Critical Portions of a Foot or Ankle Surgical Procedure From Patient and Surgeon Perspectives.

BACKGROUND: Over the past decade, overlapping procedures in orthopaedic surgery have come under increased public scrutiny. Central to this discussion is what should constitute a "critical portion" of any surgical procedure-a definition which may differ between patients and surgeons. This study therefore aimed to assess which components of three common foot and ankle procedures are considered "critical" from both the patient and surgeon perspectives. METHODS: For this survey-based study, questionnaires were administered to patients who presented to an orthopaedic foot and ankle clinic and separately administered to foot and ankle surgeons through e-mail. The questionnaires broached all steps involved in three common foot and ankle procedures: open reduction and internal fixation of ankle fracture, Achilles tendon repair, and ankle arthroscopy. Respondents were asked to characterize each step as "always critical," "often critical," sometimes critical," rarely critical," or "never critical." A combined "always critical" and "often critical" response rate of greater than 50% was used to define a step as genuinely critical. Patient and surgeon responses were thereafter compared using Mann-Whitney U and Kruskal-Wallis tests (P-value <0.05 was considered significant). RESULTS: Notably, both patients and surgeons considered informed consent, preoperative marking of the surgical site, preoperative time-out, surgical soft-tissue dissection, and certain procedure-specific steps (critical portions) of these procedures. By contrast, only patients considered skin incision and wound closure to be critical steps. CONCLUSION: Patients and surgeons were largely in agreement as to what should comprise the critical portions of several common foot and ankle procedures. Certain discrepancies did exist, however, such as skin incision and closure, and both groups were also in general agreement regarding what was not considered a critical component of these operations. Such findings highlight a potential opportunity for improved preoperative patient education and patient-physician communication. LEVEL OF EVIDENCE: Level IV: Evidence from well-designed case-control or cohort studies.

Plastic and elastic biomechanical properties of anterior cruciate ligament autografts.

BACKGROUND: Anterior cruciate ligament (ACL) rupture is a common orthopedic injury, occurring in roughly 68.6 per 100,000 persons annually, with the primary treatment option being ACL reconstruction. However, debate remains about the appropriate graft type for restoring the native biomechanical properties of the knee. Furthermore, plastic graft elongation may promote increased knee laxity and instability without rupture. This study aims to investigate the plastic properties of common ACL-R graft options. METHODS: Patellar tendon (PT), hamstring tendon (HT), and quadriceps tendon (QT) grafts were harvested from 11 cadaveric knees (6 male and 5 female) with a mean age of 71(range 55-81). All grafts were mechanically tested under uniaxial tension until failure to determine each graft's elastic and plastic biomechanical properties. RESULTS: Mechanically, the QT graft was the weakest, exhibiting the lowest failure force and the lowest failure stress (QT < HT, p = 0.032). The PT was the stiffest of the grafts, having a significantly higher stiffness (PT > QT, p = 0.0002) and Young's modulus (PT > QT, p = 0.001; PT > HT, p = 0.041). The HT graft had the highest plastic elongation at 4.01 ± 1.32 mm (HT > PT, p = 0.002). The post-yield behavior of the HT tendon shows increased energy storage capabilities with the highest plastic energy storage (HT > QT, p = 0.012) and the highest toughness (HT > QT, p = 0.032). CONCLUSION: Our study agrees with prior studies indicating that the failure load of all grafts is above the requirements for everyday activities. However, grafts may be susceptible to yielding before failure during daily activities. This may result in the eventual loss of functionality for the neo-ACL, resulting in increased knee laxity and instability.

Minimally Invasive Chevron Akin Osteotomy for Hallux Valgus Correction.

Background: The minimally invasive chevron Akin osteotomy technique is indicated for the treatment of symptomatic mild to moderate hallux valgus deformities. The aim of the procedure is to restore alignment of the first ray while minimizing soft-tissue disruption. Description: Prior to the procedure, radiographs are utilized to characterize the patient's hallux valgus deformity by determining the hallux valgus angle and intermetatarsal angle. The metatarsal rotation is also assessed via the lateral round sign and sesamoid view. To begin, a stab incision is made over the lateral aspect of the first metatarsophalangeal (MTP) joint and a lateral release is completed by percutaneous fenestration of the lateral capsule. Next, the chevron osteotomy of the first metatarsal is performed. To begin this step, a Kirschner wire is inserted in an anterograde fashion from the medial base of the first metatarsal to the lateral aspect of the metatarsal neck. The wire is then withdrawn just proximal to the osteotomy site. A stab incision is made at the medial aspect of the metatarsal neck, and periosteal elevation is utilized for soft-tissue dissection. A minimally invasive burr is utilized to complete the osteotomy cuts. With the osteotomy complete, the first metatarsal translator is utilized to lever the metatarsal head laterally. Once satisfactory alignment has been achieved, the Kirschner wire is advanced into the metatarsal head. A cannulated depth gauge is utilized to measure the length of the screw. The near cortex is drilled, and the screw is inserted over the Kirschner wire, which is then removed. The next step is the Akin osteotomy of the proximal phalanx. Again, a Kirschner wire is placed in an anterograde fashion from the medial base of the proximal phalanx to the lateral neck. The Kirschner wire is then withdrawn until the tip is just proximal to the osteotomy site. A stab incision is made over the medial aspect of the proximal phalangeal neck, and periosteal elevation is carried out. The burr is utilized to complete the osteotomy; however, care is taken not to cut the far cortex. The great toe is then rotated medially, collapsing on the osteotomy site and hinging on the intact far cortex. When satisfactory alignment has been achieved, the Kirschner wire is advanced across the osteotomy and far cortex. A cannulated depth gauge is utilized to measure the length of the screw, and the wire is then driven through the lateral skin and clamped. The near cortex is drilled, the cannulated screw is inserted, and the Kirschner wire is then removed. Final fluoroscopy is performed to assess adequate correction, alignment, and hardware placement. The stab incisions are closed with use of simple interrupted 3-0 nylon. A tongue-depressor bunion dressing is applied. The patient is discharged to home with this dressing, as well as with an offloading postoperative shoe. Alternatives: Surgical alternatives include open distal chevron osteotomy, open Akin osteotomy, MTP joint arthrodesis, Lapidus fusion, and Scarf osteotomy7. Nonsurgical alternatives include the use of insoles, nonsteroidal anti-inflammatory drugs, wide-toed footwear, bunion shields and/or toe spacers, and physical therapy. Rationale: The minimally invasive chevron Akin technique for hallux valgus correction provides alignment restoration of the first ray with less soft-tissue trauma than conventional open surgical procedures. This technique utilizes dorsal and medial stab incisions, instead of a more extensive open dorsal incision. These smaller incisions minimize the soft-tissue disruption, which has been reported to improve postoperative range of motion and to reduce loss of postoperative dorsiflexion related to scar tissue formation. Even while minimizing soft-tissue disruption, this technique still enables adequate correction and reliably stable fixation. Expected Outcomes: The expected outcome of this procedure is a return to normal activities following the recovery period. Prior to correction, the patient is counseled regarding the risk of persistent or recurrent deformity postoperatively. The patient is also informed regarding potential postoperative stiffness. According to the literature, outcomes following minimally invasive chevron Akin hallux valgus correction have been shown to be equivalent to traditional open correction, with reported recurrence rates of <1% and excellent or good patient satisfaction in >90% of patients2-4. Function, as measured with use of the Manchester-Oxford Foot Questionnaire, has been shown to improve significantly from preoperatively (58.5 ± 15.9) to postoperatively (9.6 ± 9.2)2. Lastly, reported complication rates have varied according to the author's definition of complications, but typically range from 10% to 22%2-4. Important Tips: If the chevron osteotomy cut accidentally turns into a transverse cut, then add a second screw to provide rotational stability.Obtain a perfect lateral view after placing the Kirschner wire in order to ensure satisfactory trajectory of the Kirschner wire in all planes.Drive the Akin Kirschner wire through the skin distally and clamp with a mosquito to prevent pullout after drilling.If the Akin Kirschner wire is too flimsy to get a good starting point and trajectory, exchange it for the chevron Kirschner wire and use the drill to exchange back just prior to screw insertion.Subtract approximately 4 mm from the measured screw length in order to ensure that the screw is not too long; otherwise, it may create a gap in the osteotomy site. Acronyms and Abbreviations: NSAIDs = nonsteroidal anti-inflammatory drugsK-wire = Kirschner wireHVA = hallux valgus angleIMA = intermetatarsal angleMIS = minimally invasive surgeryAP = anteroposteriorOR = operating roomMTP = metatarsophalangealVAS = visual analog scaleMOXFQ = Manchester-Oxford Foot Questionnaire.

Second Metatarsal Fracture During Lapidus Hallux Valgus Correction: A Case Report.

CASE: A 67-year-old woman with rheumatoid arthritis underwent Lapidus hallux valgus correction. Initial realignment was unsatisfactory, so the K-wire through the first and second metatarsals was removed. As the clamp was repositioned, the second metatarsal fractured through the K-wire hole. The Lapidus procedure was completed, and then, the fracture was fixed with a percutaneous K-wire. The tarsometatarsal fusion and second metatarsal fracture healed. CONCLUSION: Because second metatarsal structural integrity is imperative for use of the clamp, bone quality and K-wire holes from re-reduction should be considered. Although technically challenging, this case demonstrates percutaneous fracture reduction after Lapidus hallux valgus correction.

High variability in patient reported outcome utilization following hip fracture: a potential barrier to value-based care.

For patients with hip fractures, outcomes can be measured by giving surveys measuring "patient rated outcome measures" (PROMs), performance based measures (PBMS), and objective medical outcomes (e.g., mortality, living situation, resource utilization). This study reviewed articles on hip fracture published in top academic journals, and found that most studies are not reliably using a single set of outcome measures including PROMs, and no single PROM or outcome battery is being used commonly. PURPOSE/INTRODUCTION: Osteoporotic hip fractures are associated with high levels of morbidity, mortality, and cost, while gains in mortality over the past 30 years have been modest. To improve care beyond simple mortality metrics requires identifying and then consistently measuring outcomes that are meaningful to patients and families. The purpose of this study was to review the top-tier hip fracture literature published in the past 30 years to determine if there are consensus outcome measures being routinely used and if the rate of reporting clinically meaningful patient-rated outcome measures is improving over time. METHODS: This was a systematic review and meta-analysis on outcome measures reported in osteoporotic hip fractures. Articles were included if they had been published over the last 30 years and were from high impact factor journals. Inclusion criteria were elderly hip fractures, therapeutic or prognostic study, unique and identifiable patients, and included follow-up beyond initial hospitalization. We analyzed study type, inclusion criteria, outcomes reported, and journal specialty orientation. RESULTS: Three hundred eighty-four articles were included in the final analysis. Sixty-seven percent of the articles were therapeutic studies; 33% were prognostic studies. The average number of patients in each study was 435; the average age was 78 years. The most commonly reported outcome was mortality, and was present in 79% of studies. There was a high degree of heterogeneity in patient-reported outcome measures, with the most popular score (Harris Hip Score) reported only 14% of the time. Only 6% of articles had all components of essential core outcome sets previously defined in the literature. CONCLUSIONS: Despite the apparent advances that have been made in our ability to care for hip fractures, the overall rate of reporting outcomes beyond mortality rate remains low. This lack of consensus represents a major barrier to implementation of value-based care in this patient population.