Elective surgery in ankle and foot disorders-best practices for management of pain: a guideline for clinicians.

PURPOSE: Complex elective foot and ankle surgeries are often associated with severe pain pre- and postoperatively. When inadequately managed, chronic postsurgical pain and long-term opioid use can result. As no standards currently exist, we aimed to develop best practice pain management guidelines. METHODS: A local steering committee (n = 16) surveyed 116 North American foot and ankle surgeons to understand the "current state" of practice. A multidisciplinary expert panel (n = 35) was then formed consisting of orthopedic surgeons, anesthesiologists, chronic pain physicians, primary care physicians, pharmacists, registered nurses, physiotherapists, and clinical psychologists. Each expert provided up to three pain management recommendations for each of the presurgery, intraoperative, inpatient postoperative, and postdischarge periods. These preliminary recommendations were reduced, refined, and sent to the expert panel and "current state" survey respondents to create a consensus document using a Delphi process conducted from September to December 2020. RESULTS: One thousand four hundred and five preliminary statements were summarized into 51 statements. Strong consensus (≥ 80% respondent agreement) was achieved in 53% of statements including the following: postsurgical opioid use risk should be assessed preoperatively; opioid-naïve patients should not start opioids preoperatively unless non-opioid multimodal analgesia fails; and if opioids are prescribed at discharge, patients should receive education regarding importance of tapering opioid use. There was no consensus regarding opioid weaning preoperatively. CONCLUSIONS: Using multidisciplinary experts and a Delphi process, strong consensus was achieved in many areas, showing considerable agreement despite limited evidence for standardized pain management in patients undergoing complex elective foot and ankle surgery. No consensus on important issues related to opioid prescribing and cessation highlights the need for research to determine best practice.

RéSUMé: OBJECTIF: Les chirurgies électives complexes du pied et de la cheville sont souvent associées à une douleur intense avant et après l'opération. Lorsque cette douleur est mal prise en charge, elle peut entraîner une douleur postopératoire chronique et une consommation d'opioïdes à long terme. Comme il n'existe actuellement aucune norme, nous avons cherché à élaborer des lignes directrices sur les meilleures pratiques en matière de prise en charge de la douleur. MéTHODE: Un comité directeur local (n = 16) a interrogé 116 chirurgiens nord-américains spécialistes du pied et de la cheville pour comprendre « l'état actuel ¼ de la pratique. Un groupe d'experts multidisciplinaire (n = 35) a ensuite été formé, composé de chirurgiens orthopédistes, d'anesthésiologistes, de médecins spécialistes de la douleur chronique, de médecins de soins primaires, de pharmaciens, d'infirmières autorisées, de physiothérapeutes et de psychologues cliniciens. Chaque expert a fourni jusqu'à trois recommandations de prise en charge de la douleur pour chacune des périodes suivantes : en préchirurgie, en peropératoire, pendant l'hospitalisation postopératoire et après le congé. Ces recommandations préliminaires ont été réduites, affinées et envoyées au groupe d'experts et aux répondants du sondage sur « l'état actuel ¼ afin de créer un document de consensus à l'aide d'une méthode de Delphi réalisée entre septembre et décembre 2020. RéSULTATS: Mille quatre cent cinq déclarations préliminaires ont été résumées en 51 énoncés. Un consensus fort (≥ 80 % des répondants étaient d'accord) a été atteint concernant 53 % des énoncés, notamment les suivants : le risque de consommation postopératoire d'opioïdes devrait être évalué avant l'opération; les patients naïfs aux opioïdes ne devraient pas commencer à prendre des opioïdes avant l'opération, à moins que l'analgésie multimodale non opioïde n'échoue; et si des opioïdes sont prescrits au congé, les patients devraient être informés de l'importance de réduire leur consommation d'opioïdes. Il n'y avait pas de consensus concernant le sevrage des opioïdes en période préopératoire. CONCLUSION: À l'aide d'experts multidisciplinaires et d'une méthode de Delphi, un fort consensus a été atteint dans de nombreux aspects, montrant un accord considérable malgré des données probantes limitées pour une prise en charge standardisée de la douleur chez les patients subissant une chirurgie élective complexe du pied et de la cheville. L'absence de consensus sur des questions importantes liées à la prescription et à l'interruption des opioïdes souligne la nécessité de recherches pour déterminer les pratiques exemplaires.

Toward an Improved Wrist View: Qualitative and Quantitative Investigation of the 20° Axial Lateral Wrist X-Ray.

AIM: In standard lateral wrist radiographs, the radiocarpal joint is often obscured because of the angulation of the radial styloid process. A modified lateral projection at a 20° angle has been shown to demonstrate the distal radius in profile in postoperative patients without superimposing of the orthopedic hardware used in open reduction and internal fixation procedures over the wrist joint. We assessed whether this 20° axial-lateral view is advantageous in a wider patient group. MATERIALS AND METHODS: Consenting adults receiving wrist radiographs in a tertiary hospital radiology department for any indication underwent posteroanterior, posteroanterior-oblique, 0° lateral, and 20° lateral views. A musculoskeletal radiologist and a radiology technologist, blinded to clinical data and to which view was 0°/20°, both evaluated 0°/20° images in random order for whether the radiocarpal joint was obscured by radial styloid, radiocarpal articular margins, or ulnar styloid process, and which view was preferred. RESULTS: In 124 cases, the radiocarpal joint was shown clearly on more 20° than 0° views (75/124 vs. 23/124, P < .001). Orthopedic hardware obscured joint lines in fewer 20° than 0° views (12/124 vs. 28/124, P < .001). There was a trend to the ulnar styloid process obscuring part of the radiocarpal joint less in 0° view (28/124 vs. 78/124 in 20°; P = .088), primarily in 20° laterals of wrists with positive ulnar variance. The 20° view was preferred by the radiologist in 76% (95/124) and preferred by the technologist in 83% (104/124). CONCLUSION: The 20° lateral view was superior to the current 0° lateral view in a wide range of patients, with the radiocarpal joint obscured significantly less by hardware or adjacent anatomy, and preferred by both the blinded radiologist and technologist.

Functional Outcomes of Isolated Infrasyndesmotic Fibula Fractures.

BACKGROUND: Ankle fractures are among the most common injuries encountered by orthopedic surgeons, with an incidence ranging from 71 to 187 per 100 000 people. Few studies have reliably investigated injuries involving isolated fractures of the distal fibula below the level of the ankle syndesmosis. Therefore, this study details on the patient-reported outcomes of nonoperatively managed isolated infrasyndesmotic fibula (ISF) fractures with a minimum 3-year follow-up. METHODS: A retrospective population-based cohort study was undertaken across all emergency departments serving a major urban population. Among 159 consecutive patients meeting inclusion criteria, 108 agreed to participate. Clinical information, functional outcomes, and radiographic measurements were collected from electronic medical records and 3 validated outcome measures: the American Academy of Orthopaedic Surgeons (AAOS) Foot & Ankle Scale (FAS), the AAOS Shoe-Comfort Scale (SCS), and a general questionnaire. RESULTS: An incidence of 22 ISF fractures per 100 000 people/year was found with FAS (91.2 ± 12.9) and SCS scores (76.8 ± 27.7), similar to reported population norms. Approximately 40% of patients (n = 43) reported continuing symptoms including pain (81.8%), stiffness (68.1%), and/or instability (39.0%). Less than 13% (n = 14) reported "severe" disabilities, and no patients required operative intervention within the follow-up period. Less-favorable outcomes were reported among work-related injuries, female patients, and "avulsion-type" fractures less than 10 mm in height (P < .01). No relationships were identified between age, degree of articular-incongruity, fracture-displacement, and self-reported outcomes. CONCLUSIONS: The majority of patients with nonoperatively managed ISF fractures reported good-to-excellent early functional outcomes. Less-favorable outcomes were reported among work-related injuries, female patients, and "avulsion-type" fractures. LEVEL OF EVIDENCE: Level III, comparative series.

Primary Wound Closure After Open Fracture: A Prospective Cohort Study Examining Nonunion and Deep Infection.

OBJECTIVES: Determine the proportion of subjects developing deep infection or nonunion after primary wound closure of open fractures (humerus, radius/ulna, femur, and tibia/fibula). Secondarily, a matched-series analysis compared outcomes with subjects who underwent delayed wound closure. DESIGN: Prospective cohort between 2009 and 2013 of subjects undergoing primary closure. SETTING: Trauma center. PARTICIPANTS: Eighty-three (84 fractures) subjects were enrolled. Eighty-two (99%) subjects (83 fractures) provided follow-up data. Matching (age, sec, fracture location, and grade) was performed using study data of delayed wound closure undertaken at the same center between 2001 and 2009 (n = 68 matched subjects). INTERVENTION: Primary wound closure occurred when the fracture grade was Gustilo grade 3A or lower and the wound deemed clean at initial surgery. Standardized evaluations occurred until the fracture(s) healed; phone interviews and chart reviews were also undertaken at 1 year. MAIN OUTCOME MEASUREMENTS: Deep infection is defined as infection requiring unplanned surgical debridement and/or sustained antibiotic therapy after wound closure; nonunion is defined as unplanned surgical intervention after definitive wound closure or incomplete radiographic healing 1-year after fracture. RESULTS: Three (4%) subjects had deep infections, whereas 10 (12%) subjects developed nonunion in the primary closure cohort. In the matched analyses [n = 68 pairs; (136 subjects)], the primary closure cohort had fewer deep infections [n = 3 (4%) vs. n = 6 (9%)] and nonunions [n = 9 (13%) vs. n = 19 (29%)] than the delayed closure cohort (P < 0.001). CONCLUSIONS: Primary wound closure after an open fracture appears acceptable in appropriately selected patients and may reduce the risk of deep infection and nonunion compared with delayed closure; a definitive randomized trial is needed. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Treatment of large segmental bone defects with reamer-irrigator-aspirator bone graft: technique and case series.

Treatment of large segmental defects using conventional autogenous iliac crest bone graft can be limited by volume of cancellous bone and donor site morbidity. The reamer-irrigator-aspirator (RIA) technique allows access to a large volume of cancellous bone graft containing growth factors with potency equal to or greater than autograft material from the iliac crest. The purpose of this study was to evaluate the effectiveness of RIA-harvested autogenous bone graft for treating large segmental defects of long bones.

Weightbearing CT scan of severe flexible pes planus deformities.

BACKGROUND: The three-dimensional relationships of the bones in the foot in a flatfoot deformity are difficult to assess with standard radiographs. CT scans demonstrate these relationships but are typically made in a nonweightbearing mode. Our objective was to assess the use of a weightbearing CT apparatus to image the feet in patients with severe flexible pes planus deformities and to better define the anatomical changes that occur. MATERIALS AND METHODS: A specialized device was designed and constructed to simulate weightbearing to the feet during CT examination. Eighteen normal feet and 30 painful severe and flexible pes planus feet were imaged in both the non weightbearing and weightbearing states, set at 50% of body weight. Several measurements of intertarsal relationships were made of the pes planus and normal feet. Navicular floor to skin distance, forefoot arch angle, and subtalar joint subluxation were measured in the coronal plane in both the weightbearing and nonweightbearing states. T-tests were used to analyze measurements of navicular floor to skin distance and forefoot arch angle. RESULTS: The weightbearing device had a significant effect on foot configuration for both normal and pes planus feet (p = 0.0008) and (p < 0.0001) respectively for both floor to skin distance and forefoot arch angle. There was a significant difference between normal feet and pes planus feet with regard to the forefoot arch angle in the nonweightbearing (p = 0.02) and weightbearing states (p = 0.01). Four of the pes planus patients had evidence of subtalar joint subluxation which was more pronounced in the weightbearing state. There was no significant difference between the navicular floor to skin distance in the normal versus pes planus feet in either the non weightbearing (p = 0.05) or the weightbearing states (p = 0.07). CONCLUSION: A device was designed and constructed to apply a weightbearing load equal to that of 50% body weight with minimal to no patient discomfort. The resultant effects on foot configuration were significant, and are useful for assessment of degree of flexible flat foot deformity, thus guiding clinical management. The measure which most significantly differed between pes planus patients and normal volunteers was the forefoot arch angle. Forefoot arch angle may therefore be the most useful measure for the imaging diagnosis of flexible pes planus, and the degree of planus deformity.

Does functional recovery in elderly hip fracture patients differ between patients admitted from long-term care and the community?

BACKGROUND: It is largely unknown whether functional recovery following hip fracture differs between long-term care (LTC) and community-dwelling residents. Our primary purpose was to compare recovery between these patients 6 months following hip fracture, controlling for known prognostic factors. Secondarily, we examined the contribution of residential status, in addition to patient characteristics, to functional recovery. METHODS: We studied a population-based inception cohort of 451 hip fracture patients >/= 65 years old admitted to one Canadian health region hospital between July 1999 and September 2000. Participants completed the Modified Barthel Functional Index (MBI) in hospital and again via telephone interviews 6 months postoperatively. Data were also collected on surgery and rehabilitation timing, length of hospital stay (LOS). and discharge destination. Relative change from prefracture function adjusting for known prognostic factors, and the proportion of participants returning to prefracture function were compared between the LTC and community-dwelling residents. RESULTS: LTC residents (n = 115) were older, with lower function prefracture, more comorbidities, and increased dementia than community-dwelling residents (n = 336). Six months postfracture, 17 (22%) LTC and 180 (71%) community-dwelling residents had regained prefracture function (p <.001). LTC residents had 33% lower (-40.6, -27.2) and community-dwelling residents 11.6% lower (-14.8, -8.4) 6-month MBI scores relative to prefracture scores after risk adjustment. Residential status was significantly associated with risk-adjusted functional recovery (p <.001). Median LOS was 4 days less for LTC than for community-dwelling residents (p <.001). Twelve (10%) LTC and 266 (79%) community-dwelling residents were discharged to inpatient rehabilitation (p <.001). CONCLUSION: Following hip fracture, most LTC residents do not regain prefracture function irrespective of known prognostic factors. Further investigation is needed as to the extent to which personal and environmental characteristics contribute to outcome after hip fracture.

Treatment of an infected total hip replacement with the PROSTALAC system. Part 2: Health-related quality of life and function with the PROSTALAC implant in situ.

INTRODUCTION: Infection after total hip replacement (THR) adversely affects patients' function and health-related quality of life (HRQL). A prosthesis with antibiotic-loaded acrylic cement (PROSTALAC) was designed to improve the function and quality of life of patients undergoing treatment for infected THR. METHODS: We assessed 23 patients with the PROSTALAC implant in situ for treatment of an infected THR for function and HRQL, using standardized outcome measures. These patients were compared with a referent cohort of patients who had undergone assessment of function and HRQL before and 6 months after primary THR in the same tertiary health centres. RESULTS: The mean (standard deviation) Western Ontario MacMaster (WOMAC) scores for PROSTALAC patients were 70.0 (21.1), 65.8 (20.4) and 63.0 (21.1) for pain, stiffness and function, respectively. The median Harris Hip score was 62.3 (minimum 20.4, maximum 86.3) and median global hip range of motion was 100.0 (minimum 80.0, maximum 140.0) degrees. CONCLUSION: The mean WOMAC scores for pain, stiffness and function were better than they were for patients awaiting THR but not as good as 6 months after primary THR. The PROSTALAC implant allows patients to have reasonable function and quality of life during the interim treatment for deep joint infection.

Treatment of an infected total hip replacement with the PROSTALAC system. Part 1: Infection resolution.

INTRODUCTION: Infection after total hip replacement (THR) is a serious medical complication with significant negative ramifications for both the patient and the health care system. The prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) was designed to treat the joint infection while maintaining functional movement in the hip. METHODS: We identified 28 patients treated for infected THR with the PROSTALAC system, by retrospective chart review. Preoperative and intraoperative cultures were taken to identify the causative organism. After PROSTALAC insertion, patients underwent at least 6 weeks of intravenous (IV) antibiotics. Prior to undergoing posttreatment cultures, patients were required to be antibiotic-free for a minimum of 6 weeks, with normal laboratory values. We defined resolution infection as retention of a joint prosthesis for a minimum of 2 years. RESULTS: Infection was identified in 28 patients in either the joint aspirate or intraoperative cultures. Of these patients, 2 failed to clear infection, requiring repeat PROSTALAC insertion. Two additional patients had positive 48-hour cultures post-second stage, treated with additional IV antibiotics. Retention of the post-PROSTALAC prosthesis is 100% at 2 years. CONCLUSION: PROSTALAC has acceptable infection resolution outcomes and appears effective for treating infected THR.

Does standardized rehabilitation and discharge planning improve functional recovery in elderly patients with hip fracture?

OBJECTIVE: To determine whether standardized early rehabilitation and discharge planning increase risk-adjusted function and reduce risk-adjusted institutionalization in the first 6 months after hip fracture. DESIGN: Pre-post study of 2 independent population-based inception cohorts. SETTING: Two tertiary hospitals in an urban health region. PARTICIPANTS: Patients with hip fracture (N=919) 65 years and older. INTERVENTION: Subjects were enrolled before (control) and after (intervention) implementation of standardized rehabilitation and discharge planning. MAIN OUTCOME MEASURES: Function and institutionalization status were assessed at time of fracture and 3 and 6 months postfracture. Administrative databases provided length of stay (LOS) data. RESULTS: After risk-adjustment, the Barthel Index score was significantly lower 3 months postfracture in control patients with low social support compared with those with higher social support (P<.05). Social support did not affect 3-month function in the intervention cohort. Control subjects with low social support were also significantly more likely to reside in long-term care by 6 months postfracture than intervention subjects with similar social support or those with higher social support (odds ratio=3.3; 95% confidence interval, 1.4-7.5). Total LOS did not change between cohorts. CONCLUSIONS: Overall, standardized rehabilitation and discharge planning did not affect postoperative function or institutionalization in elderly patients with hip fracture. In intervention patients with low social support, function improved and institutionalization was reduced.

Augmented external fixation versus percutaneous pinning and casting for unstable fractures of the distal radius--a prospective randomized trial.

PURPOSE: Many outcome studies of various surgical techniques for unstable fractures of the distal radius have been published but applicability of the results remains limited because the majority of these trials were not done in a prospective and/or randomized manner. In this study we evaluated 2 common surgical techniques used in the treatment of unstable distal radius fractures in a randomized prospective fashion with a 1-year radiographic and clinical follow-up period. Our hypothesis was that external fixation with augmentation would provide superior results compared with percutaneous pinning and casting. METHODS: Fifty patients younger than 65 years of age with unstable fractures of the distal radius were randomized into 1 of 2 surgical treatment groups: percutaneous pins with casting or augmented external fixation. All surgery was performed by 1 of 3 surgeons within 10 days of injury. Over 80% of the fractures were classified as AO-ASIF C2 or C3 and there was a similar distribution of fracture types in each group. RESULTS: The use of augmented external fixation did not improve the mean radiographic parameters of radial length, radial angulation, or volar tilt. Restoration of volar tilt of highly comminuted fractures was difficult to achieve regardless of the technique. Improved articular surface reduction was realized with the use of an external fixator but overall only 3 patients were noted to have steps or gaps greater than 2 mm. No significant differences in mean Disabilities of the Arm, Shoulder, and Hand scores, total range of motion, grip strength, or health-related quality of life were observed between the groups. All 3 patients diagnosed with sympathetic dystrophy had had external fixation. CONCLUSIONS: Although augmented external fixation represents a popular first line treatment for unstable fractures of the distal radius this study suggests that for fractures with minimal articular displacement similar clinical results can be obtained with percutaneous pinning and casting.

Variations in treatment of femoral neck fractures in Alberta.

OBJECTIVES: To examine, in the province of Alberta, temporal trends, regional variations in treatment options and in-hospital death rates after a femoral neck fracture. DESIGN: A retrospective cohort study. PATIENTS: Six years' data were abstracted from the Alberta Morbidity File, the Alberta Health Stakeholder File and the Alberta Health Care Claims File. Patients were included if they were Alberta residents, aged 65 years or older, had sustained a femoral neck fracture and had undergone internal fixation, hemiarthroplasty or total hip arthroplasty. MAIN OUTCOME MEASURES: Death rates, arthroplasty rates and hospital stay. RESULTS: In-hospital death rates were similar across hospitals, with risks being higher for men, patients aged 80 years or older and those with more comorbid conditions. Arthroplasty rates varied from 58% to 77% among hospitals, and hospital stays associated with arthroplasty were significantly longer than those associated with internal fixation. The chance of undergoing arthroplasty varied from hospital to hospital by gender and by the number of comorbid conditions. CONCLUSION: Regional variations suggest lack of agreement among Alberta's surgeons as to how best to treat femoral neck fractures.