1
|
Griffin JT, Landy DC, Mechas CA, Nazal MR, Foster JA, Moghadamian ES, Srinath A, Aneja A. The Hawkins Sign of the Talus: The Impact of Patient Factors on Prediction Accuracy. J Bone Joint Surg Am 2024:00004623-990000000-01054. [PMID: 38512980 DOI: 10.2106/jbjs.23.00906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND Osteonecrosis is a complication of talar neck fractures associated with chronic pain and poor functional outcomes. The Hawkins sign, the radiographic presence of subchondral lucency seen in the talar dome 6 to 8 weeks after trauma, is a strong predictor of preserved talar vascularity. This study sought to assess the accuracy of the Hawkins sign in a contemporary cohort and assess factors associated with inaccuracy. METHODS A retrospective review of talar neck fractures at a level-I trauma center from 2008 to 2016 was conducted. Both the Hawkins sign and osteonecrosis were evaluated on radiographs. The Hawkins sign was determined on the basis of radiographs taken approximately 6 to 8 weeks after injury, whereas osteonecrosis was determined based on radiographs taken throughout follow-up. The Hawkins sign accuracy was assessed using proportions with 95% confidence intervals (CIs), and associations were examined with Fisher exact testing. RESULTS In total, 105 talar neck fractures were identified. The Hawkins sign was observed in 21 tali, 3 (14% [95% CI, 3% to 36%]) of which later developed osteonecrosis. In the remaining 84 tali without a Hawkins sign, 32 (38% [95% CI, 28% to 49%]) developed osteonecrosis. Of the 3 tali that developed osteonecrosis following observation of the Hawkins sign, all were in patients who smoked. CONCLUSIONS A positive Hawkins sign may not be a reliable predictor of preserved talar vascularity in all patients. We identified 3 patients with a positive Hawkins sign who developed osteonecrosis, all of whom were smokers. Factors impairing the restoration of microvascular blood supply to the talus may lead to osteonecrosis despite the presence of preserved macrovascular blood flow and an observed Hawkins sign. Further research is needed to understand the factors limiting Hawkins sign accuracy. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Jarod T Griffin
- Harvard Medical School Orthopedic Trauma Initiative, Brigham and Women's Hospital, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Charles A Mechas
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Mark R Nazal
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Jeffrey A Foster
- Harvard Medical School Orthopedic Trauma Initiative, Brigham and Women's Hospital, Massachusetts General Hospital, Boston, Massachusetts
| | - Eric S Moghadamian
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Arjun Srinath
- Department of Orthopaedic Surgery, University of Miami Hospital, Miami, Florida
| | - Arun Aneja
- Harvard Medical School Orthopedic Trauma Initiative, Brigham and Women's Hospital, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
2
|
Hoffler HL, Powers NS, Evans JK, Blazek CD. Metatarsal Protrusion Distance and Its Influence on Recurrent Ulceration Rates After Partial First-Ray Amputations: A Retrospective Study. J Am Podiatr Med Assoc 2022; 112:20-104. [PMID: 36115035 DOI: 10.7547/20-104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Recurrent ulceration is a common problem after partial first-ray amputations. Loss of the first metatarsophalangeal joint contributes to altered biomechanics and increased pressure on the foot. This may increase risk of adjacent ulcerations and additional amputations. Preserving first-ray length maintains the metatarsal parabola and limits transfer lesions, but few data support this. We aimed to evaluate the incidence of ulceration after partial first-ray amputations and to assess the association between metatarsal protrusion distance and recurrent ulceration. METHODS Thirty-two consecutive patients underwent unilateral partial first-ray amputation at various levels along the first metatarsal, and the metatarsal protrusion distance was measured after surgery. Incidence of ulceration was evaluated on the ipsilateral foot. We hypothesized that patients with a longer first metatarsal were less likely to ulcerate again on the ipsilateral foot. RESULTS Fourteen patients (43.8%) ulcerated again after partial first-ray amputation. Mean time to ulceration was 104 days. Active smoking status was associated with increased risk of another ulceration (P = .02), and chronic kidney disease was associated with a decreased risk of recurrent ulceration (P = .03). The average metatarsal protrusion distance for patients who ulcerated again after surgery was 36.1 mm versus 25.9 mm for patients who did not (P = .04). Logistic regression analysis of the receiver operating characteristic curve demonstrated an ideal cutoff length for recurrent ulceration of 37 mm (area under the curve = 0.7381). Patients with a protrusion distance greater than 37 mm were nine times as likely to ulcerate again (95% CI, 1.7-47.0). CONCLUSIONS Partial first-ray amputations can be a good initial salvage procedure to clear infection and prolong bipedal ambulatory status. Unfortunately, these patients are prone to recurrent ulceration. Significant loss of first metatarsal length is a poor prognostic indicator for recurrent ulceration.
Collapse
Affiliation(s)
- Hayden L Hoffler
- *Podiatric Medicine and Surgery Residency Program, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Nicholas S Powers
- †Lower Extremity Limb Salvage/Trauma, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Joni K Evans
- ‡Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Cody D Blazek
- §Podiatric Medicine and Surgery Residency, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC
| |
Collapse
|
3
|
Beahrs TR, Reagan J, Bettin CC, Grear BJ, Murphy GA, Richardson DR. Smoking Effects in Foot and Ankle Surgery: An Evidence-Based Review. Foot Ankle Int 2019; 40:1226-1232. [PMID: 31423824 DOI: 10.1177/1071100719867942] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this article was to review the basic science pertaining to the harmful effects of cigarette smoke, summarize recent clinical outcome studies, and examine the benefits of smoking cessation and the efficacy of current smoking cessation strategies. METHODS The literature concerning basic science, clinical outcomes, and smoking cessation was reviewed; over half (56%) of the 52 articles reviewed were published in the last 5 years. RESULTS Smoking is associated with low bone mineral density, delayed fracture union, peri-implant bone loss, and implant failure. Orthopedic surgical patients who smoke have increased pain and lower overall patient satisfaction, along with significantly increased rates of wound healing complications. DISCUSSION/CONCLUSION Active smoking is a significant modifiable risk factor and should be discontinued before foot and ankle surgery whenever possible. Orthopedic surgeons play an important role in educating patients on the effects of smoking and facilitating access to smoking cessation resources. LEVEL OF EVIDENCE Level V, expert opinion.
Collapse
Affiliation(s)
- Taylor R Beahrs
- Department of Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - James Reagan
- Department of Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Clayton C Bettin
- Department of Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - Benjamin J Grear
- Department of Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - G Andrew Murphy
- Department of Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| | - David R Richardson
- Department of Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA
| |
Collapse
|
4
|
Abstract
INTRODUCTION Smoking tobacco is a risk factor for impaired wound healing, infection, delayed fracture healing, and prolonged hospital stay. Smoking cessation before surgery has shown a 40% relative risk reduction in total perioperative complications. The primary purpose of this study was to evaluate the effectiveness of preoperative smoking cessation on long-term smoking habits in patients undergoing elective lower extremity orthopaedic surgery. The secondary outcome is patient-reported effectiveness of the smoking cessation method. METHODS A retrospective cohort study was performed by identifying all patients who were smokers that were required to quit and subsequently had a normal nicotine/cotinine serum test before lower extremity orthopaedic surgery. Attempts were made to contact all patients and administer a survey inquiring about their demographics, medical history, smoking history, smoking cessation process, and the current smoking status. RESULTS Of 36 eligible patients, 23 completed the survey. Eleven patients identified as current nonsmokers (48%) at the time of survey follow-up (mean follow-up was 55 months with a range of 12 to 88 months). Of these 11, 82% said they were very likely to continue to refrain from smoking. Twelve patients identified as current smokers at the time of survey, and more than half of them stopped smoking for at least three months perioperatively. The most effective smoking cessation techniques reported were "cold turkey," "nonnicotine medication," and "transdermal nicotine patches." DISCUSSION Elective surgery offers a unique opportunity for smoking cessation. Of 23 patients required to quit smoking before surgery, 48% maintained smoking cessation for at least one year postoperatively. Of the 12 patients who relapsed, 55% stated that they did not resume smoking until at least 3 months postoperatively, suggesting that this particular period may be an important time for intensified smoking cessation counseling. LEVEL OF EVIDENCE Therapeutic level III.
Collapse
|
5
|
Gibb C, Fitridge R. Smoking and the surgeon: no more excuses. ANZ J Surg 2018; 88:815-816. [PMID: 30182406 DOI: 10.1111/ans.14774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 06/21/2018] [Accepted: 06/21/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Catherine Gibb
- Department of Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Robert Fitridge
- Vascular and Endovascular Service, Discipline of Surgery, Royal Adelaide Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
6
|
|
7
|
Greenhagen RM, Raspovic KM, Crim BE, Ryan MT, Gruen GG. Lawn mower injuries to the lower extremity: a 10-year retrospective review. Foot Ankle Spec 2013; 6:119-24. [PMID: 23349382 DOI: 10.1177/1938640012473149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Lawn mower injuries occur frequently in the United States and oftentimes result in extensive trauma to the lower extremities. These injuries can be quite devastating and cause there to be loss of function and amputation. The purpose of this study was to determine if there are specific factors that would help determine the best treatment protocol, patient outcomes, and prognosis after lawn mower injury to the foot and ankle. MATERIAL AND METHODS A retrospective review of medical records was performed on all patients treated at a university level 1 trauma center from 2000 to 2010. Only subjects 18 years or older who sustained an injury below the level of the knee were included for review. RESULTS Seventy-three patients were included in this review. The results revealed that patients who developed a complication were significantly older than the group of patients without complications (P = .03). Digits were found to be injured most often but the odds of developing a complication were much higher if these injuries involved the plantar foot, dorsal foot, or ankle. Interestingly, patients on prolonged antibiotic therapy had a significantly higher risk of developing complications. The presence of comorbidities significantly increased the risk of complication (P = .008); the greatest risk factors were cardiovascular disease (P = .001) and diabetes (P = .06). DISCUSSION The authors present the largest cohort of lawn mower injuries in the medical literature, which demonstrates that factors such as age, location of injury, and the presence of comorbidities influence the outcome and increase the risk of injury to the foot and ankle. These results may be useful in determining the best treatment plan possible for patients with these severe injuries. LEVELS OF EVIDENCE Therapeutic, Level IV, Retrospective case series.
Collapse
|
8
|
Anderson JJ, Boone J, Hansen M, Spencer L, Fowler Z. A comparison of diabetic smokers and non-smokers who undergo lower extremity amputation: a retrospective review of 112 patients. Diabet Foot Ankle 2012; 3:19178. [PMID: 23082237 PMCID: PMC3474996 DOI: 10.3402/dfa.v3i0.19178] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 09/19/2012] [Accepted: 09/22/2012] [Indexed: 11/14/2022]
Abstract
Background A diabetic foot or lower extremity amputation may be exacerbated by or related to the smoking habits and history of the patient. Patients and methods Of the 112 diabetic patients in this retrospective study, 46 were non-smokers and 66 were smokers. The smokers were further categorized into patients who: 1) did not cease smoking; 2) ceased in the immediate post-operative period but resumed within 3 months; and 3) ceased up to and at the 3-month post-operative period. The patients were also divided by their amputation level of forefoot, midfoot/rearfoot, and proximal leg. Results Smoking diabetic patients underwent more amputations, as well as more proximal amputations than those who did not smoke. The higher amount of smoking in pack years followed an increasing trend of more proximal amputations as well. Conclusion Neither the amputation level nor the amputation itself was enough motivation for the patients to participate in smoking cessation.
Collapse
|
9
|
King CM, Hamilton GA, Cobb M, Carpenter D, Ford LA. Association between ankle fractures and obesity. J Foot Ankle Surg 2012; 51:543-7. [PMID: 22789485 DOI: 10.1053/j.jfas.2012.05.016] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Indexed: 02/07/2023]
Abstract
Obesity is an epidemic in the United States and is associated with an increased risk of musculoskeletal problems. Rotational injuries of the ankle with a Weber C fibula fracture have a greater risk of syndesmosis disruption and instability. The goal of the present study was to explore the association between obesity and ankle fractures. Using a retrospective review, the radiographs of 280 patients with an ankle fracture were reviewed and classified using the Weber classification, which was then associated with the body mass index, gender, age, diabetes, tobacco use, and osteoporosis. Patients with a body mass index of 30 kg/m(2) or greater (odds ratio 1.78), men (odds ratio 1.74), and age 25 years or younger (odds ratio 3.97) had greater odds of having a Weber C ankle fracture (compared with Weber A and B) and Weber C and B (compared with Weber A). Diabetes mellitus, osteoporosis/osteopenia, and current tobacco use were not significantly associated with the severity of the ankle fracture. The results from the present study suggest that obesity presents a greater risk of sustaining a more proximal distal fibula fracture.
Collapse
Affiliation(s)
- Christy M King
- Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Oakland, CA 94611, USA.
| | | | | | | | | |
Collapse
|
10
|
Abstract
This article presents an overview of current ankle arthrodesis techniques. Surgical indications, pathophysiology of the ankle joint, preoperative assessment of the patient, surgical techniques for ankle fusion, and complications/sequelae are discussed. The surgical techniques section focuses on crossed screws arthrodesis and intramedullary nailing for tibiotalocalcaneal arthrodesis. Other techniques, including arthroscopic fusion, are also discussed.
Collapse
Affiliation(s)
- Steven F Boc
- Podiatric Medicine and Surgery Residency Program, Drexel University College of Medicine/Hahnemann University Hospital, Philadelphia, PA 19107, USA
| | | |
Collapse
|
11
|
|
12
|
Gonzalez AB, Salas D, Umpierrez GE. Special considerations on the management of Latino patients with type 2 diabetes mellitus. Curr Med Res Opin 2011; 27:969-79. [PMID: 21385020 DOI: 10.1185/03007995.2011.563505] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Latinos are the largest minority population in the United States, and are characterized by higher rates of obesity and diabetes compared to Whites. The prevalence of diagnosed diabetes in Latinos is two-fold higher than in Caucasians, and Latinos suffer from higher rates of diabetic complications and mortality. As the diabetes epidemic continues to expand and exert greater socioeconomic strain on national healthcare systems, the success of global and national healthcare initiatives for diabetes prevention and improvement of care will depend upon strategies targeted specifically toward this population. Essential to such strategies is an understanding of success factors unique to the Latino population for diabetes prevention and achievement of optimal treatment outcomes. METHODS A PubMed search was conducted for literature describing type 2 diabetes and its complications in Latinos. Specifically, we sought data describing epidemiology, disparities, management considerations, and success factors in this population. RESULTS The title search yielded more than 2000 articles, 80 of which were deemed directly relevant to this review. The inherent limitations of this subjective selection process are acknowledged. CONCLUSIONS A number of studies have highlighted various ethnic disparities in Latinos with diabetes including higher HbA1c levels, greater rates of obesity and metabolic syndrome, and a larger proportion of individuals with inadequate access to care. While relatively fewer studies describe success factors for redressing cultural disparities in diabetes, the current body of literature supports primary care strategies aimed at effective provider-patient relationships and culturally tailored education and lifestyle modification regimens. Further research demonstrating effective, culturally tailored practices that are suitable to the primary care setting would be of value to providers treating Latinos with diabetes.
Collapse
|