Transverse versus longitudinal incision for minimally invasive Achilles tendon repair

Category: Sports Introduction/Purpose: The rate of wound complications following traditional open Achilles tendon repair is reported at 7-8%. In an effort to reduce the rate of wound complications, orthopaedic surgeons have adopted novel minimally invasive techniques. The purpose of this study is to characterize the rate of wound and other early complications following a minimally invasive Achilles tendon repair, to identify any factors associated with increased risk. Methods: The postoperative courses of 55 patients who underwent minimally invasive Achilles tendon repair by two surgeons at separate academic medical centers were retrospectively reviewed. Repair technique was similar in all cases, making use of the same commercially available suture-guidance jig, silicone-impregnated deep suture material, and locking stitch technique. However, 31 procedures used a longitudinal incision and a tourniquet (one surgeon’s preference), while 24 procedures used a transverse incision and no tourniquet (the second surgeon’s preference). Of the 24 procedures using transverse incisions, 2 had to be converted to L-shaped incisions to achieve better access to the tendon. The rates of early complications within 3 months after surgery were characterized and compared between patients with differing procedural characteristics. Results: Of the 55 patients included in the study, 2 (3.6%) developed wound complications. Both wound complications appeared to be reactions to the deep suture material (see Table 1 for details). There was no statistical difference in the rate of wound complications between patients in the longitudinal incision/tourniquet group and patients in the transverse incision/no tourniquet group (6.5% versus 0.0%; p=0.499). Three patients (5.5%) developed sural neuropraxia, which manifested as mild-to-moderate subjective numbness with sensation remaining intact to light touch. There were no cases of re-rupture. At 3-month follow-up, all 55 patients had intact Thompson tests and well-healed wounds. Conclusion: The rate of wound complications following minimally invasive Achilles repair is low at 3.6%. The present study could not demonstrate a difference in risk for wound complications between patients treated with a longitudinal incision and tourniquet and patients treated with a transverse incision and no tourniquet. The wound complications we observed were primarily attributable to inflammatory reactions to the silicone-impregnated deep suture material. Patients should be counseled that although risk for wound complications may be lower with minimally invasive techniques, such techniques do risk sural neuropraxia and deep suture reaction. Further prospective analysis is warranted

A Longitudinal Analysis of 25 Years of Foot & Ankle Fellowship Training

Category: Other Introduction/Purpose: There is a growing demand for orthopaedic surgeons trained in management of foot and ankle conditions, yet there remains wide variation in the process of fellowship training and a dearth of outcomes assessment. The 2016- 2017 American Orthopaedic Foot & Ankle Society (AOFAS) Fellowship Match consisted of 75 available positions—a 44% increase over that a decade prior. Of the 48 programs offering positions, 6 offer standardization and oversight by the Accreditation Council for Graduate Medical Education (ACGME). We aimed to assess the educational curriculum, research production and career paths of 25 years of graduates from the longest running ACGME accredited foot and ankle fellowship program in the United States. Methods: A database of graduates from a single foot and ankle fellowship program was utilized to identify practice types and locations as well as tabulate PubMed indexed articles authored by fellows while in the program. The educational curriculum corresponding to their training is described. Additionally, historical data from the AOFAS Match Program was evaluated for trends. Results: Between 2005-2015, there were 515 graduates of AOFAS sponsored foot & ankle fellowship programs in the U.S. (Figure 1). Successful match rates for fellowship applicants ranged from 80-96% and program fill rates varied between 61-93%. Our fellowship program has graduated 50 fellows in the past 25 years of whom 37 (74%) practice in the U.S. and 13 (26%) practice abroad. When accounting for international, military and academic practitioners, 54% of our graduates entered practice types with a teaching component. Research articles for each fellow were examined and on average 1.9 PubMed indexed articles (range 0-12) were published by fellows during their tenure in the program. Graduates going into military, international and U.S. academic practices published 2.5, 2.8 and 3.7 articles during training, respectively. Conclusion: As technical and cognitive demands of foot and ankle surgeons increase, the need for optimized fellowship training has become paramount. Assessment of educational curriculum, research production and graduate practice type may help fellowships identify areas for improvement in order to meet program and trainee goals

Virtual Scribe Services Are Associated with Higher Physician Satisfaction than Traditional Documentation

Category: Other Introduction/Purpose: Introduction of a novel virtual scribe service is theorized to eliminate waste from clinic operations. The iScribes virtual scribe application is activated in clinic and records audio proceedings of patient encounters. Recordings are transmitted to a remotely located medical scribe who translates patient-physician discussions into comprehensive clinic notes per the physician’s preferences. We hypothesize that virtual scribe services result in accurate notes, simple integration and high satisfaction. Methods: A modified version of a previously validated survey on physician documentation quality and satisfaction was digitally distributed to 193 orthopaedic surgeons who were using the iScribes system. The survey consisted of 16 domains relating to implementation, ease-of-use, efficiency, integration with electronic medical records, information quality, overall satisfaction and comparison to prior documentation systems. Results: Of the 193 physicians surveyed, 94 responded (49%). The majority (85%) were in private practice with the remaining in private-academic hybrids (2%), university systems (5%) and hospital employment (7%). Prior documentation modes were standard dictation (80%), Dragon voice-recognition (14%) and self-written/typed notation (6%). The average practice duration was 15 years (range: 1-34 years), and the average time utilizing the virtual scribe service was 12 months (range: 1-48 months). Providers rated the following domains as “agree” or “strongly agree”: easy to use (96%), fast (92%), integrates with workflow (94%), acceptable security (90%), allows me to perform work well (95%), reliable (90%), information is complete/accurate (88%), satisfaction with technical support (92%), overall satisfaction (92%) and prefer iScribes over previous system (93%) (Figure 1). Conclusion: The iScribes virtual scribe service was associated with high physician satisfaction in all tested domains and was preferred over traditional documentation in the present cohort of orthopaedic surgeons. Prospective analysis of time, quality and cost metrics is warranted

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

The Use of Patient-Specific 3D Printed Titanium Implants for Complex Foot and Ankle Limb Salvage, Deformity Correction, and Arthrodesis Procedures

Category: Ankle,Ankle Arthritis,Basic Sciences/Biologics,Trauma Introduction/Purpose: Large lower extremity bony defects, complex foot and ankle deformities, and high-risk arthrodesis situations can be difficult to treat. These challenging pathologies, often require a critical-sizes and/or shaped structural bone void filler which may not be available with allograft bone. The advancement of 3D printing technology has allowed for the use of custom designed implants for foot and ankle surgery. This study reports on the radiographic and functional outcomes of a case series of patients treated with patient-specific 3D printed titanium implants. Methods: Seven consecutive patients who were treated with custom designed 3D printed implant cages for severe bone loss, deformity correction, and arthrodesis procedures were included in this study. A minimum of 1-year follow-up was required. No patients were lost to follow-up. Patients completed preoperative and most recent follow-up VAS for pain, FAAM, and SF-36 outcomes questionnaires. All patients had post-operative radiographs and CT scans to assess bony incorporation. Results: The mean age of these patients was 54.6 (35-73 years of age). The mean follow-up of these seven patients was 17.1 months (range 12 to 31). Radiographic fusion with cage ingrowth and integration occurred in all seven patients verified by CT scan. There was statistically significant improvement in all functional outcome score measures (VAS for pain, FAAM, and SF-36). All patients returned were satisfied with surgery. There were no failures. Case examples are demonstrated in Figure 1. Conclusion: This cohort of patients demonstrated the successful use of custom 3D printed implants to treat complex large bony defects, deformities and arthrodesis procedures of the lower extremity. These implants offer the surgeon a patient specific approach to treat both pain and deformity that is not necessarily available with allograft bone

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

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

Efficacy of Particulated Juvenile Cartilage Allograft Transplantation for Osteochondral Lesions of the Talus

Category: Ankle, Arthroscopy, Basic Sciences/Biologics, Sports Introduction/Purpose: Symptomatic osteochondral lesions of the talus (OLTs) are difficult to treat. As such, a broad array of cartilage treatment options exist. Despite the various techniques, many patients require multiple procedures due to persistent pain, failure of cartilage adherence, or persistent mechanical symptoms. The cartilage replacement technique, particulated juvenile cartilage allograft transplantation (PJCAT), is a novel treatment option supported by the benefits of ease of application, no need for perpendicular access to the OLT, and the delivery of viable hyaline cartilage. However, there is minimal clinical data to support this treatment option. The purpose of this study was to determine the efficacy of PJCAT. Methods: After obtaining IRB approval, we conducted a retrospective review of patients that underwent PJCAT for the treatment of OLTs at a single academic institution. From 2012 to 2015, 18 patients were identified. However, one patient died of an unrelated cause and two patients were lost to follow-up leaving 15 patients (7 males and 8 females) whom had a minimum of 12 months of follow up (mean 34.6, range, 12-51 months). The mean age of this cohort was 32.7 years (15-48) at time of surgery with BMI average 29.9 (18.8-40.2). The primary outcome was failure of the procedure defined as: recurrent or worsening symptoms with corresponding imaging demonstrating delamination, and/or the need for a secondary cartilage restoration procedure. Variables studied included: size of lesion denoted by MRI, intraoperative size, etiology (traumatic versus atraumatic), location of lesion, sex, age, and history of prior surgery. Results: Failure of primary procedure as defined by continued pain with corresponding imaging and/or necessity of secondary cartilage procedure after use of PJCAT was 40% (6/15). Preoperative MRI size (188.7 +/- 81.7mm2 vs. 113.5 +/- 50.5mm2, p<0.05) was significant predictors of PJCAT failure. Furthermore, male sex was predictive of failure(p<0.05). Age, BMI, etiology, technique (open versus arthroscopic), history of prior surgery nor location were predictors of failure. Lastly, patients with lesions greater than 125mm2 area were at a statistically significant increased risk of clinical failure. Functional outcome scores were significantly better at final follow-up in the patients who had undergone successful treatment versus those who did not: AOFAS score (89.4 +/- 8.4 vs. 65.8 +/- 26.7) and FAOS total (77.9 +/- 13.2 vs. 47.9 +/- 24.8). Conclusion: These findings demonstrate the association of preoperative MRI lesion size, intraoperative lesion size and male sex as risk factors for failure of PJCAT setting of an already difficult to treat pathology

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