Query: foot and ankle surgery

title: Ultrasound guided regional anaesthesia in foot and ankle surgery.
abstract: The use of regional anaesthesia in foot and ankle surgery is becoming well recognised, particularly in patients who prefer to stay awake during the procedure and for better post operative analgesia. Its use is ideal for patients with multiple co morbidities, in whom general anaesthesia (GA) otherwise would could be challenging. The procedures performed with landmark/anatomical guidance alone carry a relatively higher risk of complications, risk of inadvertant injection into the intarvascualr space leadinf to local anaesthetic toxicity, the majority of which complications are caused by incorrect placement of the needle. Hence, ultrasound guidance is frequently used to minimise those risks. Although various regional anaesthetic techniques for foot and ankle surgery have been described, their comprehensive review is lacking. This manuscript aims to fulfil this void. The focus will be on the peripheral methods of regional anaesthesia including the plexus and single nerve blocks. Various techniques with their benefits and potential complications will be discussed. In addition, the evidence on the efficacy of an ultrasound guided approach as well as its cost implications will be explored. There are significant considerations in deciding whether to implement this technique in routine clinical practice and this review aims to summarise the available literature to establish the evidence base behind it.

title: Comparison of Patients' and Surgeons' Expectations in Foot and Ankle Surgery
abstract: Aligning patient and surgeon expectations may improve patient satisfaction and outcomes. This study aimed to assess differences in expectations of foot and ankle surgery between patients and their surgeons.  Two hundred two patients scheduled to undergo foot or ankle surgery by one of 7 fellowship trained foot and ankle surgeons were enrolled. Preoperatively, patients and surgeons completed the Hospital for Special Surgery Foot Ankle Surgery Expectations Survey independently. Differences between patient and surgeon overall expectations scores, number of expectations, and number of expectations with complete improvement expected were assessed. A difference of =10 points was considered a clinically important difference in expectations score. Associations between patient demographic and clinical characteristics, major/minor surgery, and individual surgeon with differences in expectations were also assessed.  Overall, 66.3% of patients had higher expectations, 21.3% had concordant expectations, and 12.4% had lower expectations compared with their surgeons. On average, patients had higher expectations scores than their surgeons (70 20 vs 52 20 points, P .001) Patients expected complete improvement in a greater number of expectations than surgeons (mean 11 7 vs 1 3, P .001) Patients had higher expectations than surgeons for 18 of 23 items (78% Items that had the greatest number of patients with higher expectations than surgeons were "improve confidence in foot/ankle," "prevent foot/ankle from getting worse," and "improve pain at rest." Higher body mass index (BMI) (P .027) and individual surgeon (P .001) were associated with greater differences between patient surgeon expectations. Major/minor surgery was not associated with differences in expectations (P .142)  More than two thirds of patients had significantly higher expectations than their surgeons. Higher BMI was associated with higher patient than surgeon expectations. These results emphasize the importance for foot and ankle surgeons to adequately educate patients preoperatively.

title: The influence of smoking on foot and ankle surgery: a review of the literature.
abstract: The effect of tobacco smoking on foot and ankle procedures is likely to be more pronounced when compared to other orthopaedic surgery. This is due to the peripheral nature of the vasculature involved. This paper reviews the current clinical evidence on the effects of smoking foot and ankle surgery. In the trauma setting, the evidence suggests that wound complications and non unions are significantly higher in the smoking population. In the elective setting there is a significantly increased risk of non union in ankle and hindfoot arthrodeses in smokers. In the setting of diabetes, ulceration rate in smokers is higher and there may be a higher risk of amputation.

title: Effect of Postoperative Oral Antibiotics on Infections and Wound Healing Following Foot and Ankle Surgery
abstract: There is controversy regarding the effectiveness of postoperative antibiotics to prevent wound infection. Some surgeons still use a routine postoperative oral antibiotic regimen. The purpose of this study was to review a series of cases and document statistically any difference in infection rates and whether routine postoperative antibiotics in foot and ankle surgery are justified.  A retrospective chart review of 649 patients was performed who underwent elective foot and ankle surgery. Six hundred thirty one patient charts were included in the final analysis. Evaluated were patients who did and did not receive postoperative oral antibiotics in order to identify whether a difference in infection rate or wound healing occurred. The study also evaluated risk factors for developing infection following foot and ankle surgery.  The number of infections in patients receiving postoperative oral antibiotics was 6 (3% while the number of infections in those who did not receive postoperative oral antibiotics was 10 (2% (P .597) The difference of deep versus superficial infections and delays in wound healing between the 2 groups was not statistically significant. Patients who developed infections were older and had a higher prevalence of hypertension, a history of neoplasm, and a greater American Society of Anesthesiologists Classification of Physical Health.  This study suggests that routine use of postoperative antibiotics in foot and ankle surgery does not affect wound complications or infection rates. Additionally, patients who are older and those with multiple medical problems may be at higher risk for developing postoperative infection following foot and ankle surgeries.

title: Association Between Baseline PROMIS Scores, Patient Provider Communication Factors, and Musculoskeletal Health Literacy on Patient and Surgeon Expectations in Foot and Ankle Surgery.
abstract: Various factors may affect differences between patient and surgeon expectations. This study aimed to assess associations between patient reported physical and mental status, patient surgeon communication, and musculoskeletal health literacy with differences in patient and surgeon expectations of foot and ankle surgery.  Two hundred two patients scheduled to undergo foot or ankle surgery at an academic hospital were enrolled. Preoperatively, patients and surgeons completed the Hospital for Special Surgery Foot Ankle Surgery Expectations Survey. Patients also completed Patient Reported Outcomes Measurement Information System (PROMIS) scores in Physical Function,  Patient surgeon communication and musculoskeletal health literacy were assessed via the modified Patients' Perceived Involvement in Care Scale (PICS) and Literacy in Musculoskeletal Problems (LiMP) questionnaire, respectively.  Greater differences in patient and surgeon overall expectations scores were associated with worse scores in Physical Function (P .003) Pain Interference (P .001) Pain Intensity (P .009) Global Physical Health (P .001) and Depression (P .009) A greater difference in the number of expectations between patients and surgeons was associated with all of the above (P .003) and with worse Global Mental Health (P .003) Patient perceptions of higher surgeons' partnership building were associated with a greater number of patient than surgeon expectations (P .017) There were no associations found between musculoskeletal health literacy and differences in expectations.  Worse baseline patient physical and mental status and higher patient perceptions of provider partnership building were associated with higher patient than surgeon expectations. It may be beneficial for surgeons to set more realistic expectations with patients who have greater disability and in those whom they have stronger partnerships with. Further studies are warranted to understand how modifications in patient and surgeon interactions and patient health literacy affect agreement in expectations of foot and ankle surgery.

title: What's New in Foot and Ankle Surgery.
abstract: This update summarizes recent research pertaining to the subspecialty of orthopaedic foot and ankle surgery that was published or presented between August 2007 and July 2008. The sources of these studies include The Journal of Bone and Joint Surgery (American and British Volumes) Foot and Ankle International, and the proceedings of Specialty Day at the Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) held on March 8, 2008, in San Francisco, California, and the summer meeting of the American Orthopaedic Foot and Ankle Society (AOFAS) held on June 25 through 28, 2008, in Denver, Colorado.

title: Skin Preparation Techniques for Orthopedic Foot and Ankle Surgery: A Current Concepts Review
abstract: Surgical site infection (SSI) following orthopedic foot and ankle surgery is associated with morbidity, mortality, and cost to the healthcare system. The local anatomy and physiology predispose patients undergoing procedures to elevated risk. In particular, sterilizing of the webspaces, nailfolds, and subungual areas presents challenges, and the preferred skin antisepsis technique for foot and ankle procedures has not yet been defined. Skin antiseptic solutions (SASs) consist of 3 main categories: alcohol, chlorhexidine, and iodine based solutions. This review of the literature supports a combined chlorhexidine and alcohol preparation technique; however, there are a number of studies that suggest otherwise. In addition, there is variable evidence for the use of alternatives to the standard soft sponge application technique, including immersion, bristled brush, and cotton gauze application. These alternatives may have a particular advantage in the forefoot. Most studies to date use growth from skin swab cultures after skin preparation as the primary outcome. Higher level studies with large subject populations and more meaningful clinical outcomes will be required to solidify guidelines for preoperative skin antisepsis prior to foot and ankle procedures.

title: Trends in arthrodeses and total joint replacements in Foot and Ankle surgery in Germany during the past decade Back to the fusion?
abstract: The goal of this study was to analyze trends in Foot and Ankle surgery in Germany during the past ten years.  Data of the German Federal Statistical Office from 2008 until 2018 were screened. We focused on the analysis of fusions and total joint replacements.  The total amount of the surgeries increased +39.5% Especially fusions like arthrodesis of the ankle +31% and of the MTP 1 joint +77% were on the rise. In 2017 60% of ankle arthrodesis were conducted in men, while 69% of MTP 1 arthrodesis were performed in women. The amount of joint replacements showed a decline during the last decade, in TAR 39% and in the MTP 1 48% Regarding the patients age while undergoing a TAR, we observed a shift of the peak age group from 65 to 70 years in 2008 towards 55 60 years in 2017.  Our study represents actual health care reality in Germany and shows a constant increase of ankle arthritis surgeries in the last decade, while there was a massive shift regarding the ratio of TAR in favour of fusion procedures.

title: Podiatric Medicine and Surgery Resident Authored Publications in The Journal of Foot and Ankle Surgery: A Systematic Review.
abstract: Since its introduction into the medical community, the Podiatric Medicine and Surgery residency has strived to graduate the most advanced and learned foot and ankle surgeons. From increasing length of training, to assuring didactics and education are sufficiently incorporated into the residency, the Council on Podiatric Medical Education has overseen this transition. One area of interest, podiatric medicine and research, remains central to this training and contributes to the field of foot and ankle surgery through journal publications. The purpose of this review was to identify Podiatric Medicine and Surgery resident authored publication rates, trends, and geographic distribution. All published case reports, original research articles, review articles, and tips, quips, and pearls in The Journal of Foot and Ankle Surgery from January 2009 to December 2018 were reviewed. Podiatric Medicine and Surgery residents comprised 8% of all authors. Residents contributed to and published as first authors in 22% and 11% of all manuscripts, respectively. An increasing trend in resident authors, resident authored manuscripts, and resident first authored manuscripts was observed. From before the mandated 3 year residency to after, the proportion of resident authored manuscripts to all manuscripts declined from 9.99% to 7.21% however, among these resident authored publications, the rate of first authorship increased from 45.32% to 51.36% To the best of our knowledge, this is the first and only study to examine publication rates among foot and ankle surgery residents.

title: Opioid Use, Perioperative Risks, and Associated Postoperative Complications in Foot and Ankle Surgery.
abstract: Opioid abuse has become a national crisis. Published data demonstrate that patients undergoing foot and ankle surgery are left with excess narcotic medications postoperatively. The purpose of our study was to evaluate factors associated with prolonged postoperative opioid use following foot and ankle surgery and identify associations between preoperative opioid use and postoperative complications.  MarketScan commercial claims and encounters database was searched to identify foot and ankle patients. Preoperative comorbidities were queried and documented. Patients utilizing opioids 1 to 3 months prior to surgery were identified. Adjusted odds ratios and 95% CIs were calculated using multivariable logistic regression to determine associations between opioid use (preoperatively and postoperatively) readmission, and complications.  A total of 112 893 patients were included in the study. Preoperative use had a statistically significant association with postoperative use out to 1 year. Tobacco use, chronic pain, mental health diagnosis, and nonopioid medications had a statistically significant association with postoperative use. Preoperative opioid use had a statistically significant association with readmission and postoperative complications.  Our study found a number of factors associated with prolonged postoperative opioid use (preoperative use, tobacco use, chronic pain, mental health disorders, and certain nonopioid medications) We identified an association between preoperative opioid use and postoperative complications and readmission. LEVELS OF EVIDENCE Prognostic Level IV Evidence.