Current Concept Review: Risk Factors for Infection Following Open Fractures.

Infection following open fracture is a significant source of morbidity and mortality. Therefore, a central tenet of treatment is to minimize the risk of infection. The initial risk of infection is determined by wound characteristics, such as size, soft tissue coverage, vascular injury, and contamination. While no consensus exists on optimal antibiotic regimen, early administration of prophylactic antibiotics, within an hour of injury, when possible, has been shown definitively to decrease the risk of infection. Infection risk is further reduced by early irrigation with normal saline and aggressive debridement of devitalized tissue. Patient factors that increase risk of infection following open fracture include diabetes mellitus, smoking, male gender, and lower extremity fracture.

The influence of concomitant hammertoe correction on postoperative outcomes in patients undergoing hallux valgus correction.

BACKGROUND: Patients with hallux valgus often develop secondary hammertoe deformities of the lesser toes. Operative management of bunions with hammertoe can be more extensive; however, it is unclear whether this affects patient-reported outcomes. The aim of this study was to compare postoperative patient-reported outcome measures and radiographic outcomes between patients who underwent isolated bunion correction and patients who underwent simultaneous bunion and hammertoe correction. METHODS: Preoperative, postoperative, and change in Patient-Reported Outcomes Measurement Information System (PROMIS) scores were compared between patients who underwent isolated hallux valgus correction and those who underwent concomitant hammertoe correction. Radiographic measures including hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal-articular angle (DMAA), and Meary's angle were also compared. Targeted minimum-loss estimation (TMLE) was used for statistical analysis to control for confounders. RESULTS: A total of 221 feet (134 isolated bunion correction, 87 concomitant hammertoe correction) with a minimum of 12 months follow-up were included in this study. Both cohorts demonstrated significant improvements in the physical function, pain interference, pain intensity, and global physical health PROMIS domains (all p < 0.001). However, patients in the concomitant hammertoe cohort had significantly less improvements in pain interference and pain intensity (p < 0.01, p < 0.05 respectively). The concomitant hammertoe cohort also had significantly higher postoperative pain interference scores than the isolated bunion cohort (p < 0.01). Radiographic outcomes did not differ between the two groups. CONCLUSION: While both isolated bunion correction and concomitant hammertoe correction yielded clinically significant improvements in patient reported outcomes and normalized radiographic parameters, patients undergoing simultaneous bunion and hammertoe correction experienced substantially less improvement in postoperative pain-related outcomes than those who underwent isolated bunion correction.

Vitamin D Deficiency and Outcomes After Ankle Fusion: A Short Report.

BACKGROUND: Vitamin D deficiency has been postulated as a cause for impaired bone healing and remodeling. The purpose of this study was to assess the potential association between low vitamin D levels and reoperation for nonunion following ankle fusion surgery. METHODS: All adult patients (aged ≥18 years) who underwent ankle fusion procedures at a tertiary referral center from January 2010 to January 2019 with available vitamin D levels within 12 months preoperatively were retrospectively reviewed (n = 47). Patients were categorized as vitamin D deficient (<30 ng/mL) vs normal (31-80 ng/mL). The primary outcome was the incidence of reoperation secondary to nonunion. Secondary outcomes included incidence of reoperation not related to nonunion and the need for repeat reoperation. RESULTS: The average level in the vitamin D-deficient group (n = 17; 36.2%) was 16.9 vs 46.4 ng/mL in the normal group (n = 30; 63.8%). All recorded reoperations for nonunion occurred exclusively in the vitamin D-deficient cohort (4/17 [23.5%]; P = .013). There were similar reoperation rates for causes other than nonunion (2/17 [11.8%] vs 4/30 [13.3%]; P > .99) and repeat reoperation rates (3/17 [17.6%] vs 1/30 [3.3%]; P = .128) among vitamin D-deficient vs normal patients. CONCLUSION: Vitamin D deficiency may be associated with an increased risk of reoperation for nonunion after ankle fusion.

Transformation from a traditional model to a virtual model of care in orthopaedic surgery: COVID-19 experience and beyond.

Virtual encounters have experienced an exponential rise amid the current COVID-19 crisis. This abrupt change, seen in response to unprecedented medical and environmental challenges, has been forced upon the orthopaedic community. However, such changes to adopting virtual care and technology were already in the evolution forecast, albeit in an unpredictable timetable impeded by regulatory and financial barriers. This adoption is not meant to replace, but rather augment established, traditional models of care while ensuring patient/provider safety, especially during the pandemic. While our department, like those of other institutions, has performed virtual care for several years, it represented a small fraction of daily care. The pandemic required an accelerated and comprehensive approach to the new reality. Contemporary literature has already shown equivalent safety and patient satisfaction, as well as superior efficiency and reduced expenses with musculoskeletal virtual care (MSKVC) versus traditional models. Nevertheless, current literature detailing operational models of MSKVC is scarce. The current review describes our pre-pandemic MSKVC model and the shift to a MSKVC pandemic workflow that enumerates the conceptual workflow organization (patient triage, from timely care provision based on symptom acuity/severity to a continuum that includes future follow-up). Furthermore, specific setup requirements (both resource/personnel requirements such as hardware, software, and network connectivity requirements, and patient/provider characteristics respectively), and professional expectations are outlined. MSKVC has already become a pivotal element of musculoskeletal care, due to COVID-19, and these changes are confidently here to stay. Readiness to adapt and evolve will be required of individual musculoskeletal clinical teams as well as organizations, as established paradigms evolve. Cite this article: Bone Joint Open 2020;1-6:272-280.

Perceived risk factors for nonunion following foot and ankle arthrodesis.

BACKGROUND: A major complication of foot and ankle arthrodesis is nonunion, which occurs in approximately 12% of cases. Various factors influence a patient's risk for nonunion following foot and ankle arthrodesis. We surveyed international foot and ankle surgeons to determine (1) risk factors perceived most important for nonunion, (2) factors considered absolute contraindications for arthrodesis, and (3) differences among expert groups regarding perceived risk factors and their stratification. METHODS: A questionnaire was e-mailed to members of a major foot and ankle journal editorial board and four foot and ankle society executive committees. The relative risk of 18 potential nonunion risk factors was rated from 1 to 10, using smoking 1 pack/day as a benchmark score of 5.00. RESULTS: The response rate was 72% (100/139); 81% declared foot and ankle surgery encompasses >90% of their practice. The highest perceived risk factors ( p < 0.001) were smoking 2 packs/day (mean score 8.69), lack of fusion site stability (8.66), and poor local vascularity (7.66). The least important risk factors ( p < 0.001) were perceived to be age >60 years (mean score 2.54), rheumatoid arthritis (3.05), and osteoporosis (3.56). The most frequently cited absolute contraindications to arthrodesis surgery were local infection (46%), poor local vascularity (41%), and smoking (32%). CONCLUSION: To improve arthrodesis outcomes, resource allocation and patient and surgeon education should focus on smoking, construct stability, and local vascularity. Development of an objective nonunion risk assessment tool to identify patients at risk for nonunion using these results could help maximize the efficiency of available resources.

The Puck Stops Here: Taking Organizational Accountability Seriously.

This commentary presents an ethical argument and practical suggestions for holding health administrators accountable for quality improvement efforts and results. Using hockey analogies and drawing on evidence from various studies and literature in organizational ethics, it argues that health leaders must promote system performance by ensuring that there is a well-organized delivery system around patients' episodes of care and that all personnel are performing at an acceptable level. Informed by system transformation and successes in the UK, this commentary proposes four strategies to hold leaders accountable: require leaders to be familiar with front-line operations, adopt a service-line approach, evaluate organizational performance by analyzing and publicizing outcome metrics and utilize outcome-based incentives.

Redefining ethical leadership in a 21st-century healthcare system.

Traditional ethical leadership in healthcare concentrated on the oversight of the individual provider-patient relationship. However, as care delivery becomes predominantly team-based and integrated across provider organizations, these ethical frameworks also need to consider meso- and macro-factors within the system. These broader issues require managers and administrative leaders to augment their ethical perspectives beyond current and prospective patients with those of the team, organization, and broader system, where high levels of coordination and oversight are essential. Administrators are increasingly ethically accountable not only for how individual care encounters are conducted (micro level) but also for how the system is organized to deliver and ensure quality care for patients receiving care (meso level) and service populations who turn to them for care when needed (macro level).

[Redéfinir le leadership éthique dans le système de santé du XXIe siècle].

Dans le milieu de la santé, le leadership éthique classique est axé sur la supervision de la relation entre le professionnel de la santé et le patient. Cependant, puisque la prestation des soins dépend désormais essentiellement d'une équipe et qu'elle est intégrée entre organisations de la santé, ces cadres éthiques doivent tenir compte de facteurs mésoscopiques et macroscopiques. En raison de ces enjeux plus vastes, les gestionnaires et les leaders administratifs doivent adopter des perspectives éthiques qui, loin de se limiter aux patients actuels et prospectifs, incluent également l'équipe, l'organisation et l'ensemble du système, où il est essentiel d'assurer un taux élevé de coordination et de surveillance. Les administrateurs ont une responsabilité éthique croissante, non seulement envers le déroulement de chaque rencontre de soins (microscopique), mais également envers l'organisation du système pour prodiguer et garantir des soins de qualité aux patients (mésoscopique) et les services aux populations qui leur demandent des soins lorsqu'elles en ont besoin (macroscopique).

Current concept review: quality and process improvement in orthopedics.

Multiple health care stakeholders are increasingly scrutinizing musculoskeletal care to optimize quality and cost efficiency. This has led to greater emphasis on quality and process improvement. There is a robust set of business strategies that are increasingly being applied to health care delivery. These quality and process improvement tools (QPITs) have specific applications to segments of, or the entire episode of, patient care. In the rapidly changing health care world, it will behoove all orthopedic surgeons to have an understanding of the manner in which care delivery processes can be evaluated and improved. Many of the commonly used QPITs, including checklist initiatives, standardized clinical care pathways, lean methodology, six sigma strategies, and total quality management, embrace basic principles of quality improvement. These principles include focusing on outcomes, optimizing communication among health care team members, increasing process standardization, and decreasing process variation. This review summarizes the common QPITs, including how and when they might be employed to improve care delivery.

Nonunion Risk Assessment in Foot and Ankle Surgery: Proposing a Predictive Risk Assessment Model.

BACKGROUND: Nonunion risk factor identification and modification are subjective. We describe and validate a predictive nonunion risk factor model to identify foot and ankle operative patients at risk for nonunion. MATERIALS AND METHODS: One hundred international experts in foot and ankle surgery were surveyed. Nineteen nonunion risk factors were stratified into 3 categories: more significant than, as significant as, and less significant than smoking 1 pack per day. A nonunion risk assessment model was developed by assigning a weighted score to each risk factor, based on its mean score from the survey. A total nonunion risk (TNR) score was calculated for individual patients. It was retrospectively validated in 2 patient cohorts from a single center's prospectively collected end-stage ankle arthritis patient database: 22 cases of ankle and/or hindfoot fusion nonunion and 40 sex- and procedure-matched controls with bony fusion. Analyses included descriptive statistics, logistic regression, and univariate and multivariate linear regression models. RESULTS: The mean TNR score was 6.6 ± 5.6 in controls and 13.5 ± 8.2 in the nonunion group (P < .001). Data showed excellent intraobserver and interobserver correlation coefficients. In a logistic regression model, the risk of nonunion exceeded 9% with a TNR score greater than or equal to 10. Multivariate linear regression analysis, adjusted for age and sex, suggested that lack of fusion site stability and obesity (body mass index greater than 30) were significantly predictive of nonunion. CONCLUSION: The nonunion risk assessment model provides a reliable, sensitive, and specific method for predicting nonunion based on objective patient assessment. Orthopaedic patients at risk for nonunion could benefit from targeted intervention. LEVEL OF EVIDENCE: Level IV, retrospective observational study.

Ethical concerns in caring for elderly patients with cognitive limitations: a capacity-adjusted shared decision-making approach.

Mrs. A is a pleasant seventy-seven-year-old widow with an increasingly symptomatic right knee that has markedly limited her activities in the past year. Mrs. A's daughter, who lives in town, urged her to seek treatment. History, physical examination, and radiographs confirmed the diagnosis of end-stage knee arthritis. Dr. Z, the orthopaedic surgeon, presented total knee arthroplasty as a potential treatment option and provided detailed information on the surgery and recovery. Mrs. A indicated that if Dr. Z thinks that total knee arthroplasty is a good idea, she would agree to have the surgery. She lives alone and goes grocery shopping once a week, but her pain makes such endeavors frustrating for her. Her daughter visits regularly, takes her to medical appointments, and helps her with medications. Mrs. A has returned for a preoperative visit with Dr. Z, and her total knee arthroplasty has been tentatively scheduled for the following month. At this visit, Mrs. A notes that she wants to drive to the adjacent state to visit her son two weeks after the surgery and is glad she will have "a new knee" for that visit. When asked more questions about her understanding of the total knee arthroplasty and postoperative instructions, Mrs. A says Dr. Z can just talk to her daughter when she comes to pick her up from the appointment.

Deep-vein thrombosis prophylaxis in foot and ankle surgery: what is the current state of practice?

BACKGROUND: When contemplating thromboprophylaxis for patients undergoing elective foot and ankle surgery the potential for complications secondary to venous thromboembolism (VTE) must be balanced against the cost, risk, and effectiveness of prophylactic treatment. The incidence of pulmonary embolism (PE) following foot and ankle surgery is considerably lower than after hip or knee surgery. The purpose of this study was to assess current trends in practice regarding VTE prophylaxis among expert orthopaedic foot and ankle surgeons. METHODS: An e-mail-based survey of active AOFAS (American Orthopaedic Foot and Ankle Society) committee members was conducted (n = 100). Surgeons were questioned as to their use, type, and duration of thromboprophylaxis following elective ankle fusion surgery. Scenarios included the following: (1) A 50-year-old woman with no risk factors; (2) a 50-year-old woman with a history of PE; and (3) a 35-year-old woman actively using birth control pills (BCPs). RESULTS: The response rate for the survey was 80% (80/100). Replies regarding the use of thromboprophylaxis were as follows: (1) in the absence of risk factors, 57% of respondents (45/80) answered, "No prophylaxis required"; (2) for the scenario in which the patient had experienced a previous PE, 97.5% of respondents (78/80) answered, "Yes" to prophylaxis use; (3) for the scenario in which the patient was on BCP, 61.3% of respondents (49/80) stated that they would give some type of thromboprophylaxis. The most commonly recommended methods of prophylaxis were aspirin, 49% (24/49), and low-molecular-weight heparin, 47% (23/49). The recommended length of time for thromboprophylaxis varied widely, from 1 day to more than 6 weeks. CONCLUSION: . There remains wide variation in the practice of deep-vein thrombosis thromboprophylaxis within the foot and ankle community. Because risks for foot and ankle patients differ from those in the well-studied areas of hip and knee, specific guidelines are needed for foot and ankle surgery. LEVELS OF EVIDENCE: Level V: Expert Opinion.

Preferred management of recalcitrant plantar fasciitis among orthopaedic foot and ankle surgeons.

BACKGROUND: There are a number of different treatment options available for recalcitrant plantar fasciitis, with limited high-level evidence to guide nonoperative and operative treatment methods. The purpose of this study was to determine the current preferred nonoperative and operative treatment methods for recalcitrant plantar fasciitis by a group of experienced orthopaedic foot and ankle surgeons. METHODS: A hypothetical patient with recalcitrant plantar fasciitis was developed as the basis for a survey comprised of seven questions. The questions related to the surgeon's preferred treatment after 4~months of failed nonoperative management and then after 10 months of recalcitrant symptoms. The survey was sent to committee members of the American Orthopaedic Foot and Ankle Society (AOFAS). RESULTS: Eighty-four orthopaedic surgeons completed the survey (84 out of 116; response rate=72%). At the 4-month visit, when questioned regarding their most preferred next step in management, 37 (44%) respondents favored initiation of plantar fascia-specific stretching (PFSS), 20 (24%) supervised physical therapy, 17 (20%) night splinting, five (6%) steroid injection, three (4%) custom orthotics, and two (2%) cast or boot immobilization. With ongoing symptoms at 10~months, 62 (74%) respondents chose surgery or ECSWT (extracorporeal shock wave therapy) as their next step in management. Some form of surgery (alone or in combination) was chosen by 46 (55%) respondents. The most popular operative interventions were gastrocnemius recession (alone or in combination with another procedure) and open partial plantar fascia release with nerve decompression. CONCLUSIONS: For shorter duration symptoms, tissue-specific stretching and conditioning methods were favored over anti-inflammatory or structural support modalities which is consistent with available high-level evidence studies. Heterogeneity of operative preferences for chronic symptoms highlighted the need for further high-quality studies.

Sciatic nerve blockade: a survey of orthopaedic foot and ankle specialists in North America and the United Kingdom.

BACKGROUND: Sciatic nerve blocks are used to reduce post-operative pain and allow early discharge for patients undergoing foot and ankle surgery. This study aimed to identify the utilization of this procedure in the US and UK and to establish the standard of care with respect to the level of anesthesia that the patient is under and use of ultrasound localization when performing sciatic nerve blocks. MATERIALS AND METHODS: A survey of current committee members of AOFAS and members of BOFAS. RESULTS: Two hundred sixty-three surgeons were contacted with a response rate of 44%. Eighty-two percent commonly used a sciatic nerve blockade. Sixty-nine percent never or only sometimes used ultrasonography and variable levels of nerve stimulation were used. Forty-two percent where happy to have the block performed under full anesthesia. There were significant differences between British and American practices regarding the level of nerve stimulation and the level of anesthesia used. The most common complication cited was prolonged anesthesia of which the vast majority spontaneously resolved. Performing blocks awake or sedated did not seem to alter number of complications seen. CONCLUSION: This study represents a current practice review of sciatic nerve blocks performed amongst senior foot and ankle surgeons. Although no absolute consensus has been reached as to the use of ultrasound or whether the patient needs to be awake for the procedure, it is clear that the standard of care does not mandate either of these. The differences between US and UK practice are probably cultural and do not appear to affect the number of complications encountered.

Special report: highlights of the Twenty-Fourth Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society, Denver, Colorado, June 26-28, 2008.

The Twenty-Fourth Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society (AOFAS) was held 26-28 June 2008 at the Denver Marriott City Center in Denver, Colorado. There were 442 registrants in attendance, including 81 individuals from 21 countries outside the United States. There were 176 abstracts submitted, and 46 (26%) abstracts were accepted for podium presentation.