The 100 most cited papers in foot and ankle surgery

BackgroundThe number of citations of a paper gives an indication of an article's merit and importance within a medical specialty. We identify and analyse the 100 most cited papers in foot and ankle surgery.MethodThe Science Citation Index Expanded was searched for citations in 15 respected journals containing foot and ankle articles. Papers were analysed for subject, authorship, institution, country and year of publication. The average yearly citation was compared to total number of citations.Results3501 foot and ankle papers were returned. The maximum number of citations was 1084 and the mean was 104. The top 100 papers were published between 1979 and 2007, with the majority published in the last decade. The ankle was the most important anatomical region discussed, and basic science and degenerative disease were popular topics. We found a large discrepancy between the total number of citations with average yearly citation.ConclusionFoot and ankle surgery is a young and rapidly developing sub-specialty within orthopaedics. Recently there has been a significant increase in influential papers published. Certain topics are popular indicating their importance within the field. This study highlights important papers in foot and ankle surgery giving an insight into readership.     

Role of anti-oxidant (vitamin-C) in post-operative pain relief in foot and ankle trauma surgery: A prospective randomized trial

BackgroundPost-operative pain may adversely affect a patient’s quality of life. Studies have shown that vitamin C, being an anti-oxidant and neuro-modulating agent, can help to reduce pain in a variety of clinical settings. The objective of this randomized controlled trial was to assess the effectiveness of vitamin C in reducing post-operative pain, analgesia requirements and improving functional outcome.MethodsPatients with isolated foot and ankle trauma, who had undergone surgery, were randomly assigned to receive either vitamin C 500 mg or a placebo tablet twice a day. VAS score, analgesia requirement and functional outcome were assessed during their regular follow up. Results were compared and analyzed at the end of 3 months.ResultsThe group which received vitamin C, showed improvement in VAS score at the end of second and sixth week of follow up, reduced analgesia requirements and improved functional outcome as compared to the placebo group.ConclusionsThis study shows that the supplementation of vitamin C in patients undergoing surgery for foot and ankle trauma helps to reduce analgesic requirements, improve VAS scores and achieve better functional outcome.     

The impact of COVID-19 on foot and ankle surgery in a major trauma centre

Introduction and aimsCOVID-19 has had a significant impact on orthopaedic surgery globally. This paper aims to evaluate the impact of COVID-19 on foot and ankle trauma in a major trauma centre.MethodsA retrospective observational study of prospectively collected data was performed. All foot and ankle trauma patients over a 33 week period (1st December 2019–16th July 2020) were analysed. All patients with trauma classified by the AO/OTA as occurring at locations 43 and 81–88 were included.ResultsOver the 33 weeks analysed, there was a total of 1661 trauma cases performed; of these, only 230 (13.85%) were foot and ankle trauma cases. As percentage of cases during each period of lockdown, foot and ankle made up 15.20% (147 out of 967) pre-lockdown, 8.81% (17 out of 193) during lockdown and 13.17% (66 out of 501) post lockdown. This difference was statistically significant (p < .001). The most significant change in trauma management was the treatment of malleolar fractures.Further analysis showed that during the lockdown period 29 foot and ankle fractures were treated the same and 13 were treated differently, (i.e. 31% of fractures were treated conservatively, when the consultants preferred practice would have been surgical intervention). Of the 13 patients, 3 have had surgical management since lockdown has been eased.ConclusionIt is evident that the trauma case activity within foot and ankle was significantly reduced during the COVID-19 period. The consequences of change in management were mitigated due to a reduction in case load.     

超声引导下腓肠肌平面阻滞对足踝部手术患者术后镇痛的影响

目的 评价单次腓肠肌平面阻滞(GPB)用于择期全身麻醉下足踝部手术患者术后镇痛的有效性。方法 选择全身麻醉下足踝部手术患者60例,男34例,女26例,年龄18～64岁,BMI 18～28 kg/m²,ASAⅠ—Ⅲ级。将患者随机分为两组：GPB组和对照组,每组30例。GPB组术前进行GPB,于腓肠肌表面共注入0.375%罗哌卡因30 ml,对照组不予GPB。两组麻醉诱导和麻醉维持方法一致。术后均行无背景剂量羟考酮静脉镇痛。记录术后4、8、12、16、24、48 h静息和活动(足踝部背曲与跖曲)时NRS评分,术后0～16、16～24、24～48、0～48 h疼痛-时间曲线下面积(AUC),术中瑞芬太尼的用量,术后48 h内地佐辛补救情况,术后0、4、8、12、16、24、48 h的羟考酮滴定量,术后48 h有效按压次数、总按压次数和首次按压时间,术后住院时间、首次下床活动时间,以及头晕、发热、恶心呕吐、皮肤瘙痒和神经并发症等不良反应发生情况。结果 与对照组比较,GPB组术后4、8、12、16 h静息和活动时NRS评分明显降低(P<0.01),静息时和活动时0～1...     

Implications of obesity in patients with foot and ankle pathology

Obesity is a growing problem defined as a body mass index of greater than 30 kg/m². It is predicted that by 2030, 48.9% of adults will be classified as obese which expands surgical risk factors to a broad population while increasing healthcare costs at the same time in different socioeconomic groups. This specific population has been widely studied in multiple surgical fields and published studies have shown the implications in each of these fields. The impact of obesity on orthopedic surgical outcomes has been previously reported in several total hip and knee arthroscopy studies, with evidence indicating that obesity is strongly associated with an increased risk of post operative complications together with higher revision rates. In line with increasing interest on the impact of obesity in orthopedics, there has been a similar output of publications in the foot and ankle literature. This review article evaluates several foot and ankle pathologies, their risk factors associated with obesity and subsequent management. It provides an updated, comprehensive analysis of the effects of obesity on foot and ankle surgical outcomes, with the ultimate aim of educating both surgeons and allied health professionals about the risks, benefits, and modifiable factors of operating on obese patients.     

Characteristics and publication discrepancies of foot & ankle surgery-related clinical trials

BackgroundTrial registration can provide more reliable study designs, however, the final publications are not exempt from bias. This study aimed to show the characteristics of foot & ankle surgery-related clinical trials registered in ClinicalTrials.gov (CTG) and analyze possible risk factors that can lead to discrepancies between the original trial registry and published results.MethodsFoot & ankle surgery-related randomized controlled studies registered in CTG with an anticipated completion date until 2018 were extracted. 157 trials were found eligible for final analysis and corresponding publications were investigated through literature databases. Discrepancies between trial registries and published results were analyzed.Results67.5% of trials were registered whether during the trial period or after completion. 46.5% were funded by industry. 54.8% of trials were reported to be completed. The results of 66 (42%) trials were published in a journal. There was a sample size discrepancy in 57.6%, follow-up time discrepancy in 28.8%, primary outcome discrepancy in 45.5%, and inclusion/exclusion criteria discrepancy in 89.4% of registries. Sample size, inclusion/exclusion criteria discrepancies were significantly more in trials funded by industry (p = 0.024, 0.001, 0.037, respectively). Industry-funded studies reported positive results more frequently (p = 0.011).ConclusionOnly 42% of all registered foot & ankle surgery-related studies had the chance to be published. The majority of studies presented discrepancies in sample size, outcome assessment method, follow-up time, or inclusion/exclusion criteria. Industry-funded studies showed a higher rate of discrepancies and were more inclined towards reporting positive results indicating a risk of bias in assessments.Level of clinical evidenceLevel 3.     

The efficacy of prophylactic intravenous antibiotics in elective foot and ankle surgery

A retrospective chart review of 555 patients who received elective foot and ankle surgeries between 1995 and 2001 at 1 outpatient podiatric hospital clinic was performed to evaluate the efficacy of preoperative intravenous antibiotic use. Only those patients who were having elective foot or ankle surgery for the first time, were being followed up at the hospital's outpatient clinic, and had a nontraumatic cause for their surgery were included in this study. A wound was considered infected when purulent material from the wound sites was noted and an organism(s) was cultured. A wound complication was defined as a superficial dehiscence, edema, erythema, or stitch abscess. Three hundred six (55.1%) patients received a preoperative antibiotic and 249 (44.9%) patients did not. Of the 306 patients who received a preoperative antibiotic, 9 (1.6%) acquired a postoperative wound infection, whereas 8 (1.4%) of the 249 patients who did not receive preoperative antibiotics acquired a postoperative infection. A logistic regression model and chi square tests of association were used to determine if preoperative antibiotic use, age, gender, type of surgical procedure, operative time, tourniquet use, past medical history, and internal fixation were predictive of or associated with postoperative wound infection or complication. None of the study factors was predictive of postoperative wound infection or complication (P >.01). Preoperative antibiotic use was associated with surgical category and internal fixation use (P <.001) but not postoperative wound infection or complication (P >.01). The results suggest that prophylactic intravenous antibiotic use in routine elective foot and ankle surgery is not warranted.     

Vitamin D and spine surgery

Vitamin D is crucial for musculoskeletal health, maintenance, and function. Vitamin D insufficiency is common among patients undergoing spine surgery and the ideal vitamin D level for spine surgery has yet to be investigated. There is a high prevalence of hypovitaminosis D in patients with musculoskeletal pain regardless of surgical intervention. With the frequency and costs of spine surgery increasing, it is imperative that efforts are continued to reduce the impact on patients and healthcare services. Studies into vitamin D and its associations with orthopaedic surgery have yielded alarming findings with regards to the prevalence of vitamin D deficiency. Importantly, altered vitamin D status also contributes to a wide range of disease conditions. Therefore, future investigations are still essential for better understanding the relationship between vitamin D and spine surgery outcomes. Whilst further research is required to fully elucidate the extent of the effects of hypovitaminosis D has on surgical outcomes, it is strongly advisable to reduce the impacts by appropriate vitamin D supplementation of deficient and at-risk patients.     

Advanced foot and ankle fixation techniques in patients with diabetes

This article presents advanced techniques and current fixation constructs that are advantageous for the management of diabetic foot and ankle trauma and Charcot neuroarthropathy. Both these pathologies are often intimately related, and the fixation constructs that are required often require sound biomechanical concepts coupled with innovative approaches to achieve bone healing and limb salvage.     

足踝手术后连续腓肠肌平面阻滞的镇痛效果

目的：探索连续腓肠肌平面阻滞镇痛用于足踝部手术患者术后镇痛效果。
方法：选择全麻下行足踝部择期手术患者42例,男19例,女23例,年龄18～64岁,BMI 18～28 kg/m²,ASAⅠ—Ⅲ级。将患者随机分为两组：连续腓肠肌平面阻滞镇痛组（CN组）和患者自控静脉镇痛（PCIA）组（I组）,每组21例。CN组术毕行连续腓肠肌平面阻滞镇痛,配方为0.125%罗哌卡因300 ml,背景剂量为3 ml/h,单次给药剂量为 8 ml,锁定时间为25 min。I组术毕使用羟考酮PCIA,配方为羟考酮30 mg、托烷司琼6 mg加生理盐水至150 ml,输注速度0.5 ml/h,单次追加剂量5 ml。观察两组术后0～16、16～24、24～48、0～48 h时段静息和活动时NRS评分曲线下面积（AUC）,1、8、16、24、32、48 h静息和活动时NRS评分,CN组术后胫神经和腓总神经运动功能恢复时间、羟考酮滴定量、术后48 h内补救镇痛药物的吗啡当量累计使用量、补救镇痛次数、补救镇痛率、首次下床活动时间、术后恶心呕吐的发生情况和患者满意度评分。
结果：与I组比较,CN组0～16、16～24、24～48、0～48 h静息和活动时NRS评分AUC明显降低（P<0.01）,术后1、8、16、24、32、48 h NRS评分明显降低（P<0.01）,CN组16 h有10例（50%）患者腓总神经运动功能恢复,24 h有17例（85%）患者腓总神经运动功能恢复,32～48 h所有患者腓总神经运动功能恢复,48 h内所有患者胫神经运动功能正常。与I组比较,CN组吗啡当量累计使用量和补救镇痛次数明显减少（P<0.01）,补救镇痛率明显降低（P<0.01）,患者满意度评分明显升高（P<0.01）。两组羟考酮滴定量、首次下床活动时间,恶心呕吐发生率差异无统计学意义。
结论：超声引导下连续腓肠肌平面阻滞可以实现胫神经运动和感觉阻滞分离,可在足踝手术后提供良好且持续的镇痛效果。     

The implications of biologic therapy for elective foot and ankle surgery in patients with rheumatoid arthritis

IntroductionRheumatoid arthritis (RA) is one of a number of inflammatory arthropathies resulting in foot pain and deformity. Patients with this disease may require surgical intervention as part of their management. Many of these patients are now taking biologic agents which pose several risks to patients in the perioperative phase. The surgical team therefore need to be aware of these associated complications and how to manage these cases.AimThis paper aims to review the current literature about perioperative needs (foot and ankle surgery) associated with patients with rheumatoid arthritis receiving biologic therapy.Main findingsThe majority of the literature discusses the perioperative complications associated with patients on anti-TNFα therapy with few studies investigating the other biologics in common use. There is conflicting evidence as to the safety of continuing or stopping biologic drug therapy prior to orthopaedic procedures. The British Society for Rheumatology (BSR) have produced guidelines for the management of patients on anti-TNFα therapy or the biologic agent Tocilizumab. These recommendations suggest the risks of post-operative infection need to be balanced against the risk of a post-operative disease flare. In essence, it is suggested anti-TNFα therapy is stopped 3–5 times the half-life of the drug whilst Tocilizumab is stopped 4 weeks prior to surgery.ConclusionGood communication is needed between the surgical team and the local Rheumatology department managing the patient’s disease in order to optimise perioperative care. Local pathways may vary from the BSR recommendations to determine the most suitable course of action with regards to continuing or stopping biologic therapy prior to foot and ankle surgery.     

Validity of five foot and ankle specific electronic patient-reported outcome (ePRO) instruments in patients undergoing elective orthopedic foot or ankle surgery

BackgroundPatient-reported outcomes (PROs) are widely accepted measures for evaluating outcomes of surgical interventions. As patient-reported information is stored in electronic health records, it is essential that there are valid electronic PRO (ePRO) instruments available for clinicians and researchers. The aim of this study was to evaluate the validity of electronic versions of five widely used foot and ankle specific PRO instruments.MethodsAltogether 111 consecutive elective foot/ankle surgery patients were invited face-to-face to participate in this study. Patients completed electronic versions of the Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), the modified Lower Extremity Function Scale (LEFS), the Manchester–Oxford Foot Questionnaire (MOXFQ), and the Visual Analogue Scale Foot and Ankle (VAS-FA) on the day of elective foot and/or ankle surgery. Construct validity, coverage, and targeting of the scales were assessed.ResultsBased on general and predefined thresholds, construct validity, coverage, and targeting of the ePRO versions of the FAAM, the FAOS, the MOXFQ, and the VAS-FA were acceptable. Major issues arose with score distribution and convergent validity of the modified LEFS instrument.ConclusionsThe ePRO versions of the FAAM, the FAOS, the MOXFQ, and the VAS-FA provide valid scores for foot and ankle patients. However, our findings do not support the use of the modified LEFS as an electronic outcome measure for patients with orthopedic foot and/or ankle pathologies.     

Large variation in use of patient-reported outcome measures: A survey of 188 foot and ankle surgeons

Background

There is an increasing interest in the use of patient reported outcome measures (PROMs). However, there is a large variety of PROMs and a lack of consensus regarding preference for their use. Aim of this study is to determine how often PROMS are used for foot and ankle disorders, for what purpose PROMs are used, and what the preferences of the foot and ankle surgeons are, when choosing a PROM to use.

Comparison of postoperative pain control methods after bony surgery in the foot and ankle

Background

We performed a prospective study to evaluate and compare the effectiveness of postoperative pain control methods after bone surgery in the foot and ankle.

The influence of smoking on foot and ankle surgery: a review of the literature

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.     

Retrospective review of complications following long tourniquet time in foot and ankle surgery

BackgroundTourniquet use is ubiquitous in orthopaedic surgery to create a bloodless field and to facilitate safe surgery, however, we know of the potential complications that can occur as a result of prolonged tourniquet time. Experimental and clinical research has helped define the safe time limits but there is not much literature specific to foot and ankle surgery.MethodsA retrospective review of the postoperative course of patients with prolonged tourniquet time (longer than 180 min) for foot and ankle procedures was done. Data related to the patient factors and the surgical procedure was collected. The length of stay, re-admissions and complications were the important indicators of the individual patient’s recovery.ResultsTwenty patients were identified with longer than 180-min tourniquet times for complex foot and ankle procedures. The average uninterrupted tourniquet time was 191 min. Eight of the twenty procedures were revision surgeries. The average length of stay was 3 days and there were no re-admissions within 30 days. Eight patients (40%) had at least one recorded complication. The complications seen in this group were transient sensory loss, wound issues, superficial infection, ongoing pain and non-union.ConclusionsThis case series has not revealed any major systemic complications resulting from the prolonged tourniquet such as pulmonary embolism or renal dysfunction. Unlike past literature on knee procedures with extended tourniquet times, no major nerve palsies were seen in our patient group. Our understanding of the local and systemic effects of tourniquet is not complete and this study demonstrates that the complications do not necessarily increase in a linear fashion in relation to the tourniquet time.