Search

Background: Extremity surgeons frequently operate on the preoperative stretcher rather than the operating room (OR) table. This study sought to identify differences between stretcher-based (SB) and OR table–based (TB) procedures with regard to time efficiency and OR team member preferences. Methods: We conducted a prospective randomized controlled trial comparing the efficiency of SB vs OR TB foot and ankle procedures. Fifty-two patients undergoing a hardware removal, isolated gastrocnemius recession, soft tissue procedure, or foreign body removal at our day surgery unit were included. Start time and exit time were recorded. “Start time” was the number of minutes between the patient entering the OR and first incision. “Exit time” was the number of minutes between the procedure ending and the patient exiting the OR. Surveys were disseminated to OR staff who participated in the included cases. Results: The total measured time in the OR was an average 6 minutes shorter in the Stretcher group compared to the OR Table group (10 minutes vs 16 minutes, P

Introduction/Purpose: This study sought to establish normative values for baseline physical and mental health by foot and ankle diagnosis using validated Patient-Reported Outcomes Measurement Information System (PROMIS) scores and to compare the correlation between these two outcomes across common foot and ankle diagnoses. Additionally, it investigated the effect of specific foot and ankle diagnoses on self-reported mental health at first presentation. Methods: We retrospectively reviewed baseline PROMIS Physical Function Short Form 10a (PF10a) and PROMIS Global-Mental (PGM) scores of 14,374 patients who had one of the 10 most common foot and ankle diagnoses seen at our institution between 2016 and 2021. Pearson correlation coefficients were calculated to assess the relationship between PF10a and PGM by diagnosis. A multivariable regression model was also used to determine the effect of each diagnosis on PGM score. Results: On unadjusted analysis, patients diagnosed with an ankle fracture had the lowest mean physical function, while patients with hallux valgus had the highest (PF10a=33.9 vs 46.7). Patients with foot/ankle osteoarthritis had the worst mean self-reported mental health, while patients with hallux rigidus had the best (PGM=49.9 vs 53.4). PF10a and PGM scores were significantly positively correlated for all diagnoses; the correlation was strongest in patients diagnosed with foot/ankle osteoarthritis or hammertoes (r=0.511) and weakest in patients with ankle fractures (r=0.239) or ankle sprains (r=0.287). Chronic conditions, including hammertoes (β=-4.9, 95%CI [-5.6, -4.2], p< 0.001), foot/ankle osteoarthritis (β=-4.8, 95%CI [-5.5, -4.1], p< 0.001), and hallux valgus (β=-4.6, 95%CI [-5.3, -3.9], p< 0.001) were associated with the largest negative effects on patients’ self-reported mental health. Conclusion: Self-reported physical function and mental health varied across common foot and ankle diagnoses and were more tightly correlated in chronic than acute conditions. The effect of diagnosis on mental health scores appears to be worse for more chronic diagnoses, including those that are generally associated with relatively unimpaired physical function. Comparison of mean unadjusted PROMIS Physical Function 10a and PROMIS Global-Mental scores by diagnosis.

Background: Climate change poses a substantial threat to human health, and operating rooms (ORs) have an outsized environmental impact. The Program for Research in Sustainable Medicine (PRiSM) designed a protocol for minor foot and ankle surgery intended to reduce waste, streamline instrument trays, and minimize laundry. We conducted a randomized controlled trial to compare the carbon footprint of procedures performed using the PRiSM protocol vs a traditional protocol. Methods: Forty adult patients undergoing foreign body removal, hammertoe correction, toe amputation, hardware removal, mass excision, or gastrocnemius recession were randomized to the PRiSM or our “Traditional” protocol. The PRiSM protocol used a smaller instrument tray, fewer drapes and towels, and minimal positioning blankets. No changes were made to surgical site preparation or operative techniques. Environmental impact was estimated using the carbon footprint, measured in kilograms of carbon dioxide equivalents (CO 2 e). Emissions associated with OR waste, instrument processing, and laundry were calculated. Results: On average, PRiSM cases had a smaller carbon footprint than Traditional cases (17.3 kg CO2e [SD = 3.2] vs 20.6 kg CO 2 e [SD = 2.0], P

Background: Intraarticular corticosteroid injections (ICIs) are widely used to treat foot and ankle conditions. Although laboratory studies indicate certain corticosteroids and local anesthetics used in ICIs are associated with chondrotoxic effects, and selected agents such as ropivacaine and triamcinolone may have less of these features, clinical evidence is lacking. We aimed to identify the patterns of drug selection, perceptions of injectate chondrotoxicity, and rationale for medication choice among surgeons in the American Orthopaedic Foot & Ankle Society (AOFAS). Methods: An e-survey including demographics, practice patterns, and rationale was disseminated to 2011 AOFAS members. Frequencies and percentages were calculated for demographic data, anesthetic and steroid choice, rationale for injectate choice, and perception of chondrotoxicity. Bivariate analysis was used to identify practice patterns significantly associated with perceptions of injectate risk and rationale. Results: In total, 387 surveys were completed. Lidocaine and triamcinolone were the most common anesthetic and corticosteroid used (51.2% and 39.3%, respectively). Less than half of respondents felt corticosteroids or local anesthetics bear risk of chondrotoxicity. Respondents agreeing that corticosteroids are chondrotoxic were more likely to use triamcinolone ( P = .037). Respondents agreeing local anesthetics risk chondrotoxicity were less likely to use lidocaine ( P = .023). Respondents choosing a local anesthetic based on literature were more likely to use ropivacaine ( P

Category: Other Introduction/Purpose: Musculoskeletal consultations constitute a growing portion of primary care physician (PCP) referrals. Optimization of communication between PCPs and orthopaedists can potentially reduce the time PCPs spend in the electronic medical record (EMR). This, in turn, may help reduce burnout. However, little is known about the preferences of PCPs regarding communication from orthopaedic specialists. The current study therefore investigated the preferences of PCPs across a large health network regarding communication from orthopaedists. Methods: One hundred and seventy-five PCPs across 15 practices within our health network were surveyed. These providers universally used the Epic Systems EMR. PCPs were asked to report their years in practice, panel size, typical number of electronic clinical messages received each day, time spent in the EMR after normal clinical hours, and burnout level. Likert scales and top-box scores were used to assess the PCPs’ perceived importance of communication from orthopedists in specific clinical scenarios. PCPs were further asked to report their preferred method of communication in each scenario and overall interest in communication from orthopaedists. Regression analyses were performed to determine if any PCP characteristics are associated with communication preferences and overall PCP interest in communication from orthopaedists. Results: A total of 107 (61%) PCPs completed the survey. PCPs most commonly rated communication from orthopaedists as highly important when the orthopaedist needed information from the PCP. In this scenario, PCPs preferred to receive an Epic Staff Message. Other scenarios rated as important included: the decision for surgery, hospitalization, and a major clinical change. In these scenarios, a CC’d Chart rather than Staff Message was preferred. Increased EMR use after-hours was associated with diminished odds of having high interest in communication from orthopaedists (odds ratio=0.65, 95% confidence interval: 0.48-0.88, P=0.005). Ninety-three PCPs (86.9%) reported spending at least 1 hour a day in Epic after normal clinical hours. Twenty-seven (25.2%) spent more than 3 hours. Forty-six PCPs (42.9%) reported experiencing at least one symptom of burnout. Conclusion: In the current study, there were distinct preferences among PCPs regarding clinical communication from orthopaedic surgeons. In addition, there was evidence of substantial burnout and after-hours work effort by PCPs. Our results may be helpful in optimizing communication between PCPs and orthopaedists, while also reducing time spent in the EMR by PCPs.

Category: Ankle; Trauma Introduction/Purpose: Although the medial clear space (MCS) is commonly used to assess talar alignment and ankle stability, its measurement is variable with multiple reported “normal” values. We have observed that the lateral tibial shaft is a reliable landmark to assess talar alignment. The objective of the current investigation was to determine the normal relationship of the lateral tibia to the superolateral talus using a tangent drawn inferiorly from the lateral tibial shaft, which we refer to as the “lateral tibial line” (LTL). Methods: The relationship of the LTL to the superolateral talus was assessed and characterized on ninety-nine standing ankle mortise radiographs in uninjured patients. This relationship was quantified by measuring the distance (in millimeters) between the LTL and the superolateral talus. Additionally, the inter-observer reliability of the LTL measurement, determined by three reviewers, was recorded and compared to medial clear space measurements. Results: The median value for the lateral tibial line was -0.50 mm with an interquartile range of -1.4mm - 0.0mm. The LTL was within 1mm of the lateral talus in 176 of 297 reviewer measurements (59.3%). Moreover, it was either lateral to or was at most 1mm medial to the lateral talus in 90.9% of cases. The LTL measurement also demonstrated good inter-observer reliability (0.764, 95% CI: 0.670-0.834), similar to the measurement of MCS (0.742, 95% CI: 0.539-0.846). Conclusion: The LTL is easily measured with good reliability for assessing the anatomic relationship of the tibia and talus. It uncommonly fell more than 1 mm medial to the superolateral talus. In other words, it was uncommon for the talus to shift lateral to this line, as might be seen with displaced ankle fractures. These findings will hopefully serve as a standard for future studies evaluating the role of the LTL in assessing lateral displacement and stability of isolated fibula fractures.

Category: Ankle Arthritis Introduction/Purpose: Despite advancements in surgical techniques, implants, and biologics, nonunion remains the most common major complication of ankle arthrodesis. While previous studies have reported delayed union or nonunion rates, few have elaborated on the clinical course of patients experiencing delayed union. We sought to better understand the trajectory of patients with delayed union by determining the rate of clinical success and failure and whether the extent of fusion on computed tomography (CT) was associated with outcomes. Methods: Delayed union was defined as incomplete ( < 75%) fusion seen on CT scan between 2 and 6 months postoperative. A total of 36 patients met inclusion criteria: isolated tibiotalar arthrodesis with delayed union. Patient-reported outcomes were obtained and patients were asked about satisfaction with their fusion. Success was defined as patients who were not revised and reported satisfaction with the procedure. Failure was defined as patients who progressed to revision or reported being not satisfied. Fusion was assessed by measuring the percent of osseous bridging across the joint on CT scan. The extent of bony bridging was categorized as absent (0%-24%), minimal (25%-49%), or moderate (50%-74%). Results: We determined the clinical outcome in 28 of the 36 eligible patients (78%) with mean follow-up of 5.6 years (range, 1.3 to 10.2 years). The majority (71%) of patients failed. A mean of 3.9 months (standard deviation, 1) elapsed between time of surgery and CT scan. Patients with minimal or moderate fusion on CT were more likely to succeed clinically than those with ‘absent’ fusion (X2 = 4.215, p = 0.040). Of those with absent ( < 25%) fusion, 11 of 12 (92%) failed. In patients with minimal or moderate fusion, 9 of 16 (56%) failed. Conclusion: We found that 71% of patients with a delayed union at roughly 4 months after ankle fusion required revision or were not satisfied. Patients with less than 25% osseous bridging on CT had an even lower rate of clinical success. These findings may help surgeons in counseling and managing patients experiencing a delayed union after ankle fusion.

Ulnar nerve entrapment at the wrist can cause debilitating sensory, motor, or sensory and motor deficits in the hand. The sources of compression have been well documented, with ganglions, lipomas, and trauma being common etiological factors. We treated a professional sculptor with intrinsic pain and weakness in her dominant hand because of compression caused by the subperiosteal course of her deep motor branch of the ulnar nerve. The nerve traversed on the radial side of the hook of the hamate and descended into the floor of the palm in the carpal tunnel through the transverse carpal ligament. We present this previously unreported anatomical anomaly and the subsequent operative treatment. Knowledge of this anatomical variation is paramount in avoiding injury to the ulnar nerve when operating the Guyon canal or carpal tunnel, among other hand and wrist surgeries.

Background: Tachycardia and heart rate irregularity are proposed triggers of premature ventricular contraction–induced cardiomyopathy (PVC-cardiomyopathy). Bigeminal premature atrial and ventricular contractions (PACs and PVCs) increase heart rate and result in rhythm irregularities but differ in their effects on ventricular synchrony. Comparing chronic bigeminal PACs with PVCs would provide insights into mechanisms of PVC-cardiomyopathy. Objective: To compare the impact of chronic PACs and PVCs on ventricular hemodynamics, structure, and function. Methods: Pacemakers were implanted in 27 canines to reproduce atrial (PACs, n = 7) or ventricular bigeminy (PVCs, n = 11) for 12 weeks, and compared to sham-operated animals (n = 9). Four additional animals were exposed to long-term bigeminal PVCs (48 weeks). Hemodynamic changes were assessed using a pressure-transducing catheter at baseline and 12 weeks. Cardiac remodeling was monitored by transthoracic echocardiography throughout the 12- and 48-week protocols in the respective groups. Results: PVC group demonstrated a significant decrease in left ventricular (LV) ejection fraction and contractility (max dP/dt), impaired LV lusitropy (min dP/dt), and increase in LV dimensions and LV mass at 12 weeks without further deterioration beyond 16 weeks. Despite increased LV mass, relative wall thickness decreased, consistent with eccentric hypertrophy. No significant cardiac remodeling was noted in either sham or PAC groups at 12 weeks. Conclusion: In contrast to bigeminal PACs, PVCs result in a cardiomyopathy characterized by reduced LV ejection fraction, LV dilation, and eccentric hypertrophy that plateaus between 12 and 16 weeks. The lack of remodeling in chronic PACs suggests that tachycardia and heart rate irregularity do not play a significant role on the development of PVC-cardiomyopathy.

Purpose: Communication between patients and physicians is critical in reaching a diagnosis, improving compliance, and optimizing outcomes and patient satisfaction. The doctor–patient relationship begins when a physician introduces himself or herself to a patient; however, no optimal method has been reported on how best to perform an introduction in hand surgery. Methods: We enrolled 254 consecutive patients presenting for initial outpatient consultation with a board-certified hand and upper-extremity surgeon at a level 1 urban academic medical center. A brief questionnaire was administered assessing patients’ preference toward how the hand surgeon should introduce himself or herself in the initial patient encounter. Preferences were quantified in the context of demographic characteristics such as age, sex, race, ethnicity, education level, and type of presenting injury (eg, urgent or nonurgent). Results: Among all respondents, patients meeting the hand surgeon for the first time in an outpatient clinic setting most preferred the construct “Hello, my name is Dr Appleseed,” in which “Appleseed” is the physician’s last name (n = 156, 61%), followed by first–last (n = 54; 21%), no preference (n = 28; 11%), and first only (n = 16; 6%). These preferences persisted across groups irrespective of race, ethnicity, type of injury, education level, and sex, and when assessing shared demographic variables with the treating physician. Among generational cohorts stratified by age, only patients born before 1943 differed in the preferred greeting construct; they selected first and last name as the desired option (33%). Conclusions: Results revealed that patients preferred hand surgeons to introduce themselves as “Hello, my name is Dr Appleseed,” in which “Appleseed” corresponds to the treating physician’s last name. Age, sex, race, ethnicity, and education level did not influence the choice of preferred greeting. Physicians should consider introducing themselves in this fashion to optimize the initial stages of the doctor–patient relationship. Type of study/level of evidence: Economic/Decision Analysis IV. Key words: doctor–patient relationship, initial encounter, introductions, patient satisfaction, surgery

Background . The COVID-19 pandemic has shed light on communities of racial/ethnic minority groups in the US where long-standing health issues and structural inequities are now known to have resulted in increased risk for infection, severe illness, and death from the virus. The objective of our study was to describe demographic characteristics, clinical presentations, medical interventions and outcomes of pediatric patients with COVID-19 treated at Children’s Hospital of Michigan (CHM), a tertiary care center in urban Detroit, an early hotspot during the initial surge of the SARS-CoV-2 pandemic. Methods. A retrospective chart review was performed of children ≤18 years of age who had polymerase chain reaction (RT-PCR) testing via NP swab or serum IgG antibody testing for SARS-CoV-2 during March 1, 2020–June 30, 2020. Results. Seventy-eight COVID-19 infected children were identified of whom 85.8% (67/78) were from minority populations (African American, Hispanic). Hospitalization rate was 82% (64/78). About 44% (34/78) had an associated comorbidity with asthma and obesity being most common. Although all ages were affected, infants

In contrast to patients with an apparent life-threatening event (ALTE), the American Academy of Pediatrics recommends very limited evaluation for patients categorized as lower-risk brief resolved unexplained event (BRUE). This retrospective review aims to explore potential missed diagnostic opportunities for patients with a lower-risk BRUE (n = 10) through comparison with a subset of patients with ALTE (n = 72). None of the patients with a lower-risk BRUE had laboratory, imaging or ancillary studies that were diagnostic. Among patients with ALTE, 5 had laboratory and 3 had imaging studies that were diagnostic. None of the patients with a lower-risk BRUE had recurrent events during hospitalization or a serious underlying diagnosis identified within the 90 day follow-up period. As recommended by the AAP, patients with a lower-risk BRUE do not need diagnostic evaluation and can be discharged home with outpatient follow-up.

Purpose: Radiation therapy (RT) and nivolumab are standard therapies for a wide range of advanced and metastatic cancers, yet little is known about the toxicity profile of their combined treatment. The rate of grade ≥3 toxicities from nivolumab monotherapy and radiation-only palliative treatments has been reported at 10% to 18% and 0% to 26%, respectively. We reviewed our experience to assess the acute toxicity profile of concurrent RT-nivolumab. Methods and materials: A retrospective review of all consecutive patients from January 2015 to May 2017 who received concurrent RT-nivolumab was conducted at 4 separate centers. Concurrent RT-nivolumab was defined as RT completed between 3 days prior to initial nivolumab infusion and 28 days after the last nivolumab infusion. Results: Of the 261 patients who received nivolumab, 46 (17.6%) had concurrent RT to 67 treatment sites. The median follow-up was 3.3 months (interquartile range, 1.7-6.1 months) and the 1-year overall survival rate was 22%. For the 11 of 46 patients (24%) who were alive at last analysis, the median follow-up was 12.8 months (interquartile range, 8.3-14.9 months). The most common histology, RT prescription, and treatment site were non-small cell lung cancer (23 of 46 patients; 50%), 30 Gy in 10 fractions (24 of 67 patients; 35.8%), and abdomen/pelvis (16 of 67 patients; 24%), respectively. Four patients with melanoma had concurrent ipilimumab and were removed from the final toxicity analysis of RT-nivolumab. Within 3 months of treatment with RT-nivolumab, 4 of 42 patients (9.5%) experienced grade 3 toxicity and 2 of these patients' toxicities were attributed specifically to the addition of RT: grade 3 hearing loss after whole brain RT and grade 3 pancreatitis after stereotactic body RT to the left adrenal gland. One death from transaminitis was attributed to nivolumab alone because the RT field did not encompass the liver. Conclusions: Concurrent RT-nivolumab did not appear to increase the toxicity profile from the previously reported toxicity rates from nivolumab or radiation alone.

Category: Trauma, Soft Tissue Introduction/Purpose: Considerable debate exists regarding how soft-tissue edema should influence timing of surgery for lower extremity fractures. Assessment of swelling is subjective and timing varies amongst surgeons. However, timing of surgery is one of the few modifiable factors in fracture care. Ultrasonography can objectively measure swelling and help determine optimal timing. The purposes of this study are: 1) determine whether objective measures of swelling, timing to surgery, and patient-specific risk factors correlate with wound complications and; 2) create a prediction model for post-operative wound complications based on identified modifiable and non-modifiable risk factors. Methods: Patients with closed lower extremity fractures requiring surgery with an uninjured, contralateral extremity were included. Demographic information and sonographic measurements on both lower extremities were obtained pre-operatively. Subjects were followed for 3 months and wound complications were documented. A predictive algorithm of independent risk factors was constructed, determining wound complication risk. Results: 93 subjects completed the study with 71/93 sustaining ankle fractures. Overall wound complication rate was 18.3%. Timing to surgery showed no correlation with wound complications. A heel-pad edema index >1.4 was independently associated with wound complications. Subgroup analysis of ankle fractures demonstrated a 3.4x increase in wound complications with a heel- pad edema index >1.4. Tobacco history and BMI >25 kg/m2 were independent predictors of wound complications. An algorithm was established based on heel-pad edema index, BMI >25, and tobacco history. Patients with none of the 3 factors had a 3% probability of a wound complication. Patients with 1/3, 2/3 and 3/3 factors had a 12-36%, 60-86% and 96% probability of a wound complication, respectively. Conclusion: Timing to surgery had no correlation with wound complications. Heel-pad edema index >1.4, BMI >25, and tobacco- use correlated with wound complications. Risk of wound complications significantly increased with each factor. In patients with increased BMI and/or tobacco-use, resolution of heel edema may significantly reduce wound complications in lower extremity trauma.

Medical students require a strong foundation in normal histology. However, current trends in medical school curricula have diminished time devoted to histology. Thus, there is a need for more efficient methods of teaching histology. We have developed a novel software program (Novel Diagnostic Educational Resource; https://pcs-webtest0.pathology.washington.edu/academics/pattern/ ) that uses annotated whole slide images to teach normal histology. Whole slide images of a wide variety of tissues were annotated by a trainee and validated by an experienced pathologist. Still images were extracted and transferred to the Novel Diagnostic Educational Resource web application. In Novel Diagnostic Educational Resource, an image was displayed briefly and the user was forced to identify the tissue type. The display time changed inversely based on cumulative accuracy to challenge the user and maintain engagement. A total of 129 second-year medical students completed the 30-minute Novel Diagnostic Educational Resource module. Surveys showed an increase in confidence from premodule (0% extremely confident, 4% very, 47% somewhat, and 49% not) to postmodule (9% extremely confident, 57% very, 32% somewhat, and 2% not), P < .0001. Accuracy increased from 72.6% pretest to 95.7% posttest, P < .002. The effect size (Cohen d = 2.30) was very large, where 0.2 is a small effect, 0.5 moderate, and 0.8 large. Ninety-six percent of students would recommend Novel Diagnostic Educational Resource to other medical students, and 98% would use Novel Diagnostic Educational Resource to further enhance their histology knowledge. Novel Diagnostic Educational Resource drastically improved medical student accuracy in classifying normal histology and improved confidence. Additional study is needed to determine knowledge retention, but Novel Diagnostic Educational Resource has great potential for efficient teaching of histology given the curriculum time constraints in medical education.