Evidence Versus Practice: Operative Treatment Preferences in Hallux Valgus

Background: There is substantial variability in the operative treatment of hallux valgus despite the existence of high quality evidence to guide treatment decisions. The purpose of this study was to determine the current trends in the treatment of mild, moderate, and severe hallux valgus and if greater degrees of consensus correlate with the presence of higher-level evidence. Methods: Members of the American Orthopaedic Foot & Ankle Society completed a 14-item survey. A total of 131 (14%) of 922 members completed the survey. Three cases representing 3 stages of HV were presented, and respondents selected their preferred treatment. Preferred forms of proximal and distal metatarsal osteotomies, as well as mode of fixation for each, were inquired. Results: In the treatment of mild hallux valgus without second metatarsalgia, 80% of those surveyed chose a distal metatarsal osteotomy, while, if second metatarsalgia was present, 56% chose a distal metatarsal osteotomy with a second metatarsal-shortening osteotomy. In the treatment of moderate hallux valgus, there was generally less consensus, while, in the treatment of severe hallux valgus, a majority of those surveyed chose a Lapidus procedure, with the addition of a second metatarsal-shortening osteotomy in the presence of second metatarsalgia. The most popular distal and proximal metatarsal osteotomies, respectively, were chevron osteotomy (80%) and opening wedge osteotomy (33%). The presence of Level I evidence did not significantly correlate with higher degrees of consensus. Conclusion: Despite the existence of high-quality evidence supporting the use of certain procedures in the treatment of HV, there exists an apparent lack of consensus among surgeons about the choice of surgical procedures. Moreover, higher-level evidence was not correlated with greater consensus in hallux valgus. Level of Evidence: Level II

Quality and Variability of Online Physical Therapy Protocols for Isolated Meniscal Repairs.

The ideal meniscal repair postoperative rehabilitation protocol has yet to be determined. Further, patients are attempting to access health care content online at a precipitously increasing rate given the efficiency of modern search engines. The purpose of this investigation was to assess the quality and variability of meniscal repair rehabilitation protocols published online with the hypothesis that there would be a high degree of variability found across available protocols. To this end, Web-based meniscal repair physical therapy protocols from U.S. academic orthopaedic programs as well as the first 10 protocols identified by the Google search engine for the term meniscal repair physical therapy protocol were reviewed and assessed via a custom scoring rubric. Twenty protocols were identified from 155 U.S. academic orthopaedic programs for a total of 30 protocols. Twenty-six protocols (86.6%) recommended immediate postoperative bracing. Twelve (40.0%) protocols permitted immediate weight-bearing as tolerated (WBAT) postoperatively, while the remaining protocols permitted WBAT at an average of 4.0 (range, 1-7) weeks. There was considerable variation in range of motion (ROM) goals, with most protocols (73.3%) initiating immediate passive ROM to 90°. The types and timing of strength, proprioception, agility, and pivoting exercises advised were extremely diverse. Only five protocols (16.7%) employed functional testing as a marker for return to athletics. The results of this study indicate that only a minority of academic orthopaedic programs publish meniscal repair physical therapy protocols online and that within the most readily available online protocols there are significant disparities in regards to brace use, ROM, weight-bearing, and strengthening and proprioception exercises. These discrepancies reflect the fact that the best rehabilitation practices after a meniscal repair have yet to be elucidated. This represents a significant area for improved patient care through standardization

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