Anterior Talofibular Ligament Abnormality on Routine Magnetic Resonance Imaging of the Ankle

The anterior talo­fibular ligament (ATFL) extends from the anteroinferior border of the ­fibula to the talar neck. Primary restraint to ankle inversion in plantar‑exion. Injury (acute or chronic) can be diagnosed with physical exam, stress X-Rays, ultrasound or magnetic resonance imaging (MRI). Purpose: MRI abnormalities in asymptomatic individuals known in other areas of orthopaedics (shoulder and spine). Purpose of our study: determine the prevalence of ATFL abnormalities found on MRI in asymptomatic individuals. Asymptomatic individuals - those undergoing MRI for pathology unrelated to lateral ankle trauma, instability, or inversion injuries

A Case Study of Pseudo-Neuropathic Pseudogout

Background This interesting case highlights the clinical progression of a rare disease process and the important role of a multi-disciplinary team in achieving a diagnosis and successful management plan. Case Presentation A 76-year-old male with a history of coronary artery disease, hypertension and hyperlipidemia presented as an outpatient with left foot pain and swelling. He had spent a week bicycling in Colorado one month prior to presentation. The pain was initially localized to the plantar surface of his foot and progressed to involve the lateral and dorsal aspects of the foot, as well as his great toe. The pain was accompanied by swelling of the midfoot without erythema and he was unable to bear weight. His podiatrist prescribed Ibuprofen and a foot brace for empiric treatment of tendonitis. An outpatient MRI demonstrated extensive bony edema and synovial enhancement within the midfoot, as well as severe superficial edema and peroneal tendonitis with mild subluxation. The patient was sent to the emergency department to be evaluated for osteomyelitis

Local bone graft harvested from the distal tibia or calcaneus for surgery of the foot and ankle.

BACKGROUND: Numerous operative procedures around the foot and ankle use bone graft to augment healing. Autologous bone graft remains the preferred type for these procedures. This can be harvested from the iliac crest, but complications are frequent. The purpose of our study was to investigate the option of harvesting the bone graft from the ipsilateral distal tibia or calcaneus. METHOD: Bone graft was harvested in 114 patients from the distal tibia (70 patients) or calcaneus (44 patients). The patients were followed postoperatively for an average of 16 (range 5 to 28) months and were evaluated for complications (minor and major), satisfaction, and healing rates. RESULTS: There were no major complications. Ten patients (8.7%) had minor complications including initial incisional sensitivity or local numbness, none of which affected function or required additional treatment. Satisfaction rate for the procedure was 100%. CONCLUSION: Use of autologous bone graft harvested from the ipsilateral distal tibia or calcaneus is a safe and reliable alternative to iliac crest bone graft harvest for operative procedures of the foot and ankle

The association of a varus hindfoot and fracture of the fifth metatarsal metaphyseal-diaphyseal junction: the Jones fracture.

BACKGROUND: Fractures to the fifth metatarsal metaphyseal-diaphyseal junction (Jones fracture) have high nonunion rates. Surgical intramedullary screw fixations have excellent results but a high refracture rate. This has been associated with inadequate screw size and too early return to activity. HYPOTHESIS: Varus hindfoot alignment overloads the lateral column of the foot and acts as a predisposing factor to the development of and failure of treatment of Jones fractures. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty-one primary Jones fractures (20 patients) treated surgically with a 4.5-mm cannulated screw were retrospectively reviewed. Detailed clinical and radiographic data and outcomes were recorded, including measurements of hindfoot alignment. RESULTS: A 100% union rate with return to prior activity level and no refractures were found at a mean follow-up of 49 months. Clinical varus was present in 16 feet, whereas radiographic measurements revealed 18 of 21 hindfeet to be in varus. The mean calcaneal pitch angle was 28.5 degrees , and the mean Meary angle was 13 degrees convex upward. Patients with varus alignment were fitted postoperatively with lateral hindfoot and forefoot posted orthotic inserts to correct alignment. CONCLUSION: The majority of patients sustaining Jones fractures have evidence of varus hindfoot alignment. This may be a predisposing factor to developing the fracture or refracture after fixation. Postoperative varus unloading (lateral hindfoot and forefoot posting) orthotic insert appears to be helpful in preventing reinjury or refracture of Jones fractures

Economic Burden of Inpatient Admission of Ankle Fractures

Category: Trauma Introduction/Purpose: Ankle fractures are one of the most prevalent traumatic orthopaedic injuries. A large proportion of patients sustaining operative ankle fractures are admitted directly from the emergency room prior to surgical management. In our experience, however, many closed ankle injuries may be safely and effectively managed on an outpatient basis. This study aims to characterize the economic impact of routine inpatient admission of ankle fractures. Methods: A retrospective review of all closed ankle fracture surgery performed by a single foot and ankle fellowship trained surgeon at a tertiary level academic center in 2012 was conducted to identify patients requiring postoperative inpatient admission. The National Inpatient Sample was queried for operative lateral malleolus, bimalleolar, and trimalleolar ankle fractures in 2012 to evaluate national estimates and length of stay by age. The maximum allowable Medicare inpatient facility reimbursements and Medicare outpatient facility reimbursements were obtained from the Medicare Acute Inpatient Prospective Pricer and a Medicare Outpatient Pricer Code respectively. Private facility reimbursement rates were estimated at 139% of inpatient Medicare reimbursement and 280% of outpatient reimbursement as described in the literature. Surgeon and anesthesiologist fees were considered similar between both inpatient and outpatient groups. A unique stochastic decision tree model was derived from probabilities and associated costs and evaluated with modified Monte Carlo simulation. Results: Of 76 lateral malleolar, bimalleolar, and trimalleolar ankle fracture ORIF performed in 2012 by the senior author, 7 required admission due to polytrauma, medical comorbiditites or age. Of the 67 outpatient cases, all were discharged home the day of surgery. In the 2012 national cohort analyzed, 48,044 estimated inpatient admissions occurred postoperatively for closed ankle fractures. Median length of stay was three days, and associated with facility reimbursement ranging from $12,920 for Medicare lateral malleolus fractures to$18,613 for private reimbursement of trimalleolar fractures. Outpatient facility reimbursements per case were $4,125 for Medicare patients and$11,459 for private insurance patients. The national cohort’s inpatient admission accounted for $796,033,050 in reimbursements, while outpatient surgery would have been associated with$419,327,612 for treatment of these ankle fractures. Conclusion: Closed lateral malleolus, bimalleolar, and trimalleolar fractures may be safely and effectively treated as outpatient procedures. Routine perioperative admission for ankle fractures results in over $367 million of excess facility reimbursements annually in the US. Even if a conservative 25$282 million dollar excess economic burden annually. While certain cases necessitate inpatient admission, with value based decision making becoming increasingly the responsibility of the orthopaedic surgeon, understanding cost implications of inpatient ankle fracture management may result in savings to the US healthcare system and patients individually

The Agility Total Ankle Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: Ankle arthritis is a debilitating condition causing severe functional impairment. In contrast to degenerative arthritis of the knee and hip, ankle arthritis is typically post-traumatic and affects a younger population. While arthrodesis has been the gold standard of surgical treatment for this condition, significant improvements in total ankle arthroplasty have made it a viable alternative for select patients. As the Agility total ankle implant has the longest follow-up in the United States, the purpose of this study is to look at mid-term follow up of patients with this implant. Methods: Following IRB approval, a retrospective review of prospectively collected data was conducted on 127 consecutive Agility total ankle arthroplasties between 2001-2010 performed by one fellowship-trained orthopaedic surgeon. Patient charts were reviewed to collect demographics including age, gender, BMI, diabetes, inflammatory arthropathy, tobacco, FAAM, SF-12, and VAS pain scores. In addition, a five-view radiographic series was obtained to determine coronal alignment, overall arc of motion, tibiotalar component motion, zones of osteolysis, and subsidence. A Kaplan-Meier survival analysis was performed and a linear regression analysis was used to predict implant failure. A multivariate regression analysis was used to assess whether radiographic measures were predictive of patient satisfaction. Results: 90 of 115 still had their primary implant. 105 were available to participate (average 9.1 years follow-up). Twenty-five had their implant removed. Average FAAM-ADL score was 82.4, FAAM-sport score 55.3, post-operative VAS pain score 12.7, SF-12 physical score 45.8 and SF-12 Mental 56.1. Average motion across the implant was 22.3° and 6.3° in adjacent joints. Osteolysis occurred on average at 2.3 zones, significant at zones 1 and 6. No differences were found for rate or location of subsidence. Linear regression analysis demonstrated younger patients, inflammatory and atraumatic arthritis lead to higher likelihoods of revision. No correlation was detected between radiographic parameters of implant success and outcome scores. Significant reduction in VAS pain scores was detected at an average of 8 years (mean difference of 67.64). Conclusion: Our results are consistent with what has been described in the literature. Survivorship approaches 70.9% at an average of 8 years. Patients that have retained their original implant are functioning at a high level of satisfaction based on statistically validated patient-centered outcome scores. Interestingly, this is independent of the radiographic appearance of their implant. Advanced age at the time of surgery was predictive of failure with younger patients having a higher likelihood of requiring secondary surgery and the pre-operative diagnosis was also predictive of failure with both inflammatory arthritis and atraumatic arthritis

Open Repair of Acute Achilles Tendon Ruptures: Is the Incidence of Clinically Significant Wound Complications Overestimated?

Background: Conflicting evidence exists regarding the optimal management of acute Achilles tendon ruptures. Operative repair is thought to afford patients a lower risk of rerupture, albeit at a higher overall risk of wound complications. Methods: A retrospective chart review of 369 consecutive patients undergoing open repair of acute Achilles tendon ruptures performed by a single foot and ankle fellowship-trained orthopedic surgeon was undertaken. Healing was classified as no complications, complications without prolonging treatment, complications requiring prolonged local treatment, and complications requiring operative intervention. A statistical analysis comparing the rates of complications in this cohort to that reported in the literature was conducted. Results: There were a total of 33 (8.94%) wound complications. Compared to the rates reported in the literature, no significant difference was detected ( P = .3943; CI 6.24-12.33). However, when the complications not requiring additional treatment or prolonged care were excluded, only 9 wound complications (2.44%) were identified—a significantly lower complication rate than that reported in the literature ( P < .0001; CI 1.12-4.58). There were only 2 (0.54%) major complications requiring operative intervention, also a significantly lower rate than in the literature ( P < .0001; CI 0.067-1.94). Conclusion: In the past, wound-healing complications have been cited as a concern when treating patients operatively. We found that when solely looking at healing complications prolonging the patients’ overall recovery, a significantly lower rate of complications existed compared to that reported in the literature. Level of Evidence: Level IV

Self-Reported Pain Tolerance and Opioid Pain Medication Use after Foot and Ankle Surgery

Category: Pain Management Introduction/Purpose: The opioid epidemic in the United States continues to take lives. As one of the top prescribing groups, orthopaedic surgeons must tailor post-surgical pain control to minimize the potential for harm from prescription opioid use. Patients often reference their own pain threshold as a benchmark for how they will tolerate the pain of surgery, but current literature suggests that there is not a significant correlation between an individual’s perceived pain threshold and their actual threshold for heat stimulus. The purpose of this study was to determine whether there is a correlation between a patient’s self- reported pain tolerance and their actual prescription narcotic medication usage after foot and ankle surgery. Methods: This was a prospective cohort study of adult patients that underwent outpatient foot and ankle surgeries performed by 5 fellowship-trained foot and ankle surgeons at a large, multispecialty orthopaedic practice over a one year period. Demographic data, procedural details and anesthesia type were collected. Narcotic usage data including number of pills dispensed and pill counts performed at the first postoperative visit were obtained. Patients were contacted via email or telephone between 7-19 months postoperatively, and asked to respond to the validated statement “Pain doesn’t bother me as much as it does most people” by choosing “strongly disagree”, “disagree”, “neither”, “agree” or “strongly agree”. Patients scored their pain threshold on a scale of 1- 100 with 0 being “pain intolerant” and 100 a ”high pain threshold" and ranked their expectations of the pain after surgery and satisfaction with pain management on respective five-point Likert scales. Data was analyzed using a Spearman’s correlation. Results: Of the 486 patients who completed surveys, average age was 51.24 years, 32.1% were male and 7.82% current smokers. After controlling for age and anesthesia type, both agreement with the validated statement and higher pain tolerance score had a weak negative correlation with pills taken (r=-0.13, p=0.004 and r=-0.14, p=0.002, respectively); patients with higher perceived pain thresholds took fewer opioid pills after surgery (Table 1). Correlation between high expectations of postoperative pain and pills taken was weakly negative (r=-0.28, p=<0.001) (Table 1). Patients who found surgery more painful than they expected took less pain medication. There was a small, positive correlation between pain tolerance and satisfaction with pain management (r=0.12, p=0.008), indicating that patients with a relatively high pain tolerance had more satisfaction (Table 1). Conclusion: Assessment of both subjective description and quantitative score of a patient’s pain threshold prior to surgery may assist the surgeon in tailoring postoperative pain control regimens. Unexpectedly, patients who found surgery less painful than expected actually took a greater number of opioid pills. This may highlight an educational opportunity regarding postoperative pain management in order to reduce narcotic requirement. Setting expectations on safe utilization of prescribed pain medications may also increase satisfaction. This study provides useful information for surgeons to customize pain management regimens and to perform effective preoperative education and counseling regarding postoperative pain management. Table 1. Correlation Between Pain Threshold Assessment, Expectation of Postoperative Pain and Satisfaction with Postoperative Pain Management and Opioid Medication Taken Spearman Correlation Coefficient p-value Agreement with statement “pain doesn’t bother me as much as it does most people” and opioid intake -0.13 0.004 Increasing quantitative pain threshold score and opioid intake -0.14 0.002 Assessment of postoperative pain as more painful than expected and opioid intake -0.28 <0.001 Increasing satisfaction with postoperative pain management and opioid intake 0.12 0.00