Incidence of Venous Thromboembolism in Patients Receiving Anticoagulation for Foot and Ankle Surgery.

Venous thromboembolism (VTE) is a serious medical condition that can be an unfortunate complication arising from foot and ankle surgery. Many factors may predispose a patient to a VTE event including prolonged postoperative immobilization, comorbidities, extended length of tourniquet time, and higher risk surgeries. Unfortunately, there is no clinical consensus for guidelines on VTE prophylaxis following foot and ankle surgery. In this retrospective cohort study, we present our patient population who were prophylactically anticoagulated following foot and ankle surgery along with their incidence of deep vein thrombosis and pulmonary embolism (PE). Included in the study were patients who had undergone elective and traumatic foot and ankle surgery from June 2017 to December 2018. Using retrospective data obtained we compared patient demographics, surgery type, length of tourniquet time, postoperative immobilization, type of VTE prophylaxis, and comorbidities including history of smoking, peripheral vascular disease, bleeding disorders, and patients undergoing dialysis. Five of 425 (1.2%) patients were diagnosed with a deep vein thrombosis and 1 of 425 (0.2%) patients was diagnosed with a pulmonary embolism. Risks factors statistically significant for developing a VTE in our patient population included extended periods of immobilization and an increasing patient age. We were able to conclude that routine prophylaxis for elective and traumatic foot and ankle surgery is both effective and safe for especially in older patients requiring extended immobilization. It's also important to take into consideration comorbidities, smoking history, tourniquet time, and the type of surgery that is being performed.

Using Quantitative D-Dimer to Determine the Need for Pulmonary CT Angiography in COVID-19 Patients.

INTRODUCTION: COVID-19 has been frequently cited as a condition causing a pro-inflammatory state leading to hypercoagulopathy and increased risk for venous thromboembolism. This condition has thus prompted prior studies and screening models that utilize D-dimer for pulmonary embolism (PE) into question. The limited research to date has failed to provide tools or guidance regarding what COVID-19 positive patients should receive pulmonary CT angiography screening. This knowledge gap has led to missed diagnoses, CT overutilization, and increased morbidity and mortality. OBJECTIVE: The purpose of this study was to examine the utility of the quantitative D-dimer lab marker in a convenience sample of 426 COVID-19 positive patients to assist providers in determining the utility of pulmonary CT angiography. METHODS: The authors conducted a retrospective analysis on all COVID-19 positive patients within the Henry Ford Medical System between March 1st, 2020 through April 30th, 2020 who received pulmonary CT angiography and had a quantitative D-dimer lab drawn within 24 hours of CT imaging. RESULTS: Our sampling criteria yielded a total of n = 426 patients, of whom 347 (81.5%) were negative for PE and 79 (18.5%) were positive for PE. The average D-dimer in the negative PE group was 2.95 µg./mL. (SD 4.26), significantly different than the 9.15 µg./mL. (SD 6.80) positive PE group (P < 0.05; 95% CI -7.8, -4.6). Theoretically, applying the traditional ≤ 0.5 µg./mL. D-dimer cut-off to our data would yield a sensitivity of 100% and specificity of 7.49% for exclusion of PE. Based on these results, the authors would be able to increase the D-dimer threshold to < 0.89 µg./mL. to maintain their sensitivity to 100% and raise the specificity to 27.95%. Observing a D-dimer cut-off value of ≤ 1.28 µg./mL. would reduce sensitivity to 97.47% but increase the specificity to 57.93%. CONCLUSIONS: These study results support the utilization of alternative D-dimer thresholds to exclude PE in COVID-19 patients. Based on these findings, providers may be able to observe increased D-dimer cut-off values to reduce unnecessary pulmonary CT angiography scans.

Effect of a 6 am-9 am Dedicated Orthopaedic Trauma Room on Hip Fracture Outcomes in a Community Level II Trauma Center.

OBJECTIVE: To assess the outcomes of elderly hip fracture surgeries performed 12 months before and 12 months after the implementation of a daily 6 am-9 am dedicated orthopaedic trauma room (DOTR) at a Level II community trauma center. DESIGN: Retrospective cohort study. SETTING: Level II academic trauma center. PATIENTS: A total of 431 consecutive trauma patients undergoing surgical management of isolated low-energy hip fractures from January 1, 2018, to December 31, 2019. INTERVENTION: Implementation of a 6 am-9 am DOTR Monday through Friday. MAIN OUTCOME MEASURES: Time to surgery, number of cases performed after hours, surgical time, 90-day morbidity and mortality, and time to therapy. RESULTS: Retrospective analysis showed that despite a 24% increase in surgical hip fracture volume, implementation of a part-time DOTR led to a decrease in after-hours surgery (32.4% vs. 19.6%; P = 0.008) and patients requiring the intensive care unit postoperatively (7% vs. 3.8%; P = 0.036). Surgeries performed after hours were longer than that of surgeries performed during the daytime (82.0 vs. 68 minutes; P = 0.003) and had more complications (pneumonia, pulmonary embolism, and surgical site infection; P = 0.002, 0.047, 0.024, respectively). CONCLUSIONS: Our results show that a part-time DOTR in a community Level II hospital is associated with improvement in patient care. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Conservative Versus Surgical Management of Fifth Metatarsal Avulsion Fractures.

Fifth metatarsal avulsion fractures are among the most common fractures seen by foot and ankle surgeons. Studies have centered around classification systems, but debate continues regarding surgical versus conservative treatment modalities. The present study focused on quantifying the time for healing fifth metatarsal base avulsion fractures. Specifically, we compared healing time, displacement, and incidence of nonunion among surgically managed and conservatively managed avulsion fractures. Surgically managed patients underwent either open reduction with internal fixation or closed reduction with percutaneous fixation. Conservatively managed fractures were immobilized with a below-knee cast or pneumatic walking boot. Fifty-one patient records (51 feet) were retrospectively compared for basic demographics, smoking, and diabetes status, presence of peripheral neuropathy, Stewart classification, amount of displacement, rate of nonunion, and radiographic healing time. The groups did not differ significantly based on age, sex, or the remaining clinical characteristics including time to consolidation. However, among the 31 conservatively managed patients, 11 (35.5%) developed an asymptomatic nonunion versus none among the 20 patients treated surgically (p = .004). All patients were asymptomatic at 1 year. This study provides insight into the time required for fifth metatarsal avulsion fractures to heal or become asymptomatic. The surgical management of these fractures helped to eliminate the risk of nonunion and helped ensure a timely return to preinjury activity. We recommend surgical management of any fifth metatarsal avulsion fracture displaced >2 mm. Both patients and physicians should have realistic expectations when making decisions regarding treatment modalities for fifth metatarsal avulsion fractures.

Surgical Management of Stage 2 Adult and Pediatric Acquired Flatfoot Without Tendon Transfer or Arthrodesis: A Retrospective Study.

Posterior tibial tendon dysfunction (PTTD) is a common pathology of the foot and ankle. Numerous techniques are available to reconstruct the flatfoot. Fusions and tendon transfers are popular methods; however, a wide range of complications have been associated with these procedures. The objective of the present study was to demonstrate the outcomes of reconstructive surgery for flatfoot correction without tendon transfer or arthrodesis. We performed a retrospective study of 43 patients and 56 feet who had undergone flatfoot reconstructive surgery from November 2011 to June 2016, with a mean follow-up period of 60 weeks (range 12 to 60 months). Each patient demonstrated a stage 2 flatfoot deformity classified using the Johnson and Strom classification. Depending on the patient's deformity, the procedures consisted of different variations of gastrocnemius recession, medial displacement calcaneal osteotomy, Evans osteotomy, and Cotton osteotomy. Six different preoperative and postoperative angles were radiographically measured on each foot studied. In all cases, the differences in the preoperative versus postoperative measurements were statistically significant (p < .003). We believe the foot and ankle surgeon can correct flatfoot deformity with the use of extraarticular procedures and create a plantigrade functional foot without fusion or tendon transfer.

Psychiatric Presentations During All 4 Phases of the Lunar Cycle.

Context • Anecdotal evidence concerning a relationship between human illnesses and a full moon is frequently claimed by as many as 81% of mental health workers. Previous scientific investigations have studied only the full-moon phase and its possible effect on psychiatric presentations. However, information is limited about all 4 phases of the lunar cycle and their effects on different types of psychiatric disorders. Objective • This study primarily intended to evaluate the number of psychiatric presentations to a hospital's emergency department across all 4 phases of the lunar cycle. The secondary objective was to investigate the statistical differences among 5 categories of common mental disorders in relation to the 4 lunar phases. Design • This study was an observational analytic cohort study. Setting • The study took place in the emergency department of a 140-bed, community-teaching hospital. Participants • Participants were 1857 patients who were aged >17 y and who had had a psychiatric component to a visit to the emergency department. Outcome Measures • Data from electronic medical records were collected for 41 consecutive months. The participants were divided into 5 diagnostic groups based on the Diagnostic and Statistical Manual of Mental Disorders, 5th ed (DSM-5). The study measured the number of psychiatric presentations for each group during the 4 National Aeronautics and Space Administration (NASA)-defined phases of the lunar cycle, and the study was statistically powered to detect small effects. Results • The following psychiatric presentations occurred: (1) 464 during the new moon; (2) 483 during the first quarter; (3) 449 during the full moon; and (4) 461 during the third quarter (4-group overall χ2, P = .89). Differences between the 5 diagnostic categories across the 4 lunar phases were not statistically significant (4-group overall χ2, P = .85 for the 5 diagnostic categories). Conclusions • Although many traditional and nontraditional providers believe in effects caused by the full moon based on casual observation or anecdotal evidence, this perception was not supported in the current study. Furthermore, no evidence demonstrated increased psychiatric presentations during the other 3 phases of the lunar cycle. The study found that the lunar cycle did not have an effect on the incidence of psychiatric presentations or on the DSM-5 categories. If lunar effects exist, they are probably small or infrequent, making them difficult to validate statistically. The current study's results, in concert with those of most other studies on the subject, provide evidence that should help dismiss misconceptions about the magnitude or frequency of lunar effects on psychiatric illnesses.

Surgical Management of Fifth Metatarsal Diaphyseal Fractures: A Retrospective Outcomes Study.

Fifth metatarsal diaphyseal fractures are a common injury treated by foot and ankle surgeons. The limited data on this specific fracture type has promoted nonoperative treatment with immobilization. The primary objective of the present study was to record the radiographic healing time of fifth metatarsal diaphyseal fractures after surgical intervention and present the specific fracture characteristics. The medical records of a series of 64 patients with surgically managed fifth metatarsal diaphyseal fractures were retrospectively reviewed. The data collected consisted of radiographic healing times, fracture characteristics, and patient demographics. The mean average age at injury was 49.23 ± 15.35 years with greatest incidence in females at 73.44%. The mean healing time was 7.73 ± 4.74 weeks, with an overall complication rate of 6.25%. The fractures were classified into 2 specific categories according to the anatomic location. Type I fractures occurred in a significantly older population, were significantly longer in length, and healed faster. The mean displacement and angulation at injury was 3.20 ± 1.22 mm, and 5.89° ± 4.60°, respectively, for all fractures. Of the 64 patients, 1 (1.56%) experienced nonunion, 2 (3.13%) delayed unions, and no malunions. One patient (1.56%) underwent repeat operation for hardware removal. One case (1.56%) of superficial postoperative infection developed and was treated with oral antibiotics. We observed good surgical outcomes with minimal postoperative complications. We also identified 2 specific entities of fifth metatarsal diaphyseal fractures. On the basis of our results, we advocate surgical intervention even for minimally displaced diaphyseal fractures to maintain even weightbearing across the metatarsal parabola.

Improving symptoms and quality of life of female cancer survivors: a randomized controlled study.

BACKGROUND: Surgeons, along with the Centers for Disease Control and Prevention, emphasize the importance of managing symptoms and improving the quality of life of cancer survivors. A 2008 meta-analysis of mindfulness-based stress reduction (MBSR) concluded that this technique might improve patients' adjustment to their disease. However, randomized controlled trials using standardized measures for evaluating MBSR are limited. The primary objective of this study was to evaluate, using valid and reliable measures, the effects of a unique, interactive, 8-week cancer recovery and wellness program on symptoms and quality of life of female cancer survivors. METHODS: Sixty-eight female cancer patients were randomized into either an intervention or waitlisted control group. Patients were evaluated using the Symptoms Checklist (SCL-90-R), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-30), and the Symptoms of Stress Inventory (SOSI). RESULTS: Of the participants, 70.6% were breast cancer survivors. Mean age was 57.5 years (treatment group) and 56.4 years (control group). Between-group demographic differences were not significant (P > 0.6). The treatment group improved significantly on the EORTC QLQ-30 (P = 0.005), on six of the eight SOSI subscales (P ≤ 0.049), and on both SCL-90-R subscales (P ≤ 0.023), while the control group did not improve on any of these measures (P > 0.2). CONCLUSION: The MBSR-based cancer recovery and wellness intervention improved the symptoms and quality of life of this largely breast cancer survivor population across a variety of cancer symptoms and quality-of-life measures.