RESUMEN

Background The repair of trimalleolar fractures can be challenging for surgeons and may be managed as an inpatient or an outpatient. However, it is often unclear whether these patients should be admitted immediately or sent home from the emergency department (ED). This study aims to evaluate trimalleolar fractures treated surgically in the inpatient or outpatient settings to evaluate differences in outcomes for these patients. Methods A retrospective chart review of 223 patients undergoing open reduction internal fixation of a trimalleolar ankle fracture was performed from January 2015 to August 2022. Patients were classified by whether the fixation was performed as an inpatient or outpatient. Outcomes of interest included time from injury to surgery, complications, ED returns, and readmissions within 90 days. Results Inpatients had significantly higher ASA scores, BMI, and rates of comorbidities. Inpatient treatment was associated with faster time to surgery (median 2.0 vs. 9.0 days) and fewer delayed surgeries more than seven days from injury (18.4 vs. 67.9%). There were no differences in complications, 90-day ED returns, readmissions, or reoperation between groups. Conclusions Inpatient admission of patients presenting with trimalleolar ankle fractures resulted in faster time to surgery and fewer surgical delays than outpatient surgery. Despite having more preoperative risk factors, inpatients experienced similar postoperative outcomes as patients discharged home to return for outpatient surgery. Less restrictive admission criteria may improve the patient experience by providing more patients with support and pain control in the hospital setting while decreasing the time to surgery.

RESUMEN

INTRODUCTION: Foot and ankle fractures present common challenges in emergency departments, warranting careful follow-up protocols for optimal patient outcomes. This study investigates the predictors of orthopaedic follow-up for these injuries after an emergency department (ED) visit. METHODS: A retrospective observational study of 1450 patients seen in the ED with foot or ankle fractures from July 2015 to February 2023 was conducted. All included patients were discharged with instructions to follow-up with an orthopaedic provider. Demographic data, fracture details, and follow-up patterns were extracted from medical records. Social vulnerability was assessed using the Centers for Disease Control (CDC) Social Vulnerability Index. Univariate and multivariate analyses were performed to identify predictors of follow-up. A subgroup analysis comparing patients who followed up >7 days from ED presentation (ie, delayed follow-up) to those who followed up within 7 days of presentation was then performed. Statistical significance was assessed at P < .05. RESULTS: Overall, 974/1450 (67.2%) patients followed up with orthopaedics at an average time of 4.16 days. After risk adjustment, Medicaid coverage (odds ratio [OR] = 0.56, P = .018), increased overall social vulnerability (OR = 0.83, P = .032), and increased vulnerability across the dimensions of socioeconomic status (P = .002), household characteristics (P = .034), racial and ethnic minority status (P = .007), and household type and transportation (P = .032) were all associated with lower odds of follow-up. Phalangeal fractures were also associated with decreased odds of follow-up (OR = 0.039, P < .001), whereas ankle fractures were more likely to follow-up (OR = 1.52, P = .002). In the subgroup analysis, patients of older age (P = .008), non-white race (P = .024), motor vehicle accident (MVA) (P = .027) or non-private insurance (P = .027), those experiencing phalangeal fractures (P = .015), and those seen by an orthopaedic provider in the ED (P = .006) were more likely to present with delayed follow-up. CONCLUSION: Patients with increased social vulnerability and Medicaid insurance are less likely to seek follow-up care after presentation to the ED with foot and ankle fractures.

RESUMEN

Background In the ankle, suture bridge fixation for syndesmotic injuries is commonly employed. Initial recommendations for suture bridge constructs advised against using the device in patients with insufficient quantity or quality of bone. Therefore, many surgeons limit its use to younger, more athletic patients and use traditional screw fixation in older, less active patients. The purpose of this study is to compare the outcomes of suture bridge fixation for syndesmotic repair in patients ≥ 60 years old vs patients < 60 years old. Methods A retrospective review of 140 ankle fracture patients from a single institution who received suture bridge fixation between July 13, 2010, and February 2, 2022, was performed. Patient data was obtained from patient records in the electronic health record. Univariate analysis, including chi-square and independent t-tests, was used. Complications included delayed wound healing, infection, hardware loosening, and non-union. Results There were no significant differences in demographics, comorbidities, primary or other procedures, loss of fixation, and neuropathy between groups. There was also no difference within the distribution of the mechanism of injury, affected side, or Weber classification. Finally, the rate of complication and complication type showed no significant differences between patients 60 years and older versus 60 years and younger. Complication rates and types in patients > 60 years versus < 60 years were not significantly different. Conclusion The use of the suture bridge fixation in patients > 60 years may not lead to an increased risk of complications and appears to be safe for use.

RESUMEN

BACKGROUND: Venous thromboembolism (VTE) are rare but serious complications after foot and ankle fracture surgery. A consensus definition of a high-risk patient has not been reached, leading to significant variability in the use of pharmacologic agents for VTE prophylaxis. The aim of this study was to develop a model for predicting VTE risk in patients undergoing surgery for foot and ankle fractures that is usable and scalable in clinical practice. METHODS: A retrospective review of 15,342 patients, within the ACS-NSQIP database, who had undergone surgical repair of foot and ankle fractures from 2015 to 2019 was performed. Univariate analysis evaluated differences in demographics and comorbidities. Stepwise multivariate logistic regression was generated based on a 60 % development cohort to evaluate risk factors for VTE. A receiver operator curve based on the 40 % test cohort calculated area under the curve (AUC) to measure the accuracy of the model in predicting VTE within the 30-day postoperative period. RESULTS: Of the 15,342 patients, 1.2 % patients experienced VTE, and 98.8 % patients did not. Patients who experienced VTE were significantly older and had an overall higher comorbidity burden. Those who had VTE spent on average 10.5 more minutes in the operating room. In the final model, age over 65, diabetes, dyspnea, CHF, dialysis, wound infection and bleeding disorders were all found to be significant predictors of VTE after controlling for all other factors. The model generated an AUC of 0.731, indicating good predictive accuracy. The predictive model is publicly available at https://shinyapps.io/VTE_Prediction/. CONCLUSIONS: In alignment with previous studies, we identified increased age and bleeding disorders as independent risk factors for VTE after foot and ankle fracture surgery. This is one of the first studies to generate and test a model for identifying patients at risk for VTE in this population. This evidence-based model may help surgeons prospectively identify high-risk patients who may benefit from pharmacologic VTE prophylaxis.

Asunto(s)

RESUMEN

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has resulted in a global pandemic with several hundred million infections worldwide. COVID-19 causes systemic complications that last beyond the initial infection. It is not known whether patients who undergo elective orthopaedic surgeries after COVID-19 are at increased risk of complications. The purpose of this study was to evaluate whether patients who undergo orthopaedic procedures after recent COVID-19 diagnosis are at increased risk of complications compared with those who have not had a recent COVID-19 diagnosis. METHODS: The TriNetX Research Network database was queried for patients undergoing elective orthopaedic surgeries from April 2020 to January 2022 in the following subspecialties: arthroscopic surgery, total joint arthroplasty, lumbar fusion, upper extremity surgery, foot and ankle (FA) surgery. Cohorts were defined by patients undergoing surgery with a diagnosis of COVID-19 from 7 to 90 days before surgery and those with no COVID-19 diagnosis 0 to 90 days before surgery. These cohorts were propensity-score matched based on differences in demographics and comorbidities. The matched cohorts were evaluated using measures of association analysis for complications, emergency department (ER) visits, and readmissions occurring 90 days postoperatively. RESULTS: Patients undergoing arthroscopic surgery were more likely to experience venous thromboembolism (VTE) ( P = 0.006), myocardial infarction ( P = 0.001), and ER visits ( P = 0.001). Patients undergoing total joint arthroplasty were more likely to experience VTE ( P < 0.001), myocardial infarction ( P < 0.001), pneumonia ( P < 0.001), and ER visits ( P = 0.037). Patients undergoing lumbar fusion were more likely to experience VTE ( P = 0.016), infection ( P < 0.001), pneumonia ( P < 0.001), and readmission ( P = 0.006). Patients undergoing upper extremity surgery were more likely to experience VTE ( P = 0.001) and pneumonia ( P = 0.015). Patients undergoing foot and ankle surgery were more likely to experience VTE ( P < 0.001) and pneumonia ( P < 0.001). CONCLUSION: There is an increased risk of complications in patients undergoing orthopaedic surgery after COVID-19 infection; all cohorts were at increased risk of VTE and most at increased risk of pneumonia. Additional investigation is needed to stratify the risk for individual patients.

Asunto(s)

RESUMEN

The use of total ankle arthroplasty has expanded over the past decade, primarily due to improvements in implant design and survivorship that have significantly reduced the high failure rates observed in first-generation implants. A retrospective review of 65 consecutive patients undergoing primary total ankle arthroplasty with a single senior orthopedic surgeon in a community hospital from January 2014 to December 2019 was performed. All procedures were performed for end stage osteoarthritis, with the most common secondary diagnoses being Achilles contracture (23%), retained hardware (17%) and calcaneovalgus deformity (11%). Preoperatively, patients averaged 10.45 ̊ ± 10.00 ̊ of non-weightbearing dorsiflexion and 30.00 ̊ ± 8.79 ̊ of plantarflexion. Postoperatively, patients averaged 13.33 ̊ ± 7.62 ̊ dorsiflexion, and 25.48 ̊ ± 7.87 ̊ of plantarflexion. A total of 8 (12.3%) patients required reoperation, and average time to reoperation was 1.55 ± 1.58 years. Implant failure, defined as reoperation requiring prosthesis removal, occurred in 2 (3.1%) patients, with an average time to failure of 342 days (105 days in failure due to periprosthetic joint infection and 582 days in failure due to subsidence). Patients undergoing total ankle arthroplasty at our institution had a 12.3% reoperation rate, and a 96.9% implant survival rate over an average follow-up period of 2.42 years, results that compare favorably with previously reported outcomes. Based on these findings, we suggest that this procedure, which is often offered only in academic tertiary care facilities, can be safely and effectively performed by experienced surgeons in the community hospital setting.

Asunto(s)

RESUMEN

OBJECTIVE: To date, the majority of studies have focused on the adverse effect of opioid overutilization on outcomes, risk factors for overutilization and dependence, and the development of procedure-specific guidelines. We present the results of a multiphased approach to reducing opioid prescribing. DESIGN: A retrospective pre-post study of opioid prescriptions across 386,393 patient encounters was conducted. The preintervention cohort included patient encounters from November 2016 to March 2017, and the post-intervention cohort included encounters from April 2017 to October 2019. SETTING: Single-institution orthopedic practice. PATIENTS, PARTICIPANTS: 386,393 patient encounters. INTERVENTION: Multiple prescribing reduction interventions were implemented from April 2017 to July 2018. MAIN OUTCOME MEASURE: Average morphine milligram equivalent (MME) per patient encounter. RESULTS: Implementation of the interventions resulted in an average reduction of 15.2 MME per encounter (54.5 percent) compared to the preimplementation cohort (pre: avg. MME = 27.9, SD 113.6; post: avg. MME = 12.7, SD 66.1; p < 0.001). The number of pills per opioid prescription was reduced by 13.4 (29.5 percent) (pre: avg. pill count = 45.5, S.D. 25.1; post: avg. pill count = 32.1, SD 21.1; p < 0.001), and the percent of patients receiving opioids was reduced from 8.3 percent to 5.8 percent (p < 0.001). Prescribing compliance was evaluated for 7,664 surgical encounters, with 98.2 percent of prescriptions meeting stated guidelines; 5.5 percent of these encounters required second prescriptions. CONCLUSIONS: The use of a multiphase approach effectively reduced the opioid prescribing patterns of a large orthopedic practice and was successful across subspecialties. This approach provides a template that other institutions may use to reduce opioid overprescribing in orthopedic practices.

Asunto(s)

RESUMEN

BACKGROUND: Optimal fixation of soft tissue grafts in anterior cruciate ligament (ACL) reconstruction remains a controversial topic, and tibial-sided fixation is frequently cited as the "weak point" of the femur-graft-tibia construct. Some studies have recommended the use of hybrid fixation (combining intratunnel aperture fixation and extracortical suspensory fixation) on the tibial side to increase the strength of the reconstructed ACL and decrease the risk of graft slippage and subsequent failure. However, no consensus has emerged on the necessity or suitability of this technique, relative to single modes of fixation. PURPOSE: This study sought answers to the following questions: (1) Does hybrid fixation result in stronger, stiffer initial fixation of soft tissue grafts? (2) Does hybrid fixation reduce side-to-side laxity differences in clinical practice? (3) Does hybrid fixation increase complication rates when compared with a single mode of tibial fixation? STUDY DESIGN: Systematic review. METHODS: A systematic keyword search of PubMed, EMBASE, the Cochrane Library of Systematic Reviews, and the PROSPERO International Prospective Register of Systematic Reviews was performed. Candidate articles were included if they compared biomechanical or clinical characteristics of tibial-sided hybrid fixation (defined as a combination of aperture and suspensory fixation methods) with single-mode fixation of soft tissue grafts in ACL reconstruction. RESULTS: A total of 21 studies (15 biomechanical, 6 clinical) met criteria for inclusion. Most biomechanical studies reported significantly increased strength and stiffness with hybrid fixation versus single modes of fixation. Among clinical studies, 66% reported significantly decreased anterior-posterior laxity when hybrid fixation methods were employed, with the remainder showing no difference. CONCLUSION: Hybrid methods of tibial-sided graft fixation in ACL reconstruction result in stronger initial fixation and less side-to-side laxity after healing but do not change patient-reported outcomes at 1- to 3-year follow-up. REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews No. 42014015464.

Asunto(s)

RESUMEN

This study aims to report the clinical and functional outcomes of revision anterior cruciate ligament (ACL) reconstruction in a young, active duty military population. Patients undergoing revision ACL reconstruction were enrolled in an institutional clinical database and followed prospectively. The primary outcomes were patients' scores on a timed run, as compared with recorded scores before reinjury. Secondary outcomes included scores on the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Western Ontario and McMaster Universities Arthritis Index (WOMAC), the International Knee Documentation Committee subjective (IKDC subjective), the Short Form - 36 health survey (SF-36) version 2, the Single Assessment Numeric Evaluation (SANE), and the Tegner activity scale. A total of 13 patients were identified who met the inclusion criteria and had complete follow-up. The mean age at revision ACL reconstruction was 20.5 years (range, 19-22 years), and mean follow-up was 40.2 months (range, 13-66 months). All patients underwent a single stage revision ACL reconstruction with ipsilateral bone-patellar tendon-bone autograft, ipsilateral hamstring autograft, or bone-tendon-bone allograft. Mean physical readiness test (PRT) score at final follow-up was not statistically different than documented preinjury PRT score (77.9 vs. 85.5, p > 0.05), nor was the mean run time (7:12 vs. 6:43/mile, p > 0.05). Significant improvements exceeding published minimal clinically important differences were seen in SANE score, SF-36 physical component summary score, KOOS sports and recreation, KOOS quality of life, WOMAC pain score, and WOMAC function score. Patients undergoing revision ACL reconstruction at our facility show good recovery of baseline physical performance as measured by the semiannual PRT and timed run test, and significant improvements in patient-reported outcome scores. Level of Evidence Level IV, case series.

Asunto(s)

Asunto(s)

RESUMEN

BACKGROUND: The effect of synthetic playing surfaces on the risk of injury in athletes is frequently debated in the orthopaedic literature. Biomechanical studies have identified increased frictional force at the shoe-surface interface, theoretically increasing the risk of injury relative to natural grass. This increase in frictional force is potentially relevant for the risk of anterior cruciate ligament (ACL) rupture, where noncontact mechanisms are frequent. However, clinical studies examining this issue have shown mixed results. HYPOTHESIS/PURPOSE: The purpose of this study was to systematically review the available literature on risk of ACL rupture on natural grass versus artificial turf. We hypothesized that the risk of ACL rupture on synthetic playing surfaces would not be higher than that of natural grass playing surfaces. STUDY DESIGN: Systematic review. METHODS: A systematic keyword search was performed of OVID, EMBASE, the Cochrane Library of Systematic Reviews, and the PROSPERO International Prospective Register of Systematic Reviews. Candidate articles were included if they reported the risk ratio of ACL rupture on natural grass versus synthetic playing surfaces, were of level 3 evidence or better, and included only ACL injuries sustained during organized athletic events. Exclusion criteria included a study with non-field-related sports and the use of historical cohorts for calculating risk ratios. RESULTS: A total of 10 studies with 963 ACL injuries met criteria for inclusion, all of which reported on soccer and football cohorts. Among these, 4 studies (753 ACL injuries) found an increased risk of ACL injury on artificial playing surfaces. All 4 of these articles were conducted using American football cohorts, and they included both earlier-generation surfaces (AstroTurf) and modern, 3rd-generation surfaces. Only 1 study in football players found a reduced risk of ACL injury on synthetic playing surfaces. No soccer cohort found an increased risk of ACL injury on synthetic surfaces. CONCLUSION: High-quality studies support an increased rate of ACL injury on synthetic playing surfaces in football, but there is no apparent increased risk in soccer. Further study is needed to clarify the reason for this apparent discrepancy.

Asunto(s)

RESUMEN

Discoid menisci can be a source of pain for patients, and pose treatment challenges to the treating surgeon. Additional associated intra-articular pathology, specifically osteochondral defects, can further complicate the clinical picture. The incidence of lateral discoid meniscus is variable based on the population, with a range of 0.4 to 17%, with bilateral involvement in up to 19% of these cases. Osteochondritis dissecans (OCD) is exceedingly rare, with an incidence of 0.015% in one study; however, some authors have suggested a correlation between the development of OCD and the presence of an unstable or torn lateral discoid meniscus. We present a case, the first to our knowledge, of bilateral lateral femoral condyle OCD in the presence of bilateral, asymptomatic, complete lateral discoid menisci.

Asunto(s)

RESUMEN

BACKGROUND: Hamstring muscle strains represent a common and disabling athletic injury with variable recurrence rates and prolonged recovery times. OBJECTIVES: To present the outcomes of a novel rehabilitation protocol for the treatment of proximal hamstring strains in an intercollegiate sporting population and to determine any significant differences in the rate of reinjury and time to return to sport based on patient and injury characteristics. STUDY DESIGN: Retrospective case series. METHODS: A retrospective review was performed of 48 consecutive hamstring strains in intercollegiate athletes. The rehabilitation protocol consisted of early mobilization, with flexible progression through supervised drills. Athletes were allowed to return to sport after return of symmetrical strength and range of motion with no pain during sprinting. Primary outcomes included time to return to sport and reinjury rates. RESULTS: All patients returned to their sports, and 3 sustained repeat hamstring strains (6.2% reinjury rate) after a minimum follow-up of 6 months. The average number of days missed from sport was 11.9 (range, 5-23 days). There was no statistically significant difference for time to return to sport between first-time and recurrent injuries and between first- and second-degree injuries (P > 0.05). CONCLUSIONS: Grade I and II hamstring strains may be aggressively treated with a protocol of brief immobilization followed by early initiation of running and isokinetic exercises-with an average expected return to sport of approximately 2 weeks and with a relatively low reinjury rate regardless of injury grade (I or II), injury characteristics (including first-time and recurrent injuries), or athlete characteristics.

RESUMEN

BACKGROUND: Few studies have reported the intermediate to long-term results of minimally constrained total ankle replacements. The purpose of this study was to investigate the efficacy and safety of a minimally constrained total ankle prosthesis in a select low-demand patient population. METHODS: We reviewed a consecutive series of patients with rheumatoid arthritis who underwent a Buechel-Pappas total ankle replacement (BP TAR) between 1990 to 1997. Thirty-one ankle arthroplasties were performed in 23 patients with rheumatoid arthritis. One patient was lost to followup (deceased) and two ankles that failed resulted in fusion (overall survivorship - 93%). This left 28 ankles (21 patients) that were re-evaluated clinically and radiographically with an average followup of 8.3 (range 5.0 to 12.2) years. Preoperative and postoperative ranges of motion were measured and AOFAS hindfoot scores were calculated. Recent weightbearing radiographs were reviewed for evidence of component subsidence, radiolucent lines, and osteolysis. RESULTS: In 25 of 28 ankles (89%), patients were completely satisfied with the result of their ankle replacement and rated their pain as only mild to none; three (11%) patients were dissatisfied. Radiographic analysis revealed stable, well-positioned implants with evidence of biologic ingrowth in 23 ankles (82%), while five implants were interpreted as being at risk for impending failure because of marked tibial or talar component subsidence (18%). Component subsidence did not correlate with the presence or absence of radiolucent lines. Only one ankle demonstrated clear evidence of osteolysis. Ten intraoperative medial malleolar fractures occurred (32% of ankles) during implantation of the prosthesis, though in only one did this adversely affect patient outcome. Nine postoperative complications (29%) occurred; four wound dehiscences, four stress fractures, and one medial malleolar nonunion. CONCLUSIONS: Improvements in prosthetic design such as cementless fixation and decreased constraint appear to make total ankle arthroplasty a more predictable procedure over this period of followup. Despite a variety of complications, we are encouraged by the intermediate-term results in a select low-demand arthritic population.

Asunto(s)

RESUMEN

BACKGROUND: The most efficient way to prepare the skin for foot and ankle surgery is unknown. In recent studies, >70% of aerobic bacterial cultures of specimens taken from the nail folds following skin preparation with povidone-iodine were positive. The goal of the current study was to determine the effect of isopropyl alcohol on the eradication of bacteria from the nails and skin of the normal foot and ankle. In addition, the effect of using a bristled brush rather than sponges to scrub the foot was investigated. METHODS: Four skin-preparation techniques were studied in two sets of twenty-five volunteers. In phase I of the study, the right foot and ankle of each member of the first set of volunteers was prepared with method 1, which consisted of a two-stage povidone-iodine scrub and paint with use of soft sponges. The left foot and ankle was prepared with method 2, which consisted of method 1 as well as an additional pre-wash with 70% isopropyl alcohol. In phase II, the right foot and ankle of each member of the second set of volunteers was prepared with method 3, which consisted of a povidone-iodine scrub and paint with use of a bristled brush to scrub the foot. The left side was prepared with method 4, which consisted of an alcohol scrub and paint with use of a bristled brush to scrub the foot. At the end of the preparation process, specimens for aerobic bacterial cultures were obtained from the hallucal nail fold, interdigital web spaces, and anterior aspect of the ankle. Cultures were interpreted as positive or negative, and the results were also assessed quantitatively. RESULTS: The rates of positive cultures of the nail-fold specimens were 76% and 80% after methods 1 and 2 (soft sponges) and 76% and 12% after methods 3 and 4 (bristled brush). The reduction in the percentage of positive cultures with method 4 was highly significant (p < 0.001). Cultures of the specimens from the web spaces showed a significant difference in the rates of positive results between methods 1 and 2 (36% and 8%, p < 0.05) but no significant difference between methods 3 and 4 (12% and 0%, p = 0.25). The rates of positive cultures of specimens from the anterior aspect of the ankle were consistently low (< or = 4% for all methods). Quantitative analysis of positive cultures demonstrated significant reductions (p < 0.01) in heavy growth when bristled brushes had been used, both with povidone-iodine and isopropyl alcohol. CONCLUSIONS: The use of isopropyl alcohol and the use of a bristled brush both have beneficial effects on the skin-preparation process before foot and ankle surgery. In the current investigation, the most effective technique was the use of isopropyl alcohol in conjunction with scrubbing with a bristled brush. Merely washing the foot with alcohol-soaked sponges provided limited benefit to the web spaces only.

Asunto(s)