago; London; and Tokyo was predicted to diminish the CO 2 e emissions of round-trip air travel by an estimated 71%. CONCLUSION: The 2019 AOFAS annual meeting had an enormous carbon footprint and resulted in many individuals exceeding their annual allotted carbon budget (2.5 tons) according to the Paris Agreement. Hosting the meeting virtually greatly reduced the annual meeting carbon footprint, and our hub-based meeting models identified potential in-person alternatives for reducing the carbon footprint of conference attendance. CLINICAL RELEVANCE: Professional societies must consider our responsibility to decarbonizing the healthcare sector by considering innovative approaches-perhaps such as our multihub proposals-to decarbonize carbon-intensive annual meetings without stalling academic progress.

The Effects of Sociodemographic Factors on Baseline Patient-Reported Outcome Measures in Patients with Foot and Ankle Conditions.

BACKGROUND: Racial and ethnic care disparities persist within orthopaedics in the United States. This study aimed to deepen our understanding of which sociodemographic factors most impact patient-reported outcome measure (PROM) score variation and may explain racial and ethnic disparities in PROM scores. METHODS: We retrospectively reviewed baseline PROMIS (Patient-Reported Outcomes Measurement Information System) Global-Physical (PGP) and PROMIS Global-Mental (PGM) scores of 23,171 foot and ankle patients who completed the instrument from 2016 to 2021. A series of regression models was used to evaluate scores by race and ethnicity after adjusting in a stepwise fashion for household income, education level, primary language, Charlson Comorbidity Index (CCI), sex, and age. Full models were utilized to compare independent effects of predictors. RESULTS: For the PGP and PGM, adjusting for income, education level, and CCI reduced racial disparity by 61% and 54%, respectively, and adjusting for education level, language, and income reduced ethnic disparity by 67% and 65%, respectively. Full models revealed that an education level of high school or less and a severe CCI had the largest negative effects on scores. CONCLUSIONS: Education level, primary language, income, and CCI explained the majority (but not all) of the racial and ethnic disparities in our cohort. Among the explored factors, education level and CCI were predominant drivers of PROM score variation. LEVEL OF EVIDENCE: Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Scope of the Problem: Ankle Arthroscopy.

Ankle arthroscopy has seen increased utilization and application in recent years. Through the advent of improved instrumentation and techniques, indications have been expanded to include the management of traumatic, degenerative, inflammatory, and neoplastic conditions. It is important to review anterior and posterior ankle arthroscopies along with the history, pertinent anatomy, techniques, indications, and complications as well as gain insight into the future of ankle arthroscopy.

Scope of the Problem: Tendoscopy and Small Joint Arthroscopy of the Foot and Ankle.

It is important to identify and describe practical applications of arthroscopy in the management of foot and ankle pathology. Utilization of the arthroscope provides a minimally invasive means of evaluating and addressing pathology. It obviates the need for a large open approach, which has additional value in the setting of a multiprocedure surgery. In addition to reducing surgical time, arthroscopy provides a potentially enhanced field of view and an adequate working space to address injury. As interest in minimally invasive options grows, the need for safe, effective tendoscopic and arthroscopic options in the foot and ankle increases. A clear and high-yield reference is needed with which to approach these procedures.

Isolated Gastrocnemius Recession for Progressive Collapsing Foot Deformity.

INTRODUCTION: Progressive collapsing foot deformity (PCFD) is frequently associated with a gastrocnemius contracture. Surgical treatment of PCFD often includes a gastrocnemius recession in addition to other corrective procedures, which typically requires a period of restricted weight bearing postoperatively. Isolated gastrocnemius recession may allow passive correction of the deformity, improve orthotic fit, and obviate the need for full reconstruction and restricted weight bearing. The goal of this study was to evaluate patient-reported outcomes after an isolated gastrocnemius recession for flexible PCFD in patients anticipated to have difficulty with postoperative restricted weight bearing. METHODS: A total of 47 patients met the inclusion criteria: isolated gastrocnemius recession for flexible PCFD, no previous ipsilateral surgery, and more than 6 months of follow-up. Of 47 eligible patients, 29 (31 feet) participated. Available preoperative and postoperative patient-reported outcomes were gathered, including the Foot and Ankle Ability Measure Activities of Daily Living, visual analog scale, and the Patient-Reported Outcome Measurement Information System Physical Function Short Form 10a. In addition, patients were asked about satisfaction, willingness to undergo the procedure again, and whether orthotics provided better relief. RESULTS: At a mean of 5.1 (range, 0.6 to 9.0) years postoperatively, median Foot and Ankle Ability Measure Activities of Daily Living was 82.1, mean Patient-Reported Outcome Measurement Information System Physical Function Short Form 10a was 44.2, and median visual analog scale was 10 (of 100). Sixty-nine percent of patients were either satisfied or very satisfied, 69% would undergo the procedure again, and 62% reported improved relief with use of orthotics postoperatively. Among the 47 eligible patients, there were 5 (11%) subsequent flatfoot reconstructions. CONCLUSIONS: Isolated gastrocnemius recession for the management of flexible PCFD can be effective as this procedure demonstrated good outcomes scores with high procedural satisfaction and 11% of patients proceeding to subsequent flatfoot reconstruction. This alternative approach may be of particular value for patients anticipated to have difficulty with postoperative weight-bearing restrictions. LEVEL OF EVIDENCE: :IV.

Is minimally invasive orthopedic surgery safer than open? A systematic review of systematic reviews.

BACKGROUND: To assess the safety of minimally invasive surgery (MIS) for orthopedic spinal, upper limb and lower limb procedures, this systematic review of systematic reviews compared their complications with open procedures. MATERIALS AND METHODS: A literature search was conducted electronically (PubMed, Cochrane library and Web of Science; May 8, 2021) without language restriction in the past five years. Reviews that consulted at least two databases, compared MIS with open orthopedic surgery, and reported the following: intraoperative, post-operative or total complications, function, ambulation, pain, hospital stay, reoperation rate and operation time were included. Article selection, quality assessment using AMSTAR-2, and data extraction were conducted in duplicate on predesigned forms. In each review, a subset analysis focusing on prospective cohort and randomized studies was additionally performed. PROSPERO: CRD42020178171. RESULTS: The search yielded 531 articles from which 76 reviews consisting of 1104 primary studies were included. All reviews were assessed as being low quality. Compared to open surgery, MIS had fewer total, postoperative and intraoperative complications in 2/10, 2/11 and 2/5 reviews of spinal procedures respectively, 1/3, 1/4 and 1/2 reviews of upper limb procedures respectively, and 4/6, 2/7 and 0/2 reviews of lower limb procedures respectively. CONCLUSIONS: MIS had greater overall safety compared to open surgery in spinal procedures. In upper limb and lower limb procedures, MIS was not outright superior to open procedures in terms of safety hence a general preference of MIS is not justified on the premise of a better safety profile compared to open procedures.

Selecting the Next Class: The "Virtual Orthopaedic Rotation".

INTRODUCTION: When the COVID-19 pandemic forced the cancellation of visiting subinternships, we pivoted to create a virtual orthopaedic rotation (VOR). The purpose of this study was to assess the effect of the VOR on the residency selection process and determine the role of such a rotation in the future. METHODS: A committee was convened to create a VOR to replace visiting orthopaedic rotations for medical students who are interested in pursuing a career in orthopaedic surgery. The VOR was reviewed and sanctioned by our medical school, but no academic credit was granted. We conducted three 3-week VOR sessions. During each session, virtual rotators participated in regularly scheduled educational conferences and attended an invitation-only daily conference in the evenings that was designed for a medical student audience. In addition, students were paired with faculty and resident mentors in a structured mentorship program. Students' orthopaedic knowledge was assessed using prerotation and postrotation tests. RESULTS: From July to September 2020, 61 students from 37 distinct medical schools participated in the VOR. Notable improvements were observed in prerotation and postrotation orthopaedic knowledge test scores. In postrotation surveys, both students and faculty expressed high satisfaction with the curriculum but less certainty about how well they got to know each other. In the subsequent residency application cycle, 27.9% of the students who participated in the VOR were selected to interview, compared with 8.7% of the total application pool. DISCUSSION: The VOR was a valuable substitute for in-person clinical rotations during the COVID-19 pandemic. Although not likely to be a replacement for conventional away rotations, the VOR is a possible adjunct to in-person clinical rotations in the future.

Orthopedic telemedicine encounter during the COVID-19 pandemic: A cautionary tale.

The COVID-19 pandemic has necessitated increased use of telemedicine for diagnosis and management of musculoskeletal disorders. We describe the virtual/telemedicine encounter and management of a patient with knee pain initially diagnosed as gonarthrosis but that actually resulted from an impending pathologic fracture of the femur. Definitive diagnosis and treatment occurred only after completion of the impending fracture. The multiple factors making telemedicine encounters challenging which contributed to this outcome are highlighted. Orthopedists need awareness of these challenges and must take steps to mitigate the risk of complications possible with continued increased utilization of telemedicine during this pandemic and beyond.

Satisfactory functional and MRI outcomes at the foot and ankle following harvesting of full thickness peroneus longus tendon graft.

AIMS: To evaluate the donor site morbidity and tendon morphology after harvesting whole length, full-thickness peroneus longus tendon (PLT) proximal to the lateral malleolus for ligament reconstructions or tendon transfer. METHODS: A total of 21 eligible patients (mean age 34.0 years (standard deviation (SD) 11.2); mean follow-up period 31.8 months (SD 7.7), and 12 healthy controls (mean age, 26.8 years (SD 5.9) were included. For patients, clinical evaluation of the donor ankle was performed preoperatively and postoperatively. Square hop test, ankle strength assessment, and MRI of distal calf were assessed bilaterally in the final follow-up. The morphological symmetry of peroneal tendons bilaterally was evaluated by MRI in healthy controls. RESULTS: Among the patients, the mean pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and Karlsson-Peterson score were 98.7 (SD 2.5; p = 0.480) and 98.5 (SD 2.4; p = 0.480), and 98.3 (SD 2.4; p = 0.162) and 97.9 (SD 2.5; p = 0.162), respectively. There was no significant difference between square hop test bilaterally (p = 0.109) and plantar flexion peak force bilaterally (p = 0.371). The harvested limb had significantly less eversion peak force compared to the contralateral limb (p < 0.001). Evidence of probable tendon regeneration was observed in all the patients by MRI and the total bilateral peroneal tendon index (mean ratio of harvested side cross-sectional area of peroneal tendon compared with the contralateral side) was 82.9% (SD 17.4). In 12 healthy controls, peroneal tendons (mean 99.4% (SD 4.3) were found to be morphologically symmetrical between the two sides. CONCLUSION: The current study showed satisfactory clinical foot and ankle outcomes after full-thickness PLT harvesting and indicated the regenerative potential of PLT after its removal. Level of Evidence: Level IV, therapeutic retrospective case series. Cite this article: Bone Joint J 2020;102-B(2):205-211.

The Impact of Music Therapy in the Postoperative Setting on Overall Patient Satisfaction Using Validated Outcome Scores.

PURPOSE: Previous studies have examined music therapy (MT) as a potential modality to relieve negative postoperative symptoms such as pain. This randomized control trial examined the use of MT on patient satisfaction in the postanesthesia care unit. DESIGN: Fifty patients undergoing outpatient orthopaedic surgery were enrolled and randomized into two groups, those receiving MT postoperatively and a control group who did not. METHODS: After hospital discharge, subjects were assessed with two validated outcome measurements for overall patient satisfaction, the visual analog satisfaction scale and the Patient Judgment of Hospital Quality survey. FINDINGS: The results showed no statistically significant differences between the MT and control group on the Patient Judgment of Hospital Quality survey (MT = 3.42, standard therapy = 3.41, P = .94) and the visual analog satisfaction scale (MT = 91.20, standard therapy = 91.65, P = .88). CONCLUSIONS: MT given in the postoperative setting has no impact on overall patient satisfaction.

Economic Analysis and Patient Satisfaction Associated With Outpatient Total Ankle Arthroplasty.

BACKGROUND: Total ankle arthroplasty (TAA) is a rapidly growing treatment for end-stage ankle arthritis that is generally performed as an inpatient procedure. The feasibility of outpatient total ankle arthroplasty (OTAA) has not been reported in the literature. We sought to establish proof of concept for OTAA by comparing outpatient vs inpatient perioperative complications, postoperative emergency department (ED) visits, readmissions, patient satisfaction, and cost analysis. METHODS: From July 2010 to September 2015, a total of 36 patients underwent TAA. Patients with prior ankle replacement, prior ankle infections, neuroarthropathy, or osteonecrosis of the talus were excluded from the study. All patient demographics, tourniquet times, estimated blood loss, comorbidities, concomitant procedures, complications, return ED visits, and readmissions were recorded. Patient satisfaction questionnaires were collected. Twenty-one patients had outpatient surgery and 15 had inpatient surgery. The cohorts were matched demographically. RESULTS: The average length of stay for the inpatient group was 2.5 days. The overall cost differential between the groups was 13.4%, with the outpatient group being less costly. This correlates to a cost savings of nearly $2500 per case. One patient in the outpatient group had a return ED visit on postoperative day 1 for urinary retention. There were no 30-day readmissions in either group. Seventy-one percent of the outpatient group and 93% of the inpatient group would not change to a different postoperative admission status if they were to have the procedure again. CONCLUSION: Our results show that OTAA was a cost-effective and safe alternative with low complication rates and high patient satisfaction. With proper patient selection, OTAA was beneficial to both the patient and the health care system by driving down total cost. It has the capacity to generate substantial savings while providing equal or better value to the patient. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Patient Compliance with Postoperative Lower-Extremity Non-Weight-Bearing Restrictions.

BACKGROUND: A period of non-weight-bearing is prescribed following many orthopaedic injuries and procedures. It is believed that a period of non-weight-bearing is important for proper healing and recovery. The degree to which patients are compliant with non-weight-bearing instructions is unknown. The purpose of this study was to measure patient compliance with a period of prescribed non-weight-bearing. METHODS: In this single-blinded study, pressure-sensitive film was embedded into short leg casts of 51 consecutive adult orthopaedic patients with unilateral lower-extremity abnormality who had been instructed to be strictly non-weight-bearing. Sensors were retrieved at the time of cast removal (mean, 24.3 days [range, 7 to 48 days]) and then were analyzed for force distribution and magnitude. Noncompliance was defined as maximum detectable pressure exerted on ≥50% of the film. Patient characteristics and the time of year that the casts were worn were also examined to determine if they correlated with weight-bearing. RESULTS: Fourteen (27.5%) of 51 patients were noncompliant with the non-weight-bearing restriction. Six (42.9%) of the 14 noncompliant patients compared with 11 (29.7%) of the 37 compliant patients experienced an adverse event (p = 0.51). Sex, age, language spoken, body mass index, time in the cast, and the treating surgeon did not have a significant influence on weight-bearing performance (p > 0.05). Significantly greater weight-bearing was found (p = 0.04) in warmer months (June to October) than in colder months (November to March) in the United States. CONCLUSIONS: The noncompliance rate with the postoperative non-weight-bearing restriction was 27.5% (95% confidence interval, 15.2% to 39.8%) in this patient group, despite explicit instructions and education about possible complications associated with weight-bearing. The only factor found to have a significant effect on weight-bearing compliance was the time of year that the cast was worn. No significant difference was found between the complication rate of the compliant patients and that of the noncompliant patients. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Ankle Arthritis: You Can't Always Replace It.

End-stage arthritis of the tibiotalar joint is disabling and causes substantial functional impairment. End-stage arthritis of the tibiotalar joint is often the residual effect of a previous traumatic injury. Nonsurgical treatment for end-stage arthritis of the ankle includes bracing, shoe wear modifications, and selective joint injections. For patients who fail to respond to nonsurgical modalities, the two primary treatment options are arthroplasty and arthrodesis. Each treatment option has strong proponents who argue the superiority of their treatment algorithm. Although there is no ideal treatment for ankle arthritis, there are high-quality studies that help guide treatment in patients of varying demographics. Many inherent risks are linked with each treatment option; however, the risks of greatest concern are early implant loosening after arthroplasty that requires revision surgery and the acceleration of adjacent joint degeneration associated with arthrodesis.

Operating Room Time Savings with the Use of Splint Packs: A Randomized Controlled Trial.

BACKGROUND: The most expensive variable in the operating room (OR) is time. Lean Process Management is being used in the medical field to improve efficiency in the OR. Streamlining individual processes within the OR is crucial to a comprehensive time saving and cost-cutting health care strategy. At our institution, one hour of OR time costs approximately $500, exclusive of supply and personnel costs. Commercially prepared splint packs (SP) contain all components necessary for plaster-of-Paris short-leg splint application and have the potential to decrease splint application time and overall costs by making it a more lean process. We conducted a randomized controlled trial comparing OR time savings between SP use and bulk supply (BS) splint application. METHODS: Fifty consecutive adult operative patients on whom post-operative short-leg splint immobilization was indicated were randomized to either a control group using BS or an experimental group using SP. One orthopaedic surgeon (EMB) prepared and applied all of the splints in a standardized fashion. Retrieval time, preparation time, splint application time, and total splinting time for both groups were measured and statistically analyzed. RESULTS: The retrieval time, preparation time and total splinting time were significantly less (p<0.001) in the SP group compared with the BS group. There was no significant difference in application time between the SP group and BS group. CONCLUSION: The use of SP made the process of splinting more lean. This has resulted in an average of 2 minutes 52 seconds saved in total splinting time compared to BS, making it an effective cost-cutting and time saving technique. For high volume ORs, use of splint packs may contribute to substantial time and cost savings without impacting patient safety.

Ankle Arthritis: You Can't Always Replace It.

End-stage arthritis of the tibiotalar joint is disabling and causes substantial functional impairment. Most often it is the residual effect of a previous traumatic injury. Nonsurgical treatment of end-stage arthritis of the ankle includes bracing, shoe-wear modifications, and selective joint injections. For patients who fail to respond to nonsurgical modalities, the two primary treatment options are arthroplasty and arthrodesis. Each has its proponents. Although no ideal treatment of ankle arthritis exists, high-quality studies can help guide treatment in patients of varying demographics. Inherent risks are linked with each treatment option, but those of greatest concern are early implant loosening that requires revision following arthroplasty and the acceleration of adjacent joint degeneration associated with arthrodesis.