A Prospective Study Assessing Wound Complications in a Series of Foot and Ankle Patients Treated With Enoxaparin: A Baseline for Future Studies.

Background and objective Low-molecular-weight heparin (LMWH) prophylaxis has now become the gold-standard practice in patients requiring lower limb immobilization. We had noticed an increase in the incidence of wound-healing problems at our center, and the severity of the problems was found to be worse in patients undergoing foot and ankle surgery since we had adopted this practice. In this study, we aimed to describe the incidence and severity of wound-healing problems in this group of patients. Methods This was a prospective study and we collected data on the frequency and severity of wound problems occurring in patients undergoing a variety of foot and ankle operations. All patients underwent a standard agreed-on method of wound closure and dressings. Wounds were reviewed after two weeks and wound characteristics were noted using a rigid proforma. The primary outcome measure was to determine the incidence of delayed wound healing (DWH) and wound infections requiring antibiotics. Secondary outcomes were the characteristics of each delayed-healing wound. Results A total of 158 patients met the inclusion criteria of the study. One patient was not given postoperative LMWH and was excluded from the final analysis. Seven patients (4.5%) were noted to have DWH and four patients (2.6%) had a wound infection at the two-week postoperative follow-up. None of the patients required a second operation. Among patients with wound-healing problems, wound contour irregularities were noted in 51% and margin separation was noted in 65%. Conclusion The overall incidence of wound-healing problems such as DWH and wound infections was low in patients receiving prophylactic LMWH for foot and ankle surgery. Where postoperative wound problems did occur, these were associated with poor wound characteristics such as margin separation or contour irregularity. Further studies should be conducted to ascertain if the use of LMWH leads to problems with wound appearance.

Use of peripheral blocks and tourniquets in foot surgery: A survey of Australian orthopaedic foot and ankle surgeons.

BACKGROUND: The most common reasons for unplanned admission to the hospital from outpatient surgery have the potential to be minimised or eliminated by peripheral nerve blocks (PNB). Tourniquets are commonly used in elective extremity surgery but it's use is mostly guided by personal preferences and does no correlate with the existing literature. Our aim was to explore the current practice of PNB and tourniquet use by foot and ankle surgeons in Australia. METHODS: The Australian Orthopaedic Foot and Ankle Surgery Society (AOFAS) annual meeting was held in Adelaide in 2011. Members were asked to complete an electronic survey on their current use of peripheral nerve blocks and tourniquets. Two specific elective case scenarios were included for comment, one pertaining to forefoot pathology, the other hindfoot pathology. RESULTS: Twenty-three AOFAS members replied to the survey, an overall response rate of 76.6%. Of these, only two surgeons did not use ankle blocks in elective surgery and none were prepared to operate without a tourniquet. Most Australian foot and ankle surgeons were reluctant to use local anaesthetic techniques without an accompanying GA. CONCLUSIONS: While the literature suggests that GA may add to complications without any benefit for the procedure and that distally based tourniquets may add benefit, these are not the favoured techniques in Australian foot and ankle surgeons.

Prevalence of interdigital nerve enlargements in an asymptomatic population.

BACKGROUND: Morton's neuroma is a common primary diagnosis for referral to foot and ankle surgeons. On presentation, many patients have had an ultrasound reporting the presence of Morton's neuroma, which may not correlate with the clinical examination findings. The prevalence of such sonographic findings in the general population remains unknown. METHODS: In this observational prospective study, patients with asymptomatic forefeet who were seen by two foot and ankle surgeons for unrelated mid- or hind foot pathology were examined clinically and sonographically for the presence of interdigital nerve thickening. Forty-eight volunteers participated in the study (96 feet). For the purpose of this study, asymptomatic thickenings greater than 5 mm in diameter were termed sonographic neuromas. Ultrasound examination was performed by two specialist musculoskeletal radiologists. RESULTS: Fifty-four percent of the volunteers (26 of 48) had sonographic nerve thickening and in 17 cases (35.4%) enlarged nerves were found bilaterally. Differences for gender, original diagnosis or side of original pathology were not significant. Older subjects were more likely to have a sonographic neuroma (p = 0.018). Feet with a positive Mulder's click were more likely to have a sonographic neuroma (p = 0.015). CONCLUSION: Ultrasound, even in highly skilled hands, has a high rate of incidental finding of an asymptomatic interdigital nerve enlargement, which can lead to a false diagnosis of a Morton's neuroma. Sonographic evidence of Morton's neuroma per se is unreliable unless it is correlated with an equivocal clinical examination. Clinical examination is still the gold standard for the diagnosis of a Morton's neuroma.

Sutures versus sterile strips for closure of ankle arthroscopy portals: prospective crossover trial.

BACKGROUND: Either a nylon single suture or adhesive tape in the form of Steri strip are commonly used for the closure of portals in ankle arthroscopy. The purpose of this study was to compare the two methods with regards to their safety, complications and cosmetic result. METHODS: This was a prospective cross over study of 100 patients who underwent ankle arthroscopy. Materials used for wound closure were either a 3-0 nylon suture or a single Steri strip. Portals were reviewed according to a validated wound scoring system. Parameters such as the age and gender of the patients, the duration of tourniquet use and the use of an intraarticular corticosteroid injection at wound closure were also studied. RESULTS: Ninety-five patients were included in the statistical analysis. No technique was found to be superior in terms of the wound description (p = 0.164), infection grade (p = 0.232), infection treatment (p = 0.557) and the cosmetic appearance (p = 0.371). Seventy-two percent of patients had a good to excellent cosmetic result. There were two cases of infection requiring administration of antibiotics, one from each method of closure. Of the independent parameters, the use of cortisone was related to a lower infection treatment score (p = 0.013). Patients with signs of infection had a shorter total tourniquet time compared to the patients with no infection (p = 0.002). CONCLUSION: The use of either a single suture or Steri strip in the closure of ankle arthoscopy portals has equivalent results. Both methods were safe with equivalent cosmesis and low infection rates.

Bilateral ankle blocks: a prospective audit.

BACKGROUND: There are significant advantages to the practice of bilateral ankle block. However, clinicians are reluctant to employ this technique due to concerns over reliability, local anaesthetic longevity and toxicity, surgical efficiency, and patient comfort. METHODS: Sixty-six patients undergoing bilateral ankle blocks during mid- and forefoot surgery were audited to determine success rate, local anaesthetic safety and efficacy, and patient acceptance. Intravenous sedation was administered both during insertion of ankle blocks and intraoperatively, as requested by the patient and as deemed necessary by the anaesthetist. The choice of local anaesthesia was either a 50/50 mixture of lignocaine 1.5% plain and ropivacaine 7.5 mg/mL, ropivacaine 7.5 mg/mL alone or ropivacaine 7.5 mg/mL and clonidine 1 microg/kg. RESULTS: A total of 89% of patients had a successful bilateral ankle block. Ropivacaine and clonidine combination, ropivacaine, and ropivacaine and lignocaine combination provided a mean length of action of 17 h, 14 h and 8 h, respectively. No adverse local anaesthetic events were reported. Sixty-one per cent of patients remembered intraoperative events; only one patient would choose not to have the procedure performed again under ankle blocks. CONCLUSIONS: The present audit demonstrates that bilateral ankle blocks are a safe and efficient technique. With appropriate doses of sedative drugs both during insertion of the ankle block and surgery, patients remain comfortable.

Acceptability of ankle tourniquet use in midfoot and forefoot surgery: audit of 1000 cases.

BACKGROUND: While use of a thigh tourniquet with general anesthesia is widely accepted, use of an ankle tourniquet in the awake patient is more controversial. In particular, it is not clear how long patients tolerate this device or what the consequences are of intraoperative tourniquet pain. METHOD: A prospective audit was done of 1000 patients undergoing midfoot and forefoot surgery using an ankle block. We examined the intraoperative problems associated with the use of an ankle tourniquet, particularly the role and consequences of intraoperative tourniquet pain. Risk factors for tourniquet pain were statistically examined, and patient acceptance was gauged through followup questions. RESULTS: With correct application and the option of sedation, 3.1% of patients complained of tourniquet pain. In 0.4% of patients tourniquet pain necessitated a conversion to general anesthesia. A significant association was found between tourniquet pain and both age and tourniquet time. We found that for patients younger than 70 years of age, the tourniquet can be applied comfortably for up to 30 minutes in over 97%. For each 11 minutes beyond this, another 1% of patients reported tourniquet pain. However, patients 70 years or older had an average 3.5 times increase in tourniquet pain. In this age group the tourniquet can be applied comfortably for up to 30 min in 91%. For each 3.2 minutes beyond this, another 1% reported tourniquet pain. When questioned, 97.2% of our patients reported that they would have surgery again with an ankle tourniquet. CONCLUSIONS: Our audit shows that with correct application and the option of sedation the ankle tourniquet is well tolerated by most patients. However, clinicians need to be mindful that patients 70 years of age or older are at greater risk of tourniquet pain and that in all patients the risk of tourniquet pain gradually increases when application times exceed 30 min.