The relationship between orthopaedic foot and ankle surgeons and podiatric surgeons has been checkered. Many have advocated that the orthopaedic community should isolate itself from interaction with the podiatric community. Conversely, a smaller group of orthopaedic foot and ankle surgeons have recommended sharing CME endeavors with podiatric surgeons, and combining clinical services with them. As long as individual states continue to legislate surgeon scope-of-practice matters (38 states currently allow podiatric surgeons to perform ankle surgery), it seems to me that shared learning, combined clinical services, and collaborative research make the most sense for advancing foot and ankle care for as many patients as possible. We should all be willing to work with our surgical colleagues to improve everyone’s decision making and skill.
In the January 16, 2019 issue of The Journal, Chan et al. probe an administrative database to evaluate several outcomes after total ankle arthroplasty (TAA) and ankle arthrodesis performed by both types of surgeon. Probably because many podiatrists self-limit their practices to forefoot surgery, podiatric surgeons provided the treatment for only 18% of the patients in both ankle-surgery groups. When podiatrists were the primary surgeon, the authors found increased lengths of stay for both procedures and increased hospital costs for arthrodesis patients. The authors did not investigate the reasons for these increases, but they should be investigated in the future. Chan et al. did find that, in general, podiatric surgeons operated on sicker patients and tended to work in smaller, non-teaching hospitals.
The authors also found an increasing percentage of these procedures being performed by podiatrists over the period from 2011 to 2016. This is likely related to multiple factors, including variable availability of orthopaedic foot and ankle surgeons relative to podiatric surgeons in many communities, and an increased number of podiatry training programs that specialize in hindfoot surgery.
It seems to me that data like these from Chan et al. should be shared with both communities to foster discussions regarding how to optimize length of stay, costs, and patient outcomes across the board. The goal should always be to raise every surgeon’s level of care for the benefit of all patients.
Marc Swiontkowski, MD
When planning for any type of surgical procedure, the orthopaedist considers many patient and injury-specific variables. With a distal radius fracture, for example, the main goal of the surgery—anatomic reconstruction of the distal radius—remains constant. However, there are numerous other variables (fracture morphology and patient age, just to name 2) that have to be considered to achieve that goal. Yet, when it comes to postoperative pain control, I imagine that most orthopaedic surgeons prescribe the same amount of opioids to almost every patient undergoing an open reduction/internal fixation of a distal radius fracture, regardless of unique patient characteristics. Our medical mantra that “no two patients are the same” seems to fall by the wayside when it comes to postoperative pain control.
This disconnect is what I thought about while reading the article by Stepan et al. in the January 2, 2019 issue of The Journal. The authors’ institution developed and disseminated to all prescribers a 1-hour opioid education program and consensus-based postoperative opioid prescription guidelines. They then compared the number of opioid pills and total oral morphine equivalents prescribed after 9 ambulatory procedures within 3 subspecialty services (sports medicine, hand, and foot and ankle) prior to and after implementation of the guidelines. Stepan et al. found a significant decrease in the amount of narcotics prescribed after 6 of the 9 surgery types after implementation of the guidelines. Over the course of a year, those decreases would have equaled about 30,000 fewer opioid pills!
Interestingly, there was no significant post-guideline decrease in opioid prescribing after any of the 3 foot-and-ankle procedures. The authors attribute that finding to the slow adoption of the guidelines due to adherence to previously developed pain-management recommendations in this subspecialty.
It has become apparent that we tend to overprescribe opioids postoperatively (see related OrthoBuzz post). This study supports previous data showing that prescription guidelines can be useful in decreasing the amount of postoperative narcotics prescribed to patients, while maintaining adequate pain management and good levels of patient satisfaction. While further work in developing educational tools and procedure-specific “standards” to help surgeons guide their postoperative prescribing practices would be useful, a surgeon’s mindfulness is equally important. We need first to recognize that orthopaedic surgeons tend to overprescribe postoperative opioids—and second, we must be willing to change our habits. Without both awareness and willingness, the best guidelines and recommendations will be ignored, and an opportunity for us to help curb the opioid crisis in our country will be wasted.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
To our knowledge, there are no reports of the Ponseti method initiated after walking age and with >10 years of follow-up. Our goal was to report the clinical findings and patient-reported outcomes for children with a previously untreated idiopathic clubfoot who were seen when they were between 1 and 5 years old, were treated with the Ponseti method, and had a minimum follow-up of 10 years.
Multisite Evaluation of a Custom Energy-Storing Carbon Fiber Orthosis for Patients with Residual Disability After Lower-Limb Trauma
Background: Congenital idiopathic clubfoot is a condition that affects, on average, approximately 1 in 1,000 infants. One broadly adopted method of management, described by Ponseti, is the performance of a percutaneous complete tenotomy when hindfoot stall occurs. The use of onabotulinum toxin A (BTX-A) along with the manipulation and cast protocol described by Ponseti has been previously reported. Our goal was to compare the clinical outcomes between BTX-A and placebo injections into the gastrocnemius-soleus muscle at the time of hindfoot stall in infants with idiopathic clubfoot treated with the Ponseti method of manipulation and cast changes.
The number of articles published each year in orthopaedics that evaluate infections seems to approach, if not exceed, 1,000. Yet, despite all of these publications, consensus statements, and guidelines, we seem to have very few concrete recommendations about which every surgeon will say, “This is what needs to be done.” So we send out samples, run cultures, sonicate implants, and sometimes even perform DNA sequencing, and then we mix the data with selected recommendations and intuition to make our final treatment decisions. Foolproof? No, but it is the best we can do in many situations.
The article by Mijuskovic et al. in the September 5, 2018 edition of The Journal helps simplify this type of decision making in the setting of residual osteomyelitis after toe or forefoot amputation. The authors evaluated 51 consecutive patients with gangrene and/or infection who underwent either digit or partial foot amputations. They found that, after surgery, 41% of the patients without histological evidence of osteomyelitis (which the authors considered the reference, “true positive” analysis) had a positive culture from the same sample. In addition, only 12 patients (24%) had both positive histological findings and positive cultures, the criteria set forth by the Infectious Disease Society of America for the definitive diagnosis of osteomyelitis.
As interesting as the main findings of the study are, some of the “minor” results are even more curious. The decision regarding which patients received antibiotics after amputation seemed largely arbitrary, with 10 of the 14 patients who had a positive histological result not receiving any postoperative antibiotics. (Five of those patients ended up needing a secondary procedure.) In addition, because of the need for decalcification prior to analysis, the median time to receiving histological results was almost a week. Based on the findings in this study, in many instances patients are sent home or to a rehabilitation facility with antibiotics based only on the results of a potentially “false-positive” culture.
The authors conclude that their results “cast doubt on the strategy of relying solely on culture of bone biopsy specimens when deciding whether antibiotic treatment for osteomyelitis is necessary after toe or forefoot amputation.” But this paper also highlights the fact that we are still looking for definitive answers about which data to use and which to disregard when it comes to the detection and treatment of post-amputation osteomyelitis. We surgeons decide on which side to err, and we need to appreciate all three facets—data, guidelines, and patient factors—when discussing treatment options with patients.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original full-text content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Fractures of the Neck of the Talus
L G Hawkins: JBJS, 1970 July; 52 (5): 991
This article, richly illustrated with radiographs, reports on >1-year results from 43 patients treated after sustaining a vertical fracture of the neck of the talus. Hawkins introduced a 3-group classification system based on the initial radiographic appearance of the fracture, and he provided an in-depth discussion of the complication of avascular necrosis.
Autologous Chondrocyte Implantation and Osteochondral Cylinder Transplantation in Cartilage Repair of the Knee Joint
U Horas, D Pelinkovic, G Herr, T Aigner, R Schnettler: JBJS, 2003 February; 85 (2): 185
In the 15 years since this paper appeared in JBJS, nearly 800 articles have been published that have “autologous chondrocyte implantation” (ACI) in their title. This study—replete with histologic, biopsy-specimen, and electron microscopy images—compared 2-year results among 40 patients who had received either ACI or autologous osteochondral transplants for knee cartilage defects. Both treatments decreased symptoms, but the authors concluded that “the improvement provided by the [ACI] lagged behind that provided by the osteochondral cylinder transplantation.” For more current information on these cartilage-repair techniques, see the JBJS Clinical Summary on Knee Cartilage Injuries.
Up to 40% of patients with idiopathic clubfoot who are treated with the Ponseti method experience recurrence of deformity. https://bit.ly/2IuVOm1
It is not often that The Journal of Bone & Joint Surgery publishes an article about data-linkage efforts. To even raise the topic with most readers of The Journal would elicit a yawn and quick dismissal of the abstract without a second thought. With this fact duly noted, the possibility of linking health-system joint-replacement registries with Medicare claims data is a first step in a potentially game-changing approach to achieving the long-term clinical research our specialty needs.
In the June 20, 2018 issue of JBJS, Raman et al. detail their successful linkage of a total ankle arthroplasty (TAA) registry with Medicare data without the use of unique patient identifiers. Among 280 TAA patients over the age of 65, 250 had their registry data linked with their Medicare record with exact matches for date of procedure, date of birth, and sex. Of the linked records, 214 (76.4%) had ≥3 years of postoperative claims data.
Why are these findings so important? The answer is follow-up. Every clinician and/or researcher who has attempted to follow patients beyond the first year after a procedure understands how difficult long-term follow-up is. We live in a mobile society in which informative posttreatment data is easily lost. The younger the patient group, the more difficult it usually is to locate patients as time passes. If patients are doing well, many stop coming to our offices, no matter how strongly we recommend annual follow-ups. Everyone is busy—including retirees—and most have better things to do than drive to their surgeon’s office or even complete a web-based questionnaire. Additionally, some patients care only about their own outcomes; they are not as focused as we are on contributing to the advancement of the profession and improving outcomes at the population level.
By linking patient data from a local health-system registry to nationwide claims data, we can gain a better understanding of long-term patient progress. We can use the patient- and implant-specific data housed in the registry and essentially substitute the information from follow-up visits that did not take place within the registry system with the data contained within the Medicare system, which follows beneficiaries wherever they live.
The marriage of registry and claims data is not perfect, though, because patients who are still working probably have private insurance coverage that is not captured by the Medicare system. (Of course, if universal coverage were to come to pass, that issue would be eliminated.) Furthermore, any time claims data are used, uncertainty about the accuracy of coding must be considered. These real-world limitations notwithstanding, the linkage of registry data with claims data does have great potential for enhancing our ability to analyze—and improve—long-term orthopaedic outcomes.
Marc Swiontkowski, MD
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Shahriar Rahman, MS, in response to a recent study in Foot and Ankle Clinics of North America.
It makes sense that orthopaedic conditions with multiple etiologic factors have a corresponding variety of treatment options. So it is with hallux valgus (bunion deformity). In the June 2018 edition of Foot and Ankle Clinics of North America, Smyth and Aiyer1 focus on the pathoanatomy of hallux valgus and various approaches to selecting an operative option.
With more than 100 different operative procedures described to correct hallux valgus, it can be challenging to pick the “right” procedure for each patient. The etiology of hallux valgus includes intrinsic factors (e.g., a long first metatarsal, the shape of the metatarsal head, and soft-tissue imbalances across the hallux metatarsophalangeal [MP] joint) and extrinsic factors (e.g., high-heeled, narrow toe-box shoes). Other kinematic factors of the foot, such as hypermobility of the first ray, are associated with hallux valgus, as is pes planus (flatfoot). Whatever the etiology, hallux valgus almost always progresses in a relatively predictable manner.1
Careful preoperative analysis is required to successfully treat hallux valgus, with the goal of restoring static and dynamic balance around the first MP joint. For optimum outcomes, a soft-tissue procedure (e.g., modified McBride procedure) is now commonly combined with osseous corrective techniques. The chevron osteotomy, which has been modified in multiple ways, achieves acceptable outcomes with reportedly high patient satisfaction levels, as does a percutaneous distal metatarsal osteotomy.2
More severe deformities are usually treated with proximal first metatarsal osteotomies—such as a proximal chevron, Ludloff osteotomy, or Scarf osteotomy—to increase the possible angular correction of the metatarsal. While these procedures are more “powerful” correction options, some studies have shown recurrence rates up to 30% at 10 years of follow up.1,2 In cases of severe deformity accompanied by arthritis of the tarsometatarsal (TM) joint, a modified Lapidus procedure may be an option for stabilizing the first TM joint. Hallux MP arthrodesis is also considered in patients who have severe deformity, arthritis, and neuromuscular disorders, and for the revision of a previously failed hallux valgus surgery.
There is currently no consensus as to which procedure is the gold standard for treating hallux valgus. Despite multiple comparative studies assessing the outcomes of different techniques, the decision ultimately depends on surgeon and patient preferences.
Shahriar Rahman, MS is a consultant orthopaedic surgeon at the Ministry of Health & Family Welfare in Bangladesh and a member of the JBJS Social Media Advisory Board.
- Smyth NA & Aiyer AA 2018, ‘Introduction: Why Are There so Many Different Surgeries for Hallux Valgus?’, Foot and Ankle Clinics, 23, no.2, pp.171-182.
- Adams SB, 2017, JBJS Clinical Summary: Hallux Valgus (Bunion Deformity), viewed 27 may 2018, https://jbjs.org/summary.php?id=188
Related Articles from JBJS Essential Surgical Techniques
- Hallux Valgus Correction With Bunionectomy, Lateral Release, And Proximal Opening Wedge Osteotomy Using Wedge-plate Fixation
- Lateral Soft-tissue Release With Medial Transarticular Or Dorsal First Web-space Approach Combined With Distal Chevron Osteotomy For Moderate-to-severe Hallux Valgus
- Treatment Of Advanced Stages Of Hallux Rigidus With Cheilectomy And Proximal Phalangeal Osteotomy
- Arthrodesis Of The Hallux Metatarsophalangeal Joint