Consumer Prices for Surgical Management of Ankle Arthritis: Limited Availability and Wide Variability.

Background: Healthcare costs for the surgical management of ankle arthritis continue to rise. Patients are generally unaware of the prices of the services they use. Understanding the costs associated with surgical management of ankle arthritis is an important facet of patient care. The purposes of this study were to (1) determine the access to the surgical cost of total ankle arthroplasty (TAAs) and ankle arthrodesis and (2) the variability of the price between the two procedures. Methods: Fifty foot and ankle centers (25 academic, 25 private) that perform TAAs and ankle arthrodeses were contacted using a standardized patient script. The described patient was a 63-year-old man who had failed conservative treatment of ankle arthritis. Each institution was contacted up to three times in an attempt to obtain a full-bundled surgical quote for a TAA and an ankle arthrodesis. Results: Twenty-one centers (42%, 14 academic, 7 private) were able to provide a quote for a TAA and an ankle arthrodesis. The mean bundled price for a TAA was $50,332 (SD ±$25,744), with the mean academic and private center quote being $56,529 and$37,937, respectively. The mean bundled price for an ankle arthrodesis was $41,756 (SD ±$26,033), with the mean academic and private center quote being $48,116 and$29,037, respectively. No statistically significant difference was found between the bundled prices for TAA and ankle arthrodesis. Discussion: This study demonstrated limited availability of consumer prices for TAA and ankle arthrodesis. When comparing different institutions for surgical management of ankle arthritis, there was a wide range of quotes for both TAA and ankle arthrodesis. When comparing the choice of surgical management for ankle arthritis, no statistically significant difference was observed in price between TAA and ankle arthrodesis

Impact of COVID-19 Pandemic on Patients\u27 Perceptions of Safety and Need for Elective Foot and Ankle Surgery in the United States

Background: With the development of the COVID-19 pandemic, elective foot and ankle surgeries were delayed throughout the United States to divert health care resources and limit exposure. Little is known about the impact of COVID-19 on patient\u27s willingness to proceed with elective procedures once restrictions are lifted and factors contributing to such decision. Methods: Patients across 6 US orthopedic institutions who had their elective foot and ankle surgeries cancelled secondary to the pandemic were given a questionnaire. Specifically, patients were asked about their willingness to move forward with surgery once restrictions were lifted and if not why. Pain-level and pain medication use were also assessed. Univariate analysis was used to identify factors that contribute to patient\u27s decisions. Results: A total of 150 patients participated in this study. Twenty-one (14%) opted not to proceed with surgery once restrictions were lifted. Forty-three percent (n = 9) listed concern for COVID infection as the reason; however, 14% of them would proceed if procedures were performed in surgery center. Twenty-nine (19% of the total cohort) patients had increased pain and 11% of patients were taking more pain meds because of the delay to their procedure. Patients who decided not to proceed with surgery reported pain reduction (3% vs 14%) and lower increase in pain medication used (5% vs 12%). Conclusion: COVID-19 has made a significant impact on the health care system. Delay of elective foot and ankle procedures impact patient quality of life and outcomes. Access to surgery centers may provide a partial solution during the pandemic. Level of Evidence: Level III

Metatarsalgia in Metatarsus Adductus Patients updates A Rational Approach

Metatarsus adductus (MA) is a congenital condition resulting in adduction of the forefoot at the tarsometatarsal joint, medial metatarsal deviation, supination of the hindfoot through the subtalar joint, and plantarflexed first ray. The exact underlying pathophysiology remains elusive. There is increasing evidence highlighting the importance of recognizing MA as an associated deformity that complicates management of hallux valgus (HV). Unfortunately, metatarsalgia and lesser toe pathology is also common in this population. We present a review regarding the epidemiology, pathomechanics, and a comprehensive surgical treatment algorithm to optimize the management of patients with MA, HV, lesser toe deformity, and metatarsalgia

The Contribution of Medial Cuneiform Osteotomy to Correction of Longitudinal Arch Collapse in Stage IIb Adult Acquired Flatfoot Deformity

Category: Midfoot/Forefoot Introduction/Purpose: Residual forefoot supination present after correcting the hindfoot in Stage IIb adult acquired flatfoot deformity (AAFD) can be addressed with a dorsal opening wedge medial cuneiform (Cotton) osteotomy. The amount of correction is generally judged clinically and there currently are no preoperative guides that can predict the size of graft needed. The aim of this study was to evaluate the relationship between the Cotton osteotomy graft size and other accessory flatfoot reconstructive procedures, and the amount of correction of longitudinal arch collapse. We hypothesized that correction of longitudinal arch collapse, as measured by the cuneiform articular angle (CAA), would primarily be influenced by the Cotton osteotomy performed. More specifically, we hypothesized that the size of the graft would have the largest effect on the CAA. Methods: Seventy-nine feet in 74 patients undergoing Cotton osteotomy as part of flatfoot reconstruction were reviewed retrospectively. Preoperative and minimum 40-week postoperative lateral weightbearing foot radiographs were compared to assess correction of longitudinal arch collapse as measured by 13 radiographic parameters, with particular emphasis on the CAA. Additional demographic and intraoperative variables analyzed for association with radiographic change included age, gender, body mass index (BMI), amounts and graft types of Cotton osteotomy and lateral column lengthening (LCL), and amount of medializing calcaneal osteotomy (MCO). Other concomitant procedures at the time of surgery, namely Achilles lengthening, flexor digitorum longus (FDL) transfer, spring ligament reconstruction, gastrocnemius recession, and excision of accessory navicular were also recorded. Ultimately, a multivariable linear regression model was developed to estimate the effect of Cotton osteotomy on change in the CAA, adjusting for patient and clinical variables. Results: Cotton osteotomy graft size was significantly associated with changes in the CAA (P < .001), calcaneal pitch (P = .03), lateral talo-navicular Cobb angle (P = .03), and lateral naviculo-medial cuneiform Cobb angle (P = .03). Multivariable linear regression models included age at surgery, gender, BMI, and the use of all concomitant procedures (LCL, Achilles lengthening, FDL transfer, gastrocnemius recession, and excision of accessory navicular) except for spring ligament reconstruction, since this was not associated with any of the four radiographic measurements. Cotton graft size was the only factor found to significantly predict a change in the CAA in the final linear regression model (P < .001, R2 = .27), with each millimeter of Cotton corresponding to a 2.1-degree decrease of the CAA (figure 1). Conclusion: Correction of longitudinal arch collapse, as measured by the CAA, was primarily influenced by graft size of the Cotton osteotomy in a linear fashion. The results also demonstrate that the procedure has a more distal effect in correction of longitudinal arch collapse and is of particular importance when the apex of deformity is at the medial cuneiform. Because the relationship between the Cotton osteotomy graft size and the CAA can be modeled linearly, we believe that preoperative measurement of the CAA can be a useful guide in helping surgeons to titrate the proper amount of longitudinal arch collapse correction intraoperatively

Current Trends in Anesthesia Management in Hallux Valgus

Anesthesia management during hallux valgus surgery trends toward multimodal pain control. Locoregional anesthesia with peripheral nerve blocks and wound instillation increase pain control. Peripheral nerve blocks as first-line analgesia are effective with minimal side effects. Local wound instillation has a variable but positive effect with minimal negative side effects. Nonsteroidal anti-inflammatory drugs in bone-to-bone healing remain controversial; however, they reduce opiate requirements and enhance patient satisfaction. Opiate agonists remain the mainstay for postoperative pain; long-acting formulations minimize pain crises. Multimodal analgesia with locoregional anesthesia facilitate the progress of hallux valgus surgery as an outpatient procedure

What Are the Indications for Aspiration of a Possibly Infected Total Ankle Arthroplasty (TAA)?

Whenever a periprosthetic joint infection (PJI) of a total ankle arthroplasty (TAA) is clinically possible or suspected, especially when elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) levels exist, and in correspondence to the literature on PJI in total hip and knee arthroplasties, joint aspiration is indicated. Consensus. Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus)

The Use of a Synthetic Cartilage Implant for Hallux Rigidus A Systematic Review

Category: Other Introduction/Purpose: Hallux rigidus is one of the most common pathologies afflicting the foot. Various joint salvage techniques have been described with a multitude of different implants. Recently, a synthetic cartilage implant composed of polyvinyl alcohol (PVA) received FDA premarket approval for treatment of arthritis of the great toe and has been used in over 4,000 cases. The purpose of this study was to systematically review the clinical evidence supporting the use of a PVA implant in hallux rigidus. Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Using the terms “cartiva OR polyvinyl alcohol OR synthetic cartilage OR hemiarthroplasty AND hallux rigidus OR great toe arthritis OR first toe arthritis “ we searched the PubMed/Medline database in December 2017. In addition, the reference list of publications were scanned for further relevant studies. Results: 4 studies met the inclusion criteria, all of which were derived from a single randomized controlled trial. At short-term follow-up (2 years), patients undergoing placement of a PVA implant had significant improvement in Foot and Ankle Ability Measure (FAAM) sports and activity of daily living, as well as VAS pain scores. The outcomes of the surgery were found to be noninferior compared to arthrodesis. At intermediate follow-up (5 years), the improvement in clinical outcomes persisted and implant survivorship was 96%. Conclusion: There are limited studies available detailing the outcomes of a PVA implant for hallux rigidus, however the results that are available demonstrate a high level of evidence. There are no long-term publications assessing the outcomes of a PVA implant for hallux rigidus