Two-Year Survivorship and Patient-Reported Outcomes of a Prospectively Enrolled Cohort of INFINITY Total Ankle Arthroplasties.

BACKGROUND: The INFINITY total ankle implant is a widely and successfully used option for total ankle arthroplasty. The purpose of this study is to assess the 2-year survivorship, complication rates, patient-reported outcomes, and radiologic findings of prospectively enrolled patients undergoing a fixed-bearing total ankle arthroplasty (TAA). This study sought to determine if factors such as traditional vs patient-specific instrumentation, preoperative degree of arthritis, deformity, or etiology of arthritis impact surgical or clinical outcomes. METHODS: A total of 143 prospectively enrolled patients (148 ankles) underwent TAA with a fixed-bearing total ankle implant between 2017 and 2019 at 9 different institutions by 9 different surgeons. A total of 116 completed 2-year follow-up. Patients were stratified by instrumentation used, degree of preoperative deformity, the Canadian Orthopaedic Foot and Ankle Society (COFAS) grading system, and etiology of arthritis. Outcomes used included implant survivorship and adverse events within 2 years of surgery. Additionally, patient-reported outcomes and radiographs were collected at 6-month, 1-year, and 2-year postoperatively. PROMs used included Ankle Osteoarthritis Score (AOS), Patient-Reported Outcomes Measurement Information System (PROMIS) global health score, the Foot and Ankle Outcome Score (FAOS), and patient satisfaction (rated from excellent to poor). RESULTS: Implant survivorship at 2 years was 97.79%. There were 17 reoperations (11.5%), with 4 of the implants requiring revision (2.7%). Significant improvements in all PROMs were observed among all subgroups at all postoperative time points without significant variation between subgroups. Patients classified as COFAS type 2 arthritis preoperatively demonstrated significantly more improvement in FAOS Total Symptom Score at the 1- and 2-year measurements than COFAS type 3 patients at both time points. CONCLUSION: Total ankle arthroplasty with a fixed-bearing implant system is a safe and reliable treatment option for patients with end-stage arthritis regardless of degree of deformity or COFAS grading. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Cost Analysis and Reimbursement of Weightbearing Computed Tomography.

Background: Weightbearing computed tomography (WBCT) is becoming a valuable tool in the evaluation of foot and ankle pathology. Currently, cost analyses of WBCT scanners in private practice are lacking in the literature. This study evaluated the costs of acquisition, utilization, and reimbursements for a WBCT at a tertiary referral center, information of particular interest to practices considering obtaining such equipment. Methods: All WBCT scans performed at a tertiary referral center over the 55-month period (August 2016 to February 2021) were retrospectively evaluated. Patient demographics, pathology location, etiology, subspecialty of the ordering provider, and whether the study was unilateral or bilateral were collected. Reimbursement was calculated based on payor source as a percentage of Medicare reimbursement for lower extremity CT. The number of total scans performed per month was evaluated to determine revenue generated per month. Results: Over the study period, 1903 scans were performed. An average of 34.6 scans were performed each month. Forty-one providers ordered WBCT scans over the study period. Foot and ankle fellowship-trained orthopaedic surgeons ordered 75.5% of all scans. The most common location of pathology was the ankle, and the most common etiology was trauma. The device was cost neutral at 44.2 months, assuming reimbursement for each study was commensurate with Medicare rates. The device became cost neutral at approximately 29.9 months when calculating reimbursement according to mixed-payor source. Conclusion: As WBCT scan becomes more widely used for evaluation of foot and ankle pathology, practices may be interested in understanding the financial implications of such an investment. To the authors' knowledge, this study is the only cost-effectiveness analysis of WBCT based in the United States. We found that in a large, multispecialty orthopaedic group, WBCT can be a financially viable asset and a valuable diagnostic tool for a variety of pathologies. Level of Evidence: Level III, diagnostic.

The chevron bunionectomy for moderate to severe hallux valgus deformity: Effects of procedural factors on hallux valgus correction.

BACKGROUND: Effects of procedural factors on chevron bunionectomy outcomes were studied. METHODS: Included were 109 feet with distal chevron osteotomy and preoperative intermetatarsal angle (IMA) greater than 15 degrees. IMA and hallux valgus angles (HVA), release type, fixation, second-digit procedures, and risk factors were evaluated. RESULTS: Eighty-three percent (91/109 feet) had satisfactory outcomes; nine had moderate pain. From preoperative, IMA improved 7.2 and HVA 20.5 degrees. Risk factors or second-digit procedures had no effect. Lateral release improved IMA (p < 0.01), with no difference between open lateral and transarticular release; 86% percent (64/74) were satisfied with open lateral release compared with 83% (19/23) and 66% (8/12) with no release and transarticular release, respectively. Fixation did not affect outcomes. CONCLUSION: Chevron bunionectomy corrected IMA and HVA to normal with few complications. Lateral release increased IMA correction. Transarticular release had lower satisfaction than open lateral release or no release. LEVEL OF EVIDENCE: Level III, retrospective.

Comparing Rates of Fusion and Time to Fusion in Viable Cellular Allograft and Autograft.

BACKGROUND: Autograft or allograft frequently are used to enhance bone union in foot and ankle surgery. Viable cellular bone allograft uses viable cells and bone scaffolding in a gel base, but uncertainty remains around allograft's greater efficacy than autograft regarding rates of fusion (ROF) and time to fusion (TTF). METHODS: Autograft, viable cellular allograft, and viable cellular allograft with autograft were compared in 199 forefoot, midfoot, and hindfoot arthrodeses performed over a 6-year period. Data collected from electronic medical records and radiographs were analyzed to determine ROF and TTF as well as rates of revision surgery for delayed or nonunion and compared among groups. RESULTS: Eighty-seven patients comprised the autograft group, 81 the allograft group, and 31 the combined group. No significant differences were noted in patient demographics among the groups. No statistically significant differences in ROF were noted among the 3 groups, with 86% (75 of 87) fusion in the autograft group, 93% (75 of 81) in the allograft group, and 84% (26 of 31) in the combined group (P = .20). After conducting a multivariate analysis, we found no statistically significant difference for allograft or combined graft on TTF (P = .1379 and .2311, respectively). No significant difference was found in rate of revision surgery for nonunion, which was 1.2% (1 of 81) in the allograft group, 3.4% (3 of 87) in the autograft group, and 6.5% (2 of 31) in the combined group (P = .3). CONCLUSION: No significant difference was found in ROF, TTF, or rate of revision surgery when comparing viable cellular allograft to autograft or combined allograft-autograft. Viable cellular allograft may be a reasonable alternative to the gold standard of autograft and should be considered an option in patients undergoing arthrodesis in foot and ankle surgery. LEVEL OF EVIDENCE: Level III, therapeutic.

Efficacy of Postoperative Oral Antibiotics in Foot and Ankle Surgery.

BACKGROUND: Preoperative oral antibiotic use in patients undergoing foot and ankle surgery is standard practice, but no consensus has been reached regarding the efficacy of postoperative oral antibiotics. The purpose of this study was to determine whether postoperative oral antibiotics reduce the rate of surgical site infections (SSIs) in patients, with and without comorbidities, undergoing foot and ankle surgery. METHODS: A retrospective chart review was conducted identifying patients who underwent foot and ankle surgery by 4 fellowship-trained, foot and ankle orthopaedic surgeons between January 1, 2015, and January 1, 2019. Patients were divided into 2 groups: those who received postoperative oral antibiotics (group 1) and those who did not (group 2). Two surgeons routinely prescribed postoperative oral antibiotics, and 2 did not. Demographics, comorbidities, and procedure complexity based on surgical site and Current Procedural Terminology code were recorded from the charts. The primary outcome was postoperative infection (superficial or deep) within 6 months after surgery. Patients with antibiotic use prior to surgery, preoperative infection, or lack of follow-up >6 weeks were excluded. Multivariate logistic regression modeling was used to analyze differences in infection rate and severity. RESULTS: Chart review identified 3631 patients, 1227 of whom did not receive postoperative oral antibiotics whereas 2394 patients did. Routine postoperative oral antibiotic use did not significantly affect postoperative infection rates or severity. However, all covariates studied (diabetes, hypertension, obesity, tobacco use, alcohol use, rheumatoid conditions, and age) influenced postoperative infection rates and severity. CONCLUSION: The results of this study indicate that postoperative oral antibiotics are not associated with differences in infection rates or severity. We do not recommend routine use in foot and ankle surgery.

Understanding Penicillin Allergy, Cross-reactivity, and Antibiotic Selection in the Preoperative Setting.

Penicillin allergies are reported by 8% to 15% of the US population, but up to 95% of these allergies do not correspond to a true allergy when tested. Recent studies have demonstrated that having a penicillin allergy label (PAL) results in a 50% increased odds of surgical site infection among patients reporting a penicillin allergy entirely attributable to the use of a beta-lactam alternative antibiotic (primarily clindamycin or vancomycin). This study provides a review of the prevalence of PAL, the cross-reactivity with cefazolin, immunogenic components of cefazolin and penicillin, and current guidelines for preoperative antibiotic selection in patients with PALs. On understanding these principles, a new set of guidelines and a risk stratification tool are proposed for assessing allergies and determining appropriate antibiotic choice, dosage, and timing in the orthopaedic preoperative setting.

Analysis of Wheeled Knee Walker Use following Foot and Ankle Surgery or Injury.

To determine patient satisfaction and safety with wheeled knee walkers, we performed a retrospective, observational, and descriptive study. Inclusion criteria were age ≥18 years, unilateral foot or ankle surgery, non-weightbearing status, and being given the option of using the knee walker. Surveys were sent to eligible patients, and chart review included only those patients who returned surveys. Primary endpoints were occurrence and frequency of falls. Secondary endpoints were patient demographics, comorbidities, knee walker characteristics, duration of use, and patient satisfaction. We also attempted to identify associations between falls and patient characteristics. Eighty participants, 51 females and 29 males, responded adequately to the survey. The mean age of respondents was 55.6 ± 13.0 years and their mean body mass index (BMI) was 30.2 ± 5.9 kg/m2. Most used a steerable, 4-wheeled knee walker. Almost half (46%) had no prior experience with any type of walking aids, and none had experience using a knee walker. Two thirds (66%) did not receive any instruction on usage of the knee walker. Thirty-four (43%) of the 80 respondents fell while using the knee walker; nearly two thirds (62%) of those who fell reported multiple falls. Sixteen (55%) of 29 males compared to 18 (36%) of 50 females reported falling (p = .097). There was no statistical association between falls and age, BMI, or number of comorbidities. Most respondents (91%) who fell still reported satisfaction with the knee walker. Nearly half (43%) experienced falling, and nearly two thirds (64%) of those who fell had multiple falls.

Race and Insurance Status Association With Receiving Orthopedic Surgeon-Prescribed Foot Orthoses.

BACKGROUND: This study looked at the effect of patient demographics, insurance status, education, and patient opinion on whether various orthotic footwear prescribed for a variety of diagnoses were received by the patient. The study also assessed the effect of the orthoses on relief of symptoms. METHODS: Chart review documented patient demographics, diagnoses, and medical comorbidities. Eligible patients completed a survey either while in the clinic or by phone after their clinic visit. RESULTS: Of the 382 patients prescribed orthoses, 235 (61.5%) received their orthoses; 186 (48.7%) filled out the survey. Race and whether or not the patient received the orthosis were found to be significant predictors of survey completion. Race, type of insurance, and amount of orthotic cost covered by insurance were significant predictors of whether or not patients received their prescribed orthoses. Type of orthosis, diabetes as a comorbidity, education, income, sex, and diagnosis were not significant predictors of whether the patient received the orthosis. Qualitative results from the survey revealed that among those receiving their orthoses, 87% experienced improvement in symptoms: 21% felt completely relieved, 66% felt better, 10% felt no different, and 3% felt worse. CONCLUSION: We found that white patients had almost 3 times the odds of receiving prescribed orthoses as black patients, even after controlling for type of insurance, suggesting race to be the primary driver of discrepancies, raising the question of what can be done to address these inequalities. While large, systematic change will be necessary, some strategies can be employed by those working directly in patient care, such as informing primary care practices of their ability to see patients with limited insurance, limiting blanket refusal policies for government insurance, and educating office staff on how to efficiently work with Medicare and Medicaid. LEVEL OF EVIDENCE: Level III, comparative study.

Smoking Effects in Foot and Ankle Surgery: An Evidence-Based Review.

BACKGROUND: The purpose of this article was to review the basic science pertaining to the harmful effects of cigarette smoke, summarize recent clinical outcome studies, and examine the benefits of smoking cessation and the efficacy of current smoking cessation strategies. METHODS: The literature concerning basic science, clinical outcomes, and smoking cessation was reviewed; over half (56%) of the 52 articles reviewed were published in the last 5 years. RESULTS: Smoking is associated with low bone mineral density, delayed fracture union, peri-implant bone loss, and implant failure. Orthopedic surgical patients who smoke have increased pain and lower overall patient satisfaction, along with significantly increased rates of wound healing complications. DISCUSSION/CONCLUSION: Active smoking is a significant modifiable risk factor and should be discontinued before foot and ankle surgery whenever possible. Orthopedic surgeons play an important role in educating patients on the effects of smoking and facilitating access to smoking cessation resources. LEVEL OF EVIDENCE: Level V, expert opinion.

Preoperative Risk Factors for Complications in Elective Ankle and Hindfoot Reconstruction.

BACKGROUND: The purpose of this study was to examine medical, social, and psychological factors associated with complications and reoperation after foot and ankle reconstruction. METHODS: A retrospective chart review was conducted of 132 patients (135 feet; 139 operative cases) who had elective foot and ankle reconstruction. Medical, social, and psychological variables were documented. Primary outcomes included complications and reoperations. RESULTS: The overall complication rate was 28% (39/139), and the reoperation rate was 17% (24/139). Alcohol use (P = .03) and preoperative narcotic use (P = .02) were risk factors for complications, with delayed wound healing more frequent in alcohol users (P = .03) and deep infection (P = .045) and nonunion (P = .046) more frequent preoperative narcotic use. Deep infection also was more frequent in tobacco users (P < .01). Older patients were less likely to undergo reoperation (risk of reoperation increased with age). Other variables were not associated with increased complications. CONCLUSION: Patients who consumed alcohol or had been prescribed any amount of narcotic within 3 months preoperatively were at increased risk for complications. Patients who smoked were more likely to have a wound infection. Surgeons should be aware of these factors and counsel patients before surgery. LEVELS OF EVIDENCE: Level III: Retrospective comparative study.

Psychosocial Risk Factors for Postoperative Pain in Ankle and Hindfoot Reconstruction.

BACKGROUND: The purpose of this study was to examine factors associated with pain after elective ankle and hindfoot reconstruction. METHODS: Patients who underwent major ankle or hindfoot reconstruction over a 3-year period were identified. Retrospective chart review determined patient demographics, comorbidities, surgeries, tobacco, alcohol, and narcotic use, chronic pain, and mood disorders. Primary outcomes were cumulative amount of narcotic prescribed (morphine milligram equivalent dose) in the initial 90-day postoperative period, beyond 90 days, and visual analog pain score (VAS) at a minimum of 1-year follow-up. One hundred thirty-two patients (139 operations) met the inclusion criteria. RESULTS: The average narcotic amount prescribed in the initial 90 days after surgery was 1711 mg (morphine equivalent), and narcotic prescriptions were required after 52 surgeries (35%) past 90 days. Preoperative narcotic use (P < .01), chronic pain disorder (P = .02), and mood disorder (P < .01) were significant risk factors for continued narcotic use past 90 days. Tobacco use (P = .01) and chronic pain disorder (P < .01) also were significant risk factors for increased initial postoperative narcotic use. The average VAS score in 91 patients at an average of 2.7-year follow-up was 2.1. Mood disorder was a risk factor for increased VAS (P < .01). No other associations were noted. CONCLUSION: Patients being treated for chronic pain, diagnosed with a mood disorder, taking any amount of narcotics preoperatively, or using tobacco products had a statistically significant increased risk for pain postoperatively. The presence of risk factors should prompt physicians to discuss pain management strategies before surgery. LEVEL OF EVIDENCE: Level III, comparative series.

Effect of Obesity on Outcomes of Forefoot Surgery.

BACKGROUND: Forefoot surgery typically is elective, so it is important to define risk factors to educate patients on potential complications. The purpose of this study was to determine if obesity is an independent risk factor that contributes to increased complication rates after forefoot surgery. METHODS: Through a retrospective review of records, 633 patients were identified who had forefoot surgery at one institution between 2008 and 2010. All patients who currently smoked or smoked in the past were excluded to eliminate a confounding factor, as smoking is known to increase complication rates, leaving 427 patients for inclusion, 299 nonobese (BMI less than 30) and 128 obese (BMI more than 30). Medical records were reviewed for the occurrence of complications, including nonunion, delayed union, delayed wound healing, infection, and persistent pain. RESULTS: The overall complication rate was 9%, with similar rates between obese (10%) and nonobese patients (9%). The only specific complication approaching significance (P = .13) was a higher rate of infection in obese patients (4 % compared to 1%), which could be attributed to the higher percentage of diabetic patients in the obese group. Diabetic patients, regardless of weight, had significantly higher rates of infection (P = .03), with a trend toward higher rates of overall complications and delayed wound healing (P = .08 and P < .06, respectively). CONCLUSION: Obesity was not shown to lead to more frequent complications after forefoot surgery. Diabetes was associated with significantly higher rates of infection, regardless of weight. Though not significant, there was a trend toward higher rates of overall complications and delayed wound healing in diabetic patients as well. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Cigarette smoking increases complication rate in forefoot surgery.

BACKGROUND: Cigarette smoking is known to increase perioperative complication rates, but no study to date has examined its effect specifically in forefoot surgery. The purpose of this study was to determine whether cigarette smoking increased complications after forefoot surgery. METHODS: The records of 602 patients who had forefoot surgery between 2008 and 2010, and for whom smoking status was known, were reviewed. Patients were categorized into 3 groups based on smoking status: active smoker, smoker in the past, or nonsmoker. Medical records were reviewed for occurrence of complications, including nonunion, delayed union, delayed wound healing, infection, and persistent pain. RESULTS: Active smokers were found to have a notably higher complication rate (36.4%) after forefoot surgery than patients who previously (16.5%) or never (8.5%) smoked. Patients who continued to smoke in the perioperative period had the highest percentage of delayed union (3.0%), infection (9.1%), delayed wound healing (10.6%), and persistent pain (15.2%). Active cigarette smokers were 4.3 times more likely to have a complication than nonsmokers. Patients who smoked at any point in the past but quit prior to surgery were 1.9 times more likely than nonsmokers to incur a complication. The average time of smoking cessation for patients who had smoked at any point in the past but had quit prior to surgery was 17 years. For active smokers, those with a complication smoked an average of 18 cigarettes daily, while those without a complication smoked 14 cigarettes daily. CONCLUSIONS: Before forefoot surgery, surgeons should educate patients who smoke about their increased risk of complications and encourage smoking cessation. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The effects of conventional physical therapy and eccentric strengthening for insertional achilles tendinopathy.

STUDY DESIGN: Single-blind, randomized, clinical trial. BACKGROUND: The effect of eccentric training for mid-portion Achilles tendinopathy is well documented; however, its effect on insertional Achilles tendinopathy is inconclusive. The primary purpose of this study was to investigate the effect of eccentric training on pain and function for individuals with insertional Achilles tendinopathy. METHODS: All patients received a 12-week conventional strengthening protocol. Patients who were randomly assigned to the experimental group received additional eccentric exercises. Patients completed the Short Form-36 Health and Bodily Pain Surveys, the Foot and Ankle Outcomes Questionnaire, and the Visual Analog Scale at initial evaluation, after 6 weeks of therapy, and at 12 weeks after therapy. RESULTS: Thirty-six patients (20 control and 16 experimental; average age 54 years; 72% women) completed the study. Both groups experienced statistically significant decreases in pain and improvements in function. No statistically significant differences were noted between the groups for any of the outcome measures. CONCLUSION: Conventional physical therapy consisting of gastrocnemius, soleus and hamstring stretches, ice massage on the Achilles tendon, and use of heel lifts and night splints with or without eccentric training is effective for treating insertional Achilles tendinopathy. LEVEL OF EVIDENCE: Level 2.

The effects of nutritional deficiencies, smoking, and systemic disease on orthopaedic outcomes.

Most patients are evaluated by an internist for medical clearance before undergoing an elective orthopaedic procedure. Internists and anesthesiologists evaluate a patient's risk for morbidity or mortality from a procedure, whereas orthopaedic surgeons are often primarily concerned with a patient's risk for a poor outcome. Nutritional and systemic comorbidities can increase the risks for surgical site infections and poor outcomes. Knowing how to handle and identify these issues before surgery can have a substantial effect on improving the likelihood of good outcomes from elective orthopaedic procedures.

Surgical treatment of non-insertional Achilles tendinitis.

Noninsertional Achilles tendinitis is a distinct clinical entity, frequently characterized by swelling, pain, and lower limb dysfunction. This condition can be frustrating to treat, for the patient and the physician alike, as reflected in the various treatments, both conservative and surgical, that have been described. Although many patients with Achilles tendinitis can be successfully treated with nonoperative methods, persistent symptoms require surgical treatment, such as tenotomy, debridement, or repair.

Treatment of hallux rigidus with cheilectomy using a dorsolateral approach.

BACKGROUND: Degenerative arthritis of the hallux metatarsophalangeal (MTP) joint can be treated in a variety of ways depending on the severity of the disease. If nonoperative treatment fails, then surgical treatment of Stage I and II has traditionally been cheilectomy. The purpose of this paper was to determine the potential advantages of cheilectomy using a less conventional dorsolateral approach. MATERIALS AND METHODS: Twenty feet in 20 patients were included in the study with an average age of 53.8 (range, 29 to 69) years. The average followup was 2.8 years. Patient charts and radiographs were reviewed to determine preoperative patient characteristics and clinical-radiographic stage. All patients who qualified for the study were asked to return for evaluation using clinical examination, radiographs, and the AOFAS outcome score. Comparisons were made between preoperative and postoperative values using appropriate statistical analysis. RESULTS: The mean AOFAS score improved from 53.5 to 84.0 (p < 0.001). The mean range of motion arc improved from 45 to 58 degrees (p < 0.001). Clinical-radiographic stage progressed in 50%. The most common complication was numbness in the first web space (40%). This loss was imperceptible in all patients until asked during the exam. No patients progressed to fusion during the followup period. CONCLUSION: Using a dorsolateral approach to perform a cheilectomy is a viable alternative to the more traditional dorsal technique. No obvious advantage over the traditional technique was identified.

Long-term evaluation of interdigital neuroma treated by surgical excision.

BACKGROUND: We examined a large cohort of patients who had interdigital neurectomy and evaluated their clinical outcomes by using a previously developed scoring system as well as a visual analog scale (VAS). In addition, we wanted to identify risk factors that may lead to poorer outcomes. MATERIALS AND METHODS: A retrospective review identified 232 patients who had neuroma excision between 1994 and 2004, after failure of conservative treatment. Each patient was contacted via mail and given a Neuroma Clinical Evaluation Score survey as well as a visual analog score. Each patient received a unique identification number, allowing the evaluation process to be single-blinded. RESULTS: Of the 232 patients contacted, 120 (52%) returned their completed surveys. The average Giannini neuroma score was 53: 61 feet (51%) had good or excellent results, 12 (10%) had fair results, and 48 (40%) had poor results. The average VAS score was 2.5. The only significant (p = 0.027) difference in outcome was the location of the neuroma: second webspace had worse outcomes than third webspace neuromas on both the VAS and neuroma score. CONCLUSION: This retrospective review identified location in the second webspace as a possible prognostic indicator of poor outcome, but the more important finding may be that outcomes of neuroma excision do not appear to be as successful at long-term followup as previously reported.