Tyler Kelly

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Introduction: The purpose of this study is to assess the effect of race and ethnicity on the length of stay in hospitals following elective foot and ankle procedures. We aimed to determine whether (1) there are differences in the amount of time spent in a hospital following surgery between black, Hispanic, and white patients and (2) to assess for differences in complications. Methods: A retrospective review of the National Inpatient Sample (NIS) was conducted for 14 different foot and ankle procedures between 2016 and 2021. International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) and International Classification of Diseases, 10th Revision (ICD-10) codes guided the inclusion and exclusion criteria. Patient demographics, comorbidities, and postoperative outcomes and length of stay in hospitals were collected. A biostatistician was used to conduct all analyses. Regression analyses were used to assess differences between length of stay between races. Demographic variables, comorbidities and outcomes were analyzed using χ ² and Fisher exact tests. Results: The database search yielded 16,126 patients with a weighted sum of 84,085. White patients were older on average (61.98 years) than black patients (52.30), with an average length of stay of 3.08 days and black patients had an average of 3.35 days (P < .0001). Prevalence of pulmonary embolism, pneumonia, myocardial infarction, and stroke were not significantly different between the groups (P > .05). Conclusion: Our study found that minority patients experience longer stays in the hospital following elective foot and ankle procedures. No differences were found between complication rates among the 2 groups. These findings suggest a need for further research into reasons for longer stays in this patient population.

Introduction: Surgical cancellations have been a long-standing issue in the United States health care system, with orthopaedic surgery having some of the highest cancellation rates among all specialties. Purpose: This study aims to assess the reasons for surgical cancellations by exploring patient, surgeon, and institutional factors. Methods: A retrospective chart review of elective orthopaedic surgery procedures performed at an academic outpatient hospital between January 2019 and August 2024 was conducted. Results: Total joint and hand procedures had the highest relative cancellation rates. Among the subspecialties, trauma and joints were the most common. The predominant reasons for cancellation were patient-related, surgeon-related, clerical issues, medical/anaesthesia-related matters, and COVID-19, respectively. The most common patient-related factors included clearance, lack of transportation, and patient noncompliance with day of surgery instructions (eating, drinking, and medications). Conclusion: This study highlights opportunities for interventions to reduce same-day cancellations through patient engagement, preoperative planning, resource coordination, and administrative efficiency.

Background: Broström-Gould surgery is the gold standard operative treatment of chronic lateral ankle instability. In cases of failed nonoperative treatment, the Broström-Gould repair aims to improve lateral ankle stability via anatomic repair and the overlapping of the anterior talofibular ligament (ATFL) and calcaneofibular ligament, with reinforcement of the ATFL by the extensor retinaculum ^1–3 . Lateral ankle ligament injuries typically present with additional pathologies, including hindfoot varus, peroneal tendon lesions, and tarsal coalition ^4,9 . Previous studies have hypothesized that treatment of ligamentous injuries with concurrent osteotomy of the calcaneus can correct altered stress loading, aiding in the prevention of future injuries and complications ^4,9,10 . The presently described technique is a modification of the Broström-Gould technique that allows the addition of a calcaneal osteotomy without additional incisions. Description: Patients are positioned supine with a foam bump under the torso on the ipsilateral side and bone foam to elevate and pronate the operative foot. The incision begins 4 cm proximal to the tip of the lateral malleolus, posterior to the peroneal tendons, and ends 1 cm proximal to the base of the fifth metatarsal. Subcutaneous tissues are bluntly dissected, and neurovasculature is protected. Tenosynovectomy of the peroneus longus and brevis is performed. During the tenosynovectomy, care must be taken to avoid damaging the sural nerve, which is posterior to the tendon sheath. Hohmann retractors are utilized to better visualize the lateral calcaneus. Calcaneal osteotomy is performed with use of a micro saw for the lateral two-thirds and with use of an osteotome for the medial third. In the example case, a single 7.0-mm cancellous screw was utilized for fixation; however, 2 screws can be utilized to provide greater rotational stability. The ATFL is elevated from the talus and lateral malleolus. The lateral malleolus is freed of periosteum with use of a rongeur. Two 3.5-mm suture anchors (each with 4 needles) with number-0 FiberWire (Arthrex) are inserted through the tip of the lateral malleolus. The suture material is passed through the ATFL and calcaneofibular ligament to tighten the ligaments. The superior extensor retinaculum is advanced over, and sutured to, the ATFL. The incision is closed in layers, and a short leg splint is applied with the foot in slight eversion and dorsiflexion. Patients are transitioned from the splint to a short leg non-weight-bearing cast or boot for 6 weeks. At 6 weeks postoperatively, the patient is transitioned to a walking boot for progressive weight-bearing per a physical therapy protocol. Alternatives: Nonoperative treatment of chronic ankle instability involves rest and physical therapy with bracing or the use of orthotics. Operative treatments are performed when nonoperative treatment has failed. Alternatives include isolated open Broström-Gould repair, arthroscopic Broström repair, Broström repair augmented with a suture internal brace, a Chrisman-Snook procedure, and allograft repair of the ATFL ^1–3,11 . Recent focus has been placed on the use of minimally invasive surgical techniques, including those for calcaneal osteotomies. The proposed technique offers advantages compared to minimally invasive calcaneal osteotomies by allowing for debridement of the peroneal tendons. Rationale: A previous study on single-incision Broström-Gould surgery with calcaneal osteotomy has shown this technique to be safe and effective, without increased risk of postoperative complications ^5,6 . This approach offers a useful modification to the Broström-Gould procedure by allowing for a simultaneous calcaneal osteotomy without the need for additional incisions. Advantages include decreased risk of incision-site complications and improved cosmesis. Expected Outcomes: The Broström-Gould procedure has been shown to provide excellent patient satisfaction ⁷ . The goal of this surgery is to stabilize the ankle joint, allowing for improved mobility and decreased pain. On the basis of clinical evidence, modified versions of the Broström-Gould procedure, including a single-incision procedure with calcaneal osteotomy, have no proven clinical inferiority or increased risk of complications ^6–8 . The addition of a calcaneal osteotomy with a single-incision technique allows for the correction of varus deformities, lowering the risk of future ligamentous injury and slowing the progression of osteoarthritis ⁴ . Common surgical complications include superficial wound healing complications, sensory abnormalities, persistent ankle pain, and prolonged swelling ⁵ . Most patients can tolerate weight-bearing beginning at 6 weeks postoperatively, and patients have a high rate of return to activity ¹ . Important Tips: Avoid overtightening of the ATFL in order to prevent increased postoperative stiffness. Avoid over medialization of the micro saw blade in order to prevent potential overpenetration. Insufficiency of the calcaneofibular ligament can be identified by checking for opening of the posterior facet of the subtalar joint on an oblique view of the ankle as a guide to include calcaneofibular ligament tissue in the repair. Acronyms and Abbreviations: CLAI = chronic lateral ankle instability SLCO = sliding lateralizing calcaneal osteotomy AP = anteroposterior MRI = magnetic resonance imaging ATFL = anterior talofibular ligament CFL = calcaneofibular ligament

Background: Operative fires are rare but unforgettable events, with the potential for devastating outcomes. It is estimated that 650 operating room (OR) fires occur each year in the United States, with the use of electrocautery devices and polymethylmethacrylate (PMMA) as the primary ignition and fuel sources. There are several case reports of OR fires caused by PMMA and electrocautery in the literature, but, to our knowledge, no formal studies have been performed exposing the flammability of PMMA and how PMMA reacts to an electrocautery ignition source. Methods: We studied the flammability of PMMA with electrocautery as an ignition source in a controlled laboratory setting. We used 2 different brands of PMMA, both with and without antibiotics. The PMMA was prepared according to the manufacturer’s guidelines. In our model, which used a cadaveric leg, the PMMA was placed next to a femoral component that is used in total knee arthroplasty (TKA). Electrocautery was applied at 30-second intervals for a total of 15 minutes. Flammability was defined as any visualized spark or flame while using an electrocautery device. The heat resulting from the chemical reaction was recorded every 30 seconds with a thermal imaging camera (TIC). Video recording was used during the experiment to document the flammability events. A total of 108 tests were performed. Results: PMMA with and without antibiotics proved to be flammable with the use of electrocautery. All flammability occurred within 7 minutes of combining the monomer and the powder. Increased flammability was seen with the use of antibiotic additives. Conclusions: PMMA was found to be highly flammable in the initial curing period when exposed to electrocautery as an ignition source. When PMMA is ready for application, we recommend that an “electrocautery timeout” be performed, wherein the electrocautery device is removed from the operating field for a minimum of 7 minutes or until the PMMA has fully hardened.