Are Hindfoot Procedures More Painful than Forefoot Procedures? A Prospective Observational Study in Elective Foot and Ankle Surgery

Pain after lower limb orthopedic surgery can be severe. Poorly controlled pain is associated with adverse outcomes. Peripheral nerve blocks (PNB) have become popular in foot and ankle surgery for their effective pain control and low complication rates. It has always been assumed that hindfoot procedures are more painful than midfoot/forefoot procedures often requiring inpatient stay for pain relief. There are no published studies evaluating this assumption. To investigate whether hindfoot procedures are more painful than forefoot/midfoot procedures by measuring pain scores, assessing effectiveness of PNBs and patient satisfaction. One hundred forty patients undergoing elective foot and ankle surgery were prospectively studied. Inclusion criteria: Adults undergoing elective foot and ankle surgery. Exclusion criteria: Patients 16 years or under, those with alternate sources of pain, peripheral neuropathy, known substance abuse, psychiatric illness and incomplete pain scores. Pain was measured via the Visual Analog Scale at 3 time intervals: immediately, 6 hours and at 24 hours postoperatively. Analysis was via t-test. A p value of <.05 demonstrated a statistical significance. Forefoot/midfoot versus hindfoot surgery pain scores showed that there was no significant difference at any postoperative interval. PNB versus no PNB pain scores showed there was no significant difference, except at 24 hours postoperatively (p value .024). Patients who had a PNB experienced rebound pain at 24 hours. Hindfoot surgery is not more painful than forefoot/midfoot surgery. Patients who had a PNB experienced rebound pain at 24 hours postoperatively, a finding that requires further research.     

Parent and Child Trauma Symptoms During Child–Parent Psychotherapy: A Prospective Cohort Study of Dyadic Change

Five randomized controlled trials have shown that child–parent psychotherapy (CPP) improves trauma symptoms in children. Less is known about parent symptoms or moderators of symptom change. In a sample of 199 parent (81% biological mother; 54% Latina/o) and child (aged 2 to 6 years; 52% male; 49% Latina/o) dyads who participated in an open treatment study of CPP, this study investigated whether parent and child symptoms similarly decreased during treatment and whether improvement was moderated by parent, child, and treatment characteristics. Parents completed baseline and posttreatment interviews regarding exposure to traumatic events, posttraumatic stress symptomatology (PTSS), and other mental health indices. Latent difference score analysis showed that PTSS significantly decreased by more than 0.5 SD for parents and children. The PTSS improvement in parents was associated with reductions in child avoidance, r = .19, p = .040, and hyperarousal, r = .33, p < .001. Girls showed a greater reduction than boys in reexperiencing, β = −.13, p = .018, and hyperarousal, β = −.20, p = .001. Contrary to expectations, parent and child improvement in PTSS was greater for those with fewer parental lifetime stressors, β_range = .15 to .33, and for those who participated in fewer treatment sessions, β_range = .15 to .21. The extent of improvement in parent PTSS varied based on clinician expertise, β = −.20, p = .009. Significant reductions in parent and child PTSS were observed during community-based treatment, with CPP and symptom improvement varying according to child, parent, and treatment characteristics.     

The Financial Implications of Podiatric Foot and Ankle Fellowship: Is Another Year Worth It?

For prospective applicants many variables can factor into the decision to pursue fellowship level training. The purpose of the present study was to give prospective applicants an idea of the financial implications of podiatric foot and ankle fellowship. To calculate the net present value (NPV), weighted mean income data (clinical, general, research, associated research) from podiatric foot and ankle surgeon's (FAS's) with and without fellowship training was obtained. Income from general payments, research, and associated research was collected from manual searches of Open Source Payments. Demographic and clinical income data (based on 2080 hours) for graduate fellows from 4 programs was collected using an anonymous online survey. Socioeconomic data from the 2018 American College of Foot and Ankle Surgeons (ACFAS) compensation survey was used for comparison. The NPV of podiatric FAS's with/without fellowship training was $4.2 million and $3.03 million, respectively. The comparative NPV and cumulative net income difference over 30 years was $1.2 million and $2.5 million, respectively. The mean comparative income difference for fellowship trained podiatric FAS's annually was as follows: clinical (+$69,145.00), general (+$21,797.00), research (+$1,833.00), and associated research (+$414.00). The present study is the first attempt to provide prospective applicants with an idea of the financial implications of podiatric foot and ankle fellowship. Based on the positive NPV, pursuing an ACFAS recognized podiatric foot and ankle fellowship in advanced reconstruction could be considered an “acceptable financial investment”, which may positively affect career earnings. Prospective applicants should be cognizant that the NPV varies between fellowship programs. Therefore, the data presented from graduate fellows of the programs included may not be generalizable to graduate fellows from other programs.     

Validity and Reliability of Visual Analog Scale Foot and Ankle: The Turkish Version

The present study tested the reliability and validity of the Turkish version of the visual analog scale foot and ankle (VAS-FA) among healthy subjects and patients with foot problems. A total of 128 participants, 65 healthy subjects and 63 patients with foot problems, were evaluated. The VAS-FA was translated into Turkish and administered to the 128 subjects on 2 separate occasions with a 5-day interval. The test–retest reliability and internal consistency were assessed with the intraclass correlation coefficient and Cronbach's α. The validity was assessed using the correlations with Turkish versions of the Foot Function Index, the Foot and Ankle Outcome Score, and the Short-Form 36-item Health Survey. A statistically significant difference was found between the healthy group and the patient group in the overall score and subscale scores of the VAS-FA (p < .001). The internal consistency of the VAS-FA was very good, and the test–retest reliability was excellent. Adequate to good correlations were found between the overall VAS-FA score and the Foot Function Index, Foot and Ankle Outcome Score, and Short-Form 36-item Health Survey scores in the healthy and patient groups both. The Turkish version of the VAS-FA is sensitive enough to distinguish foot and ankle-specific pathologic conditions from asymptomatic conditions. The Turkish version of the VAS-FA is a reliable and valid method and can be used for foot-related problems.     

What Are Drivers of Readmission for Readmission-Requiring Venous Thromboembolic Events After Primary Total Hip Arthroplasty? An Analysis of 544,443 Cases

BackgroundVenous thromboembolism (VTE) is a potential postoperative complication after total hip arthroplasty (THA). These events present with a range of severity, and some require readmission. The present study aimed to identify unexplored risk factors for severe VTE that lead to hospital readmission.MethodsThe Agency of Healthcare Research and Quality’s National Readmissions Database was retrospectively queried for all patients who underwent primary THA (January 2016 to December 2018). Study population included patients who were readmitted for VTE within 90 days after an elective THA. Bivariate and multivariate regression analyses were performed using patient demographics, insurance status, elective nature of the surgery, healthcare institution characteristics, and baseline comorbidities.ResultsHigher risk of readmission for VTE was evident among elderly (71-80 years vs <40 years: odds ratio [OR] 1.7, 95% confidence interval [CI] 1.3-2.2, P = .0002), male patients (OR 1.2, 95% CI 1.2-1.3). Nonelective THAs were associated with markedly higher odds of readmission for VTE (OR 20.5, 95% CI 18.9-22.2), peripheral vascular disease (OR 1.2, 95% CI 1.1-1.4), lymphoma (OR 1.5, 95% CI 1.1-2.1), metastatic cancer (OR 1.8, 95% CI 1.4-2.2), obesity (OR 1.5, 95% CI 1.4-1.6), and fluid-electrolyte imbalance (OR 1.1, 95% CI 1.0-1.2). Home health care (OR 0.8, 95% CI 0.7-0.8) and discharge to skilled nursing facility (OR 0.7, 95% CI 0.7-0.8) had lower odds of readmission for VTE vs unsupervised home discharge, while insurance type was not a significant driver(P > .05).ConclusionOne in 135 THA patients is likely to experience a VTE requiring readmission after THA. Male patients, age >70 years, and specific baseline comorbidities increase such risk. Furthermore, discharge to a supervised setting mitigated the risk of VTE requiring readmission compared to unsupervised discharge. As VTE prophylaxis protocols continue to evolve, these patients may require optimized perioperative care pathways to mitigate VTE complications.     

Tracheostomy in Patients Who Need Mechanical Ventilation: Early or Late? Surgical or Percutaneous? A Prospective Study in Iran

Tracheostomy can be performed surgically or by percutaneous (percutaneous dilatory tracheostomy, PDT) methods, and it may be used early or late. In a 3-month follow-up, all patients who underwent tracheostomy in Semnan in 2013 were evaluated for complications of tracheostomy considering the method used and the timing of operation. A total of 55 patients underwent tracheostomy (26 cases surgery, 29 cases PDT, 30 cases early, and 25 cases late based on 14 days reference). The mean durations of operation were 19.19?±?5.78 min in the surgery method and 4.7?±?2.42 min in the PDT method (P?<?0.001). The mean durations of the need for ventilator after the tracheostomy were 10.7?±?9.25 and 18.6?±?14.39 days in early and late tracheostomy, respectively (P?=?0.024). The mean intensive care unit (ICU) stay were 12.70?±?10.24 and 23.44?±?18.49 days (P?=?0.014) and the mean hospital stay were 16.04?±?10.88 and 23.48?±?18.47 days, respectively (P?=?0.100). Short-term complications were observed in six cases (10.09 %) in the surgery group, including emphysema (two), bleeding (two), wound infection (one), and clot formation inside the tube (one). Only one complication (bleeding) occurred in one case in the PDT group. After 3 months, 21 patients survived. Compared with surgery, the most important advantage of the PDT method was its shorter duration of surgery. Nearly half of the patients underwent tracheostomy late, while the majority of the patients in the late group were referred from internal ICU. No major and minor complications were noted during the procedure, as well as no tracheostomy-related deaths were observed. Early tracheostomy was shown to be superior to late, reducing the time of mechanical ventilation and ICU or hospital stay.     

Evaluation of Preoperative and Postoperative S100β and NSE Levels in Liver Transplantation and Right Lobe Living-Donor Hepatectomy: A Prospective Cohort Study

Background and aimsThis study aimed to evaluate plasma neuron-specific enolase (NSE) and S100β levels in orthotopic liver transplantation.Materials and methodsA total of 56 patients who underwent orthotopic liver transplantation were divided into 3 groups. Healthy donors (group D), end-stage liver failure (ESLF) patients (recipient, group R), and ESLF patients diagnosed with hepatic encephalopathy (HE, group HE). Prognosis, preoperative routine laboratory findings, serum NSE, and S100β in samples obtained preoperation and first and sixth months postoperation were analyzed.ResultsSerum NSE and S100β levels were significantly higher in ESLF patients compared to healthy donors, particularly during the preoperative period. There was a significant decrease in serum NSE and S100β in ESLF patients during the postoperative measurement periods compared to preoperative levels. Serum NSE and S100β levels measured at 3 different time points showed no significant difference between ESLF patients and ESLF patients with HE. However, the recent Model of End-Stage Liver Disease (MELD) and Child-Turcotte-Pugh (CTP) scores showed a significant correlation with serum NSE and S100β in ESLF patients diagnosed with HE. Serum NSE and S100β levels in healthy donors significantly increased within the first month following hepatectomy and decreased in the sixth month following surgery.ConclusionAlthough serum NSE and S100β levels significantly decreased with improved liver function in recipients following liver transplantation, there was no complete recovery within 6 months after surgery. The increase in serum levels of NSE and S100β in donors measured following hepatectomy was detected to remain slightly higher in the sixth postoperative months.     

Contrast-Enhanced Intraoperative Ultrasonography During Surgery for Hepatocellular Carcinoma in Liver Cirrhosis: Is It Useful or Useless? A Prospective Cohort Study of Our Experience

BACKGROUND: Preliminary results showed that contrast-enhanced intraoperative ultrasonography (CEIOUS) could provide information not obtainable with conventional IOUS during surgery for hepatocellular carcinoma (HCC). The aim of the study was to prospectively validate the role of CEIOUS on the basis of a larger experience and to establish a new classification that takes into account its findings. METHODS: Eighty-seven consecutive patients underwent hepatecomies for HCC. Those patients with new lesions at IOUS underwent CEIOUS: for that patients received intravenously 4.8 mL sulphurhexafluoride microbubbles. Pattern of enhancement was classified in 4 categories: A1 (full enhancement in the arterial phase and wash-out in the delayed phases), A2 (intralesional signs of neovascularization during all phases), A3 (no nodular enhancement but detectability during the liver enhancement), and B (undetectability during the liver enhancement). Resection was recommended for A1-3 nodules and no treatment for B nodules. RESULTS: Twenty-nine patients (33%) had 59 new lesions at IOUS and underwent CEIOUS. Twenty-seven nodules showed a B pattern at CEIOUS and were not removed; 32 nodules were classified as A1 in 5 patients, A2 in 11 patients, and A3 in 16 patients. The nodules were removed, and by histology, five A1, nine A2, and six A3 nodules were confirmed to be HCC. CEIOUS modified the operative decision making in 79% of these patients. CONCLUSIONS: CEIOUS is useful during surgery for HCC; it complements the accuracy of IOUS and affects the radicalness of the surgical. Specificity of CEIOUS has to be further improved, although intrinsic drawbacks exist in the diagnostic criterion of tumor vascularity.     

Analysis of Two Different Arthroscopic Broström Repair Constructs for Treatment of Chronic Lateral Ankle Instability in 110 Patients: A Retrospective Cohort Study

Chronic lateral ankle instability is a common condition treated by most foot and ankle surgeons. Once conservative treatment has failed, patients often undergo surgical reconstruction, either anatomic or nonanatomic. The present retrospective cohort study compared the clinical outcomes of 2 different arthroscopic Broström procedures. A total of 110 patients (83 females [75.5%] and 27 males [24.5%]) were treated with 1 of the 2 lateral ankle stabilization techniques from October 1, 2014 to December 31, 2015. Of the 110 patients, 75 were included in the arthroscopic lateral ankle stabilization group with an additional suture anchor used proximally and 35 were included in the arthroscopic lateral ankle stabilization group using the knotless design. The age of the cohort was 46.05 ± 17.89 (range 12 to 83) years. The body mass index was 30.03 ± 7.42 (range 18.3 to 52.5) kg/m². Of the 110 patients, 25 (22.7%) had undergone concomitant procedures during lateral ankle stabilization. Overall, postoperative complications occurred in 14 patients (12.7%). No statistically significant differences were found between the 2 groups regarding the complication rates, use of concomitant procedures, and the presence of diabetes and workers compensation claims. No statistically significant differences were found in the mean age, body mass index, or gender distribution between the 2 groups. The preoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores were 50.85 ± 13.56 (range 18 to 76) and 51.26 ± 13.32 (range 18 to 69) in groups 1 and 2, respectively. The postoperative AOFAS Ankle-Hindfoot scores were 88.19 ± 10.72 (range 54 to 100) and 84 ± 15.41 (range 16 to 100) in groups 1 and 2, respectively. No statistically significant difference was found between these 2 groups. The preoperative visual analog scale score was 7.45 ± 1.39 (range 3 to 10) and 6.97 ± 1.25 (range 5 to 10), which had improved to 1.12 ± 1.38 (range 0 to 5) and 1.8 ± 1.98 (range 1 to 9) postoperatively for groups 1 and 2, respectively. The difference in the postoperative visual analog scale score between the 2 groups was statistically significant. The preoperative and postoperative AOFAS scale, Foot Function Index, and Karlsson-Peterson scores showed no statistically significant differences between the 2 groups. From our experience, either procedure is an acceptable treatment option for chronic lateral ankle instability, with the knotless technique showing a trend toward more complications.     

Efficacy and Safety of a Single Intra-articular Injection of Platelet-rich Plasma on Pain and Physical Function in Patients With Ankle Osteoarthritis—A Prospective Study

Ankle osteoarthritis (OA) can cause disabling symptoms, and some patients prefer to be treated with minimally invasive procedures. The aim was to evaluate the efficacy and safety of a single intraarticular injection of platelet-rich plasma (PRP) for patients with ankle OA. In a prospective study done in a university-affiliated tertiary care medical center, 44 patients with symptomatic ankle OA for at least 6 months were recruited. Patients received a single injection of PRP (3 mL) into symptomatic ankles. The primary outcome was the change from baseline in the visual analog scale (VAS) pain (0-10 cm) at 6 months. Secondary outcomes included the Ankle Osteoarthritis Scale (AOS) score, American Orthopedic Foot and Ankle Society (AOFAS) hindfoot-ankle score, single-leg stance test (SLS), rescue analgesics consumption and patient satisfaction. Thirty-nine participants (88.64%) completed the study. Significantly improvement in the VAS and AOS was noted at 1-, 3-, and 6-month follow-ups (p < .001). The mean VAS pain decreased significantly from 4.1 ± 1.7 at baseline to 2.2 ± 1.9, 1.7 ± 1.5, and 1.8 ± 1.6 at 1, 3, and 6 months (p < .001). The mean total AOS score reduced by 1.5, 2.2, and 2.1 from baseline respectively postinjection (p < .001). The mean AOFAS hindfoot-ankle score improved from 80.3 points at baseline to 87.2, 91.6, and 89.7 points at 1, 3, and 6 months (p < .001). SLS tests improved significantly (p < .001) at each follow-up. Acetaminophen consumption dropped significantly (p < .001) and no serious adverse events occurred. The study showed promise for a single intraarticular injection of PRP in the treatment of ankle OA.     

The Role of Polymethylmethacrylate Antibiotic–loaded Cement in Addition to Debridement for the Treatment of Soft Tissue and Osseous Infections of the Foot and Ankle

Polymethylmethacrylate (PMMA) has been used in skeletal surgery for >40 years as a means of securing prosthetic implants and more recently was used as a delivery agent for local high-dose antibiotics to treat soft tissue and osseous infections. The purpose of this study was to determine the role of PMMA antibiotic-loaded cement (PMMA-ALC) in combination with aggressive debridement for the treatment of foot and ankle soft tissue and osseous infections requiring operative intervention. A retrospective observational cohort study of prospectively collected data was performed for all patients who underwent aggressive debridement with placement of PMMA-ALC for foot and ankle soft tissue and osseous infections between July 2006 and January 2009. There were 35 (29 men, 6 women) patients, 29 who had diabetes, with a mean age of 61 1 13 years (range, 16-86 years). A total of 36 feet/ankles (20 right, 16 left) were involved, and the infections were anatomically divided into 6 groups: (1) toes (n = 9), (2) metatarsalphalangeal joints (MTPJ) (first MTPJ, n = 5; fifth MTPJ, n = 5), (3) forefoot (n = 11), (4) rearfoot (n = 4), and (6) ankle/lower leg (n = 3). All patients had confirmed bacterial infection via microbiologic or pathologic analysis before PMMA-ALC insertion. A total of 73 cultures were obtained at the time of PMMA-ALC removal, with 66 showing no bacterial growth (90.4%) and 7 positive for bacterial growth (9.6%). Methicillin-resistant Staphylococcus aureus was the most commonly cultured organism both preoperatively and postoperatively. When combined with aggressive irrigation and debridement, the use of PMMA-ALC appears to be a beneficial adjunctive therapy for the treatment of foot and ankle soft tissue and osseous infections.     

Do Reexcisions Impair Aesthetic Outcome in Breast Conservation Surgery? Exploratory Analysis of a Prospective Cohort Study

Purpose  

Reexcision is a clinically relevant aspect of oncological breast conservation surgery. The influence of reexcision on aesthetic outcome is described differently in the literature. Our aim was to analyze this question in a well-defined cohort with standardized study instruments.