Validation of the American Association for the Surgery of Trauma emergency general surgery grade for skin and soft tissue infection.

INTRODUCTION: Skin and soft tissue infections (SSTIs) present with variable severity. The American Association for the Surgery of Trauma (AAST) developed an emergency general surgery (EGS) grading system for several diseases. We aimed to determine whether the AAST EGS grade corresponds with key clinical outcomes. METHODS: Single-institution retrospective review of patients (≥18 years) admitted with SSTI during 2012 to 2016 was performed. Patients with surgical site infections or younger than 18 years were excluded. Laboratory Risk Indicator for Necrotizing Fasciitis score and AAST EGS grade were assigned. The primary outcome was association of AAST EGS grade with complication development, duration of stay, and interventions. Secondary predictors of severity included tissue cultures, cross-sectional imaging, and duration of inpatient antibiotic therapy. Summary and univariate analyses were performed. RESULTS: A total of 223 patients were included (mean ± SD age of 55.1 ± 17.0 years, 55% male). The majority of patients received cross sectional imaging (169, 76%) or an operative procedure (155, 70%). Skin and soft tissue infection tissue culture results included no growth (51, 24.5%), monomicrobial (83, 39.9%), and polymicrobial (74, 35.6%). Increased AAST EGS grade was associated with operative interventions, intensive care unit utilization, complication severity (Clavien-Dindo index), duration of hospital stay, inpatient antibiotic therapy, mortality, and hospital readmission. CONCLUSION: The AAST EGS grade for SSTI demonstrates the ability to correspond with several important outcomes. Prospective multi-institutional study is required to determine its broad generalizability in several populations. LEVEL OF EVIDENCE: Prognostic, level IV.

Correlation of Clinical Evaluation and Radiographic Hindfoot Alignment in Stage II Adult-Acquired Flatfoot Deformity.

BACKGROUND: Previous work has demonstrated that the amount of radiographic hindfoot correction required at the time of adult-acquired flatfoot deformity (AAFD) operative treatment can be predicted by the amount of radiographic deformity present before surgery. Successful outcomes after reconstruction are closely correlated with hindfoot valgus correction. However, it is not clear if differences exist between clinical and radiographic assessment of hindfoot valgus. The purpose of this study was to evaluate the correlation between radiographic and clinical evaluation of hindfoot alignment in patients with stage II AAFD. METHODS: Twenty-nine patients (30 feet) with stage II AAFD, 17 men and 12 women, mean age of 51 (range, 20-71) years, were prospectively recruited. In a controlled and standardized fashion, bilateral weightbearing radiographic hindfoot alignment views were taken. Radiographic parameters were measured by 2 blinded and independent readers: hindfoot alignment angle (HAA) and hindfoot moment arm (HMA). Clinical photographs of hindfoot alignment were taken in 3 different vertical camera angulations (0, 20, and 40 degrees). Pictures were assessed by the same readers for standing tibiocalcaneal angle (STCA) and resting calcaneal stance position (RCSP). Intra- and interobserver reliability were assessed by Pearson/Spearman's and intraclass correlation coefficient (ICC), respectively. Relationship between clinical and radiographic hindfoot alignment was evaluated by a linear regression model. Comparison between the different angles (RCSP, STCA, and HAA) was performed using the Wilcoxon rank-sum test. P values of less than .05 were considered significant. RESULTS: We found overall almost perfect intraobserver (range, 0.91-0.99) and interobserver reliability (range, 0.74-0.98) for all measures. Mean value and confidence interval (CI) for RCSP and STCA were 10.8 degrees (CI, 10.1-11.5) and 12.6 degrees (CI, 11.7-13.4), respectively. The position of the camera did not influence readings of clinical alignment ( P > .05). The mean HMA was 18.7 mm (CI, 16.3-21.1 mm), and the mean HAA was 23.5 degrees (CI, 21.1-26.0). Clinical and radiographic hindfoot alignment were found to significantly correlate ( P < .05). However, the radiographic HAA demonstrated increased valgus compared to both clinical alignment measurements, with a mean difference of 12.8 degrees from the RCSP (CI, 11.0-14.5, P < .0001) and 11.0 degrees from the STCA (CI, 9.2-12.8, P < .0001). CONCLUSION: We found significant correlation between radiographic and clinical hindfoot alignment in patients with stage II AAFD. However, radiographic measurements of HAA demonstrated significantly more pronounced valgus alignment than the clinical evaluation. The results of our study suggest that clinical evaluation of hindfoot alignment in patients with AAFD potentially underestimates the bony valgus deformity. One should consider these findings when using clinical evaluation in the treatment algorithm of flatfoot patients. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Validation of Patient-Reported Outcomes Measurement Information System Computerized Adaptive Tests Against the Foot and Ankle Outcome Score for 6 Common Foot and Ankle Pathologies.

BACKGROUND: The field of foot and ankle surgery lacks a widely accepted gold-standard patient-reported outcome instrument. With the changing infrastructure of the medical profession, more efficient patient-reported outcome tools are needed to reduce respondent burden and increase participation while providing consistent and reliable measurement across multiple pathologies and disciplines. The primary purpose of the present study was to validate 3 Patient-Reported Outcomes Measurement Information System computer adaptive tests (CATs) most relevant to the foot and ankle discipline against the Foot and Ankle Outcome Score (FAOS) and the Short Form 12 general health status survey in patients with 6 common foot and ankle pathologies. METHODS: Patients (n = 240) indicated for operative treatment for 1 of 6 common foot and ankle pathologies completed the CATs, FAOS, and Short Form 12 at their preoperative surgical visits, 1 week subsequently (before surgery), and at 6 months postoperatively. The psychometric properties of the instruments were assessed and compared. RESULTS: The Patient-Reported Outcomes Measurement Information System CATs each took less than 1 minute to complete, whereas the FAOS took 6.5 minutes, and the Short Form 12 took 3 minutes. CAT scores were more normally distributed and had fewer floor and ceiling effects than those on the FAOS, which reached as high as 24%. The CATs were more precise than the FAOS and had similar responsiveness and test-retest reliability. The physical function and mobility CATs correlated strongly with the activities subscale of the FAOS, and the pain interference CAT correlated strongly with the pain subscale of the FAOS. The CATs and FAOS were responsive to changes with operative treatment for 6 common foot and ankle pathologies. CONCLUSIONS: The CATs performed as well as or better than the FAOS in all aspects of psychometric validity. The Patient-Reported Outcomes Measurement Information System CATs show tremendous potential for improving the study of patient outcomes in foot and ankle research through improved precision and reduced respondent burden. LEVEL OF EVIDENCE: Level II, prospective comparative study.

MRI Evaluation of Achilles Tendon Rotation and Sural Nerve Anatomy: Implications for Percutaneous and Limited-Open Achilles Tendon Repair.

BACKGROUND: Limited-open and percutaneous Achilles tendon (AT) repair techniques have limited visibility, which may result in sural nerve violation and poor tendon targeting. The goal of this study was to assess the in vivo rotation of the AT and its distance to the sural nerve in ruptured and nonruptured ATs to develop guidelines to aid in limited-open and percutaneous repair techniques. METHODS: A retrospective review was conducted to identify magnetic resonance imaging (MRI) studies of patients with ruptured and healthy (nonruptured) ATs. AT rotation and distance to the sural nerve in the anterior-posterior (A-P) and medial-lateral (M-L) planes were measured at the level of and proximal to the ankle. RESULTS: The AT was externally rotated in both ruptured and nonruptured cohorts. Ruptured ATs showed greater external rotation than nonruptured ATs at the ankle (15.8 ± 16.2 degrees vs 5.9 ± 9.0 degrees, P = .008) but not at 10 cm proximal to the tendon's insertion (10.9 ± 10.9 degrees vs 6.1 ± 8.4 degrees, P = .139). Proximal AT rotation was negatively correlated with rupture height (r = -0.477, P = .029). At 4 cm proximal to the AT insertion, the sural nerve was closer anteriorly to and farther laterally from the AT in ruptures than in nonruptures (P < .001). At 10 cm proximal to the AT insertion, the sural nerve was farther posteriorly and laterally from the AT in ruptures than in nonruptures (P = .027 and P < .001, respectively). CONCLUSION: We found that the AT was more externally rotated in ruptured than in nonruptured tendons at the ankle and that its distance to the sural nerve differed between the 2 cohorts in the A-P and M-L planes, likely due to increased AT rotation and swelling with ruptures. To minimize sural nerve injury and improve tendon targeting, we suggest an external rotation of 11 degrees at the proximal end of the rupture and 16 degrees at the distal end when using percutaneous and limited-open AT repair devices to try to minimize sural nerve violation and increase tendon capture, which can decrease rates of complication and rerupture. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Effect of Obesity on Clinical and Radiographic Outcomes Following Reconstruction of Stage II Adult Acquired Flatfoot Deformity.

BACKGROUND: Obesity is a known risk factor for the development of adult acquired flatfoot deformity (AAFD), but obesity's effects on outcomes following AAFD reconstruction are unknown. We hypothesized that obesity would negatively impact outcomes following joint-preserving stage II AAFD reconstruction. METHODS: This retrospective study compared the outcomes of normal-weight (18.5 kg/m(2) ≤ BMI < 25 kg/m(2)), overweight (25 kg/m(2) ≤ BMI < 30 kg/m(2)), and obese (BMI ≥ 30 kg/m(2)) patients after AAFD reconstruction. Clinical outcome measures included the Foot and Ankle Outcome Score (FAOS), Short-Form 12 (SF-12), and Numeric Rating Scale of Pain (NRS Pain) administered preoperatively and at least 1 year postoperatively. Anteroposterior and lateral radiographs were taken preoperatively and at least 6 months postoperatively. Pre- to postoperative changes in outcome measures were assessed within BMI classes. Preoperative, postoperative, and pre- to postoperative changes in outcomes were compared among BMI classes. There were 41 normal-weight patients, 39 overweight patients, and 44 obese patients with a mean age of 56 years, FAOS follow-up of 2.9 years, and radiographic follow-up of 2.1 years. Demographics and reconstructive procedures were comparable among the 3 BMI classes. RESULTS: All outcomes significantly increased pre- to postoperatively in the 3 groups with the exception of the FAOS Symptoms subscale for normal-weight patients (P = .340) and SF-12 Mental Component score for all 3 BMI classes (P > .999). Preoperatively, obese patients had more symptoms than normal-weight patients, scoring 12 points lower on the FAOS Symptoms subscore (P = .008). Obese patients also scored 11 points lower preoperatively on the SF-12 Overall score (P = .028) and had 31% greater pain than normal-weight patients (P = .003). There were no differences among the 3 BMI classes in any postoperative outcomes assessed. CONCLUSION: Although obese patients had significantly worse symptoms, overall health, and NRS pain scores preoperatively, the short-term clinical and radiographic outcomes of stage II AAFD reconstruction were similar for normal-weight, overweight, and obese patients. We suggest that joint-preserving reconstruction remains a viable alternative to fusion of the triple joint complex for the treatment of overweight and obese stage II AAFD patients. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Contribution of Lateral Column Lengthening to Correction of Forefoot Abduction in Stage IIb Adult Acquired Flatfoot Deformity Reconstruction.

BACKGROUND: Correction of forefoot abduction in stage IIb adult acquired flatfoot likely depends on the amount of lateral column lengthening (LCL) performed, although this represents only one aspect of a successful reconstruction. The purpose of this study was to evaluate the correlation between common reconstructive variables and the observed change in forefoot abduction. METHODS: Forty-one patients who underwent flatfoot reconstruction involving an Evans-type LCL were assessed retrospectively. Preoperative and postoperative anteroposterior (AP) radiographs of the foot at a minimum of 40 weeks (mean, 2 years) after surgery were reviewed to determine correction in forefoot abduction as measured by talonavicular coverage (TNC) angle, talonavicular uncoverage percent, talus-first metatarsal (T-1MT) angle, and lateral incongruency angle. Fourteen demographic and intraoperative variables were evaluated for association with change in forefoot abduction including age, gender, height, weight, body mass index, as well as the amount of LCL and medializing calcaneal osteotomy performed, LCL graft type, Cotton osteotomy, first tarsometatarsal fusion, flexor digitorum longus transfer, spring ligament repair, gastrocnemius recession and any one of the modified McBride/Akin/Silver procedures. RESULTS: Two variables significantly affected the change in lateral incongruency angle. These were weight (P = .04) and the amount of LCL performed (P < .001). No variables were associated with the change in TNC angle, talonavicular uncoverage percent, or T-1MT angle. Multivariate regression analysis revealed that LCL was the only significant predictor of the change in lateral incongruency angle. The final regression model for LCL showed a good fit (R2 = 0.70, P < .001). Each millimeter of LCL corresponded to a 6.8-degree change in lateral incongruency angle. CONCLUSION: Correction of forefoot abduction in flatfoot reconstruction was primarily determined by the LCL procedure and could be modeled linearly. We believe that the lateral incongruency angle can serve as a valuable preoperative measurement to help surgeons titrate the proper amount of correction performed intraoperatively.

Glomus Tumors in the Foot: Case Series.

UNLABELLED: Glomus tumors are painful, benign neoplasms that frequently are associated with delayed diagnosis. Commonly in the hand, they rarely present in the foot. The purpose of this case series is to characterize the clinical presentation, radiology, pathology, and surgical outcomes associated with foot glomus tumors. We reviewed our pathology database for patients with foot glomus tumors diagnosed between 1995 and 2013. Medical records including physician notes, pathology, and radiology were reviewed. Eleven patients had foot glomus tumors excised at our institution during the study period. The mean age was 45.4 (range = 28-60) years. One patient was lost to follow-up. Mean follow-up for the remaining 10 patients was 44.7 (range = 3-142) months. Ten tumors were located in the subungual region, while 1 was located in the plantar pulp of the distal phalanx. All patients presented with pain. Point tenderness, cold hypersensitivity, and nail abnormalities were variably documented but frequently present. Four patients had had prior surgery for an ingrown toenail prior to presentation at our institution. Six patients had preoperative magnetic resonance imaging studies, which were diagnostic of glomus tumor in all cases except one. Radiographs failed to provide diagnosis in all 8 patients for whom they were obtained. Postoperatively, all patients had complete symptom relief with no recurrences.In conclusion, this case series demonstrates that foot glomus tumors frequently present with classic symptoms including pain, point tenderness, and cold hypersensitivity. When clinically suspected, magnetic resonance imaging should be obtained. Marginal excision results in symptom relief and cure. LEVEL OF EVIDENCE: Therapeutic, Level IV: Case series.

Costs Versus Benefits of Routine Histopathological Examination in Total Ankle Replacement.

BACKGROUND: Routine histopathological examination has previously been scrutinized as a source of extraneous cost in orthopedic foot and ankle care. As an increasingly prevalent joint replacement operation, total ankle replacement poses a notable cost to the health care market in an era of cost containment. The purpose of this study was to compare the costs and benefits of routine histopathological examination of specimens removed during total ankle replacement. We hypothesized that a new diagnosis would rarely be found and such examination would seldom alter patient care. METHODS: A retrospective review was conducted of all total ankle replacement operations between 2006 and July 2014 at the investigators' institution. Medical records for 90 patients, undergoing a total of 95 total ankle replacement operations, were reviewed to determine the clinical and pathological diagnoses for each operation and, subsequently, the rates of discrepancy and discordance. Professional charges were determined using estimated reimbursement rates for the Current Procedural Terminology (CPT) codes billed: 88304 (level III microscopic examination), 88305 (level IV microscopic examination), and 88311 (decalcification). RESULTS: Degenerative joint disease was diagnosed by the pathologist in 93.7% of cases (89/95), pseudogout in 4.2% (4/95), and rheumatoid arthritis in 2.1% (2/95). The 4 diagnoses of pseudogout were the only cases of new diagnoses based on pathological review. A total of $16,536.81 was spent for examination of all specimens, for an estimated $4,134.20 spent per discrepant diagnosis. Patient care was unaffected by pathological examination. CONCLUSION: A new diagnosis was rarely found by histopathological examination, and patient care remained unaltered in all cases. The costs of routine histopathological examination of tissue specimens removed during total ankle replacement, therefore, outweigh clinical benefits, and such examination should be left to the discretion of the operating surgeon. LEVEL OF EVIDENCE: Level IV, retrospective case series.

LincRNA-p21 activates p21 in cis to promote Polycomb target gene expression and to enforce the G1/S checkpoint.

The p53-regulated long noncoding RNA lincRNA-p21 has been proposed to act in trans via several mechanisms ranging from repressing genes in the p53 transcriptional network to regulating mRNA translation and protein stability. To further examine lincRNA-p21 function, we generated a conditional knockout mouse model. We find that lincRNA-p21 predominantly functions in cis to activate expression of its neighboring gene, p21. Mechanistically, we show that lincRNA-p21 acts in concert with hnRNP-K as a coactivator for p53-dependent p21 transcription. Additional phenotypes of lincRNA-p21 deficiency could be attributed to diminished p21 levels, including deregulated expression and altered chromatin state of some Polycomb target genes, a defective G1/S checkpoint, increased proliferation rates, and enhanced reprogramming efficiency. These findings indicate that lincRNA-p21 affects global gene expression and influences the p53 tumor suppressor pathway by acting in cis as a locus-restricted coactivator for p53-mediated p21 expression.