Journal of Foot & Ankle Surgery最新文献

Background: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are increasingly utilized in managing type 2 diabetes mellitus (T2DM) and obesity. Emerging evidence suggests their role in enhancing bone metabolism, with potential implications for orthopedic outcomes.

Purpose: To evaluate the impact of perioperative GLP-1RA use on outcomes following midfoot arthrodesis.

Study design: This retrospective cohort study used the TriNetX U.S. Collaborative Network to evaluate outcomes following midfoot fusion in patients with versus without perioperative GLP-1RA use.

Methods: Patients were propensity score matched (1:1) for key demographic and clinical variables. Primary outcomes included 90-day and 1-year surgical complications, nonunion, and mechanical issues. Logistic regression models were used to calculate odds ratios (ORs) with 95% confidence intervals (CIs).

Results: Among 1504 matched patients (752 per cohort), GLP-1RA use was associated with significantly reduced odds of nonunion at 1 year (OR = 0.712; 95% CI = 0.52-0.958). However, GLP-1RA users had higher 90-day rates of wound complications (OR = 1.713, 95% CI = 1.141-2.57), irrigation and debridement (OR = 1.873; 95% CI = 1.223-2.869), and elevated 1-year mechanical complications rates (OR = 2.446; 95% CI = 1.552-3.857). No significant differences were observed in infection rates or overall hospital admissions.

Conclusion: There is an observed association with perioperative GLP-1RA use and lower nonunion rates following midfoot arthrodesis, indicating a potential benefit for bone healing. However, increased mechanical and wound-related complications warrant further investigation into their surgical safety profile in foot and ankle procedures.

Background: Ankle fractures are a common orthopedic injury often requiring surgical fixation. Prior studies have found that inpatient treatment is associated with increased risk of 30-day complications versus outpatient treatment.

Purpose: As outpatient fixation becomes increasingly common, and as surgical and rehabilitation techniques continue to evolve, we aim to provide an updated analysis of short-term complications following inpatient and outpatient management of ankle fractures.

Study design: A retrospective cohort study was conducted.

Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients receiving surgery for ankle fracture from 2010-2021. Cohorts were divided by treatment setting and matched using the nearest neighbor method. A sub-analysis was performed to determine the most common fracture types treated for each cohort. Chi-square and independent t-tests were employed to evaluate for differences in 30-day complications. Regression analyses were employed to assess independent risk factors for adverse outcomes.

Results: 21,612 inpatient and 23,932 outpatient ankle fractures were identified, with 4,926 patients included per matched cohort. Inpatients had more bimalleolar and trimalleolar fractures, while outpatients had more lateral malleolus fractures. ASA class and prevalence of heart failure remained significantly higher in the inpatient cohort after matching. Rate of postoperative complications was greater for inpatients (6.1%) versus outpatients (2.6%). Greater age, ASA class, dependent functional status, preoperative blood transfusion, and various comorbidities were found to be independent risk factors for complications, regardless of surgical setting.

Conclusions: Inpatient management of ankle fractures resulted in more postoperative complications compared to outpatient treatment. Preoperative characteristics, including patient comorbidities, may contribute to this difference. Additionally, there are several risk factors for adverse postoperative outcomes that should be considered prior to any fixation, regardless of surgical setting. Understanding these relationships can help surgeons better optimize patients and mitigate costs of care.

Background: Routine deltoid ligament repair (DLR) during operative management of ankle fractures remains controversial.

Purpose: To compare patient-reported outcomes (PROs), complications, and radiographic outcomes in patients with bimalleolar equivalent ankle fractures treated with or without DLR.

Study design: Retrospective cohort study.

Methods: Adult patients who underwent operative fixation of bimalleolar equivalent ankle fractures at two level 1 trauma centers between 2010 and 2023 were retrospectively identified. The primary outcome was the Olerud-Molander Ankle Score (OMAS). Secondary outcomes included additional PROs, complications, and radiographic measurements. Multivariable logistic regression assessed the association between DLR and the odds of achieving an excellent (≥91) versus non-excellent OMAS.

Results: A total of 260 patients (median age 36.4 years, 38.4% female) were included. Thirty-one (12%) patients underwent DLR and 229 (88%) did not. PROs were obtained from 92 patients (18 DLR, 74 non-repair) at a median of 7.0 years postoperatively. Median OMAS was similar between cohorts (90 vs. 90, P = 0.79). DLR was not associated with increased odds of achieving an excellent OMAS (adjusted OR 1.89, 95% CI: 0.52-7.08, P = 0.335). Secondary PROs and complications were comparable between cohorts. Radiographic measurements in 111 patients (26 DLR, 85 non-repair) revealed a decreased median tibiofibular clear space in the DLR group (4.50 mm vs. 5.09 mm, P = 0.012). Medial clear space and tibiofibular overlap were similar between cohorts.

Conclusion: Patients with bimalleolar equivalent ankle fractures had comparable long-term PROs and complication rates regardless of DLR. Radiographic findings suggested adequate restoration of ankle joint congruity and medial stability in both cohorts.

Background: Lesser metatarsophalangeal (MTPJ) joint instability, often presenting as second crossover toe deformity, commonly results from plantar plate attenuation. Indirect surgical approaches, such as metatarsal osteotomy or tendon transfer, can correct alignment but often lead to complications like floating toe, transfer metatarsalgia, and stiffness. The direct plantar approach allows for anatomic repair but is underutilized due to concerns about scar-related pain.

Purpose: To evaluate outcomes of second plantar plate repair via a direct plantar approach, focusing on pain, alignment, satisfaction, and scar morbidity.

Study design: Retrospective case series.

Methods: We reviewed 196 primary second plantar plate repairs performed from 2013 to 2023. All patients had at least 12 months of follow-up (mean 48 months). Adjunctive procedures included Hohmann osteotomy and proximal interphalangeal joint arthrodesis. Outcomes included Numeric Pain Rating Scale (NPRS) scores, scar symptoms, satisfaction, symptom improvement, and willingness to recommend the procedure. Radiographic alignment was assessed in sagittal and transverse planes on weightbearing views.

Results: Radiographic correction averaged 24.0° sagittal and 3.6° transverse (11.7° with osteotomy). Mean NPRS pain scores improved from 5.4 to 0.4. 88% of patients were "very satisfied," and 91% would recommend the procedure. Scar-related pain occurred in 2.0% of cases. Plantar callus improved in 52%, and 6.1% reported postoperative stiffness.

Conclusion: Direct plantar plate repair provides durable correction, considerable pain relief, and high satisfaction with minimal scar morbidity. This is the largest, longest follow-up study of its kind.

Background: Intramedullary hindfoot nailing remains a valuable technique for deformity correction, trauma, and limb salvage in high-risk patients. Despite widespread use, limited post-market data exist characterizing device-related complications in real-world practice.

Purpose: This study examines device-related complications associated with hindfoot intramedullary nailing as reported in the FDA's Manufacturer and User Facility Device Experience (MAUDE) database.

Study design: Descriptive epidemiologic database study.

Methods: MAUDE reports from 2020-2024 related to hindfoot intramedullary nailing were reviewed, screened, and de-duplicated. Events were categorized by primary complication type. Descriptive statistics summarized complication patterns. Chi-square analysis compared mechanical versus biological complications, and linear regression assessed temporal reporting trends.

Results: Of 426 identified reports, 144 unique events met inclusion criteria. Mechanical complications accounted for 68.1% (n = 98), while biological or patient-driven complications comprised 31.9% (n = 46) (p < 0.001). The most frequent mechanical events involved targeting guide or jig failure (25.0%), nail body failure (18.8%), and screw-related failure (16.0%). Biological complications most commonly included hardware pain (10.4%), infection or wound-related events (9.7%), and nonunion (9.0%). Reporting peaked in 2021, declined in 2022, and rebounded modestly in 2023-2024, with no significant linear trend (p = 0.81).

Conclusion: Most reported complications were mechanical and often reflect expected intraoperative challenges inherent to complex hindfoot reconstruction. Nonetheless, true device failures remain clinically meaningful, highlighting the need for meticulous technique, continued implant refinement, and robust post-market surveillance to optimize patient safety.

Background: Insertional Achilles tendinopathy is an extremely common pathology to all foot and ankle surgeons. The relationship between calcaneal morphology and the Achilles has been recognized since its original description by Swedish orthopedist Dr Haglund in 1928. Minimal invasive surgery (MIS) often allows for smaller incisions, optimal skin healing, and maintenance of the Achilles tendon insertion which may be more beneficial in specific patient populations.

Purpose: The primary goal of this study was to evaluate damage to the Achilles tendon following burr resection of the calcaneal tuber.

Study design/methods: Twenty, ten matched-pairs, thawed fresh-frozen cadaveric below-knee specimens were used to assess impact of MIS burr resection to posterior superior calcaneus and potential damage caused to the Achilles tendon.

Results: We found a 15% incidence of partial Achilles tendon damage. No full thickness tearing or ruptures occurred, as well as no neurovascular damage in any specimen.

Conclusion: These findings support the use of MIS burr resection for use of calcaneal tuber resection in setting of Haglund's deformity while also underscoring the need for meticulous surgical planning to optimize patient outcomes. Further clinical trials are warranted to confirm these results and guide future surgical practices.

Background: Total ankle replacement (TAR) is an established option for end-stage ankle arthritis, providing pain relief and functional recovery. Precise implant sizing and alignment are crucial for long-term prosthesis survival. In the transfibular approach, determining the appropriate talar component size intraoperatively can be challenging, especially in the presence of residual deformities.

Purpose: To assess the correlation between preoperative CT-based mediolateral (ML) talar width and the final implanted talar component size in transfibular TAR.

Study design: Retrospective analysis of consecutive primary TAR cases.

Patients and methods: Fifty primary TARs using non-cemented Zimmer Trabecular Metal implants via a transfibular approach were reviewed. Cases requiring additional procedures were excluded. Preoperative CT scans were used to measure ML talar dome width at its highest convex point on coronal images. Measurements were performed by a blinded radiologist and compared with intraoperatively implanted component sizes.

Results: CT-based ML width showed excellent correspondence with implanted sizes. The mean difference between CT measurements and implanted components was 0.0 mm (SD 1.12 mm; range -2.4 to +2.4 mm). Exact matching occurred in 38/50 cases (76%), and all cases were within ±1 size. The maximum deviation of 1.2 mm remained below half a size increment.

Conclusion: Preoperative CT-based ML talar measurement is a reliable, reproducible, and cost-effective tool for predicting talar component size in transfibular TAR, improving preoperative planning and intraoperative decision-making.

Background: Intravenous ketorolac is widely used for perioperative pain control in arthroplasty, but its impact on wound healing, infection, and implant outcomes after total ankle arthroplasty (TAA) remains unclear.

Purpose: This study aims to compare the outcomes of patients that were given intravenous ketorolac on the day of surgery with patients who are not.

Study design: Retrospective cohort study using a large national database.

Methods: A retrospective analysis was performed using the TriNetX Research Network, identifying patients who underwent primary TAA. Patients who received intravenous ketorolac on the day of surgery were compared with those who did not and were matched 1:1 using propensity score matching with a caliper of 0.1. Outcomes were assessed at 90 days and 1 year.

Results: Among all TAA patients, 10.4% received IV ketorolac. A total of 2,200 ketorolac patients were matched to 2,200 controls with balanced baseline characteristics (p > 0.05). At 90 days, ketorolac use was associated with higher rates of surgical site infection (5.10% vs 2.85%, RR 1.79, p = 0.0001), wound dehiscence (4.00% vs 1.98%, RR 2.02, p < 0.0001), and acute post-hemorrhagic anemia (5.00% vs 2.91%, RR 1.72, p = 0.0004). At 1 year, ketorolac recipients had higher rates of periprosthetic joint infection (4.89% vs 3.66%, RR 1.34, p = 0.0436) and revision surgery (2.74% vs 1.28%, RR 2.14, p = 0.0006).

Conclusions: Perioperative ketorolac exposure during TAA was associated with higher ninety-day and one-year complications. However, these findings should be interpreted cautiously given ketorolac's short half-life and limited exposure.

Background: Venous thromboembolism (VTE) is a potentially fatal complication following surgery. Incidence rates vary significantly depending on the procedure, ranging from 45-57% after pelvic surgery to 0.22-5.09% after foot surgery. Because of this variability, the use of prophylaxis in foot and ankle surgery has been debated.

Purpose: This study aimed to evaluate the incidence of VTE in forefoot and rearfoot procedures and assess whether a patient-specific prophylaxis protocol reduced risk.

Study design: Retrospective and prospective cohort study conducted over a four-year period.

Methods: Patients were divided into two cohorts. In Period 1 (retrospective), patients did not receive prophylaxis. In Period 2 (prospective), patients were managed with a standardized protocol incorporating chemoprophylaxis and mechanical pneumatic compression based on patient-specific risk factors. A total of 1305 patients were included: 342 in Period 1 (174 forefoot, 168 rearfoot) and 963 in Period 2 (719 forefoot, 244 rearfoot). VTE incidence rates were calculated for each group.

Conclusion: This study highlights the importance of distinguishing forefoot from rearfoot surgery when evaluating VTE risk. There were six occurrences of VTE following rearfoot surgery without prophylaxis. The use of a risk factor-based prophylaxis protocol was associated with a marked reduction in VTE events, supporting objective risk stratification to guide prophylaxis decisions and improve patient outcomes.

Purpose: To investigate the prognostic value of neutrophil-to-lymphocyte ratio (NLR) in predicting post-traumatic osteoarthritis (PTOA) following surgical fixation of intra-articular ankle fractures.

Methods: This retrospective cohort study included patients who underwent surgery for closed, intra-articular ankle fractures in a tertiary care center between January 2019 and December 2021, with a minimum follow-up of 3 years. NLR was calculated from routine blood tests within 24 hours post-injury. PTOA was diagnosed radiographically based on the Kellgren-Lawrence grading system. Multivariable logistic regression was employed to assess the independent predictive role of NLR after adjusting for covariates.

Results: A total of 764 patients were included, including 455 (59.6%) males and 309 (40.4%) females, with a mean age of 43.9 ± 14.6 years. The restricted cubic spline (RCS) model demonstrated a nonlinear relationship between NLR and PTOA, with risk sharply rising above the 6.5 threshold. High-NLR patients (n = 159) also exhibited higher surgical complexity, increased bleeding, and more frequent emergency interventions, as compared with low-NLR group (n = 605). The risk of PTOA was 37.7% (60/159) and 19.5% (118/605) in both groups, respectively (P < 0.001). An NLR ≥ 6.5 was associated with a significantly increased risk of PTOA (adjusted OR = 2.299, 95% CI: 1.517-3.483, P < 0.001).

Conclusions: These findings suggest that elevated early post-injury NLR may be associated with the development of PTOA following ankle fracture surgery; however, given the single time-point assessment, further prospective studies with serial measurements are needed to clarify its role.