Mechanism of Injury for Traumatic Mid-Foot Lisfranc Injuries: Impact of the COVID-19 Pandemic.

Background During the COVID-19 pandemic, Americans transitioned away from their normal routines, drove in motor vehicles less, and reduced their physical activity, ultimately influencing the incidence and nature of orthopedic injuries that were operatively managed. The purpose of this study was to evaluate the effect of the COVID-19 pandemic lockdown and subsequent deconditioning on the mechanism of injury and severity of Lisfranc injury. Methods This retrospective study included patients with a traumatic Lisfranc injury who were surgically treated by a foot and ankle fellowship-trained orthopedic surgeon between 2015 and 2021. Electronic health records were queried for patient demographics, mechanism of injury, physical exam findings, and pain scores. Preoperative radiographs were reviewed to grade Lisfranc injuries using the previously described Nunley-Vertullo classification system. Descriptive and univariate statistics were performed to compare 15 patients in the pre-COVID-19 cohort and 15 patients in the post-COVID-19 cohort. Results In the pre-COVID-19 cohort, 80% (n=12/15) of the patients were female, the mean age was 46±15 years, the mean BMI was 29.7±7 kg/m2, and the mean follow-up period was 18.1±12 months. In the post-COVID-19 cohort, 53% (n=8/15) of the patients were female, the mean age was 48.5±17 years, the mean BMI was 31.4±7 kg/m2, and the mean follow-up period was 9.5±4 months. Significantly higher proportions of plantar ecchymosis (n=8/15, 53%), neuropathic pain (n=7/15, 47%), and swelling (n=12/15, 80%) were present in the post-COVID-19 cohort. A low-energy mechanism of injury was sustained by 73% (n=11/15) of the pre-COVID-19 cohort and 80% (n=12/15) of the post-COVID-19 cohort. Lisfranc injuries for the pre-COVID-19 cohort and the post-COVID-19 cohort demonstrated the following classifications: Grade 1 (33%, n=5/15 vs. 40%, n=6/15), Grade 2 (60%, n=9/15 vs. 53%, n=8/15), and Grade 3 (7%, n=1/15 vs. 7%, n=1/15). Conclusion Although a higher proportion of plantar ecchymosis, neuropathic pain, and swelling was observed, there was no association between a low mechanism of injury and a higher grade of Lisfranc injury following the COVID-19 pandemic.

Risk Factors For Prolonged Opioid Use After Spine Surgery.

STUDY DESIGN: Retrospective review. OBJECTIVE: Our purpose was to evaluate factors associated with increased risk of prolonged post-operative opioid pain medication usage following spine surgery, as well as identify the risk of various post-operative complications that may be associated with pre-operative opioid usage. METHODS: The MarketScan commercial claims and encounters database includes approximately 39 million patients per year. Patients undergoing cervical and lumbar spine surgery between the years 2005-2014 were identified using CPT codes. Pre-operative comorbidities including DSM-V mental health disorders, chronic pain, chronic regional pain syndrome (CRPS), obesity, tobacco use, medications, and diabetes were queried and documented. Patients who utilized opioids from 1-3 months prior to surgery were identified. This timeframe was chosen to exclude patients who had been prescribed pre- and post-operative narcotic medications up to 1 month prior to surgery. We utilized odds ratios (OR), 95% Confidence Intervals (CI), and regression analysis to determine factors that are associated with prolonged post-operative opioid use at 3 time intervals. RESULTS: 553,509 patients who underwent spine surgery during the 10-year period were identified. 34.9% of patients utilized opioids 1-3 months pre-operatively. 25% patients were still utilizing opioids at 6 weeks, 17.3% at 3 months, 12.7% at 6 months, and 9.0% at 1 year after surgery. Pre-operative opioid exposure was associated with increased likelihood of post-operative use at 6-12 weeks (OR 5.45, 95% CI 5.37-5.53), 3-6 months (OR 6.48, 95% CI 6.37-6.59), 6-12 months (OR 6.97, 95% CI 6.84-7.11), and >12 months (OR 7.12, 95% CI 6.96-7.29). Mental health diagnosis, tobacco usage, diagnosis of chronic pain or CRPS, and non-narcotic neuromodulatory medications yielded increased likelihood of prolonged post-op opioid usage. CONCLUSIONS: Pre-operative narcotic use and several patient comorbidities diagnoses are associated with prolonged post-operative opioid usage following spine surgery. Chronic opioid use, diagnosis of chronic pain, or use of non-narcotic neuromodulatory medications have the highest risk of prolonged post-operative opioid consumption. Patients using opiates pre-operatively did have an increased 30 and 90-day readmission risk, in addition to a number of serious post-operative complications. This data provides spine surgeons a number of variables to consider when determining post-operative analgesia strategies, and provides health systems, providers, and payers with information on complications associated with pre-operative opioid utilization.

Opioid Use, Perioperative Risks, and Associated Postoperative Complications in Foot and Ankle Surgery.

INTRODUCTION: Opioid abuse has become a national crisis. Published data demonstrate that patients undergoing foot and ankle surgery are left with excess narcotic medications postoperatively. The purpose of our study was to evaluate factors associated with prolonged postoperative opioid use following foot and ankle surgery and identify associations between preoperative opioid use and postoperative complications. METHODS: MarketScan commercial claims and encounters database was searched to identify foot and ankle patients. Preoperative comorbidities were queried and documented. Patients utilizing opioids 1 to 3 months prior to surgery were identified. Adjusted odds ratios and 95% CIs were calculated using multivariable logistic regression to determine associations between opioid use (preoperatively and postoperatively), readmission, and complications. RESULTS: A total of 112 893 patients were included in the study. Preoperative use had a statistically significant association with postoperative use out to 1 year. Tobacco use, chronic pain, mental health diagnosis, and nonopioid medications had a statistically significant association with postoperative use. Preoperative opioid use had a statistically significant association with readmission and postoperative complications. CONCLUSION: Our study found a number of factors associated with prolonged postoperative opioid use (preoperative use, tobacco use, chronic pain, mental health disorders, and certain nonopioid medications). We identified an association between preoperative opioid use and postoperative complications and readmission. LEVELS OF EVIDENCE: Prognostic Level IV Evidence.

Natural History of 321 Flatfoot Reconstructions in Adult Acquired Flatfoot Deformity Over a 14-Year Period.

The purpose of this study was to report the natural history, demographics, and mechanisms of requirement for additional surgery in patients undergoing flatfoot reconstruction for adult acquired flatfoot. A total of 321 consecutive patients undergoing flatfoot reconstruction over a 14-year period were included (2002-2016). All procedures were performed by a senior orthopaedic foot and ankle surgeon at our institution. Demographic data, operative reports, clinic notes, and radiographs were available for review. Statistical analysis included calculation of relative risk (RR) ratios. The majority of patients were female (83.2%,) and most patients were overweight with a body mass index greater than 25 kg/m2 (56.4%). Patient comorbidities included diabetes (13.7%) and rheumatoid arthritis (3.7%). Additional surgery was required for 54 patients (16.8%). The most common reasons for additional surgery were the following: painful calcaneal hardware (57.4%), conversion to triple arthrodesis (16.7%), and wound healing complications (9.1%). An increased risk of need for additional surgery was associated with female gender (RR = 3.4; P = .0005), smoking status (RR = 1.9; P = .0081), and age (<60 years of age; RR = 1.8; P = .042). Although retrospective, the results provide insight into the natural history of this procedure. Clinicians may use these data to appropriately counsel patients who are at increased risk of requirement for additional surgery, such as smokers, women, and patients <60 years old, regarding treatment options.Levels of Evidence: Level IV.

Preoperative Opioid Use Is Associated With Persistent Use, Readmission and Postoperative Complications After Arthroscopic Knee Surgery.

PURPOSE: To evaluate factors associated with prolonged opioid use after arthroscopic knee surgery and to identify associations between preoperative usage and postoperative complications. METHODS: The MarketScan commercial database was searched to identify patients who underwent arthroscopic knee surgery from 2005 to 2014 (based on Current Procedure Terminology code). Preoperative comorbidities including Diagnostic and Statistical Manual of Mental Disorders mental health disorders, chronic pain, chronic regional pain syndrome, obesity, tobacco use, non-narcotic medications and diabetes were queried and documented. Patients who filled opioid prescriptions 1 to 3 months before surgery were identified. Patients who filled opioid prescriptions after surgery were identified. Adjusted odds ratios and 95% confidence intervals were calculated using multivariable logistic regression analysis to determine factors associated with prolonged postoperative opioid use. RESULTS: In total, 1,012,486 patients who underwent arthroscopic knee surgery were identified, and we determined which of these patients were on preoperative opioids. Preoperative opioid usage was associated with a statistically significant increased risk of usage out to 1 year. There was a statistically significant association between postoperative usage and preoperative variables (mental health diagnosis, smokers, chronic pain, chronic regional pain syndrome, and use of non-narcotic medications). There was a statistically significant association between preoperative opioid use and 90-day readmission and postoperative complications. CONCLUSION: In this study, we found that patients taking opioids 1 to 3 months before arthroscopic knee surgery have increased risk of postoperative use. Additionally, chronic opioid use, chronic pain, or use of non-narcotic medications has the highest risk of postoperative opioid use. Finally, preoperative use was associated with an increased risk of 90-day readmission. EVIDENCE: Prognostic Level IV Evidence.

A mathematical model for release of biologics from porous hollow fibers.

The application of porous hollow fibers has recently been extended to the controlled release of biologics such as protein growth factors and lipid angiogenesis promoters. Release of these materials tends to occur more rapidly than would be predicted by conventional diffusion-based models of controlled release. Analysis of other modalities of transport as well as structural analysis of the controlled release system itself was performed to provide insight into the observed controlled release behavior from such systems. Specifically, it was discovered that osmotic-driven processes play a significant role in controlled release of proteins including vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF). It was also found that the fiber pore microstructure and (more importantly) macrostructure influences release behavior. Model-guided design was implemented to adjust the physical properties of the fiber wall, leading to a release system that is better able to sustain the delivery of VEGF. This model may be used to more easily achieve a desired complex release behavior when used in combination with external regulation of the reservoir.

Sequential delivery of basic fibroblast growth factor and platelet-derived growth factor for angiogenesis.

An externally regulated delivery model that permits temporal separation of multiple angiogenic factors was used for the delivery of basic fibroblast growth factor (bFGF) and platelet-derived growth factor (PDGF). While bFGF plays a significant role in the sprouting of new capillaries, PDGF plays a role in the recruitment of mural cells, which stabilize neovessels. However, these two factors have been shown to inhibit each other, when presented together. Using the externally regulated model, sequential delivery of bFGF and PDGF led to not only increased endothelial cell migration, but also endothelial cell and vascular pericyte colocalization. More importantly, this delivery strategy was able to induce red blood cell-filled neovessels, suggesting integration of angiogenesis with the existing vasculature.