Predictive Factors of Poor Health Literacy in Orthopedics

Category: Ankle Introduction/Purpose: Evidence shows that patients with limited health literacy (HL) are susceptible to inferior outcomes. By identifying characteristics associated with these poor traits, healthcare policy aimed at improving HL could be more efficiently implemented. The Literacy in Musculoskeletal Problems (LiMP) survey is a validated nine-item orthopedic HL questionnaire. The purpose of this study was to assess predictors of orthopedic HL using the LiMP survey through a large patient sample at an urban academic medical center. Methods: 245 patients presenting with chief complaints previously untreated were approached in the clinic of one foot and ankle surgeon and three hand and wrist surgeons. Inclusion criteria required age greater than 18 and English proficiency. Enrolled patients completed the LiMP questionnaire in addition to a demographic form. Clinical history was retrospectively reviewed. The following information was collected: age, gender, BMI, duration of symptoms, number of children living at home, past surgical history, visit type (trauma/non-trauma), smoking status (current/non-smoker), diabetes status (yes/no), history of psychiatric disorder (yes/no), race (white/non-white), education level (more/less than bachelor’s degree), and insurance type (public/private). Pearson correlation coefficients (PCC) were calculated between LiMP score, demographic data, and medical history data. Based on results of the correlational analysis, variables that were significantly correlated with LiMP score were entered into multivariate regression analysis to assess their effect on HL. A p value less than 0.05 was considered significant. Results: 231 patients (131 hand/wrist, 100 foot/ankle) were enrolled and fully completed questionnaires. Mean age was 45.6 (±16.8, range 18 – 82), and mean score on the LiMP was 5.40 (±1.8, range 1 – 9). The following variables significantly correlated with LiMP score: race (PCC=0.23), age (PCC=0.16), education (PCC=0.22), past surgical history (SCC=0.18), and insurance type (SCC=-0.16). Multivariate regression analysis was conducted with LiMP score as the dependent variable, and the factors race, age, education, past surgical history, and insurance type as the independent variables. Results of this analysis can be found in Table 1. The final model significantly accounted for 15.0% of variation in LiMP score. Coefficients that significantly contributed to the final model were those of past surgical history, race, and education level. Conclusion: Race, past surgical history, and education level all contribute significantly to a patient’s HL. When controlling for age and past surgical history, the latter of which was significantly associated with elevated HL, race significantly increased ability to predict LiMP score. Similarly, the inclusion of education level also significantly added to our model’s ability to predict LiMP score. In conclusion, our results indicate that when designing healthcare policy aimed at improving HL, efforts should be focused on lower educated persons and minorities regardless of past experience with medical care, and that age and gender are by no means markers for HL

Sleep Quality, Pain Catastrophization, and Orthopedic Health Literacy

Category: Ankle Introduction/Purpose: Evidence increasingly indicates the importance of orthopedic health literacy, sleep quality, and a propensity for pain catastrophization in orthopedic patient outcomes. Using previously validated questionnaires including the Literacy in Musculoskeletal Problems (LiMP), Pain Catastrophization Scale (PCS), and the Pittsburgh Sleep Quality Index (PSQI), this study investigated the relationship between these factors and common functional outcome instruments including the Disability of Arm, Shoulder, and Hand (DASH) and the Foot and Ankle Outcome Score (FAOS). Methods: 245 patients in outpatient clinics of one foot and ankle surgeon and three hand surgeons were approached. Inclusion criteria required age greater than 18, English proficiency, and a newly presenting chief complaint. Enrolled patients completed a demographics form, LiMP, PCS, PSQI, and the DASH or FAOS based on extremity. Clinical history was reviewed retrospectively. DASH and FAOS scores were normalized to the same scale (0 – 100, best to worst) and termed “functional survey” (FS). Correlations were calculated between FS scores, subjective questionnaires, and demographic/clinical information. For the variables of race and education level, one-way ANOVA analysis was conducted to determine if FS scores differed based on these variables. Variables that were significantly correlated with FS score were entered into a multivariate linear regression analysis to assess their effect on FS score. Results: 231 patients (131 hand/wrist, 100 foot/ankle) were enrolled and completed all questionnaires. ANOVA analysis found that there were no significant differences in FS scores based on education or race (p > 0.05). Multivariate regression analysis was conducted with FS score as the dependent variable, and factors that were significantly correlated with FS score, including PCS, PSQI Global Score, visit type (trauma vs. non-trauma), and insurance type (private vs. public) as the independent variables. Health literacy was not significantly correlated with OS score. Results from this analysis can be found in Table 1. The model significantly (p < 0.05) accounted for 19.2% of variation in OS score. Conclusion: There is a strong correlation between tendency to catastrophize pain, sleep quality, and FS score. Every 1 unit increase in the PSQI/PCS corresponds with a 1.8/0.38 point increase in FS score; indicating higher functional disability. Given the strong correlation at baseline, such factors as poorly controlled tendency to catastrophize pain may confound functional outcomes. No significant correlation was noted between health literacy and FS scores. This suggests that an increased level of orthopedic knowledge does not affect perception of functional disability. However, our results show that sleep quality and catastrophic thinking may confound functional outcome scores

Timing of Antibiotic Prophylaxis for Preventing Surgical Site Infections in Foot and Ankle Surgery

Category: Other Introduction/Purpose: Surgical site infection (SSI) is one of the most troublesome outcomes after any surgery, for both patient and surgeon. In addition to significant morbidity for patients, SSIs have been hallmarked as an important metric in value-based purchasing by CMS. Surgical literature has suggested that 15-60 minutes prior to incision is the ideal timing of intravenous antibiotics. The purpose of this study is to find the optimal timing of antibiotic administration before foot and ankle surgery, as well as to elucidate the risk factors for SSIs. Methods: An a priori power analysis was performed in order to detect a 4% absolute increase in infection rate with delayed timing of antibiotic prophylaxis, based on a presumed baseline SSI rate of 4% in foot and ankle surgeries based on literature on healthy patients undergoing foot and ankle surgery (n=1204 to achieve a power of .80). A retrospective chart review of 1933 foot and ankle procedures in 1632 patients over 56 months was performed. Demographic data, type and amount of antibiotics, timing of antibiotic administration, incision time, and closure time were recorded. The incidence of subsequent wound infection and subsequent incision and drainage procedure (I&D) within 30 days and 90 days were documented. Comparison of outcomes and demographic variables between the group of patients who received preoperative antibiotics less than 15 minutes before incision, and those who received them between 15 to 60 minutes prior to incision was performed. Results: A total of 1569 procedures met inclusion criteria. There were a total 17 cases (1.1%) of subsequent wound infection, of which 11 required a subsequent I&D within 90 days. There were 59 additional cases (3.8%) of wound complications which did not meet SSI criteria. When antibiotics were administered between 15 and 60 minutes prior to incision, there was a 2.7-fold, statistically significant higher rate of SSIs as compared to the group of patients receiving antibiotics < 15 minutes before incision (p < 0.05). When comparing the patients who had subsequent SSIs to those who did not, the only significant independent predictors were longer surgeries and non-ambulatory surgeries (both p < 0.05). When a stepwise multivariate logistic regression was performed to see which variables would predict an SSI, it was found that 91.8% of the risk of an SSI could be predicted by ASA score and length of surgery alone. Conclusion: In foot and ankle surgeries, the timing of intravenous antibiotic prophylaxis does not appear to play as large of a role as in other surgical subspecialties. Our studies revealed that host factors length/complexity of surgery may play a much larger role in determining the rate of infections than the timing of antibiotic prophylaxis

Time to Diagnosis and Treatment of Superficial versus Deep Incisional Surgical Site Infections in Foot and Ankle Surgery

Category: Ankle Introduction/Purpose: Surgical site infections (SSI) are among the most expensive healthcare-associated infections and result in a substantial psychosocial and financial burden for both patients and the healthcare system. A majority of SSIs are estimated to be preventable. Previous literature has focused on antibiotic prophylaxis as the primary intervention to reduce the incidence of SSI. However, little work in the foot and ankle literature has been done on the characterization and risk stratification of patients who will go on to develop superficial versus deep incisional SSIs. Moreover, the time at which patients typically present with an SSI has not been characterized. The primary aim of this study was to quantify the time from surgical intervention to the onset of superficial versus deep SSI. Methods: A retrospective review of 1933 foot and ankle procedures in 1632 patients from January 1, 2011 through August 31, 2015 was performed. Demographic data, type of surgery, subsequent diagnosis of superficial or deep incisional SSI, as well as amount and timing of antibiotic administration, incision, tourniquet and closure time were recorded. Superficial incisional SSIs were defined as those successfully treated with antibiotic therapy alone. Deep incisional SSIs were defined as those requiring subsequent wound irrigation and debridement (I&D). Time to treatment, outcomes and demographic variables were compared between patients that were treated with antibiotics alone and those that required I&D for definitive management. Results: 1569 procedures with complete data met inclusion criteria. There were 17 deep incisional SSIs (1.1%) that required I&D as part of definitive management. There were 63 superficial incisional SSIs (4.0%) that were treated successfully with antibiotics alone. The time interval between surgery and the initial treatment of deep incisional SSI (range: 11 to 42 days) was significantly greater than the time interval between surgery and initial treatment of superficial incisional SSI (range: 4 to 38 days) (28.18 ± 9.11 vs. 13.40 ± 4.65 days, p=<0.001). A total of 11 of 17 (64.7%) infections ultimately diagnosed as deep incisional SSIs failed a trial of antibiotics prior to I&D, in the remaining 6 of 17 (35.3%) infections antibiotics were held until intra-operative wound cultures were obtained. Conclusion: In our cohort of patients undergoing foot and ankle surgery the time to initial diagnosis and treatment of deep incisional SSI was longer than the time to diagnosis and treatment of superficial incisional SSI. Moreover, deep infections did not present until four weeks after surgery on average; this data is of some benefit in trying to define and understand SSIs

Timing of Open Reduction and Internal Fixation of Ankle Fractures

Category: Ankle, Trauma Introduction/Purpose: Unstable ankle fractures are typically treated with open reduction and internal fixation (ORIF) for stabilization in an effort to ultimately prevent post-traumatic arthritis. It is not uncommon for operative treatment to be performed as an outpatient in the ambulatory surgery setting several days to a couple weeks after the injury to facilitate things from a scheduling perspective. It is unclear what effect this delay has on functional outcome. The purpose of this study is to assess the impact of delayed operative treatment by comparing the functional outcomes for groups of patients based on the amount of time between the injury and surgery. Methods: A retrospective chart review of 122 ankle fracture patients who were surgically treated by ORIF over a three year period was performed. All ankle fracture patients older than 18 years with a minimum of 24 months of follow-up were included. A total of 61 patients were included for this study. Three patients were excluded; 2 patients had an open injury and 1 patient presented with a delayed union. Demographic data, comorbidities, injury characteristics, duration from injury to surgery, operative time, length of postoperative stay, complications and functional outcomes were recorded. Functional outcome was determined by Foot and Ankle Outcome Score (FAOS) at the latest follow-up visit. Comparison of demographic variables and the subcategory of FAOS including symptoms, pain, activities of daily living (ADL), sport activity and quality of life (QOL) was performed between patient underwent ORIF less than 14 days after injury and 14 days or greater. Results: A total of 58 patients were included in this study. Thirty-six patients (62.1%) were female. The mean age of patients was 48.14 ± 16.84 years (19-84 years). The mean follow-up time was 41.48 ± 12.25 months (24-76 months). The duration between injury and operative fixation in the two groups was 7 ± 3 days (14 days), respectively. There was no statistically significant difference in demographic variables, comorbidities, injury characteristics, or length of operation. Each subcategory of FAOS demonstrated no statistically significant difference between these two groups. (Table 1) Additionally, further analysis for the delayed fixation more than 7 days and 10 days also revealed no significant difference of FAOS. Conclusion: Open reduction and internal fixation of ankle fracture more than 14 days does not significantly diminish functional outcome according to FAOS. Delay of ORIF for ankle fractures does not play a significant role in the long-term functional outcome

Functional Outcomes after Fracture-Dislocation of the Ankles

Category: Ankle, Trauma Introduction/Purpose: Fracture-dislocation of the ankle represents a substantial injury to the bony and soft tissue structures of the ankle. Although there is a wealth of reported outcome after operative treatment of ankle fractures, there has been a limited focus on functional outcome of surgically treated ankle fracture-dislocations. The purpose of this study is to compare short-term functional outcome after open reduction and internal fixation (ORIF) in ankle fractures with and without dislocation. Methods: A retrospective chart review of ankle fractures surgically treated by ORIF over a three year period was performed. All ankle fracture patients 18 years or older with a minimum of 12 months follow-up were included. Demographic data, type of injury (bimalleolar, trimalleolar, etc.), operative time, complications, and functional outcomes were recorded. Functional outcome was determined by Foot and Ankle Outcome Score (FAOS) at the latest follow up visit. Comparison of demographic variables and the subcategories of FAOS including symptoms, pain, activities of daily living (ADL), sport activity and quality of life (QOL) were performed in ankle fractures with dislocation and without dislocation. A total of 62 patients were eligible for analysis, 38 (61.3%) were female. Twenty patients (32.3%) were fracture-dislocations and 42 (67.7%) had no dislocation. Mean age of patients was 48.44 ± 17.89 years (range, 19-85 years). Mean follow-up time is 39.79 ± 13.53 months (range, 12-76 months). Results: The fracture-dislocation cohort demonstrated worse FAOS than the nondislocation cohort (symptoms 73 vs 79, pain 75 vs 85, ADL 80 vs 88, Sport 63 vs 76 and QOL 54 vs 60, respectively), although none of these differences were statistically significant. Patients with ankle fracture-dislocation had more bony injury (i.e. more bimalleolar and trimalleolar injuries) (P = .007) and had a higher rate of subsequent hardware removal (11.9% vs 35%, P = .031) There was no statistically significant difference in patient demographics or the rate of complications. Conclusion: Fracture-dislocations of the ankle presented with more bimalleolar and trimalleolar fractures, although there was no statistically significant difference in terms of functional outcome. Subsequent surgery for hardware removal was higher in the dislocation cohort. Although our data showed no difference in outcome, there was a trend towards worse outcomes in the dislocation cohort that a larger study may be able to discern