Complication Rates Following Total Ankle Arthroplasty in Inpatient versus Outpatient Populations: A Systematic Review & Meta-Analysis.

Total ankle arthroplasty (TAA) is used as an alternative to ankle arthrodesis for adults with severe ankle arthritis. Numerous orthopedic centers have entered the healthcare market offering fast-tracked joint replacement protocols, meanwhile, TAA has been excluded from these joint centers, and is primarily performed in the inpatient setting. The purpose of this study is to examine short-term complications in the inpatient and outpatient settings following TAA using a systematic review and quantitative analysis. We considered all studies examining short-term complications following TAA performed in the inpatient versus outpatient setting occuring within 1 year of the index operation. We summarized data using a pooled relative risk and random effects model. A pooled sensitivity analysis was performed for studies with data on complication rates for inpatient or outpatient populations, which did not have a control group. The quality of included studies was assessed using the Cochrane risk of bias tool. Nine studies were included in the quantitative analysis, with 4 studies in the final meta-analysis. Subjects undergoing inpatient surgery experienced a 5-times higher risk of short-term complications compared to the outpatient group (risk ratio 5.27, 95% confidence interval 3.31, 8.42). Results did not change after sensitivity analysis (inpatient weighted mean complication rate: 9.62% vs outpatient weighted mean 5.02%, p value <.001). The overall level of evidence of included studies was level III, with a moderate to high risk of bias. Outpatient TAAs do not appear to pose excess complication risks compared to inpatient procedures, and may therefore be a reasonable addition to experienced centers that have established a fast-track outpatient total joint protocol.

Radiographic Union Scoring Scale for Determining Consolidation Rates in the Calcaneus.

The reliable evaluation of osseous consolidation after hindfoot osteotomy can be difficult. Concomitant hindfoot osteotomies often dictate the advancement of weightbearing, and radiographs are the mainstay imaging tool owing to cost, efficiency, and radiation exposure. Understanding the radiographic parameters that can be used to reliably determine osseous healing is paramount. However, currently, no reliable or validated method is available to determine osseous healing of hindfoot osteotomies in irregular bones of the foot. The purpose of the present study was to develop a radiographic healing scoring system that would enhance the diagnostic healing assessment after elective calcaneal osteotomy. We adapted existing orthopedic scales validated for healing in the leg for application in the irregular bones of the foot. A total of 168 cases were evaluated by 6 blinded assessors to test the interrater reliability of subjective healing assessment compared with the proposed scoring system. The radiographs were classified by postoperative period: ≤4 weeks, 5 to 12 weeks, and >12 weeks. The proposed scale had high interrater reliability but was burdensome. Using a priori item reduction protocols, a limited 6-item scale further improved internal consistency and reduced the burden. The result was excellent interrater reliability (α = 0.98, standard deviation 0.02, 95% confidence interval 0.91 to 0.96) among all assessors when using the scoring scale compared with unacceptable reliability (α = 0.438) for subjective osteotomy healing. The reliability of our system appeared superior to that of subjective assessment of osseous healing alone, even in the absence of clinical correlates after osteotomy of the calcaneus.

Development of a Radiographic Union Score for Determining Osteotomy Union Rates in Long Bones of the Foot.

Determining the status of bone healing after osteotomy can be challenging and has implications ranging from clinical decision-making to standardization of research outcomes without the use of computed tomography. To date, no method has been validated for determining osseous healing of an osteotomy site of the long bones of the foot. The purpose of the present study was to develop a radiographic union scoring system that would enhance the diagnostic healing assessment. We adapted existing orthopedic scales that had been validated for healing in the leg for application in the long bones of the foot. One hundred cases were evaluated by 6 blinded assessors to test the inter- and intrarater reliability of the subjective healing assessment compared with the proposed scoring system. The radiographs were classified by postoperative period: ≤4, 5 to 12, and >12 weeks. The proposed scale had a high interrater reliability but was burdensome. Using a priori item reduction protocols, the scale was limited to the 5 items with the best internal consistency, which significantly reduced the burden. The result was excellent interrater reliability (α = 0.87) among all assessors compared with acceptable reliability (α = 0.66) for the subjective osteotomy healing assessment. The intrarater reliability during the subsequent retest phase demonstrated similar relationships, with low agreement (r = 0.38) for subjective healing. Each of the items included in the final scoring scale had moderate to good agreement across all assessors (r = 0.51 to 0.63). The reliability of this system appeared superior to the subjective assessment of osseous healing alone, even in the absence of clinical correlates after an osteotomy in the foot.

Amnion: The Ideal Scaffold for Treating Full-Thickness Wounds of the Lower Extremity.

Amnion and amniotic tissue has been studied for more than 100 years in the treatment of acute and chronic wounds. Recent studies have focused on the use of amnion tissue in the management of full-thickness diabetic wounds, particularly of the lower extremities. With new harvesting, processing, and distribution technologies, amnion is increasingly available in treating these wounds. Current data and research show increased healing potential and decreased healing times, pain, drainage, and infection in wounds treated with amnion products. There are a variety of amnion products with varying differences and purposes, requiring additional research and comparison trials.

Clinical Outcomes Following an Open Gastrocnemius Recession Combined With an Endoscopic Plantar Fasciotomy.

At present, there is a paucity of literature describing the clinical outcomes following a combined gastrocnemius recession and endoscopic plantar fasciotomy. The purpose of the present report is to describe our preliminary findings following a combined gastrocnemius recession and endoscopic plantar fasciotomy for the treatment of plantar fasciitis and gastrocnemius equinus recalcitrant to conservative therapy. Twenty-five consecutive ankles in 23 patients (age 51.2 ± 12.5 years, 4 men) met the inclusion and exclusion criteria. The average follow-up was 3.7 months. Compared across time, there were statistically significant improvements in pain, t(24) = 7.878, P < .001; dorsiflexion, t(24) = -6.125, P < .001; and eversion, t(23) = -3.610, P = .001. Plantar flexion and inversion remained similar across time ( P = .722 and P = .268, respectively). No statistically significant correlations were found between age and any of the postoperative outcome variables ( P ≥ .056) or body mass index and any of the postoperative outcome variables ( P ≥ .140). The authors believe that an isolated plantar fasciotomy alleviates symptoms in the majority of patients. When gastrocnemius equinus is also present, however, the authors advocate performing an open gastrocnemius recession as well. If the gastrocnemius pathology is not addressed, symptoms are likely to persist. The findings of the present report confirm the effectiveness of a combined gastrocnemius recession and endoscopic plantar fasciotomy to improve pain and range of motion. LEVELS OF EVIDENCE: Case series, Level IV: Retrospective.

Healing in the new millennium: bone stimulators: an overview of where we've been and where we may be heading.

Electromagnetic fields and their uses in bone healing have been fairly well studied, with most results showing improvement in healing of both bone and cartilage. Most supportive data are found in relation to the spine, femur, and tibia, but there is increasing evidence for its use in the foot and ankle for treatment of nonunions and as an adjunctive device in arthrodeses, particularly in high-risk populations. There are varying data and a significant variety of quality in the current research and publications concerning the use of electrical bone stimulation in the treatment of the foot and ankle. Thus, there is a definite need for further investigation and high-quality study designs to determine the most effective treatment modalities and pathologies best used with bone stimulation. Bone stimulation should be viewed as an adjunctive procedure in which the surgeon optimizes the high-risk patient both medically or surgically whenever possible. But when used appropriately, bone stimulation has the potential to influence outcomes and aid in bone healing when complications arise and in high-risk populations.

Fractures of the talus: a comprehensive review.

The talus, a highly specialized bone with a unique anatomic design, is crucial for normal ambulation. Although uncommon, talar fractures can be potentially devastating to the patient. Although all talar fractures require appropriate diagnosis and treatment, some require surgical skill for appropriate correction. This article reviews the literature on talar fractures and their treatments.

Overview of concepts and treatments in open fractures.

Open fractures are one of the few lower extremity surgical emergencies. These injuries require immediate treatment. If untreated, severe cases of open fracture can be limb threatening. This article is a review of the literature of open fractures and the current treatment guidelines.