Query: foot surgery

title: Fulfillment of Expectations After Orthopedic Foot and Ankle Surgery
abstract: To date, no study has assessed fulfillment of patients' expectations after foot and ankle surgery. This study aimed to validate a method of assessing expectation fulfillment in foot/ankle patients postoperatively.  Preoperatively, patients completed the expectations survey, consisting of 23 questions for domains including pain, ambulation, daily function, exercise, and shoe wear. At 2 years postoperatively, patients answered how much improvement they received for each item cited preoperatively. A fulfillment proportion (FP) was calculated as the amount of improvement received versus the amount of improvement expected. The FP ranges from 0 (no expectations fulfilled) to between 0 and 1 (expectations partially fulfilled) to 1 (expectations met) to greater than 1 (expectations surpassed) Receiver operating characteristic (ROC) curves and areas under the curve (AUCs) with 95% confidence intervals (CIs) were used to compare the expectations survey to other outcome surveys, including Foot and Ankle Outcome Score, improvement, overall fulfillment, Delighted Terrible scale, and satisfaction.  Of the 271 patients (mean age 55.4 years, mean BMI 27.5, 65% female) 34% had expectations surpassed (FP >1) 4% had expectations met, 58% had expectations partially fulfilled (FP between 0 and 1) and 5% had no expectations met. The mean FP was 0.84 0.41 (range 0 3.13) indicating partially fulfilled expectations. FP correlated significantly with all outcome measures (P .007) FP was associated most closely with satisfaction (r 0.66 [95% CI 0.57 0.75] AUC 0.92 [95% CI 0.88 0.96] P .001) and improvement (r 0.73 [95% CI 0.64 0.81] AUC 0.94 [95% CI 0.91 0.96] P .001) Based on the associations with satisfaction and improvement outcomes, a clinically important proportion of expectations fulfilled is 0.68, with sensitivity 0.85 0.90 and specificity 0.84 0.86.  The proportion of expectations fulfilled is a novel patient centered outcome that correlated with validated outcome measures. The expectations survey may be used by surgeons to counsel patients preoperatively and also to assess patients' results postoperatively.

title: Outcomes after foot surgery in people with a diabetic foot ulcer and a 12 month follow up.
abstract: The aim of this study was to retrospectively measure the outcomes of foot sparing surgery at one year follow up for patients with diabetic foot ulcers (DFUs) We assessed wound healing and the need for further surgery in relation to the variables that influence healing.  Data were retrospectively collected by reviewing the electronic files of patients attending the Wound Expert Clinic (WEC) Outcomes of surgical debridement, toe, ray and transmetatarsal amputations were assessed.  A total of 129 cases in 121 patients were identified for inclusion. The results demonstrated that complete wound healing was reached in 52% (61/117) of the patients within 12 months. The need for additional surgery or for major amputation was 56% (n=72/129) and 30% (n=39/129) respectively. The need for an additional procedure was particularly high after surgical debridement (75% 33/44) and transmetatarsal amputation (64% 7/11) Risk factors for non healing or for a major amputation were: infection (p=0.01) ischaemia (p=0.01) a history of peripheral arterial occlusive disease (p<0.01) and smoking (p=0.01) Additional findings were that not all patients underwent vascular assessment and in half of the patients there was a delay in undergoing revascularisation.  The results of the study reveal some areas for improvement including timely revascularisation and performance of multiple debridement procedures if needed in order to save a limb.

title: Clinical applications of allografts in foot and ankle surgery
abstract: PurposeThe purpose of this review is to systematically analyse current literature on the use of allografts in the surgical treatment of foot and ankle disorders in adult patients. Based on this study, we propose evidence based recommendations.MethodsThe database for PubMed was searched for all published articles. No timeframe restrictions were applied. Clinical studies eligible for inclusion met the following criteria: performed on patients over 18 years old; subject to surgical treatment of foot and ankle disorders; with report on the outcome of the use of allografts; with a report and assessment of pain and function, or equivalent; minimum follow up of 1 year was required. Two reviewers independently screened and selected studies for full text analysis from title and abstract. 107 studies were included from 1113 records. Studies were grouped according to surgical indications into ten categories: musculoskeletal tumours (n 16) chronic ankle instability (n 15) ankle arthritis (n 14) osteochondral lesions of the talus (n 12) Achilles tendon defects (n 11) other tendon defects (n 9) fusions (n 9) fractures (n 8) hallux rigidus (n 3) and other indications (n 10).ResultsMost studies displayed evidence level of IV (n 57) and V (n 39) There was one level I, one level II and nine level III studies. Most studies reported allografting as a good option (n 99; 92.5% Overall complication rate was 17% (n 202).ConclusionsFair evidence (Grade B) was found in favour of the use of allografts in lateral ankle ligament reconstruction or treatment of intra articular calcaneal fracture. Fair evidence (Grade B) was found against the use of allogeneic MSCs in tibiotalar fusions.

title: Opioid Consumption Following Foot and Ankle Surgery
abstract: Orthopedic surgeons frequently prescribe pain medications during the postoperative period. The efficacy of these medications at alleviating pain after foot/ankle surgery and the quantity of medication required (and conversely, leftover) are unknown.  Patients undergoing foot/ankle surgery during a 3 month period who met inclusion criteria were surveyed at their first postoperative visit. Information collected included gender, number of prescribed pills remaining, satisfaction with pain control, and willingness to surrender leftover opioids to a Drug Enforcement Administration (DEA) disposal center. Additional data, including utilization of a perioperative nerve block and type (bony versus nonbony) and anatomic region of procedure, were collected through review of the medical record. All data were analyzed in a retrospective fashion. A total of 171 patients with a mean age of 53.1 15.5 years (range, 18 81 years) were included in the study.  The mean number of opioids taken was 27.2 17.5 pills (range, 0 70) The mean number of short acting opioids and long acting opioids taken was 21.4 14.8 and 9.2 5.0 pills, respectively. Most (73.5% patients were satisfied with their pain control. Patients who underwent ankle/hindfoot surgery took more long acting opioids on average than others (P .047) There was not a significant difference in opioid usage between bony and nonbony procedures. Of those with leftover opioids, 63% were willing to surrender them to a DEA disposal center. Patients willing to surrender leftover medications had both more short acting (P .001) and long acting (P .015) opioids leftover than those not willing to surrender them.  Most patients undergoing foot/ankle surgery had opioids leftover at the first postoperative visit, and most were willing to surrender them. We can adequately treat patients' pain and decrease the number of opioid pills available in the community by decreasing the number of pills prescribed and encouraging disposal of leftovers.

title: The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system predicts wound healing better than direct angiosome perfusion in diabetic foot wounds.
abstract: Previous studies show conflicting results in wound healing outcomes based on angiosome direct perfusion (DP) but few have adjusted for wound characteristics in their analyses. We have previously shown that the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification correlates with wound healing in diabetic foot ulcers (DFUs) treated by a multidisciplinary team. The aim of this study was to compare WIfI classification vs DP and pedal arch patency as predictors of wound healing in patients presenting with DFU and peripheral arterial disease.  We performed a retrospective review of a prospectively maintained database of all patients with peripheral arterial disease presenting to our multidisciplinary DFU clinic who underwent angiography. An angiosome was considered directly perfused if the artery feeding the angiosome was revascularized or was completely patent. Wound healing time at 1 year was compared on the basis of DP vs indirect perfusion, Rutherford pedal arch grade, and WIfI classification using univariable statistics and Cox proportional hazards models.  Angiography was performed on 225 wounds in 99 patients (mean age, 63.3 1.2 years; 62.6% male; 53.5% black) during the entire study period. There were 33 WIfI stage 1, 33 stage 2, 51 stage 3, and 108 stage 4 wounds. DP was achieved in 154 wounds (68.4% and indirect perfusion in 71 wounds (31.6% On univariable analysis, WIfI classification was significantly associated with improved wound healing (57.2% for WIfI 3/4 vs 77.3% for WIfI 1/2; P .02) whereas DP and pedal arch patency were not (both, P .08) After adjusting for baseline patient and wound characteristics, WIfI stage remained independently predictive of wound healing (WIfI 3/4: hazard ratio [HR] 0.77; 95% confidence interval [CI] 0.67 0.88) whereas DP (HR, 0.82; 95% CI, 0.55 1.21) and pedal arch grade (HR, 0.85; 95% CI, 0.70 1.03) were not.  In our population of patients treated by a multidisciplinary diabetic foot service, the Society for Vascular Surgery WIfI classification system was a stronger predictor of diabetic foot wound healing than DP or pedal arch patency. Our results suggest that a measure of wound severity should be included in all future studies assessing wound healing as an outcome, as differences in patients' wound characteristics may be a strong contributor to the variation of angiosome directed perfusion results previously observed.

title: Pain Management After Outpatient Foot and Ankle Surgery
abstract: The number of opioids prescribed and used has increased precipitously over the past 2 decades for a number of reasons and has led to increases in long term dependency, opioid related deaths, and diversion. Most studies examining the role of prescribing habits have investigated nonoperative providers, although there is some literature describing perioperative opioid prescription and use. There are no studies looking at the number of pills consumed after outpatient foot and ankle surgeries, nor are there guidelines for how many pills providers should prescribe. The purpose of this study was to quantify the number of narcotic pills taken by opioid naive patients undergoing outpatient foot and ankle surgeries with regional anesthesia.  Eighty four patients underwent outpatient foot and ankle surgeries under spinal blockade and long acting popliteal blocks. Patients were given 40 or 60 narcotic pills, a 3 day supply of ibuprofen, deep vein thrombosis prophylaxis, and antiemetics. Patients received surveys at postoperative day (POD) 3, 7, 14, and 56 documenting if they were still taking narcotics, the quantity of pills consumed, whether refills were obtained, their pain level, and their reason for stopping opioids.  Patients consumed a mean of 22.5 pills, with a 95% confidence interval from 18 to 27 pills. Numerical Rating Scale pain scores started at 4 on POD 3 and decreased to 1.8 by POD 56. The percentage of patients still taking narcotics decreased from 55% on POD 3 to 2.8% by POD 56. Five new prescriptions were given during the study, with 3 being due to side effects from the original medication.  Patients receiving regional anesthesia for outpatient foot and ankle surgeries reported progressively lower pain scores with low narcotic use up to 56 days postoperatively. We suggest that providers consider prescribing 30 pills as the benchmark for this patient population.

title: Transcranial Motor Evoked Potential Alarm Criteria to Predict Foot Drop Injury During Lumbosacral Surgery
abstract: A retrospective cohort analysis.  This study aims to investigate whether waveform alterations in transcranial motor evoked potentials (TCMEPs) can reliably predict postoperative foot drop.  Nerve injury leading to foot drop is a potential complication of lumbosacral surgery. Very limited data exist on the use of intraoperative TCMEPs to identify iatrogenic foot drop.  We retrospectively reviewed neuromonitoring data from 130 consecutive spine surgeries with instrumentation involving L4 S1. TCMEP waveform analysis included amplitude (A) area under the curve (AUC) latency (L) and duration (D) Patient outcomes were correlated with neuromonitoring results. Intraoperative alert criteria were established on the basis of observed intraoperative changes.  Three patients developed severe foot drop with a muscle weakness functional grade ranging from 0/5 to 3/5. Two patients developed a mild foot drop with functional grade 4/5. Twenty three patients had preoperative weakness in an L5 distribution. One hundred two patients who had neither preoperative nor postoperative neurological complications served as a control group. Amplitude significantly decreased in patients with a severe postoperative deficit (P 0.005) as did AUC and duration (P 0.05) Intraoperative alert criteria defined as a >65% decrease in AUC resulted in a sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 100% 91.4% 12% and 100% respectively. When defining an alert criteria as a >50% decrease in amplitude, sensitivity, specificity, PPV, and NPV were 100% 87.9% 8.8% and 100% respectively.  Reduction of TCMEP waveform associated with postoperative severe foot drop can be detected during lumbar surgery. Other waveform parameters such as AUC may predict foot drop better than the amplitude. Additional examinations in larger samples of foot drops are needed to validate these alert threshold findings.

title: Patient Reported Allergies Do Not Predict Poorer PROMIS Function, Pain, and Depression Scores Following Foot and Ankle Surgery
abstract: Identifying preoperative risk factors that may portend poorer operative outcomes remains a topic of current interest. In hip and knee arthroplasty patients, the presence of patient reported allergies (PRAs) has been associated with worse pain and function after joint replacement. However, these results have not been replicated across studies, including in shoulder arthroplasty cases. The impact of PRAs on foot and ankle outcomes has yet to be studied. The purpose of our study was to evaluate whether PRAs influence patient reported outcome in foot and ankle surgery.  To determine if PRAs are linked to poorer operative outcomes, we retrospectively identified 159 patients who underwent elective foot and ankle surgery. PRA data were obtained via chart review, and patient reported outcomes were assessed preoperatively and postoperatively via multiple domains, including Patient Reported Outcome Measurement Information System (PROMIS) physical function, pain interference, and depression measures. Consistent with prior methodology, we compared outcome measures (preoperative, postoperative, and the change in outcome scores) between patients without self reported allergies to patients with at least 1 PRA.  There were 159 patients studied; 79 patients had no allergies listed, and 80 patients had at least 1 PRA. Of the 80 patients with at least 1 PRA, there were a total of 170 possible allergies. There were no differences in preoperative, postoperative, or the change in outcome scores for all PROMIS measures (physical function, pain interference, and depression; P .05) between patients with at least 1 PRA and those patients without any listed PRAs.  We were unable to prove our hypothesis that PRAs were linked to poorer patient reported outcomes following foot and ankle surgery. Closer review of the published reports linking PRAs to worse total joint arthroplasty outcomes revealed data that, while statistically significant, are likely not clinically relevant. Our negative findings, then, may in fact parallel prior studies on hip, knee, and shoulder arthroplasty patients. The presence of PRAs does not appear to be a risk factor for suboptimal outcomes in foot and ankle surgery.

title: Influence of Diagnosis and Other Factors on Patients' Expectations of Foot and Ankle Surgery
abstract: Many patient factors have been associated with higher or lower expectations of orthopedic surgery. In foot and ankle surgery, the diverse diagnoses seen may also influence expectations. The aim of this study was to investigate the relationship between diagnosis and patients' preoperative expectations of elective foot and ankle surgery.  Two hundred seventy eight patients undergoing elective foot or ankle surgery for 1 of 7 common diagnoses were enrolled in a prospective cohort study. Preoperative expectations were assessed with the Hospital for Special Surgery Foot Ankle Surgery Expectations Survey. Patients also completed the Foot Ankle Outcome Score, Short Form 12, pain visual analog scale, and questionnaires for depressive and anxiety symptoms. Demographic and clinical data were collected. Patient factors and diagnosis were analyzed using multivariate regression analysis to identify independent predictors of higher expectations and determine the effect of diagnosis relative to other patient factors on expectations.  The multivariate regression analysis adjusting for demographics and other clinical characteristics showed that diagnosis contributed the most to the model, accounting for 10.5% of the variation in expectations survey scores. Patients with mid or hindfoot arthritis (P .001) hallux valgus (P .001) or hallux rigidus (P .005) had lower scores (lower expectations) than those with ankle instability or osteochondral lesion. In the model, female sex (P .001) non Caucasian race (P .031) and lower scores on the Foot Ankle Outcome Score daily activities subscale (P .024) were associated with higher scores.  Diagnosis of ankle instability or osteochondral lesion, female sex, non Caucasian race, and lower Foot Ankle Outcome Score daily activities subscale score were all associated with higher expectations. These findings may help inform and guide surgeons as they counsel patients preoperatively.

title: Complications After Multiple Site Peripheral Nerve Blocks for Foot and Ankle Surgery Compared With Popliteal Sciatic Nerve Block Alone
abstract: Single or combined multiple site peripheral nerve blocks (PNBs) are becoming popular for patients undergoing surgery on their feet or ankles. These procedures are known to be generally safe in surgical settings compared with other forms of anesthesia, such as spinal block. The purposes of this study were to assess the incidence of complications after the administration of multiple PNBs for foot and ankle surgery and to compare the rates of complications between patients who received a single PNB and those who received multiple blocks.  Charts were reviewed retrospectively to assess peri and postoperative complications possibly related to the PNBs. The records of 827 patients who had received sciatic nerve blocks, femoral nerve blocks adductor canal blocks, or combinations of these for foot and/or ankle surgery were analyzed for complications. The collected data consisted of age, sex, body mass index, presence of diabetes mellitus, smoking history, tourniquet time, and complications both immediately postoperatively and 1 year later.  Of these 827 patients, 92 (11.1% developed neurologic symptoms after surgery; 22 (2.7% of these likely resulted from the nerve blocks, and 7 (0.8% of these were unresolved after the patients' last follow up visits. There were no differences in complication rates between combined blocks and single sciatic nerve blocks.  There were more complications, both transient and long term, after anesthetic PNBs than previous literature has reported. Combined multiple site blocks did not increase the rate of neurologic complications.