Validated Risk Stratification System for Prediction of Adverse Events Following Open Reduction and Internal Fixation of the Ankle

Category: Ankle Introduction/Purpose: As orthopaedic surgery moves towards bundled payments, there is growing interest in identifying patients at high risk for postoperative adverse events. The purpose of this study is to develop and validate a risk stratification system for the occurrence of adverse events following open reduction and internal fixation (ORIF) of the ankle. Methods: Patients undergoing ORIF of closed ankle fractures as part of the National Surgical Quality Improvement Program (NSQIP) were identified. For patients undergoing surgery during 2006-2014, multivariate Cox proportional hazards modeling was used to identify factors that were independently associated with the occurrence of adverse events (including events such as surgical site infection, myocardial infarction, and pulmonary embolism). Based on these results, a nomogram was used to generate a point-scoring system for risk stratification. To evaluate the validity of the point-scoring system, the system was applied to patients undergoing ankle ORIF during 2015-2016. Results: Of the 6,140 patients undergoing surgery during 2006-2014, 5.8% developed an adverse event. Based on the Cox proportional hazards regression, patients were assigned points for each of the following statistically significant risk factors: anemia (+2 points), insulin-dependent diabetes (+2 points), age=65 (+1 point), dependent functional status (+1 point), chronic obstructive pulmonary disease (COPD; +1 point), and hypertension (+1 point; Figure 1A). 4,702 patients were identified in the 2015-2016 validation cohort. Among these patients, the risk-stratification system was found to strongly predict the risk for adverse events (p<0.001, Figure 1B). Conclusion: The occurrence of adverse events following ankle ORIF is associated with anemia, insulin-dependent diabetes, age=65, dependent functional status, COPD, and hypertension. We present and validate a simple point-scoring risk stratification system to predict the risk of adverse events. Future systems of bundled payments for ankle ORIF should exclude high-risk patients from the bundling systems, or make appropriate adjustments in reimbursement based on risk

Timing of Adverse Events Following Open Reduction and Internal Fixation of the Ankle

Category: Ankle Introduction/Purpose: There is increasing interest in the early identification and treatment of adverse medical events following orthopaedic procedures. The purpose of this study is to characterize the timing of adverse events following open reduction and internal fixation of closed fractures of the ankle. Methods: A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program. A total of 17,318 patients undergoing open reduction and internal fixation of closed ankle fractures were identified. For each of eight different adverse events, the median postoperative day of diagnosis, interquartile range for day of diagnosis, and middle 80% for day of diagnosis were determined. Timing was compared between uni-malleolar and bi-/tri-malleolar fractures. Results: The median day of diagnosis (and interquartile range; middle 80%) for myocardial infarction was 2 (1-5; 0-17), pneumonia 3 (2-7; 1-19), acute kidney injury 6.5 (2-18; 2-20), urinary tract infection 7 (2-14; 0-24), pulmonary embolism 10 (3-21; 0-27), sepsis 15 (4-22; 1-28), deep vein thrombosis 17 (10-22; 3-27), and surgical site infection 19 (14-25; 8-28; Figure 1). Myocardial infarction occured earlier in patients with bi-/tri-malleolar fractures than in patients with uni-malleolar fractures (median postoperative day 2 versus 10, p=0.041). Similarly, sepsis occured earlier in patients with bi-/tri-malleolar fractures than in patients with uni-malleolar fractures (median day 10 versus 20.5, p=0.022). For the other 6 adverse events, there was no difference in timing between patients with uni-malleolar and patients with bi-/tri-malleolar fractures (p>0.05 for each). Conclusion: These precisely described time periods for occurrence of specific adverse events enable heightened awareness amongst orthopaedic surgeons during the first month following open reduction and internal fixation of the ankle. Orthopaedic surgeons should have the lowest threshold for testing for each adverse event during the time period of greatest risk

Total Ankle Arthroplasty Is Safer than Total Hip and Knee Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: Total hip and knee arthroplasty (THA and TKA) are performed far more commonly than total ankle arthroplasty (TAA), so patients and the orthopaedic community have a better understanding of the complication profile for THA and TKA than for TAA. The present study compares adverse event rates, the rate of blood transfusion, operative times, length of stay, and the rate of hospital readmission between TAA, THA, and TKA procedures. Methods: Patients were identified who underwent TAA, THA, or TKA during 2006-2016 as part of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Multivariate regression was used to compare TAA to THA and TKA in terms of adverse event rates, the rate of blood transfusion, operative times, length of stay, and the rate of hospital readmission. All analyses were fully adjusted for differences in baseline demographic, comorbidity, and procedural characteristics, including type of anesthesia. The level of significance was set at p<0.05. Results: A total of 138,325 patients were identified as having undergone THA, 223,587 TKA, and 839 TAA. The total complication rate was lower for TAA (2.98%) compared to THA (4.92%, p=0.011) and TKA (4.56%, p=0.049; Table 1). Similarly, the rate of blood transfusion was lower for TAA (0.48%) compared to THA (9.66%, p<0.001) and TKA (6.44%, p<0.001). Interestingly, operative time was approximately an hour longer for TAA (157.7 minutes) compared to THA (93.6 minutes, p<0.001) and TKA (93.7 minutes, p<0.001). Length of stay was approximately one day shorter for TAA (1.9 days) compared to THA (2.9 days, p<0.001) and TKA (3.0 days, p<0.001). Finally, the rate of readmission was lower for TAA (1.5%) compared to THA (3.7%, p=0.002) and TKA (3.4%, p=0.005). Conclusion: TAA is a relatively rare procedure to which patients may not have had much exposure. Patients considering TAA are more likely to have had exposure to more common procedures such as THA and TKA (through family, friends, their own procedures, etc.). Patients can be counseled that relative to THA and TKA, TAA is a safer procedure in the perioperative time frame, with significantly lower rates of adverse events, blood transfusion, additional surgery, and hospital readmission. Their procedures can be expected to take longer, but their hospital stays can be expected to be shorter

Quality of Modern Total Ankle Arthroplasty Research

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) is gaining popularity as an alternative to ankle arthrodesis in the setting of end-stage ankle arthritis. However, compared to hip and knee arthroplasty, there is a relative dearth of evidence to support its use. This study assesses the quality of literature surrounding modern TAA designs. Methods: A search of all peer-reviewed, English-language journals was conducted to identify publications involving TAA. The initial search identified 444 articles published during 2006-2016. Of these, 182 were excluded because they were not clinical outcomes studies, 46 because the TAA implant was no longer available, and 15 because the primary outcome of the study was not related to TAA, leaving 201 articles for analysis. Results: No Level I studies were identified. Seventeen (8%) studies were Level II, 48 (24%) Level III, 128 (64%) Level IV, and 8 (4%) Level V. One hundred forty-three studies (71%) were retrospective in nature. Stratification by study design revealed 128 (64%) case series, 33 (16%) experimental cohort studies, 19 (10%) case-control studies, 13 (6%) observational cohort studies, and 8 (4%) case reports. The number of studies published each year steadily increased from 2006 to 2016. A total of 51% of TAA research was published in only two journals: Foot and Ankle International and the Journal of Bone and Joint Surgery. Publications from the United States accounted for 36% of total publications. The most published implant was the Scandinavian Total Ankle Replacement (Figure 1). Conclusion: While the number of TAA studies published each year has steadily increased since 2006, the quality of this research as measured by level of evidence remains suboptimal. This analysis highlights the need for continued improvement in methodology and development of robust prospective registries to advance our knowledge of TAA as a treatment for end-stage ankle arthritis

Sensitivity of the Saline Load Test for Traumatic Arthrotomy of the Ankle

Category: Ankle Introduction/Purpose: The saline load test is routinely used to evaluate for traumatic arthrotomy in orthopaedics. The purpose of this study was to determine the volume of saline required to detect traumatic arthrotomy of the ankle. Methods: 42 patients undergoing elective ankle arthroscopy were prospectively enrolled. For each patient, a standard 4 mm anteromedial portal was established. Next, an 18-guage needle was inserted at the site of the anterolateral portal. Sterile saline was slowly injected through the needle until saline extravasated from the anteromedial portal. Saline volumes at the time of extravasation were recorded and analyzed. Results: The saline volume required to achieve extravasation ranged from 0.2mL-60.0 mL (Figure 1A). The median saline volume required to achieve extravasation (and interquartile range) was 9.7 mL (3.8-29.6 mL); however, five of 42 patients required volumes between 50.0 mL and 60.0 mL. A total of 50.0 mL was required to achieve 90% sensitivity, 55.0 mL to achieve 95% sensitivity, and 60.0 mL to achieve 99% sensitivity (Figure 1B). Conclusion: The previously recommended 30 mL of saline required to reliably detect traumatic arthrotomy of the ankle may be too small a volume. The present study suggests that clinicians should attempt to inject 60 mL in order to effectively rule out a traumatic arthrotomy injury

Authorship and Citations in Foot and Ankle International from 1980-2017

Category: Other Introduction/Purpose: Orthopaedic foot and ankle surgery is a young and rapidly evolving orthopaedic subspecialty. Little is known regarding the authors contributing to the field. The purpose of this study is to characterize the demographics of the authors publishing foot and ankle research since the inception of the research journal of the American Orthopaedic Foot and Ankle Society. Methods: All publications in the journal Foot and Ankle International between 1980 and 2017 were reviewed. Papers were characterized in terms of number of authors, number of institutions, and number of references. The first and corresponding authors were also characterized in terms of country of origin, gender, and degree qualification. Each of these characteristics was tested for trends over time. Results: In total, 5,323 publications were reviewed, including 4,297 research articles, 367 case reports, 262 editorials, 159 letters, and 121 technique tips. The mean number of authors per paper increased from 2.3 during the 1980s to 4.3 during the 2010s (p0.05). The mean number of references to other work increased from 13.8 during the 1980s to 24.4 during the 2010s (p<0.001). Conclusion: The authors of the foot and ankle literature have changed markedly over the past 4 decades. Most notably, there have been shifts towards female and international authorship. The number of authors per paper has also nearly doubled over time. Such trends are likely to continue as the field of foot and ankle grows

Time related effects of non-steroidal anti-inflammatory drugs on Achilles tendinopathy in a murine model

Category: Basic Sciences/Biologics Introduction/Purpose: Tendinopathy has been identified to result from work and sports-related activities, in many patients. Common treatment for such degenerative tendon pathology includes non-steroidal anti-inflammatory drugs (NSAIDs). Although they provide pain relief, their mechanistic effects, on modulating inflammation associated with tendinopathy is poorly understood. Recent reports suggest impaired functional healing of rat rotator cuff tear repairs when treated in the early postoperative period with ibuprofen, while delayed treatment did not affect healing. We have now identified, using a murine model, a cascade of genes associated with innate inflammation, which influence premature fibrotic scarring without repair. The objective of this study was to evaluate the effects of orally administered ibuprofen on inflammation and wound-healing responses after initiation and during progression of Achilles tendinopathy in a murine model. Methods: All animal experimentation was carried out under IACUC approval. C57BL/6 wild-type male mice (12 wks) received two injections, two days apart, of 100ng rhTGF-β1 into the midportion of the Achilles tendon. Ibuprofen (IBU) was administered orally as described by Ezell et al5, for 7 days either 1 day (Early) or 8 days (Late) after the initiating injury. Experimental groups were 1) Tendinopathy + NO drug, 2) Tendinopathy + IBU Early, 3) Tendinopathy + IBU Late, 4) Naïve mice + IBU Early. Following sacrifice of the mice at 28 days post injury, Achilles tendons were harvested, and RNA was prepared as described by Trella et al6, for transcriptomic analyses using wound healing and NfKb target gene platforms (PAMM-121A, PAMM-225ZA Qiagen, Valencia, CA). Tendon histopathology was assessed on paraffin embedded thin sections using standard methods for HE and Safranin O staining. Results: Both early and late dosing times with ibuprofen prolonged the innate inflammation response genes (e.g., PGE Synthase, Interleukin1b, Interferon gamma, Cxcl3 chemokine), relative to untreated tendinopathy. Furthermore, early dosing also elevated collagen genes (Collagens 1, 3 and 5), and such a response has been associated with fibrotic scarring. Drug administration to naïve mice showed no significant effects on gene expression in the tendons. Conclusion: This study represents the first report of the time related effect of ibuprofen on mechanisms involved in healing of tendinopathy. If the drug is administered early after the initiating injury, a prolonged increase in inflammation and potential for scarring in the tendon was observed, whereas later administration resulted in persistent inflammation only. The data suggest that the anti-inflammatory action of such NSAID may occur outside of the tendon (such as the bone marrow) resulting in a dysregulated systemic mechanism that controls the innate (tendon) inflammation and healing pathways