Safety and Outcomes of Inpatient Compared with Outpatient Procedures for Elective Orthopaedic Foot and Ankle Surgery

Category: Ankle Introduction/Purpose: With increasing implementation of the bundled payment model and meteoric rise in healthcare prices over the past decade, efforts to minimize unnecessary costs are highly warranted. One potential method to do this is by performing foot and ankle surgery on patients either in an appropriate inpatient or outpatient setting. There is evidence suggesting that outpatient orthopaedic foot and ankle surgery for ankle fractures leads to lower risk of 30-day medical morbidities, reoperation, and admissions as compared to inpatient surgeries. The purpose of this study is to compare the inpatient versus outpatient outcomes of patients undergoing elective orthopaedic foot and ankle surgery using a large national database. Methods: Data from the National Surgical Quality Improvement Program (NSQIP) years 2005-2015 were used in this study. There were 216 CPT codes specific to orthopaedic foot and ankle surgery queried for inclusion in the analysis, 36 of which were identified in the database. CPT codes representing ORIF of ankle fractures were excluded. These codes were manually reviewed by a licensed orthopaedic foot and ankle surgeon to confirm their elective nature, reducing the number of codes to 30. Demographic, comorbidity, and outcome variables were calculated and stratified by inpatient versus outpatient status. Significant differences in these variables were evaluated using ANOVA for continuous variables and Pearson’s Chi-Square for categorical variables. There was a total of 7,672 cases identified. Results: The most common elective inpatient procedures were transmetatarsal amputation (57.9%), total ankle arthroplasty (13.0%), and midtarsal amputation (5.2%). The most common elective outpatient procedures were collateral ligamentous repair (15.8%), transmetatarsal amputation (10.7%), and extensor tendon repair (8.7%). As compared to patients receiving outpatient treatment, patients who received inpatient treatment for elective foot and ankle surgeries were significantly older, male, had lower BMI, and were more likely to smoke. Inpatients were also more likely to receive general anesthesia, have shorter operative times, and have functional limitations (p<0.05). Inpatients were more likely to suffer from various complications, including surgical site infection, pneumonia, unplanned intubation, renal insufficiency, acute renal failure, urinary tract infections, myocardial infarction, cardiac arrest, stroke, transfusions, sepsis, and reoperation (p<0.05). Conclusion: Our results show that outpatient procedures for elective foot and ankle surgery were significantly safer than inpatient procedures in regard to complication profiles. However, the inpatients who received surgery were significantly older than the outpatients, which may explain the described findings. Additional advanced regression modeling is currently underway to examine the multivariable associations between inpatient status and total hospital costs

A Comparative Analysis of Risk and Cost-effectiveness of Outpatient versus Inpatient Hindfoot Fusion

Category: Hindfoot Introduction/Purpose: Hindfoot fusion procedures are increasingly being performed in the outpatient setting. However, the cost-effectiveness of hindfoot fusion procedures compared with risk and benefit have not been clearly investigated. The primary objective of this study was to investigate the cost-effectiveness of outpatient versus inpatient hindfoot arthrodesis. Secondary objectives were to compare patient characteristics and short-term complications of patients in each cohort. Methods: This was a retrospective review of all patients who underwent inpatient and outpatient hindfoot fusion procedures at a single institution from 2013-2017. Data collected for each patient included demographic information, operative variables, comorbidities, complications, and any subsequent emergency department visits, readmissions or reoperations. Cost data was collected for each inpatient or outpatient encounter, as well as any subsequent encounters related to the index procedure. Results: Of 151 total hindfoot procedures performed over the study period, 37 were inpatient and 114 were performed in the outpatient setting. There were 3 more readmissions, 22 more ED visits, and 0 more reoperations after outpatient surgery vs inpatient surgery. The average total cost for an outpatient hindfoot fusion procedure was significantly lower than the average total cost for inpatient hindfoot fusion, without a significant increase in complication rate. We are currently in the process of performing the total cost analysis, and will have the completed cost and risk/benefit information within the next two weeks. Conclusion: Outpatient hindfoot fusion surgery may be more cost-effective when compared to inpatient fusion surgery without a significant increase in complications, ED visits, or readmissions

First Tarsometatarsal Joint Shape and Orientation

Category: Bunion Introduction/Purpose: Studies have demonstrated that patients with hallux valgus (HV) deformities have increased mobility in the first tarsometatarsal (TMT) joint. Anatomical factors widely considered to play a role in the instability are shape and frontal plane orientation of the joint. An oblique rather than horizontal orientation of the articular surfaces and a round shape, rather than a flat shape, are believed to predispose to the deformity. The purpose of this study was to assess whether the shape and angulation of the first TMT joint are affected by the positioning of the foot and orientation of the x-ray beam. Methods: Ten adult above knee fresh frozen cadaveric specimens were used, with a mean age of 79.9 (range, 54-88) years. There were no clinical forefoot deformities noted in any of the feet. One of the specimens had moderate ankle arthritis and one had a mild cavus-varus. A radiolucent loading apparatus was built that, allowing neutral positioning of a plantigrade foot and controlled angulation of 5o, 10 o, 15o and 20o in dorsiflexion, plantarflexion, inversion and eversion. Fluoroscopic images were obtained of each cadaveric specimen in all seventeen different positions, with the x-ray beam perpendicular to the floor and aiming to the base of the 1st metatarsal. Two blinded orthopaedic surgeons independently measured the 1st tarsometatarsal (TMT) joint angle and graded the distal articular cartilage of the medial cuneiform as flat or curved. Readers also graded the image quality into assessing the joint into “Low”, “Intermediate” and “Good”. Results: 1st TMT joint angle was 112.92o ± 6.89o. Values were significantly different between cadaveric specimens (p<.0001). There was a tendency for increased valgus angulation of the joint in images positioned in neutral, plantarflexion and inversion and decreased valgus angulation with dorsiflexion and eversion.Regarding the shape of the distal articular cartilage of the medial cuneiform, joints with flat configuration showed significantly increased mean 1st TMT joint angle when compared to curved surfaces (115.9o vs. 110.7o, p<.0001). In 8 out of 10 of the cadaveric specimens (80%) the shape of the 1st TMT joint changed between curved or flat configuration depending on the positioning of the foot. In only 2/10 (20%) the joint configuration remained the same for all different positions (one flat and one curved). Conclusion: Our cadaveric study found that the shape and angulation of the first TMT joint is affected by the positioning of the foot and orientation of the x-ray beam. Clinical usefulness of the 1st TMT radiographic anatomical characteristics is limited and should not influence in the treatment of patients with possible instability the first tarsometatarsal (TMT) joint

Intraoperative Syndesmotic Instability Test

Category: Ankle, Trauma Introduction/Purpose: Precise diagnosis of distal tibiofibular syndesmotic injury is challenging and a gold standard diagnostic test has still not been established. Tibiofibular clear space identified on radiographic imaging is considered the most reliable indicator of the injury. The Cotton test is the most widely used intraoperative technique to evaluate the syndesmotic integrity although it has its limitations. We advocate for a novel intra operative test using a 3.5 mm cortical tap. Methods: Tibiofibular clear space was assessed in nine cadaveric specimens using three sequential fluoroscopic images. The first image was taken prior to the application of the tap test representing the intact and non-stressed state. Then, a 2.5 mm hole was drilled distally on the lateral fibula, and a 3.5 mm cortical tap was then threaded in the hole. The tap test involved gradually advancing the blunt tip against the lateral tibia, providing a tibiofibular separation force (intact, stressed). This same stress was then applied after all syndesmotic ligaments were released (injured, stressed). Measurements were compared by one-way ANOVA and paired Student’s t-test. Intra and inter-observer agreements were evaluated by intraclass correlation coefficient (ICC). P-values 6 mm as diagnostic for syndesmotic instability, the tap test demonstrated a 96.3% sensitivity and specificity, a 96.3% PPV and NPV and a 96.3% accuracy in diagnosing syndesmotic instability. Conclusion: Our cadaveric study showed that this novel syndesmotic instability test using a 3.5 mm blunt cortical tap is a simple, accurate and reliable technique able to demonstrate significant differences in the tibiofibular clear space when injury was present. It could represent a more controlled and stable low-cost alternative to the most used Cotton test

Percutaneous Tendon Achilles Lengthening

Category: Hindfoot Introduction/Purpose: Percutaneous Achilles tendon lengthening (TAL) is a common procedure used to address equinus contracture of the foot. A triple hemisection technique has become popular due to its ease and efficiency. Several studies evaluate the surgical outcomes of this procedure, but currently, descriptive anatomical studies are lacking. The objective of the study was to evaluate the accuracy of performing Achilles tendon percutaneous hemisections, the amount of tendon excursion in the tensile gaps of the cuts after forced dorsiflexion and the improvement in the range of motion for dorsiflexion of the ankle joint. Methods: Ten fresh-frozen above-knee cadaveric specimens were used. A percutaneous triple hemisection of theAchilles tendon (proximal, intermediate, and distal) was performed. Maximum ankle dorsiflexion was evaluated pre- and postprocedure with a digital goniometer. After proper dissection, the relative width of the cuts was noted. Followingforced ankle dorsiflexion, displacement in the tensile gaps was measured in all 3 cuts with a precision digital caliper. Results: The overall relative width of the percutaneous cut was 51.3% ± 16.3% of the Achilles tendon diameter, 44.3%± 13.6% for the proximal cut, 50.3% ± 15.6% for the intermediate cut, and 59.3% ± 18.4% for the distal cut. Tendonexcursion averaged 13.0 ± 3.8 mm for the proximal cuts, 12.5 ± 4.7 mm for the intermediate cuts, and 8.2 ± 3.7 mm forthe distal cuts. One cadaver had a complete rupture of the Achilles tendon and was excluded from the excursion dataanalysis. The mean range of motion for ankle dorsiflexion was 8.1 ± 3.9 degrees preprocedure and 27.6 ± 5.3 degreespostprocedure. The dorsiflexion angle significantly increased (P < .0001) at an average of 19.5 ± 5.0 degrees following TAL. Conclusion: Our cadaveric study demonstrated that the percutaneous triple hemisection of the Achilles was an accuratetechnique that provided successful lengthening of the tendon and increased ankle dorsiflexion. Complete ruptures arepossible complications. Our cadaveric study showed that in a clinical situation, triple hemisections of the Achilles tendon can be performed reliably, with significant improvement of the ankle dorsiflexion, mainly through increased tendon excursion at the proximal and intermediate cuts, and with low risk of complete ruptures

Syndesmotic Fixation With Suture Button. Neurovascular Structures at Risk. A Cadaver Study

Category: Trauma Introduction/Purpose: Damage to distal tibiofibular syndesmosis occurs in 25% of operative ankle fractures. Syndesmotic stabilization is crucial to prevent significant pain, instability and degeneration of the joint. One operative method is insertion of suture buttons. Though effective, this method can result in entrapment and damage of the saphenous neurovasculature of the medial tibia. The purpose of this study was to describe the anatomic risk of direct injury to the saphenous nerve and greater saphenous vein during syndesmotic suture button fixation. Methods: This study was performed on 10 below knee cadaveric leg specimens. Under fluoroscopic guidance, syndesmotic suture buttons were placed from lateral to medial at 1cm, 2cm, and 3cm above the tibial plafond at an anterior angle of 30 degrees to the coronal plane. Dissection was performed through medial tibial incision to record the distance and position of each button from the greater saphenous vein and saphenous nerve. Statistical measurement and analysis was performed with SPSS. Results: The mean age of cadavers was 78.2 ± 6.9 years and mean BMI was 21.6 ± 2.2. The mean distance of the saphenous nerve to the suture buttons at 1cm, 2cm, and 3cm were 7.1 ± 5.6mm, 6.5 ± 4.6mm, and 6.1 ± 4.2mm, respectively. The saphenous nerve was compressed in 2 cadavers (20%) at 1cm, 2 cadavers (20%) at 2cm and 1 cadaver (10%) at 3cm by suture buttons. Mean distance of the greater saphenous vein from the suture buttons at 1cm, 2cm and 3cm were 8.6 ± 7.1, 9.1 ± 5.3, and 7.9 ± 4.9mm respectively. The great saphenous vein was compressed in 2 cadavers (20%) at 1cm, 1 cadaver (10%) at 2cm and 1 cadaver (10%) at 3cm by suture buttons. Conclusion: There was at least one case of injury to both the saphenous vein and nerve at every level of button insertion at a rate of 10-20%. The close proximity of the suture button to neurovasculature combined with significant anatomic variation in saphenous nerve anatomy suggest that neurovascular injury may be best avoided by direct visualization prior to suture button placement. Great care should be taken to avoid injury to saphenous neurovascular structures during suture button insertion. Keeping an eye on close proximity of neurovasculatures, we recommend medial incision for during syndesmotic suture button fixation

Staple versus Suture Closure for Ankle Fracture Fixation

Category: Trauma Introduction/Purpose: Ankle fractures are commonly treated fractures by orthopaedic surgeons with unique challenges to skin closure due to the lack of subcutaneous support. Metallic staples are a commonly accepted method of skin closure in other specialties, though the use of staples in orthopaedics, and more specifically in foot and ankle surgery, remains a topic of debate. Proponents of staples report several potential advantages to using staples instead of sutures, including reduced closure time, faster and less painful removal, or improved cosmetic appearance. This study aimed to compare outcomes of suture versus staple closure as well as to evaluate the safety of staple closure after open fixation of acute traumatic ankle fractures. Methods: The medical records of 94 patients treated at our institution with open fixation of an acute traumatic ankle fracture by a single surgeon between January 2011 and June 2017 were retrospectively reviewed. Demographics, preoperative characteristics, relevant comorbidities, operative characteristics, and postoperative outcomes were compared between patients who received superficial skin closure using staples versus suture techniques. Statistical analysis was performed using chi-squared test and Fisher’s exact test. Results: The staple and suture group patients were demographically similar at baseline. Of the 94 patients included in this study, 10 patients developed local wound related complications postoperatively, including 5 with wound dehiscence, 4 with superficial wound infections, and 1 deep infection . Eight patients required revision surgery due to infection or wound dehiscence. Four patients in the suture group developed superficial wound infections, compared with zero in the staple group. One patient in the staple group developed a deep infection. With the numbers available, no significant differences could be detected in the incidence of postoperative infections, local wound related complications and revision surgeries between two wound closure groups. Conclusion: Our data suggests that there is no statistical difference in outcomes between staple and suture closure after open fixation of acute ankle fractures. Because there was no difference in morbidity with possible benefits of reduced closure time, faster removal, and improved cosmetic appearance, we conclude that staple closure may be a safe alternative to sutures for superficial skin closure. This study adds evidence to a growing body of literature and suggests that staples can be used in some instances, clinical decision making, surgeon preference, and technique proficiency should remain the cornerstone of closure in ankle fracture surgery