Orthopedic Surgery Residency Program Rankings and Gender Diversity.

Background Orthopedic surgery residency programs are some of the least gender-diverse specialty programs in medicine. Despite strong representation at the undergraduate and medical school levels and increased applications to orthopedic surgery residency programs by women, there is still a substantial gender gap at the resident level. This study explores the relationship between the gender diversity of orthopedic surgery residency programs and program rankings. Methodology Program rank, program director gender identity, and gender diversity data were collected for the top 100 programs by reputation in Doximity. Gender diversity was measured as the proportion of female residents in the program and alumni. Results The greatest percentage of women in a program was 33% and the smallest was 3%. After linear regression analysis, we found that there was a statistically significant positive correlation between program rank and the proportion of women. The higher ranked a program was, the greater the proportion of women. There was no significant correlation between program director gender, appointment year, and program rank. Conclusions These results suggest that, although there is still a long way to go before closing the gender gap in orthopedic surgery residency programs, higher-ranked programs are associated with greater gender diversity than their lower-ranked counterparts.

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.

Incidental Finding of Plantar Plate Pathology on Routine Magnetic Resonance Imaging of the Foot and Ankle.

BACKGROUND: We hypothesized that there would be a comparable and high incidence of an incidental torn plantar plate on routine magnetic resonance imaging (MRI) in asymptomatic patients. METHODS: We included adult patients undergoing a foot MRI from 2019 to 2020. Based on the documented reason for MRI, patients were divided into symptomatic and asymptomatic. A separate musculoskeletal radiologist re-evaluated MRI images. Findings were categorized as "torn vs intact." We also used the anatomical grading system (AGS). RESULTS: We reviewed 218 records, including 165 asymptomatic and 53 symptomatic patients. The chance of finding a plantar plate (PP) tear on MRI of symptomatic patients was 28% (21% in PP2, 5.7% in PP3, 5.7% in PP4, and 2% in PP5), while PP tear in asymptomatic patients was only apparent in 2% of MRIs (1.5% in PP2, 0 in PP3, 0 in PP4, and 0.6% in PP5). Cohen's kappa coefficient was 0.92, showing excellent agreement between the radiologists. Odds calculation revealed that the chance of finding a torn PP in an asymptomatic patient is 2.5%. In comparison, the chance of finding an intact PP in a symptomatic patient is 72%, showing 2.5 times more likely to find an intact PP than a torn PP in symptomatic individuals. CONCLUSION: Interestingly, there was a low rate of abnormal PP appearance on MRI in both symptomatic and asymptomatic patients, which suggests that the chance of finding a false-positive PP tear in an asymptomatic patient is minimal and probably negligible. LEVEL OF EVIDENCE: Level IV diagnostic.

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.

Return to Driving After Foot and Ankle Surgery: A Novel Survey to Predict Passing Brake Reaction Time.

Introduction. Brake reaction time (BRT) is an accepted method for establishing recommendations for safe return to driving by the National Highway Traffic Safety Administration. Other than performing a BRT test in clinic, there is no established clinical tool to help physicians differentiate safe from unsafe drivers once patients reach general recovery milestones. The purpose is to present individual recommendations to the patient through a novel, validated survey evaluating safe return to driving after orthopaedic surgery of the right foot and ankle. Methods. A total of 171 patients undergoing 1 of 3 specific foot and ankle procedures were prospectively enrolled. A 4-question survey and BRT were completed 6 weeks postoperatively. The following questions were asked: (1) "I think my brake reaction time is slower than most drivers my age," (2) "I think my brake reaction time is faster than most drivers my age," (3) "I think my brake reaction time is about the same as most drivers my age," (4) "Based on what I think my brake reaction time is, I think I am ready to drive." Internal consistency was determined with Cronbach's α and item total correlation. External validity was determined by Spearman's correlation coefficient. A BRT less than 0.850 s was considered as a pass. Results. Of 171 patients, 162 (95%) with ages ranging from 21 to 83 years achieved a passing BRT by 7.6 weeks. After removing 1 question because of internal inconsistency, the optimal threshold for predicting passing BRT was 10/15 points or higher, which had 99% probability of success that a patient would pass the BRT (95% CI = 96%, 100%). Conclusion. This novel, 3-question driving readiness survey can accurately predict a passing BRT Achilles rupture repair, total ankle arthroplasty, and hallux valgus correction performed in the right foot and ankle as early as 6 weeks postoperatively.Level of Evidence: Level II: Comparative study.

High Prevalence of Degenerative Changes at the Metatarsal Head Sesamoid Articulation Found During Hallux Valgus Correction Surgery.

Background. Despite the absence of complications and a restoration of normal hallux alignment, some patients have suboptimal outcomes from hallux valgus correction surgery. One risk factor for persistent pain may be the presence of arthritic changes at the metatarsal head articulation with the sesamoids, an area not easily assessed with standard radiographs unless dedicated sesamoid views are obtained. In this study, we prospectively evaluated the metatarsal head for degenerative changes during hallux valgus correction surgery and identified preoperative risk factors associated with these changes. Methods. We prospectively evaluated 200 feet in 196 patients who underwent hallux valgus surgery intraoperatively for the pattern and severity of arthritic changes at the metatarsal head. Mann-Whitney U testing was implemented to compare differences in arthritic scores between preoperative deformity groups. The Spearman correlation test was used to determine the association between age and preoperative deformity with the severity of degenerative changes. Results. More than half of all feet assessed had severe arthritic changes at the plantar medial aspect of the metatarsal head and 40% of feet at the plantar lateral aspect. Age and intermetatarsal angle were found to be positively correlated with arthritis in this area. Conclusion. Our prospective study has demonstrated the high prevalence of arthritic changes at the metatarsal head sesamoid articulation and the positive influence of age and severity of deformity on metatarsal head arthritic changes seen during hallux valgus correction surgery. Furthermore, these arthritic changes were found to have no significant influence on preoperative functional and pain levels.Levels of Evidence: Level IV: Case series.

Coding Education in Residency and in Practice Improves Accuracy of Coding in Orthopedic Surgery.

The goal of training in orthopedic residency is to produce surgeons who are proficient in all aspects of the practice of orthopedic surgery; however, most residents receive either inadequate or no training in medical coding. The purpose of this study was to determine how well orthopedic residents code when compared with practicing surgeons and to identify whether coding education improves accuracy in medical coding. A mock coding survey was developed using commonly encountered orthopedic clinical scenarios. The survey was distributed to orthopedic trainees post-graduate years (PGY) 1 to 6 at 2 training programs and to attending surgeons. Results were analyzed in 3 groups: junior residents (PGY 1-3), senior residents (PGY 4-6), and attending surgeons. Overall and subcategory scores of (1) type of visit, (2) modifiers, (3) Evaluation and Management (E/M), and (4) Current Procedural Terminology code identification were recorded. Participants were also asked if they had ever received various forms of coding education. Sixty-seven total participants were enrolled, including 28 junior residents, 24 senior residents, and 15 attendings. Practicing surgeons performed significantly better than both senior (P<.027) and junior (P<.001) residents in all categories, with a mean overall correct response rate of 72.8%, 51.0%, and 47.4%, respectively. Any form of coding education was associated with a significantly improved overall score for residents (P=.013) and a nonsignificant increase for attending surgeons (P=.390). This study demonstrates that residents performed poorly when identifying proper billing codes for common procedures and encounters in orthopedic surgery. Further, those participants who received coding education did better than those who did not. [Orthopedics. 2020;43(6):380-383.].

Ankle Arthrodesis Through a Fibular-Sparing Anterior Approach.

BACKGROUND: The open anterior approach to ankle arthrodesis offers a technique that provides several advantages for surgeons, such as easier visualization of the joint for deformity correction and preservation of the malleoli for potential future conversion to total ankle arthroplasty. The purpose of this study was to evaluate clinical, radiographic, and functional outcomes in a large series of patients undergoing open ankle arthrodesis via a fibular-sparing anterior approach. METHODS: A retrospective review was performed of patients undergoing primary ankle arthrodesis with a single fellowship-trained foot and ankle orthopedic surgeon between 2009 and 2017. Patients were excluded if an approach other than anterior was performed. Patient-reported outcome measures (Foot and Ankle Ability Measure-Activities of Daily Living [FAAM-ADL], Short-Form 12 [SF-12], and visual analog scale [VAS] pain) were subsequently collected at a minimum of 24 months (2 years) following index surgery, along with outcome satisfaction and likelihood to repeat surgery. Fusion of the tibiotalar joint at the time of last radiographic follow-up was also assessed. Paired t tests were performed to assess change in pre- to postoperative outcomes, while linear regression analysis was performed to identify any patient factors associated with outcomes. Eighty-one patients, including 31 women and 50 men, with a mean age of 51.5 years and a mean follow-up of 58.9 (range, 24-104) months, were included. RESULTS: Sixty-two patients reported significant improvement in mean FAAM-ADL (P < .0001), SF-12 Physical Composite Scale (P < .0001), and VAS pain (P < .0001), while the SF-12 Mental Composite Scale also improved, though not significantly (P = .2854). Twelve patients (14.8%) experienced complications following their arthrodesis procedure. Seventy-nine patients (97.5%) achieved fusion at their last radiographic follow-up. Multiple linear regression analysis revealed age (B = 0.071 [0.004, 0.128]; P = .0373) to have a positive association with postoperative VAS pain. CONCLUSION: Ankle arthrodesis utilizing a fibular-sparing anterior approach combined with the transarticular screw fixation technique offers surgeons several advantages, along with a low postoperative complication rate, high rate of radiographic evidence of joint fusion, and substantially large improvement in pain and functional levels. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Midterm Results of Radiographic and Functional Outcomes After Tibiotalocalcaneal Arthrodesis With Bulk Femoral Head Allograft.

Background: Tibiotalocalcaneal (TTC) arthrodesis implementing adjunctive allografts is a method of limb salvage for patients with complex hindfoot osseous deficits, though outcome results are limited. The purposes of this study were to assess functional and radiographic outcomes after TTC arthrodesis with femoral head allograft and retrospectively identify prognostic factors. Methods: The authors reviewed 24 TTC arthrodesis procedures with bulk femoral head allografts performed by a single surgeon from 2004 to 2016. Radiographic union at the ankle and subtalar joints along with stability of the allograft were assessed. Patients who had clinically successful arthrodeses were contacted to score the Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) questionnaire, Visual Analog Scale (VAS) for pain, and Short Form-12 (SF-12) at a mean of 58.0 months (range, 28-102) postoperatively. Results: Complete radiographic union of involved joints was achieved in 15 patients (63%) and in 75% (36/48) of all joints; 21 ankles (88%) were assessed to be radiographically stable at final follow-up. Three patients (13%) underwent revision arthrodesis at a mean of 18.9 months postoperatively, and 21 patients (88%) did not require additional surgery as of final follow-up. Patients significantly improved to a mean FAAM-ADL score of 71.5 from 36.3 (P < .001). The mean VAS for pain significantly improved from 77.2 to 32.9 (P < .001). Male sex (P = .08) and a lateral operative approach (P = .03) both resulted in worse outcomes. Conclusion: Use of a femoral head allograft with TTC arthrodesis can offer improved functional scores and sustained radiographic outcomes.Level of Evidence: Level IV: Case series.

Brake Response Time Recovery After Achilles Tendon Repair.

Background. This study evaluated when patients' brake response time (BRT) recovers after right Achilles repair. Methods. Institutional review board-approved prospective study of 60 patients. Assessments included visual analogue scale pain (VAS) score, Achilles Tendon Total Rupture Score (ATRS), and a driver readiness survey. Emergent brake pedal operation was simulated at 6 weeks postoperatively and repeated until patients achieved a passing BRT. Results. Fifty-seven patients completed the study. At 6 weeks, 54 of 59 (91.5%) patients had a passing BRT with a mean of 0.60 seconds (SD 0.08 seconds). Five (8.5%) patients had a failing BRT with a significantly higher mean of 0.95 seconds (SD 0.13 seconds, P = .01). At first testing, all patients were ambulating in a walking boot with removable heel wedges. Those who passed were using significantly fewer wedges (mean 1.9 vs 2.6 wedges, P = .04). Mean VAS pain scores (Passed: 1.1, SD 1.57, vs Failed: 2.8, SD 3.35, P = .32) were not significantly different. The mean ATRS was significantly lower among those who passed (63.7, SD 16.7, vs 85.4, SD 11.1, P = .01. Three patients repeated testing at a mean 7.3 weeks (range 6.7-8). All achieved passing times (mean 0.68 seconds, range 0.55 to 0.77 seconds). The driving readiness survey was 100% sensitive but 31.3% specific for passing BRT. Its positive predictive value was 80%, and its negative predictive value was 100%. Conclusion. BRT normalizes around 6 to 7 weeks after open right Achilles tendon repair. The ATRS and driver readiness questionnaire corresponded to achieving a passing BRT. Levels of Evidence: Prognostic Level II: Prospective Cohort Study.

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.

Postoperative Opioid Consumption in Opioid-Naïve Patients Undergoing Hallux Valgus Correction.

BACKGROUND: Postoperative pain management following orthopedic surgeries can be challenging, and the opioid epidemic has made it essential to better individualize opioid prescriptions by patient and procedure. The purpose of this subgroup analysis of a prospective study was to investigate immediate postoperative opioid pill consumption and prolonged use in patients undergoing operative correction of hallux valgus (HV). METHODS: Patients undergoing outpatient HV correction procedures with 5 fellowship-trained foot and ankle surgeons over a 1-year period were included. Patients were excluded if they were being prescribed chronic opioid analgesics for an underlying condition prior to the date of initial injury or if they underwent concomitant nonforefoot procedures. At the patient's first postoperative visit, opioid pills were counted, and these were standardized to the equivalent number of 5-mg oxycodone pills. Linear regression analysis was performed to determine if any of the procedure categories or patient factors were independently associated with postoperative opioid consumption. Prolonged use of opioids 90 to 180 days after the procedure was also examined using our state's online Prescription Drug Monitoring Program (PDMP). One-hundred thirty-seven patients (86% female) were included. Thirty-six patients (26%) underwent primary chevron osteotomies, 78 (57%) underwent primary proximal osteotomies (Ludloff, scarf), 10 (7%) underwent soft tissue-only procedures with or without a first proximal phalanx osteotomy (modified McBride, Akin), and 13 (9%) underwent first metatarsophalangeal arthrodeses. RESULTS: Overall, patients consumed a median of 27 pills. There was no significant difference in postoperative opioid intake between the 4 procedures, including when subdivided into those with and without lesser toe procedures. Higher preoperative visual analog scale pain levels (P = .028) and younger patient age (P = .042) were associated with higher opioid pill consumption. A total of 1.5% of patients demonstrated prolonged opioid use. CONCLUSION: Our study demonstrated a lack of difference between HV procedures in terms of postoperative opioid consumption and an overall low rate of prolonged use in opioid-naïve patients. LEVEL OF EVIDENCE: Level III, comparative study.

What Determines the Type and Dose of Antibiotic That Is Needed to Be Added to the Cement Spacer in Patients With Infected Total Ankle Arthroplasty (TAA)?

RECOMMENDATION: We recommend tailoring the antibiotic in cement spacers to the infecting organism if it has been identified, as is typically done in total knee and hip arthroplasty. Otherwise, broad-spectrum antibiotics may be utilized. Medical comorbidities should always be considered, especially with regard to renal function and allergy profile. A thermostable antibiotic should be added to cement. LEVEL OF EVIDENCE: Consensus. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

What Is the Best Technique for Performing Aspiration of Patients With Total Ankle Arthroplasty (TAA)?

RECOMMENDATION: In the absence of evidence, we recommend that ankle joint aspiration to evaluate for periprosthetic joint infection (PJI) be performed under sterile conditions via the anteromedial approach. Ultrasound guidance may be used if available but is not necessary to obtain an acceptable synovial fluid sample. LEVEL OF EVIDENCE: Consensus. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Long-term Follow-up of Cheilectomy for Treatment of Hallux Rigidus.

BACKGROUND: Hallux rigidus is the most common arthritic condition in the foot. First metatarsophalangeal joint cheilectomy produces satisfactory results in retrospective studies with reported good to excellent results in up to 97% and pain relief and function in 92%. The results of cheilectomy for higher grades of hallux rigidus are less favorable. The purpose of this study was to evaluate the long-term functional results and survivorship of cheilectomy for treatment of hallux rigidus. METHODS: This was a retrospective, questionnaire-based study investigating the long-term results of cheilectomy for treatment of hallux rigidus. The preoperative arthritic grade was graded retrospectively according to the Hattrup and Johnson (H&J) grading system. A questionnaire was administered via email or telephone that included questions regarding pain recurrence following surgery, current functional status, and satisfaction with the operation. Kaplan-Meier survival analysis was performed to estimate survival time between arthritic grades. We reviewed 165 patients (169 feet) with an average follow-up of 6.6 (5.0-10.9) years. RESULTS: The overall survival rate (painless at the time of last follow-up) was 70.4% (119 feet), with no significant difference between the 3 H&J arthritic grades. Most of the recurrences (28 feet, 75%) were at the first 2 years following the surgery. Nine feet (5.3%) had a second procedure at a mean postoperative time of 3.6 (range, 1.6-7.4) years. Of the 169 feet, 117 (69.3%) reported being satisfied or very satisfied and 127 (75.1%) indicated they would repeat the operation under the same circumstances. CONCLUSION: Our study supports the use of cheilectomy for treatment of hallux rigidus (grade 1-3 Coughlin and Shurnas) as a reliable procedure with favorable results. At long-term follow-up, patients who underwent cheilectomy had a low revision rate and a moderately low rate of pain recurrence. LEVEL OF EVIDENCE: Level IV, retrospective case-series.

Incidence and Risk Factors for Pin Site Infection of Exposed Kirschner Wires Following Elective Forefoot Surgery.

BACKGROUND: Kirschner wires (K-wires) are commonly utilized for temporary metatarsal and phalangeal fixation following forefoot procedures. K-wires can remain in place for up to 6 weeks postoperatively and are at risk for complications. This study investigated the incidence of infectious complications of exposed K-wires after forefoot surgery and identifies risk factors for these complications. METHODS: A single-surgeon retrospective chart review of forefoot surgeries from 2007 to 2017 was undertaken. Inclusion criteria were adult patients (≥18 years) undergoing elective forefoot surgery with the use of exposed K-wires. Incidence of pin site infectious complication, defined as cellulitis, or pin site drainage and/or migration/loosening of the pin was noted. Patient demographic and perioperative data were analyzed, along with the number of K-wires placed per procedure. Mann-Whitney U and chi-square tests were performed to determine predictive factors related to pin site infection rates, with a multivariable model with significant factors subsequently performed. Two-thousand seventeen K-wires in 1237 patients were analyzed. RESULTS: There were 35 pin site infections for a rate of 1.74%. Combined forefoot procedures (507 pins in 229 patients) had a pin site infection rate of 4.93% (N = 25), followed by lesser metatarsal osteotomies (667 pins in 446 patients) at 1.05% (N = 7), then hammertoe corrections (694 pins in 421 patients) at 0.43% (N = 3), and no pin site infections with chevron osteotomies (149 pins in 141 patients). Male sex, body mass index (BMI), current smoker, and number of pins were significant risk factors (P ≤ .05). Additionally, there were 23 non-infection-related K-wire complications. No long-term sequelae were encountered based on any complications. CONCLUSION: K-wires are commonly used for temporary immobilization of the smaller bones of the forefoot following deformity correction. Male sex, BMI, current smoker, and number of pins were significant risk factors for pin site infection, with a higher rate of infection with 2 or more pins placed. LEVEL OF EVIDENCE: Level IV, case series.

Clinical Outcomes and Complications of Peroneal Tendon Sheath Ultrasound-Guided Corticosteroid Injection.

BACKGROUND: The treatment of symptomatic peroneal tendinopathy and tears traditionally begins with nonsteroidal anti-inflammatory drugs, activity modification, physical therapy, and immobilization, with surgery typically reserved for those failing nonoperative treatment. Ultrasound-(US)-guided peroneal tendon sheath (PTS) corticosteroid injection is an additional nonoperative modality, but limited data exist on its safety and efficacy. The purpose of this study was to assess clinical outcomes following US-guided PTS corticosteroid injection for chronic tendinopathy or tears. METHODS: We retrospectively identified patients who had undergone US-guided PTS corticosteroid injection for pain due to peroneal tendinopathy, tears, or subluxation at our institution from 2012 to 2018. Underlying diagnosis was based on clinical examination, magnetic resonance imaging (MRI) results, and/or intraoperative findings, when available. Medical record data were supplemented by e-mail or telephone follow-up. Collected information included patient age, sex, body mass index (BMI), smoking status, workers' compensation status, prior surgeries about the foot and ankle, duration of symptoms prior to injection, perceived improvement in pain following injection and its duration, number of injections, progression to surgery, and any adverse outcomes of injection. We identified 96 patients (109 injections). Thirty-seven (38.5%) had previous foot and ankle surgery, with 17 (17.7%) having surgery specifically on the peroneal tendons. RESULTS: Twenty-four of 96 (25%) progressed to have surgery on their peroneal tendons following injection. Following injection, 38/87 (43.7%) of patients reported 0-1 weeks of pain relief, 11/87 (12.6%) 2-6 weeks, 6/87 (6.9%) 7-12 weeks, and 32/87 (36.8%) greater than 12 weeks. Preinjection duration of symptoms was associated with postinjection duration of pain relief (P=.036). There were 2 reported complications (1.8%): 1 case of self-limited sural nerve irritation and 1 of peroneus longus tear progression. CONCLUSION: Our study demonstrates US-guided PTS corticosteroid injection was safe and relatively effective in patients with symptomatic peroneal tendon tears or tendinopathy, including those who had undergone prior surgery, and may be considered in a comprehensive protocol of nonoperative management. LEVEL OF EVIDENCE: Level IV, case series.