Patient Satisfaction After Ambulatory Phlebectomy of Varicose Veins in the Foot

BACKGROUND: Ambulatory phlebectomy is an accepted therapy for varicose veins of the ankle and foot region. Although most phlebologists regard this therapy highly, little is known about patient satisfaction. OBJECTIVE: To investigate patient satisfaction and complaints as reported by the patient after ambulatory phlebectomy for varicose veins in the ankle and foot region. METHODS: A questionnaire was taken from patients who received ambulatory phlebectomy for varicose veins of the ankle and foot region between 1996 and 2000. RESULTS: According to the results of the questionnaire, 50% of the patient population was not completely satisfied, mostly because of persisting pain, reported discoloration, and perceived recurrence. CONCLUSION: The most important factors that influence patient satisfaction are discoloration, persistent pain, and the perception of varices after surgery. To avoid misunderstandings and/or disappointments, attention should be given to patient information before and after surgery.     

Fixed and dynamic equinus in cerebral palsy: evaluation of ankle function after multilevel surgery

Multilevel surgery for gait improvement was performed on 29 ambulatory children with diplegic cerebral palsy. Patients were divided into two groups based on the presence of dynamic equinus (12 cases) and fixed equinus deformity (17 cases). Dynamic equinus deformities were not corrected surgically, and fixed deformities were corrected by intramuscular gastrosoleus lengthening. Ankle function was evaluated by clinical examination and gait analysis before surgery and a minimum of 3 years after surgery. Positive changes in ankle function were observed in both the groups. Conservative management of dynamic equinus deformities resulted in significant improvements in ankle function. Intramuscular lengthening of fixed equinus deformities does not cause a weakening of the muscle and improves static and dynamic function of the ankle.     

Ultrasound-guided ankle block. History revisited

Following forefoot surgery, compared to the traditional multimodal approach, regional anesthesia and analgesia provides high quality pain relief, decreases opioids consumption and leads to very high satisfaction scores. Traditional regional techniques relied either on wound infiltration, landmark technique ankle blocks or popliteal sciatic nerve block. Numerous anatomic variations of the different nerves might lead to failure following a blind technique.The current evolution towards ambulatory care will push surgical teams to favor techniques that simplify postoperative treatment and encourages immediate ambulation.The development of Ultrasound Guided Blocks has enabled us to perform very selective and precise nerve blocks.Ankle blocks provide excellent intraoperative anesthesia as well as long postoperative pain relief. Complications are rare using regional anesthesia for postoperative analgesia even after extensive foot surgery.Revival of ankle blocks is a perfect example of the high impact of new technological advances in improving ambulatory surgical care after foot surgery.     

Multilevel surgery in spastic diplegia: evaluation by physical examination and gait analysis in 25 children

Gait improvement surgery was performed on 25 ambulatory children with the diplegic type of cerebral palsy. Multiple soft tissue and bony procedures were performed (mean 8.2 procedures) according to criteria defined on the basis of physical examination and gait analysis. Relevant physical examination findings and kinematic and kinetic data in the sagittal plane were evaluated before surgery and at least 3 years after surgery. Physical examination showed a reduction in the ankle plantar-flexor power and in the range of hip flexion and ankle plantarflexion after surgery. Analysis of gait data showed significant improvements in the sagittal plane kinematics and the power generation at the hip and the ankle. At the knee joint there was maintenance of power of the flexor and extensor group of muscles on physical examination, with significant improvements in the kinematics after surgery. The authors conclude that well-selected surgery improves function of the spastic muscle. The importance of assessing clinical, kinematic, and kinetic data together for proper evaluation of gait is stressed.     

Arthroscopic versus Open Ankle Arthrodesis: A Retrospective Cost Analysis

Compared with traditional open arthrodesis, arthroscopic ankle arthrodesis has been associated with similar rates of fusion, decreased time to union, decreased pain, shorter hospital stay, earlier mobilization, reliable clinical results, and fewer complications. The aim of this case-control study was to analyze cost differences between outpatient arthroscopic and inpatient open ankle arthrodesis. To this end, the authors analyzed 20 ankle arthrodesis procedures: 10 performed by one surgeon on an inpatient basis using an open approach, and 10 performed by another surgeon on an outpatient basis arthroscopically. Patient age, body mass index, tourniquet time, length of stay, complications, days to clinical union, and insurance type, as well as charges and reimbursements for the surgeons and the hospital or surgery center were abstracted from the records. Statistically significant differences were observed between the outpatient arthroscopic and inpatient open arthrodesis groups for total site charges ($3898 ± 0.00 versus $32,683 ± $12,762, respectively, P < .0001), reimbursement to the surgeon ($1567 ± $320 versus $1107 ± $278, respectively, P = .003), and reimbursement to the hospital or ambulatory surgery center ($1110 ± $287 versus $8432 ± $2626, respectively); the ratio of hospital/surgery center charges to hospital/surgery center reimbursements was 28.48% for the inpatient arthroscopic group and 25.80% for the inpatient open arthrodesis group. Outpatient arthroscopic ankle arthrodesis, compared with inpatient open ankle arthrodesis, appears to be less expensive for third party payers, and surgeons are paid more, whereas hospitals and ambulatory surgical centers get paid a greater proportion of the charges that they bill.     

Ankle joint arthroscopy

Today, more emphasis is being placed on ambulatory surgery and its decreased morbidity. Arthroscopic surgery is a valid approach to many disease entities and is very responsive to early ambulation. The authors present a brief history of ankle arthroscopy--the technique, indications and contraindications, difficulties, and possible complications of the procedure.     

Conservative management of dynamic equinus in diplegic children treated by gait improvement surgery.

Multilevel surgery for gait improvement was performed on twelve ambulatory children with diplegic type of cerebral palsy and dynamic equinus deformity. Dynamic equinus deformities were defined as those who had an equinus at initial contact during preoperative gait analysis, and where the equinus deformity was correctable passively during physical examination. Ankle function was evaluated by clinical examination and gait analysis before surgery, and at least 3 years after surgery. The ankle showed an increase in dorsal flexion at initial contact, at single stance and in swing. There was an increase in dorsal flexion at the beginning of push-off, without a decrease in the range of motion of the ankle during push-off. Ankle moments demonstrated significant improvement in the maximum flexor moment in the second half of single stance. There was a change from abnormal generation of the energy in mid-stance to the normal pattern of energy absorption. Positive work during push-off was significantly increased. Conservative management of dynamic equinus deformities combined with multilevel surgery to correct other deformities of the locomotion system resulted in significant improvements in ankle function during gait.     

Surgical management of the lower extremity in ambulatory children with cerebral palsy

Despite the increasing popularity of nonorthopaedic treatment alternatives for children with cerebral palsy, bony and soft-tissue surgery remains a common component in the management of ambulatory patients. Multisite simultaneous tendon surgery provides improvement in gait by addressing hip, knee, and ankle contractures together. Careful preoperative physical examination is required; computerized gait analysis can be useful in confirming a plan for multiple tendon surgeries. Rotational osteotomies can improve transverse-plane malalignment. Shorter periods of immobilization and aggressive postoperative gait training and strengthening may optimize improvements in gait.     

Healing of partial flap necrosis in ankle disarticulation amputation by débridement and continued weight-bearing

Five patients with partial tissue loss of the weight-bearing surface of the heel pad following ankle disarticulation were treated with residual-limb debridement and continued end-weight-bearing using a total-contact cast. The patients, ranging in age from 53 to 76 years, had insulin-requiring diabetes and insensate heel pads and were low-demand, limited-activity, community walkers before amputation surgery. Each underwent amputation surgery as a consequence of peripheral vascular disease. All patients progressed to complete wound healing over 3 to 6 months and were able to return to their previous ambulatory level using a prosthesis. At a minimum 2-year follow-up, no patient experienced further residual-limb complications. Partial loss of the weight-bearing heel pad in ankle disarticulation amputation does not preclude successful return to independent ambulation using a standard ankle disarticulation prosthesis. Weight-bearing ambulation need not be avoided during healing.     

Posterior approach to the sciatic nerve in the popliteal fossa for lower limb surgery

Background and objectives: To evaluate success rate, acceptance and complications of sciatic nerve (SN) block at the popliteal fossa (popliteal block, PB) for ambulatory or inpatient orthopedic and vascular surgical procedures. Methods: A retrospective study was carried out in 312 patients who received a PB for vascular and orthopedic lower leg surgery. A single injection, posterior approach technique with 40 ml of either 0.5% ropivacaine or 1% mepivacaine was used. Data collected included demographic and clinical variables. Results: Observed success rate was 95.5%. Acceptance of anesthetic procedure among outpatients was high (94.1%). There were no intraoperative or postoperative complications. For ambulatory surgery patients, the postoperative stay was 130±25 min. Conclusions: PB was a useful anesthetic technique for minor foot and ankle surgery. The single-injection, posterior approach obtained a high success rate without untoward events. It was well accepted by patients and proved to be suitable for ambulatory surgery.     

Thirty percent of patients have moderate to severe pain 24 hr after ambulatory surgery: A survey of 5,703 patients

PURPOSE: Postoperative pain is the commonest reason for delayed discharge and unanticipated hospital admission after ambulatory surgery. We investigated the severity of pain at 24 hr postoperatively and determined the most painful procedures. The need for further medical advice and clarity of postoperative analgesia instructions were also studied. METHODS: Five thousand seven hundred and three ambulatory surgical patients were telephoned 24 hr postoperatively. Patients graded their pain using the ten-point self-assessing verbal scale (0 = no pain, 10 = worst pain). Data were analyzed in two groups, those with moderate to severe pain (pain score 4-10) and those with no or mild pain (0-3). RESULTS: Thirty percent of patients (1,495/5,703) had moderate to severe pain. Microdiscectomy, laparoscopic cholecystectomy, shoulder surgery, elbow/hand surgery, ankle surgery, inguinal hernia repair, and knee surgery were identified as the procedures causing most pain at 24 hr. 13.2% of patients needed medical advice by telephone, 1.4% made an unplanned visit to a doctor while the rate of readmission to the hospital was 0.08%. Ninety-eight percent found postoperative instruction sheets and advice helpful. Eighty-eight percent of patients indicated that analgesic instructions were absolutely clear. CONCLUSION: This study has identified the more painful common ambulatory surgical procedures which will allow take home analgesia to be tailored according to individual procedures. Further improvement in analgesic instructions may help in better pain management of ambulatory surgery patients.     

The Safety Profile of Same-Day Outpatient Total Ankle Arthroplasty

There has been significant change in the health care policy in the United States in recent years with an increasing focus on health care costs and patient satisfaction. One strategy of cost containment is to transition outpatient surgery away from high cost hospital environments. Total ankle arthroplasty has begun the evolution to outpatient settings; however, there is limited published literature on the results of outpatient total ankle arthroplasty (TAA). The purpose of the present study was to review the safety profile of same day outpatient TAA at an ambulatory surgery center. A review of consecutive patients who underwent same day outpatient TAA for end-stage ankle arthritis with a minimum of 12 months’ follow-up was performed. The primary outcomes assessed were the incidence of perioperative adverse medical events, hospital admissions related to the procedure, and postoperative complications (minor and major). Univariate analyses were performed. Fifty-one patients who underwent same-day TAA between June 2016 and July 2018 were included; mean follow-up was 20.7 months (± 7.6). The mean age at time of surgery was 56.5 years (± 7.2), with a mean body mass index of 30.4 (± 5.3). Overall, there were no perioperative adverse medical events or hospital admissions related to the procedure. Five minor complications (9.8%) and 7 major (13.7%) were recorded. Of the major complications, only 1 required TAA revision. Implant survivorship during the most recent follow-up was 98%. The present study suggests that TAA can be performed safely in an outpatient ambulatory setting. Additional comparative studies with larger TAA cohorts and patient reported outcomes are warranted.     

The Influence of Obesity on Hospital Admission After Outpatient Foot and Ankle Surgery

We examined the association of body mass index (BMI) with sociodemographic data, medical comorbidities and hospital admission following ambulatory foot and ankle surgery. We conducted an analysis utilizing data from the American College of Surgeons National Surgical Quality Improvement Program database from 2007 to 2016. Adult patients who underwent ankle surgery defined as ankle arthrodesis, ankle open reduction and internal fixation, and Achilles tendon repair in the outpatient setting. We examined 6 BMI ranges: <20 kg/m² underweight, ≥20 to <25 kg/m² normal weight, ≥25 to <30 kg/m² overweight, ≥30 to <40 kg/m² obese, ≥40 kg/m²to <50 kg/m² severely obese, and ≥50 kg/m² extremely obese. The primary outcome was hospital admission. We performed multivariable logistic regression and reported odds ratios (OR) and their associated 95% confidence interval (CI) and considered a p value of <.05 as statistically significant. Data extraction yielded 13,454 adult patients who underwent ambulatory ankle surgery. We then performed listwise deletion to exclude cases with missing observations. After excluding 5.4% of the data, the final study population included 12,729 patients. The overall rate of hospital admission was in the population was 18.6% (2,377/12,729). The overall rate of postoperative complications was 0.03% (4/12,729). We found no significant association of BMI with hospital admission following multivariable logistic regression. We recommend that BMI alone should not be solely used to exclude patients from having ankle surgery performed in an outpatient setting, especially since this patient group makes up a significant proportion of orthopedic surgery.     

Immediate Weightbearing After Operative Treatment of Bimalleolar and Trimalleolar Ankle Fractures: Faster Return to Work for Patients with Nonsedentary Occupations

The goal of this study was to compare immediate weightbearing (IWB) and traditional weightbearing (TWB) postoperative protocols in unstable ankle fractures, as this has not been compared in prior works. We hypothesize that an immediate weightbearing protocol after ankle fracture fixation will lead to an earlier return to work. An ankle fracture registry was reviewed for operatively treated unstable bimalleolar and trimalleolar ankle fractures at an ambulatory surgery center and followed up at associated outpatient clinics. All fracture cases reviewed occurred from 2009 to 2015. Immediate weightbearing patients were placed into a controlled ankle motion (CAM) boot and allowed to fully bear weight the day of surgery. Traditional weightbearing patients were placed into a CAM boot with 6 weeks of non-weightbearing. Demographics, fixation technique, and injury characteristics were surveyed. Physical job demand was stratified for 69 patients meeting the inclusion criteria (34 IWB and 35 TWB). The main outcome of this study was measured as the time to return to work. Subgroup analysis of patients with nonsedentary jobs demonstrated a significantly earlier return to work for the IWB group (5.7 versus 10.0 weeks, p = .04). Multivariate regression analysis identified a statistically significant 2.25-week (p = .05) earlier return to work for the IWB group after adjustment for occupational physical demand, demographics, fracture characteristics, and participation in a light work period before full work return. In patients with nonsedentary jobs, an IWB protocol after operative management of bimalleolar and trimalleolar ankle fractures resulted in an earlier return to work compared with traditional protocols.     

Outpatient lower extremity infusions

The considerable development of ambulatory surgery has led to an increase in the number of lower extremity procedures performed in an outpatient setting. More recently, the availability of disposable pumps has allowed us to extend the indications of continuous nerve blocks for ambulatory post-operative pain management. Indications for lumbar plexus continuous blocks include anterior cruciate ligament (ACL) reconstruction and patella repairs as well as frozen knee, whereas continuous sciatic blocks are indicated for major foot and ankle surgery. Different modes of local anaesthetic administration have been applied, including the use of repeated bolus, continuous administration and, more recently, patient-controlled perineural infusions. This latter technique seems to be the preferred mode because it offers the advantage of tailoring the amount of local anaesthetics, mostly 0.2% ropivacaine, to the individual need and also maximizes the duration of infusion for a given volume of local anaesthetic. Although the preliminary reports indicate that lower extremity continuous blocks provide effective post-operative ambulatory analgesia and are safe, especially as a part of a multimodal approach, appropriate training in these techniques represents one of the most important limiting factors of the placement of perineural catheters. Additional research is required to determine the optimal conditions in which these techniques are indicated.     

Functional outcome and cost-effectiveness of outpatient vs inpatient care for complex hind-foot and ankle surgery. A retrospective cohort study

Study objectiveTo compare the postoperative functional outcome and the total cost associated with outpatient vs inpatient care following complex hind-foot and ankle surgery.DesignRetrospective, cohort study.SettingTertiary care center.PatientsForty patients, American Society of Anesthesiologists 1-3, of either sex undergoing elective complex hind-foot and ankle surgery (fusion, osteotomy, or multiple ligament repair).InterventionsBoth inpatients and outpatients received a continuous perineural infusion of local anesthetic for 48 hours at the core of a multimodal analgesic regimen. Patients were retrospectively identified, and an outpatient cohort was matched to an inpatient cohort in a 1:1 ratio for age, sex, baseline functional score, and type of surgery.MeasurementsThe primary outcome was functional outcome upon discharge of the surgical program as measured by the Lower Extremity Functional Score. Secondary outcomes were the incidence of surgical or anesthetic complications and the total perioperative cost of care.ResultsPatients in both cohorts had similar functional outcome on discharge of the surgical program. Analgesia was effective in both groups, and no complications were reported. The cost of care for outpatients was 54% lower than that for inpatients.ConclusionThis retrospective study suggests that outpatient care including an ambulatory perineural infusion of local anesthetic may be a cost-effective alternative to inpatient care after complex foot and ankle surgery.     

Ankle arthrodesis with a retrograde femoral nail for Charcot ankle arthropathy

BACKGROUND: Tibiocalcaneal arthrodesis with retrograde intramedullary nailing has gained acceptance as a salvage procedure for a multitude of ankle and hindfoot disorders and is frequently used in Charcot arthropathy of the ankle. Because of the severe osteopenia often associated with Charcot arthropathy of the ankle, an area of stress concentration leading to stress fracture at the proximal aspect of the nail has been identified. METHODS: To determine if this potential complication can be avoided, nine consecutive diabetic individuals with Charcot arthropathy of the ankle had ankle arthrodesis with a longer retrograde femoral nail. The average age of the patients was 52.3 years. Their average weight was 102.6 kg. RESULTS: Fusion was evident on radiographs in all nine patients at an average of 10.5 weeks. None of the patients developed a stress fracture or evidence of stress concentration at the proximal metaphyseal tip of the nails. One wound infection resolved after debridement and antibiotic therapy, and one postoperative hematoma resolved without surgery. At an average 32-month followup, all patients were ambulatory, using commercially available therapeutic footwear. None had developed a new foot ulcer, infection, or new episode of Charcot arthropathy. CONCLUSIONS: The use of a retrograde femoral nail for ankle arthrodesis in patients with Charcot arthropathy appears to decrease the risk of stress fracture compared with shorter nails without increasing the risk of other complications.     

Popliteal sciatic perineural local anesthetic infusion: a comparison of three dosing regimens for postoperative analgesia

BACKGROUND: This randomized, double-blind study investigated the efficacy of continuous and patient-controlled ropivacaine infusion via a popliteal sciatic perineural catheter in ambulatory patients undergoing moderately painful orthopedic surgery of the foot or ankle. METHODS: Preoperatively, patients (n = 30) received a posterior popliteal sciatic perineural catheter and nerve block. Postoperatively, patients were discharged home with a portable infusion pump delivering 0.2% ropivacaine (500 ml) in one of three dosing regimens: the basal group (12-ml/h basal rate, 0.05-ml patient-controlled bolus dose), the basal-bolus group (8-ml/h basal rate, 4-ml bolus dose), or the bolus group (0.3-ml/h basal rate, 9.9-ml bolus dose). RESULTS: The bolus group experienced an increase in baseline pain, breakthrough pain incidence and intensity, and sleep disturbances compared with the other two groups (P < 0.05 for all comparisons). Compared with the basal-bolus group, the basal group experienced an increase in these outcome measures only after local anesthetic reservoir exhaustion, which occurred earlier than in the other two groups (P < 0.05 for all comparisons). Satisfaction scores did not differ among the three groups. CONCLUSIONS: This study demonstrates that when providing analgesia with 0.2% ropivacaine via a popliteal sciatic perineural catheter after moderately painful surgery of the foot or ankle, a continuous infusion is required to optimize infusion benefits. Furthermore, adding patient-controlled bolus doses allows for a lower continuous basal rate and decreased local anesthetic consumption and thereby increases the duration of infusion benefits when in an ambulatory environment with a limited local anesthetic reservoir.     

A Technique Guide in Ultrasound Guided Regional Ankle Blocks

The use of ultrasound guided regional blocks is supported by the National Institute for Health and Care Excellence of the United Kingdom, for its safety and efficacy. This is a technique guide which is a culmination of the experiences gained in administering regional anesthesia under ultrasound guidance for ankle blocks as part of everyday podiatric surgery practice, based on a sound understanding of the principles of ultrasound science and instrumentation. It is in the opinion of the authors that the positioning of the patient is key, combined with an in-plane ultrasound guided technique, to perform a successful block of the selected nerve based on a foundation of knowledge and experience of anatomy and use of ultrasound respectively. This technique guide depicts annotated ultrasound images of the sonoanatomy to include the five nerves which innovate the foot that are required to be anesthetized for a selective or complete regional ankle block offering predictable peri-operative anesthesia, post-operative analgesia and early ambulatory discharge.     

Single-injection applications for foot and ankle surgery

Foot or ankle surgery is often performed in an ambulatory care setting. The post-operative pain that follows can be moderate to severe in intensity and difficult to control with oral analgesics. Regional anaesthetic techniques have been advocated for such procedures. Wound infiltration with long-acting local anaesthetic provides post-operative pain relief which, though efficient, lasts for too short a time. Intravenous regional anaesthesia (IVRA) is a safe anaesthetic technique for minor surgery of short duration. It is not indicated for painful and/or complex procedures. Ankle block is convenient for most procedures but is somewhat less reliable than popliteal sciatic nerve block. Associated with a saphenous or femoral nerve block, posterior popliteal sciatic nerve block is the technique of choice. Patients can be safely discharged even when long-acting local anaesthetics are used. In major surgery a continuous technique can be proposed. When the prone position is impossible the lateral approach is an efficient alternative.