Surgical Management of Chronic Exertional Compartment Syndrome of the Lower Extremity: Outcome Analysis and Return to Sport.

OBJECTIVE: To evaluate patient-reported outcomes and return to sport after open fasciotomy for lower extremity chronic exertional compartment syndrome (CECS). DESIGN: Retrospective case series. SETTING: Foot and ankle specialty service at a large multisite academic medical center. PATIENTS: All patients undergoing lower extremity fasciotomy for CECS from 2009 to 2017 by one surgeon were eligible. Patients that underwent a fasciotomy for trauma, infection, or an acute pathologic process were excluded. Fifty-nine patients that underwent 63 procedures were included. The average age was 26.6 years, and 35 (59%) patients were women. Thirty-seven patients underwent simultaneous bilateral fasciotomies, 4 had staged bilateral fasciotomies, and 18 underwent unilateral fasciotomy. Four-compartment fasciotomy was performed 15 times. INTERVENTIONS: Retrospective email/telephone follow-up. MAIN OUTCOME MEASURES: Return to sports questionnaire, the Foot and Ankle Ability Measure-Sports subscale, and visual analog scale for pain. RESULTS: At a mean follow-up of 58.8 months, significant postoperative improvement was seen in patient-reported outcome scores compared with preoperative scores (P < 0.0001). Overall, 55 (93%) patients were able to return to sport, 42 (76%) returned to the same level of sport, and 13 (24%) returned to a lower level of competition. Bivariate regression analysis demonstrated that a higher preoperative body mass index [odds ratio: 0.829 (95% confidence interval: 0.688, 0.999); P = 0.049] was associated with a lower likelihood of return to sport. CONCLUSIONS: This study demonstrates that lower extremity fasciotomy for CECS results in improvement of patient-reported outcomes and a high rate of return to sport.

When is it Safe to Drive After Total Ankle Arthroplasty?

BACKGROUND: With the increase in the number of total ankle arthroplasties (TAA), guidelines on when physicians should begin to consider patients' return to driving are valuable. Further, due to sagittal motion strength, the ankle is the most important mover in braking motions over the knee and hip. QUESTIONS/PURPOSES: (1) Does brake-reaction time return to a safe value within 6 weeks of TAA? (2) Are there factors associated with a delay of return of brake-reaction time to safe values after TAA? METHODS: After obtaining institutional review board approval for the study, we prospectively recruited 60 patients undergoing right TAA. A large proportion of the patients undergoing TAA during the period were recruited. Patients who had extensive concomitant surgery, such as triple arthrodesis or tibial osteotomy, were excluded from the study. Patients were between 43 and 83 years old (median, 63 years), and 35 (59%) were men. Brake-reaction time was tested at 6 weeks postoperatively and repeated weekly until patients achieved a passing brake-reaction time. A control group of 20 volunteer participants matched for age and sex who did not have right lower-extremity pathology or pain were used to establish a passing brake-reaction time of 0.850 seconds. Patients were given a novel driver-readiness survey to complete; a score of 10 of 15 points or higher was considered a passing score. The following factors were explored for their association with brake-reaction time: age, American Orthopaedic Foot and Ankle Society (AOFAS)-Hindfoot assessment and VAS for pain via a patient-reported survey, and ankle plantarflexion and dorsiflexion via dedicated weightbearing lateral radiographs made with the ankle in maximum plantarflexion and dorsiflexion. RESULTS: At 6 weeks postoperatively, 92% of patients (54 of 59) achieved a passing brake-reaction time and were considered able to drive safely, and the mean brake-reaction time of the patients with a passing brake-reaction time was 0.626 seconds (± 0.111). At 9 weeks, all patients who completed the study achieved a passing brake-reaction time. Patients with a failed brake-reaction time at 6 weeks had greater median VAS scores for pain (3 [interquartile range 2 to 7] versus 1 [IQR 0 to 3]; p = 0.022) and diminished ankle plantarflexion (14° [± 5°] versus 24° [± 10°]; p = 0.037) compared with those with a passing brake-reaction time at that time point. All five patients with a failed brake-reaction time also had a failing score for the driver-readiness survey. CONCLUSIONS: More than 90% of patients in this series achieved a safe brake-reaction time within 6 weeks of TAA, and those who did not were more likely to have had more pain and a stiffer ankle. Surgeons might counsel patients with persistent pain and stiffness at 6 weeks to delay driving for an additional 3 weeks, since by 9 weeks after TAA, all patients in this series had a brake-reaction time comparable with patients who had not undergone surgery. Future studies might elucidate what key gaps in knowledge remain and determine a practical way to answer these questions. LEVEL OF EVIDENCE: Level II, therapeutic study.

How Does Perioperative Ketorolac Affect Opioid Consumption and Pain Management After Ankle Fracture Surgery?

BACKGROUND: The investigation of nonnarcotic drug regimens for postoperative pain management is important in addressing the opioid epidemic. NSAIDs can be a powerful adjunct in managing postoperative pain, but the possibility of delayed bone healing is a major concern for orthopaedic surgeons. Our recent retrospective study on ketorolac administration demonstrated that the NSAID is not associated with an increased risk of delayed union or nonunion after ankle fracture surgery. QUESTIONS/PURPOSES: To determine whether postoperative ketorolac (1) reduces opioid consumption, (2) improves VAS pain control, and (3) affects fracture healing after open reduction and internal fixation of ankle fractures. METHODS: Between August 2016 and December 2017, 128 patients undergoing open reduction and internal fixation of an acute ankle fracture were randomized before surgery via simple randomization to treatment with or without ketorolac. No patients changed treatment regimen groups or opted out of randomization. All other aspects of perioperative care were treated identically. A once-daily survey was distributed via email on postoperative Days 1 to 7. Unblinded participants were asked to report their daily opioid consumption, pain level, and sleep interference using the VAS, and pain frequency using a five-point Likert scale, and side effects with the VAS. For VAS pain, > 20 mm/100 mm on the VAS scale was required to be considered "improved." In all, 83% (106 of 128) patients completed all seven postoperative surveys with 14 in the control group and eight in the ketorolac group lost to follow-up. Fifty-six patients were administered ketorolac with opioid medication (treatment group) and 50 were administered opioids alone (control group). Participants were comprised of 42% men (44), and 58% women (62); mean age was 48 years. The treating surgeon assessed clinical healing based on the patient's ability to ambulate comfortably at 12 weeks postoperatively. Radiographic healing was assessed by two fellowship-trained orthopaedic foot and ankle surgeons blinded to the patient's name and time since surgery. The surgeons evaluated randomized standard ankle series (anteroposterior, mortise, and lateral) radiographs for resolution of each fracture line to determine fracture union, with delayed union being defined as fracture lines present on radiographs taken at 12-week postoperative visits. Intention-to-treat analysis was performed. RESULTS: Patients in the treatment group consumed a mean of 14 opioid pills, which was less than the mean of 19.3 opioids pills consumed by patients in the control group (p = 0.037). Patients with ketorolac had lower median VAS scores for pain (p < 0.035) postoperatively on postoperative Days 1 and 2 than did control patients. By contrast, patient-reported pain scores and scores for sleep did not convincingly show a benefit to the use of ketorolac. For patients whose ankle fractures healed at 12 weeks, there was no difference between the groups in terms of clinical healing (p = 0.575) and radiographic healing (p = 0.961). CONCLUSIONS: In this randomized study, adding ketorolac to the postoperative drug regimen decreased the use of opioid medication after open reduction and internal fixation of ankle fractures in the early postoperative period, and there were mixed, small effects on pain reduction. This NSAID is a valuable tool in helping patients manage postoperative pain with less use of narcotic analgesia. However, our study was underpowered to determine the true safety of this drug in terms of fracture healing and side effects and these questions warrant higher-powered randomized study investigation. LEVEL OF EVIDENCE: Level I, therapeutic study.

Avoiding Failure and Complications in Cavovarus Foot Deformity Reconstruction.

Symptomatic cavovarus foot deformity is frequently associated with neuromuscular conditions, such as Charcot-Marie-Tooth disease, which cause an imbalance between antagonistic muscle groups, thereby leading to the deformity. Avoiding complications in the treatment of patients with cavovarus foot deformity requires a detailed understanding of this imbalance between antagonistic muscle groups and the resulting three-dimensional deformity. Because of the poor outcomes reported in patients with cavovarus foot deformity who undergo nonsurgical treatment or fusion procedures, joint-sparing surgery, including tendon transfers and realignment osteotomies, remain the hallmark of successful management of cavovarus foot deformity. Joint-sparing surgery requires an individualized approach to rebalance the muscles and create a plantigrade functional foot. However, a balanced foot that is achieved via arthrodesis of the hindfoot or midfoot is preferred to undercorrection of a deformity that is managed via joint-sparing surgery. Arthrodesis often is performed in combination with tendon transfers for the salvage of severe deformity and in patients in whom joint-sparing surgery fails, particularly in patients with arthritis. Surgeons should understand the etiology and biomechanics of cavovarus foot deformity and the algorithmic approach for surgical management.

Use of a Hunter Rod for Staged Reconstruction of Peroneal Tendons.

Peroneal tendon pathology is a commonly reported cause of lateral ankle pain. The causes include cavovarus foot type, overuse, chronic tendinosis, peroneal subluxation or dislocation, acute traumatic split tears, and traumatic rupture. The purpose of the present report is to describe an alternative approach for surgical reconstruction of the peroneal tendons in patients when repair might no longer be effective. The use of a Hunter rod was originally described by Hunter in 1971 for 2-stage reconstruction of tendons in the hand. We present a 2-stage surgical technique with the use of a Hunter rod as a temporary implant to stimulate generation of a healthy peroneal tendon sheath to host a flexor hallucis longus tendon transfer. This has proved to be a successful treatment option for patients with severe peroneal tendon damage and scarring along the peroneal tendon sheath. We offer a sample case to illustrate a patient with such indications.

Heel lipoma mimicking plantar fasciitis in a ballroom dancer.

The present case illustrates a lipoma as an unusual cause of heel pain. A 64-year-old female ballroom dancer presented with 8 months of pain that was unresponsive to previous treatment of plantar fasciitis. Magnetic resonance imaging revealed a heel lipoma. Her pain was fully resolved after surgical excision. Soft tissue tumors should be included in the differential diagnosis of heel pain, especially when symptoms and treatment response do not follow the typical course of plantar fasciitis.

The proximal fibula should be examined in all patients with ankle injury: a case series of missed maisonneuve fractures.

BACKGROUND: The Maisonneuve fracture is a spiral fracture of the proximal third of the fibula. It occurs from violent twisting of the ankle that characteristically causes ligament damage and severe instability. Most patients complain of significant ankle pain but very little pain over the fracture. The clinical and radiographic examination is usually directed to the ankle region; and the proximal fibula is often ignored. OBJECTIVE: The authors intend to show the ease of missing the proximal fibular fracture when the clinical examination is directed to the ankle region. They discuss the importance of palpating the proximal fibula and ordering appropriate radiographs. CASE STUDIES: The authors report on 5 patients who presented to the Emergency Department, where the Maisonneuve fracture was missed despite having ankle radiographs taken. All patients required open reduction and internal fixation. CONCLUSION: The Maisonneuve fracture injury pattern causes untoward consequences if not promptly recognized and treated. To avoid misdiagnosis, the proximal fibula should be examined in all patients with ankle injury.

Achilles tendon injuries in a United States population.

BACKGROUND: Most studies on Achilles tendon ruptures involved US military or European populations, which may not translate to the general US population. The current study reviews 406 consecutive Achilles tendon ruptures occurring in the general US population for patterns in a tertiary care subspecialty referral setting. METHODS: An institutional review board-approved, retrospective review of the charts of 331 (83%) males (6 bilateral, nonsimultaneous) and 69 (17%) females diagnosed with Achilles tendon ruptures over a 10-year period was undertaken. Average age was 46.4 years with 310 (76%) ruptures diagnosed and managed acutely (less than 4 weeks), whereas 96 (24%) were chronic (more than 4 weeks since the injury). Patients were assessed for mechanism of injury and previously described underlying risk factors. Results were assessed according to age (greater or less than 55 years), body mass index (BMI), and time to diagnosis. RESULTS: Sporting activity was responsible for 275 ruptures (68%). This was higher in patients younger than 55 years of age (77%) than those older than 55 years (42%). Basketball was the most commonly involved sport, accounting for 132 ruptures (48% of sports ruptures, 32% of all ruptures), followed by tennis in 52 ruptures (13%, 9%), and football in 32 ruptures (12%, 8%). In all, 20 ruptures were reruptures of the same Achilles tendon, of which 17 had previously been treated nonsurgically. In this study, recent quinolone use (2%) and African American race (31%) were not major risk factors for rupture as described in other studies. Older patients and patients with a BMI greater than 30 were more likely to be injured in nonsporting activities and more likely to have their diagnosis initially not recognized resulting in their presentation more than 4 weeks following the injury. CONCLUSION: In this study, sports participation was the most common mechanism, but not to the same extent seen in the European or US military studies. Basketball was the most commonly involved sport, as compared to soccer in Europe. Age and BMI had a directly proportional correlation with time to diagnosis.

Treatment of myotendinous Achilles ruptures.

BACKGROUND: There is scant literature regarding the treatment of myotendinous Achilles ruptures. The purpose of this study was to retrospectively examine clinical outcomes from uniform nonsurgical treatment of these injuries. METHODS: Between November 2005 and May 2011, 30 patients presented with an acute, complete myotendinous Achilles rupture. The location of the Achilles injury was confirmed on magnetic resonance imaging (MRI) for all patients. All patients were treated nonsurgically, which involved 3 weeks of non-weight-bearing and then 3 weeks of progressive to full weight-bearing in an Achilles boot. Physical therapy was provided for 4 to 6 weeks after this period of immobilization. 21 patients were male and 9 were female. The patients had a mean age of 40.8 years (range, 24-54). Patients were followed an average of 40.5 months (range, 23-81). RESULTS: Full healing of the Achilles myotendinous junction was achieved clinically in all 30 patients . All patients experienced improved function and less pain at their latest follow-up. Mean Foot and Ankle Ability Measure-Sports (FAAM-Sports) increased from 20.2% at the time of initial presentation to 95.2% at the latest follow-up (P < .05). Mean Visual Analog Scores (VAS) of pain decreased from 8.2 at the time of initial presentation to 1.3 at latest follow-up (P < .01). In all, 23 (76.7%), 6 (20%), and 1 (3.3%) patients rated their satisfaction as excellent, good, and fair, respectively. No patients have developed recurrent myotendinous Achilles ruptures to date. CONCLUSION: Nonsurgical treatment of myotendinous Achilles ruptures results in a high rate of myotendinous healing with improved patient function and pain relief. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Conversion arthrodesis for failed first metatarsophalangeal joint hemiarthroplasty.

BACKGROUND: Arthrodesis is currently the most commonly performed surgical procedure for the treatment of arthritis of the first metatarsophalangeal (MTP) joint. Hemiarthroplasty of the first MTP joint has been shown to have inferior clinical results and higher revision rates. The objective of this study was to assess the clinical outcome of the salvage of failed hallux phalangeal hemiarthroplasty with conversion to arthrodesis. METHODS: A retrospective review of patients who underwent salvage of the first MTP joint hemiarthroplasty with conversion to arthrodesis was performed. Preoperative assessment included the visual analog pain (VAP) scale and AOFAS Hallux Metatarsophalangeal Interphalangeal scoring system (AOFAS-HMI). Postoperative outcomes were graded via AOFAS-HMI, VAP, and Foot and Ankle Ability Measure (FAAM). RESULTS: Twenty-one hemiarthroplasties were converted to arthrodesis in 21 patients, with 18 available for follow-up included in the study. There were 13 women and 5 men. Local autologous bone graft was used in 12 cases, while 6 patients required tricortical iliac crest bone graft for the treatment of extensive bone loss. At final follow-up, at a mean of 4.3 years, the average VAS pain score had diminished to 0.75 from 7.8 preoperatively out of 10, while the mean AOFAS-HMI improved from 36.2 out of 100 preoperatively to 85.3 out of 90 (modified to exclude first MTP motion). The mean FAAM ADL/sports were 97.3/91.3, respectively. All patients achieved fusion although at a longer interval than primary fusions. CONCLUSIONS: Conversion from a failed hallux phalangeal hemiarthroplasty to arthrodesis showed similar success to primary arthrodesis which was achieved in the majority of cases with the use of regional bone graft for small defects. However, the time to fusion was longer than that of primary arthrodesis, and it sometimes required structural bone graft for augmentation. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Republication of "Open Repair of Acute Achilles Tendon Ruptures: Is the Incidence of Clinically Significant Wound Complications Overestimated?"

Background: Conflicting evidence exists regarding the optimal management of acute Achilles tendon ruptures. Operative repair is thought to afford patients a lower risk of rerupture, albeit at a higher overall risk of wound complications. Methods: A retrospective chart review of 369 consecutive patients undergoing open repair of acute Achilles tendon ruptures performed by a single foot and ankle fellowship-trained orthopedic surgeon was undertaken. Healing was classified as no complications, complications without prolonging treatment, complications requiring prolonged local treatment, and complications requiring operative intervention. A statistical analysis comparing the rates of complications in this cohort to that reported in the literature was conducted. Results: There were a total of 33 (8.94%) wound complications. Compared to the rates reported in the literature, no significant difference was detected (P = .3943; CI 6.24-12.33). However, when the complications not requiring additional treatment or prolonged care were excluded, only 9 wound complications (2.44%) were identified-a significantly lower complication rate than that reported in the literature (P < .0001; CI 1.12-4.58). There were only 2 (0.54%) major complications requiring operative intervention, also a significantly lower rate than in the literature (P < .0001; CI 0.067-1.94). Conclusion: In the past, wound-healing complications have been cited as a concern when treating patients operatively. We found that when solely looking at healing complications prolonging the patients' overall recovery, a significantly lower rate of complications existed compared to that reported in the literature. Level of Evidence: Level IV.

Opioid Consumption Patterns and Prolonged Opioid Use Among Opioid-Naïve Ankle Fracture Patients.

INTRODUCTION: Previous literature has demonstrated an association between acute opioid exposure and the risk of long-term opioid use. Here, the investigators assess immediate postoperative opioid consumption patterns as well as the incidence of prolonged opioid use among opioid-naïve patients following ankle fracture surgery. METHODS: Included patients underwent outpatient open reduction and internal fixation of an ankle or tibial plafond fracture over a 1-year period. At patients' first postoperative visit, opioid pills were counted and standardized to the equivalent number of 5-mg oxycodone pills. Prolonged use was defined as filling a prescription for a controlled substance more than 90 days after the index procedure, tracked by the New Jersey Prescription Drug Monitoring Program up to 1 year postoperatively. RESULTS: At the first postoperative visit, 173 patients consumed a median of 24 out of 40 pills prescribed. The initial utilization rate was 60%, and 2736 pills were left unused. In all, 32 (18.7%) patients required a narcotic prescription 90 days after the index procedure. Patients with a self-reported history of depression (P = .11) or diabetes (P = .07) demonstrated marginal correlation with prolonged narcotic use. CONCLUSION: Our study demonstrated that, on average, patients utilize significantly fewer opioid pills than prescribed and that many patient demographics are not significant predictors of continued long-term use following outpatient ankle fracture surgery. Large variations in consumption rates make it difficult for physicians to accurately prescribe and predict prolonged narcotic use. LEVEL OF EVIDENCE: Level III.

MRI is unnecessary for diagnosing acute Achilles tendon ruptures: clinical diagnostic criteria.

BACKGROUND: Achilles tendon ruptures are common in middle-aged athletes. Diagnosis is based on clinical examination or imaging. Although MRI is commonly used to document ruptures, there is no literature supporting its routine use and we wondered whether it was necessary. QUESTIONS/PURPOSES: We (1) determined the sensitivity of physical examination in diagnosing acute Achilles ruptures, (2) compared the sensitivity of physical examination with that of MRI, and (3) assessed care delays and impact attributable to MRI. METHODS: We retrospectively compared 66 patients with surgically confirmed acute Achilles ruptures and preoperative MRI with a control group of 66 patients without preoperative MRI. Clinical diagnostic criteria were an abnormal Thompson test, decreased resting tension, and palpable defect. Time to diagnosis and surgical procedures were compared with those of the control group. RESULTS: All patients had all three clinical findings preoperatively and complete ruptures intraoperatively (sensitivity of 100%). MR images were read as complete tears in 60, partial in four, and inconclusive in two patients. It took a mean of 5.1 days to obtain MRI after the injury, 8.8 days for initial evaluation, and 12.4 days for surgical intervention. In the control group, initial evaluation occurred at 2.5 days and surgical intervention at 5.6 days after injury. Nineteen patients in the MRI group had additional procedures whereas none of the control group patients had additional procedures. CONCLUSIONS: Physical examination findings were more sensitive than MRI. MRI is time consuming, expensive, and can lead to treatment delays. Clinicians should rely on the history and physical examination for accurate diagnosis and reserve MRI for ambiguous presentations and subacute or chronic injuries for preoperative planning. LEVEL OF EVIDENCE: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Improved Pain and Function After TTC Fusion With a Custom Cage.

BACKGROUND: Three-dimensional custom cages can be used to treat complex ankle and hindfoot pathology and bone loss with potentially better patient satisfaction and higher fusion rates than tibiotalocalcaneal (TTC) fusion alone or in combination with bulk femoral head allograft. Yet there is limited literature to support this procedure. The purpose of this study is to objectively quantify the clinical and radiologic outcomes of patients undergoing patient-specific 3D-printed custom cage implantation to fill large defects around the ankle joint region as part of a limb-salvaging TTC fusion. METHODS: This is a retrospective review of 21 patients (mean age 59.3 years) who underwent custom cage implantation with a TTC retrograde fusion nail by a single surgeon for massive bone loss of the ankle and hindfoot. Patient charts were reviewed for pain and functional outcomes, complications, and various demographics, including number of previous surgeries to the ipsilateral ankle. Mean follow-up was 32 months. All 21 patients had preoperative and postoperative pain and function scores available for analysis. RESULTS: A total of 20 (95.2%) of the 21 patients had their cage in situ at final follow-up. Overall, with the numbers available, visual analog scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM) activities of daily living subscale, and the 12-Item Short Form Health Survey (SF-12) mental and physical health scores significantly improved from preoperative to final follow-up. However, when compared to the overall US population of age-matched 55- to 64-year-old individuals, patients still remained relatively disabled. There were 2 failures, one of which required amputation and the other was treated nonoperatively with bracing. CONCLUSION: In conclusion, in this relatively small, single-surgeon series, we found that 3D-printed custom cage technology offered a viable option for complex TTC fusion procedures performed in the presence of significant bone loss, with good fusion rates, however relatively modest improvement in functional outcomes. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Delayed pathologic tibial fracture with chronic osteomyelitis after fibula free flap.

The reported donor site morbidity of the fibula free flap (FFF) is low; however, several uncommon complications have been reported with tibia fracture rarely being reported. We present a case of a pathological tibial fracture in the setting of chronic osteomyelitis after FFF. A 54-year-old female presented with a benign fibro-osseous lesion of the right mandible and was treated with mandibulectomy and reconstructed with a left FFF. Approximately 1 year following surgery, the patient presented to the emergency department. Imaging showed a pathological fracture of the distal third of the tibial shaft with persistent erythema and cellulitis of the lateral prior graft harvest site without signs of systemic infection. She was taken to the operating room for irrigation and debridement with culture and biopsy as well as external fixation of the tibial fracture. Intraoperative biopsy and culture demonstrated fracture site change with callus formation and negative culture. The patient was discharged on 6 weeks of IV vancomycin and ceftriaxone. In conclusion, tibial fracture following FFF is an uncommon complication, yet it can be exacerbated by chronic osteomyelitis. This report highlights the importance of close observation and comprehensive wound care of donor sites after free flap harvest for head and neck reconstruction.

Comparison Between Closed Suction Drainage and No Drainage Following Total Ankle Arthroplasty.

BACKGROUND: The purpose of this study is to determine whether the use of closed suction drains after total ankle arthroplasty (TAA) is associated with lower wound complications in the first postoperative year as compared to no drain usage. METHODS: A total of 324 TAA were reviewed and included for analysis. One hundred forty-four did not have a postoperative drain placed, whereas 180 did have a postoperative drain. Demographic data, including age, sex, tobacco or alcohol use, and various medical comorbidities, were obtained. Follow-up data were collected and reviewed at 2, 6, and 12 weeks; 6 months; and 1 year postoperatively for minor and major wound complications, as well as wound-related reoperations. RESULTS: At the 2-week mark, the use of a drain demonstrated a significant increase in wound complications. No significant difference in wound complications was found at each subsequent follow-up visit. Within the first postoperative year, a total of 46 patients (31.9%) without drains and 69 patients (38.3%) with drains had a wound complication. This was not statistically significant. Most wound complications were minor, and no significant difference in reoperation rates occurred between the 2 groups. CONCLUSION: A postoperative closed suction drain may increase wound complications in the first 2 weeks after TAA and should therefore be used with caution. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Self-Reported Pain Tolerance and Opioid Pain Medication Use After Foot and Ankle Surgery.

BACKGROUND: Orthopaedic surgeons must consider their postoperative pain management strategies to minimize harm from prescription opioid use. Patients often reference their pain threshold to predict how they will tolerate surgical pain and the need for postoperative analgesia, but the direct relationship between these factors has not yet been studied. The purpose of this study was to determine the relationship between patients' self-reported pain tolerance and prescription opioid usage after foot and ankle surgery. METHODS: This is a retrospective follow-up of a prospective cohort study of adult patients who underwent outpatient foot and ankle surgeries. Patient and procedural demographics, opioid pills dispensed, and opioid pills consumed by the first postoperative visit were obtained. Patients were contacted at a mean of 13.1 ± 4.0 months postoperatively and asked to respond to the qualitative statement "Pain doesn't bother me as much as it does most people." Patients were also asked their quantitative pain threshold (0-100), with 0 being "very pain intolerant" and 100 being a "very high pain tolerance," as well other questions regarding past surgical and narcotic consumption history. RESULTS: Of the 700 survey respondents, the average age was 50.9 years and 34.7% were male. Bivariate analysis determined that predictors of lower postoperative opioid consumption included higher quantitative (P = .047) and qualitative (P = .005) pain tolerance scores. Multivariate analysis for the entire cohort demonstrated that higher qualitative pain threshold was associated with lower postoperative opioid consumption (P = .005) but this did not meet statistical significance as an independent predictor of the top quartile of pill consumers. CONCLUSION: Assessment of both qualitative and quantitative score of patients' pain threshold prior to surgery may assist the surgeon in tailoring postoperative pain control. Additionally, asking this question can create an opportunity for educating patients regarding responsible utilization of narcotic medication. LEVELS OF EVIDENCE: Level III.

Terminology for osteochondral lesions of the ankle: proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

BACKGROUND: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle is based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "terminology for osteochondral lesions of the ankle" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS: Forty-three international experts in cartilage repair of the ankle representing 20 countries were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed, and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus, 51%-74%; strong consensus, 75%-99%; unanimous, 100%. RESULTS: A total of 11 statements on terminology and classification reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Definitions are provided for osseous, chondral and osteochondral lesions, as well as bone marrow stimulation and injury chronicity, among others. An osteochondral lesion of the talus can be abbreviated as OLT. CONCLUSIONS: This international consensus derived from leaders in the field will assist clinicians with the appropriate terminology for osteochondral lesions of the ankle.

Paediatric ankle cartilage lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

BACKGROUND: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Pediatric Ankle Cartilage Lesions" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS: Forty-three international experts in cartilage repair of the ankle representing 20 countries convened to participate in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus: 51-74%; strong consensus: 75-99%; unanimous: 100%. RESULTS: A total of 12 statements on paediatric ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Five achieved unanimous support, and seven reached strong consensus (>75% agreement). All statements reached at least 84% agreement. CONCLUSIONS: This international consensus derived from leaders in the field will assist clinicians with the management of paediatric ankle cartilage lesions.

Osteochondral Lesions of the Tibial Plafond and Ankle Instability With Ankle Cartilage Lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

BACKGROUND: An international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to present the consensus statements on osteochondral lesions of the tibial plafond (OLTP) and on ankle instability with ankle cartilage lesions developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS: Forty-three experts in cartilage repair of the ankle were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 4 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held. RESULTS: A total of 11 statements on OLTP reached consensus. Four achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). A total of 8 statements on ankle instability with ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, and seven reached strong consensus (greater than 75% agreement). CONCLUSION: These consensus statements may assist clinicians in the management of these difficult clinical pathologies. LEVEL OF EVIDENCE: Level V, mechanism-based reasoning.