Comparing single and multiple imputation strategies for harmonizing substance use data across HIV-related cohort studies.

BACKGROUND: Although standardized measures to assess substance use are available, most studies use variations of these measures making it challenging to harmonize data across studies. The aim of this study was to evaluate the performance of different strategies to impute missing substance use data that may result as part of data harmonization procedures. METHODS: We used self-reported substance use data collected between August 2014 and June 2019 from 528 participants with 2,389 study visits in a cohort study of substance use and HIV. We selected a low (heroin), medium (methamphetamine), and high (cannabis) prevalence drug and set 10-50% of each substance to missing. The data amputation mimicked missingness that results from harmonization of disparate measures. We conducted Monte Carlo simulations to evaluate the comparative performance of single and multiple imputation (MI) methods using the relative mean bias, root mean square error (RMSE), and coverage probability of the 95% confidence interval for each imputed estimate. RESULTS: Without imputation (i.e., listwise deletion), estimates of substance use were biased, especially for low prevalence outcomes such as heroin. For instance, even when 10% of data were missing, the complete case analysis underestimated the prevalence of heroin by 33%. MI, even with as few as five imputations produced the least biased estimates, however, for a high prevalence outcome such as cannabis with low to moderate missingness, performance of single imputation strategies improved. For instance, in the case of cannabis, with 10% missingness, single imputation with regression performed just as well as multiple imputation resulting in minimal bias (relative mean bias of 0.06% and 0.07% respectively) and comparable performance (RMSE = 0.0102 for both and coverage of 95.8% and 96.2% respectively). CONCLUSION: Our results from imputation of missing substance use data resulting from data harmonization indicate that MI provided the best performance across a range of conditions. Additionally, single imputation for substance use data performed comparably under scenarios where the prevalence of the outcome was high and missingness was low. These findings provide a practical application for the evaluation of several imputation strategies and helps to address missing data problem when combining data from individual studies.

Technical Tip Kerfing for Lapidus Arthrodesis: Deformity Correction With Minimal Bone Resection.

The Lapidus arthrodesis can be a powerful but technically challenging procedure. Common pitfalls include gapping at the arthrodesis site, shortening, and residual malalignment. Herein is described a simple and reproducible technique to obtain a congruent arthrodesis site with excellent deformity correction and minimal bone loss by the use of joint kerfing.

Risk factors associated with different types of intimate partner violence (IPV): an emergency department study.

BACKGROUND: Domestic intimate partner violence (IPV) is a serious health care concern, which may be mitigated by early detection, screening, and intervention. OBJECTIVES: We examine posited predictors in IPV and non-IPV groups, and in four different IPV profiles. Possible factors include 1) alcohol use, 2) drug use, 3) depression, 4) impulsivity, 5) age, and 6) any childhood experience in observing parental violence. We also introduce a new "Five Steps in Screening for IPV" quick reference tool, which may assist emergency physicians in detection and treatment. METHODS: This was a cross-sectional study using survey data from 412 inner-city emergency department patients. Associations were explored using a chi-squared test of independence, independent-samples t-tests, and a one-way analysis of variance. RESULTS: Nearly 16% had experienced IPV. As a group, they were younger, and more depressed and impulsive than the non-IPV group. They were more likely to engage in binge drinking, use drugs, and had more childhood exposure to violence. In the IPV group, 31% were perpetrators, 20% victims, and 49% both victims and perpetrators. The latter group was younger, more impulsive and depressed, used drugs, and was more likely to have observed parental violence as a child. CONCLUSION: Correlates in groups affected by IPV indicate the same general risk factors, which seem to more acutely affect those who are both perpetrators and victims. Alcohol and drug use, depressive symptoms, and childhood exposure to violence may be factors and signs for which emergency physicians should screen in the context of IPV.

Radiographic Forefoot Width Following Minimally Invasive Chevron Akin Bunionectomy.

Background: Hallux valgus (HV) is a common cause of pain and deformity of the forefoot. Minimally invasive chevron Akin (MICA) bunionectomy is a method for HV correction associated with less pain and swelling, with early return to weightbearing in a regular shoe. The purpose of this study was to determine how the MICA procedure affects forefoot width. Methods: Twenty-eight patients (26 female, 2 male; 9 left, 19 right) at a single institution who underwent primary MICA for HV correction by 3 treating surgeons were retrospectively reviewed. Pre- and postoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), bony forefoot width, and soft tissue forefoot width were measured by 2 independent observers. Radiographic measurements were calibrated using fifth metatarsal length. Wilcoxon signed rank test compared changes in HVA, IMA, DMAA, and forefoot widths. Pearson correlation coefficient evaluated association between HVA, IMA, DMAA, and changes in forefoot width. Results: At mean follow-up of 5.4 (range 3-13.7) months, bony forefoot width decreased significantly by 3.7 mm (4%, P < .001) and soft tissue forefoot width decreased by 2.5 mm (2%, P < .01). Decrease in HVA was moderately correlated with change in bony forefoot width (r = .38, P < .05) and change in soft tissue forefoot width (r = .45, P < .05). Decrease in IMA was moderately correlated with change in bony forefoot width (r = .45, P < .05) and change in soft tissue forefoot width (r = .44, P < .05). Conclusion: The MICA procedure resulted in modest, yet significant, decrease in both bony and soft tissue forefoot width. Decrease in HVA and IMA demonstrated moderate correlation with changes in forefoot width. Patients can be counseled on these changes leading up to, and after, MICA bunionectomy surgery. Level of Evidence: Level III, retrospective comparative series.

Alcohol Use Among Treatment-Seeking Individuals With Opioid Use Disorder.

OBJECTIVE: Individuals in the United States with opioid use disorder (OUD) have high rates of co-occurring alcohol use disorder. However, there is limited research on co-use patterns among opioid and alcohol use. The present study examined the relationship between alcohol and opioid use in treatment-seeking individuals with an OUD. METHOD: The study used baseline assessment data from a multisite, comparative effectiveness trial. Participants with an OUD who had used nonprescribed opioids in the last 30 days (n = 567) reported on their alcohol and opioid use during the past 30 days using the Timeline Followback. Two mixed-effects logistic regression models were used to assess the effect of alcohol use and binge alcohol use (≥4 drinks/day for women and ≥5 drinks/day for men) on opioid use. RESULTS: The likelihood of same-day opioid use was significantly lower on days in which participants drank any alcohol (p < .001) as well as on days in which participants reported binge drinking (p = .01), controlling for age, gender, ethnicity, and years of education. CONCLUSIONS: These findings suggest that alcohol or binge alcohol use is associated with significantly lower odds of opioid use on a given day, which was not related to gender or age. The prevalence of opioid use remained high on both alcohol use and non-alcohol use days. In line with a substitution model of alcohol and opioid co-use, alcohol may be used to treat symptoms of opioid withdrawal and possibly play a secondary and substitutive role in individuals with OUD substance use patterns.

Patients With Chronic Foot and Ankle Conditions Experience Significant Improvements in Sleep Quality Following Surgical Intervention.

BACKGROUND: Poor sleep quality is associated with metabolic dysregulation and impaired healing. The purpose of the current study was to quantify the prevalence of poor sleep in patients with atraumatic foot and ankle (F&A) conditions and determine whether surgical treatment is associated with sleep quality improvement. METHODS: Patients scheduled for surgical management of atraumatic F&A conditions were enrolled by 4 fellowship-trained orthopaedic F&A surgeons between May 2018 and April 2019. Patients completed the Pittsburgh Sleep Quality Index (PSQI) pre- and postoperatively. The PSQI ranges from 0 to 21, with a score ≥5 indicative of poor sleep quality. Patients also reported their perception of how their current F&A pain influenced their sleep quality on a scale of 0 to 10, where 0 indicated no influence and 10 indicated a strong influence (pain perception score [PPS]). Patients with known sleep disorders, acute surgical trauma, and infection were excluded. RESULTS: A total of 115 patients were enrolled. The mean preoperative PSQI and PPS were 8.1 ± 3.6 (range, 2-19) and 3.1 ± 2.7 (range, 0-10), respectively. Overall, 86.1% of patients had poor sleep quality (PSQI score ≥5). Similarly, 64.3% of patients had a PPS ≥1, indicating the belief that F&A pain contributed to sleep disturbance. A minimum of 6 months of follow-up was collected for 72 (62.6%) patients. On average, these 72 patients experienced significant improvements in sleep quality (mean PSQI decreased from 7.8 ± 3.2 to 5.4 ± 3.1, P < .001). Of these patients, 59.7% continued to experience poor sleep quality (PSQI ≥5), and 55.6% perceived that F&A pain contributed to sleep disturbance (PPS ≥1). CONCLUSION: In this series, 86.1% of patients presenting for management of atraumatic F&A conditions had poor sleep quality at the time of their initial visit, with 64.3% perceiving their F&A conditions to influence their sleep quality. Improvements in sleep quality were observed at 6 months postoperatively, though over half of patients continued to experience poor sleep quality. The location of pathology and procedure performed was not associated with sleep quality. LEVELS OF EVIDENCE: Level IV: Prospective case series.

A Third Moment Adjusted Test Statistic for Small Sample Factor Analysis.

Goodness of fit testing in factor analysis is based on the assumption that the test statistic is asymptotically chi-square; but this property may not hold in small samples even when the factors and errors are normally distributed in the population. Robust methods such as Browne's asymptotically distribution-free method and Satorra Bentler's mean scaling statistic were developed under the presumption of non-normality in the factors and errors. This paper finds new application to the case where factors and errors are normally distributed in the population but the skewness of the obtained test statistic is still high due to sampling error in the observed indicators. An extension of Satorra Bentler's statistic is proposed that not only scales the mean but also adjusts the degrees of freedom based on the skewness of the obtained test statistic in order to improve its robustness under small samples. A simple simulation study shows that this third moment adjusted statistic asymptotically performs on par with previously proposed methods, and at a very small sample size offers superior Type I error rates under a properly specified model. Data from Mardia, Kent and Bibby's study of students tested for their ability in five content areas that were either open or closed book were used to illustrate the real-world performance of this statistic.

Characteristics associated with treatment seeking for smoking cessation among heavy-drinking research participants.

Objective: Treatment seeking for smoking cessation has tremendous clinical implications with the potential to reduce tobacco-related morbidity and mortality. The present study seeks to elucidate clinical variables that distinguish treatment seeking versus non-treatment seeking status for smoking cessation in a large sample of heavy drinking smokers using data-driven methods. Materials and methods: This secondary data analysis examines n = 911 (n = 267 female) individuals who were daily smokers and heavy drinkers (≥ 7 drinks per week for women, ≥ 14 for men) that were enrolled in either a treatment-seeking study (N = 450) or a non-treatment seeking study (N = 461) using identical pharmacotherapies. Participants completed measures of demographics, alcohol and cigarette use, alcohol craving, the Barratt Impulsiveness Scale (BIS-11), and the Wisconsin Inventory of Smoking Dependence Motives (WISDM-68). These measures were used in a random forest model to identify predictors of treatment seeking status. Results: The top variables of importance in identifying treatment seeking status were: age, drinks per drinking day, cigarettes per smoking day, BIS-11 cognitive impulsivity, WISDM social environmental goads, WISDM loss of control, WISDM craving, and WISDM tolerance. Age and drinks per drinking day were two of the most robust predictors, followed by measures of nicotine craving and tolerance. Conclusion: Individuals who are daily smokers and consume more drinks per drinking day are less likely to belong to the smoking cessationtreatment-seeking group. Targeting heavy drinking smokers, particularly younger individuals, may be necessary to engage this group in smoking cessation efforts and to reduce the burden of disease of nicotine dependence earlier in the lifespan.

Type of alcohol drink and exposure to violence: an emergency department study.

We compared the prevalence of exposure to violence across different types of alcohol consumed and the association between the type of alcohol consumed and exposure to violence. A cross-sectional analysis of data collected from a sample of 295 Emergency Department (ED) patients identified as having an alcohol problem. Outcome measure include exposure to violence, and the main study predictor was "type of alcoholic drink" including: malt liquor beer (MLB), regular beer, wine cooler, wine, fortified wine or hard liquor. Using logistic regression analysis, ED patients who drank MLB in combination with other types of alcohol increased their odds of being both threatened and physically attacked by 8.5 compared to ED patients who drank other types of alcohol. Being female increased the odds of being both threatened and physically attacked by 2.5 and using illicit drugs increased the odds by 3.8. Analysis of covariance and estimated marginal means revealed that ED patients who only drank MLB had a higher exposure to violence compared to non-MLB drinkers, and that female illicit drug users who drank MLB in combination with other types of alcohol had the highest exposure to violence. MLB was identified as a predictor of the amount of exposure to violence and in particular, that the use of malt liquor beer in combination with other types of alcohol increased the risk of being both threatened and physically attacked. Implications for ED and community interventions are suggested.

Randomized Trial of Dilute Povidone-Iodine Soak and Scrub for Orthopaedic Foot and Ankle Surgery.

BACKGROUND: There is no consensus as to which skin antiseptic solution is most effective at reducing infection following orthopaedic foot and ankle surgery. The purpose of this study is to determine if the addition of a dilute povidone-iodine soak and scrub to a standard preparation with alcohol and chlorhexidine decreases positive bacterial culture rates from the hallux nailfold. METHODS: In this prospective, randomized controlled trial, 242 subjects undergoing orthopaedic foot and ankle surgery were randomized to one of 2 groups. The control group received our standard 2-step skin antiseptic preparation of an alcohol scrub (step 1) followed by chlorhexidine/alcohol paint (step 2). The intervention group received a 3-minute dilute povidone-iodine soak and scrub followed by that same standard 2-step skin preparation. Immediately before skin incision, culture swabs were taken from the hallux nailfold of both groups. RESULTS: Of the 257 subjects enrolled and randomized, 242 (94.2%) completed the study, satisfying the a priori sample size requirement of 242 subjects. There were no crossovers between groups. There were no differences in baseline characteristics between groups (P > .05 for each). There was no difference in bacterial growth rates between groups (26.8% growth in the intervention group vs 26.9% growth in the control group, P = .991). CONCLUSION: The hallux nailfold is one of the most difficult to sterilize areas prior to orthopaedic foot and ankle surgery. This randomized controlled trail found no benefit to adding a 3-minute dilute povidone-iodine soak and scrub to a standard skin preparation with alcohol and chlorohexidine. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Transfer of the Posterior Tibial Tendon for Chronic Peroneal Nerve Palsy.

¼: The common peroneal nerve (CPN) is one of the most frequently injured nerves of the lower extremity. ¼: One-third of patients who develop CPN palsy proceed to chronic impairment without signs of recovery. ¼: Ankle-foot orthoses can provide improvement with respect to gait dysfunction and are useful as a nonsurgical treatment option. ¼: Severe cases of CPN palsy demonstrating no signs of recovery may require operative intervention with tendon transfer.

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.

Timing of Early Complications Following Open Reduction and Internal Fixation of Closed Ankle Fractures.

Introduction: There is increasing interest in the early identification and treatment of adverse medical events following orthopaedic procedures. The purpose of this study is to characterize the timing of 8 early adverse events following open reduction and internal fixation of closed fractures of the ankle. Methods: A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program. A total of 17 318 patients undergoing open reduction and internal fixation of closed ankle fractures were identified. 48.4% of patients were discharged on the day of surgery. For each of 8 different early adverse events, the median postoperative day of diagnosis, interquartile range for day of diagnosis, and middle 80% for day of diagnosis were determined. Timing was compared between unimalleolar and bi-/trimalleolar fractures and between inpatient and outpatient procedures. Results: The median day of diagnosis (and interquartile range; middle 80%) for myocardial infarction was 2 (1-5; 0-17), pneumonia 3 (2-7; 1-19), acute kidney injury 6.5 (2-18; 2-20), urinary tract infection 7 (2-14; 0-24), pulmonary embolism 10 (3-21; 0-27), sepsis 15 (4-22; 1-28), deep vein thrombosis 17 (10-22; 3-27), and surgical site infection 19 (14-25; 8-28). Patients with bi-/trimalleolar fractures had earlier occurrence of myocardial infarction (day 2 vs 10), urinary tract infection (day 6.5 vs 9.5), and sepsis (day 10 vs 20.5). Inpatients had later occurrence of acute kidney injury (day 7 vs 3), but earlier occurrence of urinary tract infection (day 6 vs 15). Conclusions: These precisely described time periods for occurrence of specific adverse events enable heightened awareness among orthopaedic surgeons during the first month following open reduction and internal fixation of the ankle. Orthopaedic surgeons should have the lowest threshold for testing for each adverse event during the time period of greatest risk.Levels of Evidence: Therapeutic, Level III: Retrospective cohort study.

Depression Following Operative Treatments for Achilles Ruptures and Ankle Fractures.

BACKGROUND: The sudden and debilitating nature of lower extremity injuries can trigger mood disturbances, including major depressive disorder. METHODS: This prospective study enrolled patients undergoing operative repair of ankle fractures and Achilles ruptures and followed them for 1 year postoperatively. The validated Patient Health Questionnaire (PHQ-9) for depressive symptoms was administered at the preoperative visit and at postoperative weeks 1, 2, 4, 8, 16, 24, 32, 40, and 52. PHQ-9 is scored 0 to 27, with higher values indicating greater depression symptoms. RESULTS: Fifty-eight patients completed 1 year of follow-up. The mean PHQ-9 score was 2.7 (range, 0-20) at the preoperative visit, peaked at postoperative week 1 (4.9; range, 0-16), and reached its low at postoperative week 52 (0.8; range, 0-7). Cumulative incidences of depressive symptoms during the first year following surgery were 51.7% for at least mild depression, 22.4% for at least moderate depression, and 6.9% for severe depression. A history of mental health disorder and the inability to work during the period of postoperative immobilization were independently associated with greater depressive symptoms. CONCLUSION: The majority of patients undergoing operative treatment of Achilles ruptures and ankle fractures develop postoperative symptoms of mild to moderate depression that normalize after several months. Patients with a history of mental health disorder or who cannot work while immobilized postoperatively are at greatest risk. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Ibudilast, a neuroimmune modulator, reduces heavy drinking and alcohol cue-elicited neural activation: a randomized trial.

Ibudilast, a neuroimmune modulator which selectively inhibits phosphodiesterases (PDE)-3, -4, -10, and -11, and macrophage migration inhibitory factor (MIF), shows promise as a novel pharmacotherapy for alcohol use disorder (AUD). However, the mechanisms of action underlying ibudilast's effects on the human brain remain largely unknown. Thus, the current study examined the efficacy of ibudilast to improve negative mood, reduce heavy drinking, and attenuate neural reward signals in individuals with AUD. Fifty-two nontreatment-seeking individuals with AUD were randomized to receive ibudilast (n = 24) or placebo (n = 28). Participants completed a 2-week daily diary study during which they filled out daily reports of their past day drinking, mood, and craving. Participants completed an functional magnetic resonance imaging (fMRI) alcohol cue-reactivity paradigm half-way through the study. Ibudilast did not have a significant effect on negative mood (ß = -0.34, p = 0.62). However, ibudilast, relative to placebo, reduced the odds of heavy drinking across time by 45% (OR = 0.55, (95% CI: 0.30, 0.98)). Ibudilast also attenuated alcohol cue-elicited activation in the ventral striatum (VS) compared to placebo (F(1,44) = 7.36, p = 0.01). Alcohol cue-elicited activation in the VS predicted subsequent drinking in the ibudilast group (F(1,44) = 6.39, p = 0.02), such that individuals who had attenuated ventral striatal activation and took ibudilast had the fewest number of drinks per drinking day in the week following the scan. These findings extend preclinical and human laboratory studies of the utility of ibudilast to treat AUD and suggest a biobehavioral mechanism through which ibudilast acts, namely, by reducing the rewarding response to alcohol cues in the brain leading to a reduction in heavy drinking.

Second Metatarsophalangeal Joint Interpositional Arthroplasty Using Decellularized Human Dermal Allograft: Operative Technique.

Arthrodesis of an osteoarthritic second metatarsophalangeal (MTP) joint is suboptimal because of altered gait mechanics; hence, joint-preserving procedures are of value. Autograft interpositional arthroplasty is one available option with excellent results, but there are potential concerns regarding donor site morbidity and insufficiency of the autograft material. We present here an alternative technique, an interpositional arthroplasty using allograft. Our technique includes a dorsal incision and joint exposure, removal of cartilage from the metatarsal head, and interposition of human decellularized dermal allograft sutured to the metatarsal head. Allograft interpositional arthroplasty is a feasible technique and can be further investigated as an alternative procedure for patients with second MTP osteoarthritis. LEVEL OF EVIDENCE: Level V, expert opinion.

Impact of Coleman Block Test on Adult Hindfoot Alignment Assessed by Clinical Examination, Radiography, and Weight-Bearing Computed Tomography.

BACKGROUND: Cavovarus foot constitutes a complex 3-dimensional deformity. The Coleman block test has traditionally been used to distinguish between forefoot- and hindfoot-driven deformity. However, there has been no objective evaluation of the Coleman block test using radiographs or weightbearing computed tomography (WBCT). The purpose of this study was to compare hindfoot alignment in adult cavovarus feet with and without the Coleman block using clinical examination, radiography, and WBCT. METHODS: Six feet in 6 patients with a clinical diagnosis of cavovarus foot deformity were prospectively enrolled. All feet underwent clinical photography with the camera positioned at 0 degrees to the heel, hindfoot alignment view radiography with the beam positioned 20 degrees off the ground, and WBCT, both with and without the Coleman block in place. Clinical photos were characterized using the standing talocalcaneal angle (STCA), radiographs were characterized using the hindfoot alignment angle (HAA), and WBCTs were characterized using manual and automated hindfoot alignment angle (HAA) and foot and ankle offset (FAO). Using paired analyses, measurements taken with the Coleman block in place were compared to those taken without the Coleman block. Finally, the different methods of measuring hindfoot alignment were tested for correlation with each other. Mean age was 56 years (range 38-69). RESULTS: On clinical photography, the STCA decreased by 3.8 degrees with addition of the block (from 10.0±6.6 degrees varus without block to 6.2±7.1 degrees varus with block; P = .001). On radiograph, HAA decreased by 9.0 degrees with addition of the block (from 16.8±8.4 degrees varus without block to 7.5±6.3 degrees varus with block; P = .07). On WBCT, hindfoot alignment angle changed an average of 3.2 degrees (33.4 degrees varus without block, 30.2 degrees varus with block; P = .008). On WBCT, FAO decreased by 1.4% (from 11.3% varus without block to 10.1% varus with block; P = .003). Clinical examination and automated WBCT measurements were strongly correlated with each other. CONCLUSION: Clinical examination, radiograph, and WBCT demonstrated improvements in hindfoot varus using the Coleman block test in adults, but no patient demonstrated complete resolution of deformity regardless of the measurement modality. Clinical examination correlated strongly with automated WBCT measurements. LEVEL OF EVIDENCE: Level IV, retrospective case review.

Longer Operative Time Is Independently Associated With Surgical Site Infection and Wound Dehiscence Following Open Reduction and Internal Fixation of the Ankle.

Background: Little is known regarding the association of operative time with adverse events following foot and ankle surgery. This study tests whether greater operative time is associated with the occurrence of adverse events following open reduction and internal fixation (ORIF) of the ankle. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for cases of ankle ORIF (primary CPT codes 27766, 27769, 27792, 27814, 27822, 27823) performed during 2005-2016. Operative time was tested for association with the occurrence of adverse events with controls for baseline characteristics and primary CPT code. Results: A total of 20 591 procedures met inclusion/exclusion criteria. The average (±SD) operative time was 75.7 (±37.3) minutes and varied by baseline characteristics and primary CPT code. After controlling for these factors, a 15-minute increase in operative time was associated with an 11% increase in risk for developing surgical site infection (SSI; relative risk [RR]: 1.11; 95% CI: 1.06-1.16), 20% for wound dehiscence (RR: 1.20; 95% CI: 1.11-1.29), 10% for anemia requiring transfusion (RR: 1.10; 95% CI: 1.04-1.17), 60% for cerebrovascular accident (RR: 1.60; 95% CI: 1.17-2.18), 14% for unplanned intubation (RR: 1.14; 95% CI: 1.03-1.26), and 7% for extended length of hospital admission (RR: 1.07; 95% CI: 1.05-1.09). Conclusion: Operative time is linearly and independently associated with the risks for SSI, wound dehiscence, and other adverse events following ORIF of the ankle. Efforts should be implemented to safely minimize operative duration without compromising the technical components of the procedure. Levels of Evidence: Therapeutic, Level IV.

Skin Preparation Techniques for Orthopedic Foot and Ankle Surgery: A Current Concepts Review.

Surgical site infection (SSI) following orthopedic foot and ankle surgery is associated with morbidity, mortality, and cost to the healthcare system. The local anatomy and physiology predispose patients undergoing procedures to elevated risk. In particular, sterilizing of the webspaces, nailfolds, and subungual areas presents challenges, and the preferred skin antisepsis technique for foot and ankle procedures has not yet been defined. Skin antiseptic solutions (SASs) consist of 3 main categories: alcohol, chlorhexidine, and iodine-based solutions. This review of the literature supports a combined chlorhexidine and alcohol preparation technique; however, there are a number of studies that suggest otherwise. In addition, there is variable evidence for the use of alternatives to the standard soft sponge application technique, including immersion, bristled brush, and cotton gauze application. These alternatives may have a particular advantage in the forefoot. Most studies to date use growth from skin swab cultures after skin preparation as the primary outcome. Higher-level studies with large subject populations and more meaningful clinical outcomes will be required to solidify guidelines for preoperative skin antisepsis prior to foot and ankle procedures.Level of Evidence: Level V, expert opinion.

Radiographic Impact of Lapidus, Proximal Lateral Closing Wedge Osteotomy, and Suture Button Procedures on First Ray Length and Dorsiflexion for Hallux Valgus.

BACKGROUND: Shortening and dorsiflexion of the first metatarsal are known potential side effects of metatarsal osteotomies for hallux valgus (HV) with the potential to cause transfer metatarsalgia. We compared the effect of the first tarsometatarsal joint arthrodesis (Lapidus procedure), proximal lateral closing wedge osteotomy (PLCWO), and intermetatarsal suture button fixation procedures on the length and dorsiflexion of the first ray. METHODS: We retrospectively evaluated 105 feet in 99 patients with 30 weeks of follow-up. The average age was 54 years. Seventy-four feet had a Lapidus procedure, 12 had a PLCWO, and 19 had intermetatarsal suture button fixation. Digital radiographic measurements were made for the pre- and postoperative hallux valgus angle (HVA) and intermetatarsal angle (IMA), absolute and relative shortening of the first ray, and dorsiflexion. RESULTS: Preoperative HVA and IMA did not differ between treatment groups (P > .05 for each). Similar corrections of HVA (30.5-13.5 degrees) were achieved between all groups (P > .05). The IMA was improved more in the Lapidus group (14.3-6.5 degrees) compared with the suture button fixation group (14.2-8.1 degrees) (P = .045). There were significant differences in the change in absolute first cuneiform-metatarsal length (FCML) between the Lapidus (-1.6 mm), PLCWO (-2.3 mm), and intermetatarsal suture button fixation (+1.9 mm) procedure (P = .004). There were also significant differences in relative first metatarsal shortening between the Lapidus (0.1 mm relative shortening), PLCWO (1.1 mm relative shortening), and intermetatarsal suture button fixation (1.3 mm lengthening) procedure (P < .001). The average dorsiflexion differed between the Lapidus (1.8 degrees) and suture button fixation (0.4 degrees) groups (P = .004). CONCLUSION: Intermetatarsal suture button fixation relatively lengthened the first ray, the Lapidus procedure maintained length, and the PLCWO relatively and absolutely shortened it. Dorsiflexion may be higher with the Lapidus and osteotomy procedures. LEVEL OF EVIDENCE: Level III, retrospective comparative series.