Vancomycin Powder Is Highly Cost-Effective in Total Ankle Arthroplasty

Prosthetic joint infection (PJI) is a costly and potentially fatal complication in total ankle arthroplasty (TAA). Some surgeons apply topical vancomycin powder to minimize the risk of infection during TAA procedures. The purpose of our study was to determine the cost-effectiveness of using vancomycin powder to prevent PJI following TAA and to propose an economic model that can be applied by foot and ankle surgeons in their decision to incorporate vancomycin powder in practice. Using our institution's records of the cost of 1 g of topical vancomycin powder, we performed a break-even analysis and calculated the absolute risk reduction and number needed to treat for varying costs of vancomycin powder, PJI infection rates, and costs of TAA revision. Costing $3.06 per gram at our institution, vancomycin powder was determined to be cost-effective in TAA if the PJI rate of 3% decreased by an absolute risk reduction of 0.02% (Number Needed to Treat = 5304). Furthermore, our results indicate that vancomycin powder can be highly cost-effective across a wide range of costs, PJI infection rates, and varying costs of TAA revision. The use of vancomycin powder remained cost-effective even when (1) the price of vancomycin powder was as low as $2.50 to as high as $100.00, (2) infection rates ranged from .05 to 3%, and (3) the cost of the TAA revision procedure ranged from $1000 to $10 000.Levels of Evidence: IV.

Improving Randomized-Controlled Trials in Foot and Ankle Orthopaedics: The Need to Include Sociodemographic Patient Data

BACKGROUND

The representation of sociodemographic data within randomized-controlled trials (RCT) regarding foot and ankle surgery is undefined. The purpose of this study was to determine the incidence of sociodemographic data being reported in contemporary foot and ankle RCTs.

METHODS

Randomized-controlled trials within the PubMed database from 2016 to 2021 were searched and the full text of 40 articles was reviewed to identify sociodemographic variables reported in the manuscript. Data regarding race, ethnicity, insurance status, income, work status, and education were collected.

RESULTS

Race was reported in the results in 4 studies (10.0%), ethnicity in 1 (2.5%), insurance status in 0 (0%), income in 1 (2.5%), work status in 3 (7.5%) and education in 2 (5.0%). In any section other than the results, race was reported in 6 studies (15.0%), ethnicity in 1 (2.5%), insurance status in 3 (7.5%), income in 6 (15.0%), work status in 6 (15.0%), and education in 3 (7.5%). There was no difference in sociodemographic data by journal (P = .212), year of publication (P = .216), or outcome study (P = .604).

CONCLUSION

The overall rate of sociodemographic data reported in foot and ankle RCTs is low. There was no difference in the reporting of sociodemographic data between journal, year of publication, or outcome study.

LEVEL OF EVIDENCE

Level II.

Venous Thromboembolism in Foot and Ankle Surgery: How Common is It?

Category:

Other; Ankle; Ankle Arthritis; Bunion; Sports

Introduction/Purpose:

Venous thromboembolism (VTE) is a feared complication following orthopaedic surgery. The limited research exploring the rate of VTE following different types of foot and ankle surgery makes it difficult to establish clear guidelines for prescribing VTE prophylaxis. Therefore, the purpose of this study was to determine the rate of VTE in patients undergoing various types of foot and ankle procedures.

Methods:

A large online retrospective database that utilizes ICD and CTP codes was queried to determine the rate of VTE that occurred within 1-month of surgery in common foot and ankle procedures. Surgeries investigated included: Arthrodesis, Total Ankle Arthroplasty, Bunionectomy, Hammer Toe Correction, Watson-Jones, and Achilles repair. Only patients that did not receive postoperative anticoagulation or antiplatelet agents were included in the analysis. Demographic data was also collected.

Results:

From 2011 to 2022, 27,872 patients underwent Arthrodesis, 1,513 had a Total Ankle Arthroplasty, 31,808 had a Bunionectomy, 26,828 had Hammer Toe correction, 7,545 had a Watson-Jones procedure, and 8,770 had an Achilles repair. Of these procedures, Achilles repair had the highest rate of postoperative VTE (1.32%), followed by Watson-Jones (1.21%), Arthrodesis (0.89%), Ankle Arthroplasty (0.86%), Hammer Toe (0.76%) and Bunionectomy (0.65%). The overall rate of VTE in all procedures was found to be 0.84% (880/104,336).

Conclusion:

Venous thromboembolism is a serious complication following foot and ankle surgery. The unknown incidence of VTE in common foot and ankle surgeries may contribute to the lack of clear guidelines for prescribing VTE prophylaxis. This study helps to define rates of VTE in patients not receiving prophylaxis that underwent Arthrodesis, Ankle Arthroplasty, Bunionectomy, Hammer Toe, Watson-Jones, and Achilles repair. More studies are needed to help establish clear guidelines for foot and ankle surgeons to follow.

Can Sociodemographic Factors be Used to Help Predict Outcomes in Charcot Neuroarthropathy?

Category:

Diabetes; Other

Introduction/Purpose:

The diabetic Charcot foot, or Charcot neuroarthropathy, is a devastating condition that arises secondary to longstanding diabetes, peripheral neuropathy, and trauma. One of the many challenges associated with the Charcot patient is the lack of data exploring factors that may predict long-term outcomes. Therefore, the purpose of this study was to evaluate how certain sociodemographic factors may influence mortality and the need to undergo lower extremity amputation in patients with Charcot.

Methods:

Following institutional board approval, all patients from 2015-2021 with a diagnosis of Charcot Foot were queried using hospital electronic medical records. Demographics collected included sex, age, race, and insurance coverage. Outcomes recorded were the need to undergo major amputation and mortality rate. Statistical analysis was then run to determine if sex, age, race, and insurance coverage was associated with increased risk of needing a major amputation or death.

Results:

From 2015-2021, 80 Charcot patients with a mean age of 60 (Range, 84-32) were identified. Of these patients, 58 were male, 26 were female, 71 were white, 3 were African American, and 6 were identified as other. In our cohort, 47 patients had government funded insurance and 33 had private insurance. Amputation occurred in 22 patients and death in 15. Government funded insurance (RR: 9.8, 95% CI:1.4-71.1, P = 0.0236) and age over 65 was associated with an increased risk of death (RR: 2.5, 95% CI: 1.02 to 6.17; P = 0.044). No statistically significant increased risk of death or amputation was found in white, African American, male, or female patients. Government insurance was also not associated with an increased risk for amputation (Table 1).

Conclusion:

Charcot Neuroarthropathy is associated with high rates of morbidity and mortality. In our cohort, there was an increased risk of mortality in patients with government funded insurance and patients over the age of 65. Further investigation exploring the role of sociodemographic factors is warranted.

Charcot Neuroarthropathy is Associated with Higher Rates of Phantom Limb after Major Amputation

Category:

Diabetes; Trauma

Introduction/Purpose:

Phantom limb is a complication associated with lower extremity amputation. However, its rate in patients with Charcot Neuroarthropathy that undergo major amputation is not well-described. Moreover, there is limited research exploring outcomes of patients with Charcot Neuroarthropathy that require amputation. Therefore, the purpose of this cohort study was to determine if patients with Charcot Neuroarthropathy that undergo major amputation had an increased rate of phantom limb compared to patients that underwent amputation without a coexisting diagnosis of Charcot.

Methods:

Using ICD and CPT codes, an online research database was used to identify patients that underwent a major lower extremity amputation. For the purposes of our study, we defined a major amputation as a below-knee amputation (BKA). Patients were then separated into two groups. Group A consisted of patients that underwent BKA and also had a coded diagnosis of Charcot Neuroarthropathy. Group B consisted of patients that underwent BKA and lacked a diagnosis of Charcot. Statistical analysis was then run to determine the relative risk of developing phantom limb in patients that underwent BKA with a diagnosis of Charcot Neuroarthropathy compared to those without the diagnosis. Demographic data of the cohort was also collected.

Results:

From 2012-2022, a total of 11,374 patients underwent a BKA. Of these patients, 804 also had a diagnosis of Charcot Neuroarthropathy (Group A) and 10,570 did not (Group B). The rate of phantom limb in Charcot patients was 23.1% (186/804). The rate of phantom limb in patients without Charcot Foot was 19.5% (2063/10570). Patients with Charcot Neuroarthropathy that underwent a BKA had an increased risk of developing phantom limb compared to patients that underwent a BKA without Charcot (RR: 1.2, 95% CI: 1.039-1.352).

Conclusion:

Phantom limb is a serious complication following major amputation. Our results indicate that patients with a coexisting diagnosis of Charcot Neuroarthropathy that go on to require BKA may have an increased risk of developing phantom limb. Furthermore, our study adds to the limited research on outcomes of patients with Charcot Neuroarthropathy.

Prophylaxis for the Prevention of PJI after TAA: Is It Economically Justifiable?

Category:

Ankle Arthritis; Ankle; Other

Introduction/Purpose:

Prosthetic joint infection (PJI) is a costly and potentially fatal complication in total ankle arthroplasty (TAA). Some surgeons will use intraoperative vancomycin powder or copiously irrigate the surgical site with Povidone-iodine to prevent this outcome. Additionally, many surgeons will prescribe a short course of postoperative antibiotics. However, the efficacy of such prophylaxis continues to be debated, and little is known about the cost-effectiveness of these agents. Therefore, the purpose of this study was to perform a 'break-even' analysis to determine the number of cases that could be performed while only preventing a single PJI and still breaking even on cost.

Methods:

The literature was searched to determine the rate of PJI and the mean cost of total ankle replacement. The prices of topical vancomycin powder and Povidone-iodine were obtained from our institution's purchasing records. An online drug database was then used to determine the cost of a 14 day twice daily course of Sulfamethoxazole/Trimethoprim (800/160 mg), Cephalexin (500 mg), and Amoxicillin/Potassium Clavulanate (875/125 mg). A break-even analysis was then performed to determine the absolute risk reduction (ARR) necessary to make a drug cost-effective. Using the ARR, we calculated the number of patients that would need to be treated with these agents to prevent a single PJI (NNT).

Results:

The price of intraoperative vancomycin powder was found to be $3.06 while povidone-iodine was found to cost $3.64. Sulfamethoxazole/Trimethoprim (800/160 mg), Cephalexin (500 mg), and Amoxicillin/Potassium Clavulanate (875/125 mg) were determined to cost $3.00, $3.64, and $14.51, respectively. At the prices obtained Vancomycin Powder, Povidone-iodine, Sulfamethoxazole/Trimethoprim, and Cephalexin were all cost-effective if the initial rate decreased by ARRs of 0.01%. Likewise, Amoxicillin/Potassium Clavulanate was cost-effective if the initial rate decreased by an ARR of 0.03%. Additional analyses run found that all drugs-maintained cost-effectiveness even if the initial rate of PJI was as low as 0.1%.

Conclusion:

PJI following TAA is devastating and costly. Despite the ongoing debate regarding the efficacy of prophylactic measures to reduce the risk of PJI in TAA, limited is known about their cost-effectiveness. Our study demonstrates that intraoperative vancomycin powder, povidone-iodine lavage, and multiple commonly prescribed antibiotics are all highly cost- effective to prevent PJI following TAA. We feel that a tailored approach to taking measures to reduce PJI with cost-effectiveness in mind is crucial to providing value-based care.

3-T MRI Outperforms 1.5-T MRI in Diagnosis of Osteochondral Lesions of the Talus in Patients Undergoing Broström Repair

Category:

Ankle; Arthroscopy

Introduction/Purpose:

Osteochondral lesions of the talus (OLT) are commonly seen in patients with lateral ankle instability. If left undiagnosed, OLTs can cause significant ankle pain, progressive osteoarthritis, and contribute to increased morbidity after an ankle sprain. Arthroscopy has long been the gold standard for OLT diagnosis. While MRI is a useful imaging modality for pre- operative evaluation and planning, prior research on the diagnostic utility of pre-operative MRI for OLTs observes low detection rates. With 3-T scanners replacing 1.5-T scanners, long considered the clinical standard, there is potential that 3-T MRIs may improve MRI's diagnostic efficacy. The purpose of this study is to assess the efficacy of 3-T MRI and 1.5-T MRI in diagnosing OLTs in patients undergoing Broström Gould procedure for lateral ankle instability.

Methods:

Following institutional review board approval, a database was obtained for all patients from 2/11/2015 to 1/21/2019 who underwent a Broström Gould procedure for lateral ankle instability in addition to diagnostic arthroscopy of the tibiotalar joint. Additionally, patients required a pre-operative MRI for inclusion in the study. Patients who underwent the Broström Gould procedure, but did not have a diagnostic arthroscopy or did not have a pre-operative MRI were excluded from the study. Patient charts were then reviewed to determine the field strength of the preoperative MRIs, and the efficacy of 3-T MRIs and 1.5-T MRIs in correctly identifying the presence or absence of OLTs using diagnostic arthroscopy as a reference standard. Patients with pre- operative MRIs where the field strength was either unlabeled or could not be determined, as they were conducted at outside institutions, were excluded from analysis.

Results:

Forty (49.4%) out of 81 patients were identified of having preoperative MRI with identifiable field strength, Broström Gould procedure for lateral ankle instability, and diagnostic arthroscopy of the tibiotalar joint. The average age was 37.3 +- 14.2 years. Twenty-four (60.0%) patients were female and 16 (40.0%) were male. Nineteen (47.5%) patients had OLTs identified via diagnostic arthroscopy. Twenty-one patients had a preoperative 3-T MRI, and 19 patients had a preoperative 1.5-T MRI (Table 1). The sensitivity and specificity of 3-T MRI was 75% and 100%; the sensitivity and specificity of 1.5-T M was 72.7% and 87.5%, respectively. For 3-T MRI, six patients were correctly identified as having OLTs, and 13 patients were correctly identified as not having OLTs. For 1.5-T MRI, eight patients were correctly identified as having OLTs, and seven patients were correctly identified as not having OLTs.

Conclusion:

Three-Tesla MRI appears to be superior to 1.5-T MRI in diagnosing OLTs in patients undergoing Broström Gould procedure for lateral ankle instability. Three-Tesla MRI demonstrates a sensitivity and specificity of 75.0% and 100%, respectively, whereas 1.5-T MRI is associated with a sensitivity and specificity of 72.7% and 87.5%. Three-Tesla MRI's low false positive rate provides support for the efficacy of this imaging modality to rule in OLTs and prompt arthroscopic surgery with subsequent OLT treatment. This suggests that 3-T MRIs may prove useful in clinical decision making regarding OLTs in patients undergoing Broström Gould procedure for lateral ankle instability.

Achilles Tendon Ruptures and Repair in Athletes-a Review of Sports-Related Achilles Injuries and Return to Play

PURPOSE OF REVIEW

Achilles tendon ruptures (ATR) are detrimental to sports performance, and optimal treatment strategy and guidelines on return to play (RTP) remain controversial. This current review investigates the recent literature surrounding nonoperative versus operative management of ATR, clinical outcomes, and operative techniques to allow the athlete a successful return to their respective sport.

RECENT FINDINGS

The Achilles tendon (AT) is crucial to the athlete, as it is essential for explosive activities such as running and jumping. Athletes that sustain an ATR play in fewer games and perform at a lower level of play compared to age-matched controls. Recent studies also theorize that ATRs occur due to elongation of the tendon with fatigue failure. Biomechanical studies have focused on comparing modes of fixation under dynamic loading to recreate this mechanism. ATRs can be career-ending injuries. Fortunately, the recent incorporation of early weight-bearing and functional rehabilitation programming for non-operative and operative patients alike proves to be beneficial. Especially for those treated nonoperatively, with the incorporation of functional rehabilitation, the risk of re-rupture among non-operative patients is beginning to approach the historical lower risk of re-rupture observed among patients treated operatively. Despite this progress in decreasing risk of re-rupture particularly among non-operative patients, operative managements are associated with unique benefits that may be of particular interest for athletes and active individuals. Recent studies demonstrate that operative intervention improves strength and functional outcomes with more efficacy compared to nonoperative management with rehabilitation. The current literature supports operative intervention in elite athletes to improve performance and shorten the duration to RTP. However, we acknowledge that surgical intervention does have inherent risks. Ultimately, most if not all young and/or high-level athletes with an ATR benefit from surgical repair, but it is crucial to take a stepwise algorithmic approach and consider other factors, which may lead towards nonoperative intervention. These factors include age, chronicity of injury, gap of ATR, social factors, and medical history amongst others in this review.