American Orthopaedic Foot and Ankle Society shoe survey of diabetic patients

A one-page written survey was completed by 402 randomly selected patients with diabetes in five cities during a scheduled visit to their endocrinologist. Patients averaged 61.5 years of age and had been diagnosed with diabetes for 27.3 years. This study suggests that approximately 25% of adults with diabetes are at risk for developing foot ulcers, the precursor to deep infection leading to lower limb amputation. The goal at the inception of this project was to obtain benchmark data on the current level of prophylactic foot care being provided to adult patients with diabetes. The results of this survey suggest that most individuals with diabetes and their physicians are aware of potential diabetic foot morbidity, yet very few take advantage of prophylactic protective footware. Even fewer are presently taking advantage of benefits established through the Medicare Therapeutic Foot Bill. This survey highlights a substantial opportunity for improvement in the long-term care of individuals with diabetes.     

Anterior Tibial Artery Pseudoaneurysm in a Patient with Hemophilia: A Complication of Ankle Arthroscopy

Arterial pseudoaneurysm formation as a complication of ankle arthroscopy is extremely rare. We present a case of anterior tibial artery pseudoaneurysm identified 10 days after ankle arthroscopy in a patient with hemophilia. The diagnosis was confirmed with a duplex ultrasound scan. The patient was referred to the vascular surgeon and underwent evacuation of the hematoma, resection of the damaged segment of the artery, and reconstruction with a reversed long saphenous vein interposition graft. The patient had an uneventful recovery after the second surgery. The prevention of this complication in patients with hemophilia is discussed, as well as diagnosis and management. Preventative measures include careful dissection while making the portals, preoperative mapping of the artery with a duplex or a handheld Doppler in patients with coagulopathy, and performance of open rather than arthroscopic surgery to excise large osteophytes.     

Ankle arthrodesis. Problems and pitfalls

Compression ankle arthrodesis remains a widely accepted surgical procedure. However, uniform efficacious results are not always obtainable. Seventeen patients treated by compression ankle arthrodesis showed 11 fusions, or a 65% union rate, with an average immobilization period of five months. The nonunion group of six patients (35%), with an average of ten months of immobilization, included two patients who were treated by below-knee amputations. The failures demonstrated basic violations of surgical, roentgenographic, and biomechanical tenets. In particular, the commonly used external fixation devices afford stability in only one plane and do not give rigid immobilization. A Triangular Compression Device solves these problems and has been used successfully.     

Guidelines for diabetic foot care. The Diabetes Committee of the American Orthopaedic Foot and Ankle Society

Foot infection is the most common reason for hospital admission of patients with diabetes in the United States. Foot ulceration leads to deep infection, sepsis, and lower extremity amputation. Prophylactic foot care has been shown to decrease patient morbidity, decrease the utilization of expensive resources, and decrease the risk for amputation and premature death. The Diabetes Committee of the American Orthopaedic Foot and Ankle Society has developed guidelines for implementing this type of prophylactic foot care. The guidelines are arranged as follows: I. Screening for Patients Who Are at Risk for Developing Diabetic Foot Complications A. Risk Factors B. Components of Screening and Examination II. Patient Education III. Basic Treatment Guidelines A. Risk Categories B. Nail Care C. Ulcer Care IV. Referral Guidelines A. Vascular Surgery Consultation B. Orthopaedic Consultation C. Endocrinologist/Diabetologist Consultation D. Infectious Disease Consultation E. Radiologic Consultation F. Pedorthic Consultation V. Resources.     

Validity and internal consistency of the American Orthopaedic Foot and Ankle Society Midfoot Scale in patients with Lisfranc injury

BackgroundThe American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale is an extensively used outcome measure instrument for evaluating outcomes after foot and ankle surgery or trauma.MethodsIn total, 117 patients with Lisfranc injury completed the AOFAS Midfoot Scale and the Visual Analogue Scale Foot and Ankle (VAS-FA) instruments. Internal consistency (correlation between different items), floor and ceiling values, convergent validity, item threshold distribution, and the coverage (item difficulty) of the AOFAS Midfoot scale were tested.ResultsAOFAS Midfoot Scale had high convergent validity and acceptable internal consistency (Cronbach’s alpha >0.70). The ceiling effect was confirmed. The person-item distribution indicated that the scale had a lack of coverage and targeting in our sample.ConclusionsOur data suggests that the AOFAS Midfoot Scale has acceptable validity and internal consistency. However, due to the lack of coverage and targeting, it should not be the primary outcome measure to be used to evaluate the outcomes after Lisfranc injury in the future studies.     

Reliability and Validity of the Subjective Component of the American Orthopaedic Foot and Ankle Society Clinical Rating Scales

This study evaluates the criterion validity of the subjective component of the American Orthopaedic Foot and Ankle Society (AOFAS) clinical rating scales by correlating scores obtained with these rating scales to scores obtained with the Foot Function Index (FFI) in patients with foot and ankle conditions. To date, the AOFAS scoring scales have not been shown to provide valid information despite their popularity. The FFI, on the other hand, has previously been shown to provide valid information in regard to conditions affecting the foot and ankle. A moderately strong inverse criterion validity correlation (Pearson correlation coefficient = -0.68) was shown when preoperative patients were administered both the AOFAS and FFI questionnaires, and the resultant scores were compared. Test-retest reliability measurements showed no significant difference (P = .27) between preoperative AOFAS scale scores measured at least 2 weeks apart. Construct validity was shown (P = .006) when dependent preoperative and postoperative (at least 3 months) AOFAS scale scores were compared, indicative of the clinical rating scales' ability to discriminate and predict quality of life related to foot and ankle conditions. The moderate level of correlation, satisfactory degree of reliability, and responsiveness (ability to distinguish differences between preoperative and postoperative conditions in the same patient) observed in this study suggest that the subjective component of the AOFAS clinical rating scales provides quality-of-life information that conveys acceptable validity regarding conditions affecting the foot and ankle.     

Guidelines for diabetic foot care: recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society

Foot infection is the most common reason for hospital admission of diabetic patients in the United States. Foot ulceration leads to deep infection, sepsis, and lower extremity amputation. Prophylactic foot care has been shown to decrease patient morbidity, decrease the utilization of expensive resources, and decrease the risk for amputation and premature death. The Diabetes Committee of the American Orthopaedic Foot and Ankle Society has developed guidelines for the implementation of this type of prophylactic foot care. The screening examination includes evaluation for peripheral neuropathy, skin integrity, ulcers or wounds, deformity, vascular insufficiency, and footwear. Foot-specific patient education includes instruction on self-examination and foot care practices. Individualized foot-specific patient education is indicated for patients with peripheral neuropathy. Treatment is outlined based on risk level, which is determined by the presence of peripheral neuropathy, deformity, and ulcer history. Treatment combines patient education, orthoses, footwear, and a timetable for ongoing skin and nail care. Ulcer care includes paring of calluses, debridement of infected or nonviable tissue, dressings, and off-loading. Specialty assistance may be required from a vascular surgeon, orthopaedic surgeon, podiatrist, endocrinologist/diabetologist, infectious disease consultant, radiologist, and pedorthist.     

Defining the patient acceptable symptom state for the American Orthopaedic Foot & Ankle Society score following hallux valgus surgery

BackgroundThis study aimed to define the patient acceptable symptom state (PASS) for the American Orthopaedic Foot & Ankle Society score (AOFAS) following hallux valgus surgery.Methods548 patients underwent hallux valgus surgery and had AOFAS assessed preoperatively, 6 months and 2 years postoperatively. Responses to an anchor question were used as external criterion in receiver operating characteristics (ROC) analyses to define PASS thresholds.ResultsIn total, 429 patients (78.3%) reported their current state as acceptable. Areas under the curve (AUC) for ROCs were 0.71?0.81 for all analyses. PASS threshold was 88.5 at 2 years (sensitivity 64%, specificity 85%). Sensitivity analyses revealed that the threshold was robust.ConclusionsPatients with an AOFAS of 88.5 consider their postoperative symptom state to be acceptable. This knowledge will enable clinicians to identify patients who have attained a satisfactory functional status after hallux valgus surgery.     

Orthopaedic Surgeons Frequently Underestimate the Cost of Orthopaedic Implants

Background

A poor understanding of cost among healthcare providers may contribute to high healthcare expenditures. Currently, it is unclear whether and how much surgeons know about the costs of implantable medical devices (IMDs).

Questions/purposes

We (1) determined the level of comfort with orthopaedic IMD costs among orthopaedic residents and attending surgeons, (2) quantified how accurately surgeons understand the costs of orthopaedic IMDs, and (3) identified which constructs yield the most accurate cost estimations among residents and attending surgeons.

Methods

A questionnaire was presented to 60 residents and 37 attending orthopaedic surgeons from two large academic medical centers. Respondents estimated the cost of 13 commonly used orthopaedic devices. Fifty-one surgeons participated (36 residents, 15 attending surgeons), for an overall response rate of 53%. Cost estimates were compared against the actual material costs, and we recorded the percentage error for each estimate.

Results

More than ½ of the respondents rated their knowledge of IMD cost as poor. The mean percentage error in estimation for all respondents was 69% (range, 29%–289%). Overall, 67% of responses were underestimations and 33% were overestimations. Residents demonstrated a mean percentage error of 73% (range, 29%–289%) while attending surgeons had a mean percentage error of 59% (range, 49%–79%). Residents and attending surgeons demonstrated differences in accuracy within groups and between groups based on the IMD being estimated.

Conclusions

We found the knowledge of orthopaedic IMD costs among the orthopaedic residents and attending surgeons surveyed was poor. Further investigation of how physicians conceptualize material costs will be important to healthcare cost control.     

Orthopaedic surgery in the elderly

The orthopaedic surgeon brings to the operating room some of the greatest challenges for the anaesthesiologist. Various factors, such as age, health status, disease process, type and extent of operative procedure, provide differing circumstances, which an anaesthesiologist is obliged to cope with. This contrasts to other surgical specialities in which patient factors and operative procedures are much more predictable. The number of older patients in orthopaedics is steadily growing, and the anaesthesiologist has to take all measures to permit an early and efficient rehabilitation, a concept which is now widely recognized for improving the success of orthopaedic surgical procedures. Factors which may hinder this concept are post-operative pain, central nervous system dysfunction, fatigue, deep sedation, delayed enteral feeding and absorption. There is no evidence that regional anaesthesia without the use of the continuous regional analgesic technique decreases morbidity and mortality as compared to general anaesthesia, in this context. However, the advantages of continuous analgesia through a perineural spinal or epidural catheter are promising and deserve further investigation. The concept of the optimal post-operative multimodal regimen needs to be defined. The application of NSAID and paracetamol is an integral part of this concept, and the dose of opioids should be titrated to the lowest efficient dose needed. Thus, this chapter discusses the different controversies and future trends of anaesthesia with regard to the elderly in orthopaedic surgery.