What A New Study Reveals About Post-Op ED Visits After Lower Extremity Surgery

A recent study in the Journal of Foot and Ankle Surgery examines the factors that can bring patients back to the emergency department (ED) after their lower extremity surgery.

The authors focused on 513 surgeries on the foot and ankle, 114 of which required emergency department visits 30 days after surgery for reasons related to the surgery. The study found patients were two to three times more likely to go to the emergency department if they had at least one previous ED visit within six months prior to surgery or if patients had non-elective surgery.

Among outpatient cases, the researchers say both a longer surgery duration and having a previous ED visit were factors associated with a post-op ED visit. Patients being a younger age (under 20 years of age relative to being over 60 years of age) and having no insurance were associated with a postoperative ED visit.

Study lead author Naohiro Shibuya, DPM, MS, FACFAS, notes his study focused on finding risk factors for ED readmittance. Surgeons can use such risk factors to identify patients who are more likely to be readmitted, suggests Dr. Shibuya, a Professor of Surgery at the Texas A&M University College of Medicine.

How can podiatric surgeons reduce the chance of their patients heading back to the ED postoperatively? Thanh Dinh, DPM, FACFAS, suggests better communication regarding expected outcomes, pain and possible complications.  

“Both verbal and written instructions are helpful, and providing a specific mechanism for the patient to contact the physician for any questions/concerns is helpful,” says Dr. Dinh, an Assistant Professor of Surgery at Harvard Medical School and the Program Director of the Podiatric Surgical Residency Program at the Beth Israel Deaconess Medical Center in Boston.

On the flipside, Dr. Dinh urges that patients must listen to their surgeon’s instructions and read the provided surgical materials. She suggests patients ask questions in advance about the recovery, and what is normal and what is not. Dr. Shibuya agrees, emphasizing the importance of patients reading their surgeon’s instructions and asking questions before surgery. Dr. Dinh adds that patients should call the physician’s office for any/all concerns instead of using the ED as a first-line resource.

Dr. Dinh suggests the importance of further investigation into the exact causes for ED visits to examine the modifiable risk factors in reducing the number of ED visits after surgery. Dr. Shibuya advocates focusing further research on whether the modification of the transitional protocol can prevent readmission to the ED.

For further reading, see “A Critical Look At Readmissions For Patients With Diabetic Foot Infections” in the September 2018 issue of Podiatry Today, “A Closer Look At Health Care Costs And Common Pitfalls In Treating Patients With Diabetes” in the May 2018 issue, or the DPM Blog “Teaching Residents About Post-Op Protocols” at https://tinyurl.com/y9867fj7 .
 

Study: Gastroc Recession With Stretching Effective For Plantar Heel Pain 

By Brian McCurdy, Managing Editor

The combination of gastrocnemius recession and stretching can be effective for chronic plantar heel pain, according to a recent study in Foot and Ankle International.

In the randomized study, 40 patients with plantar heel pain of over one year’s duration performed either home stretching only or had a proximal medial gastrocnemius recession plus stretching. At 12 months, the average American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score increased from 59.5 to 88.0 in the gastroc recession group and increased from 52.5 to 65.5 in the nonoperative group, notes the study. The authors add that Short Form–36 (SF-36) and Visual Analogue Scale (VAS) pain scores were better in the surgical group in comparison to the non-surgical patients.

Patrick DeHeer, DPM, FACFAS, notes a recurrence rate of approximately 20 percent for posterior muscle group recontracture despite the gastroc surgical lengthening technique. He believes some form of maintenance therapy via stretching after surgery is critical to maintaining correction. His Baumann recession patients typically start stretching at eight weeks post-op.

Dr. DeHeer says the best approach to stretching for plantar fasciitis is a combination of plantar fascia specific stretching with gastrocsoleal complex stretching, which patients can do with one specific brace or manual stretching. As he notes, manual stretching has several potential downfalls that make it a less reliable method. Dr. DeHeer prefers using a brace that accomplishes both stretching of the plantar fascia and gastrocsoleal complex. He discloses that he is the inventor of the Equinus Brace and the owner of IQ Med, which manufactures the brace.

The literature notes approximately 80 percent of patients with plantar fasciitis have an underlying gastrocnemius equinus deformity, says Dr. DeHeer, a Diplomate of the American Board of Podiatric Surgery, who is in private practice with various offices in Indianapolis. He emphasizes treating equinus as part of any comprehensive treatment plan for plantar fasciitis. For patients with recalcitrant plantar fasciitis, Dr. DeHeer notes there are currently nine published studies that report an 85 to 90 percent success rate on the sole use of gastroc recession to treat recalcitrant plantar fasciitis without touching the plantar fascia.

“I have taken this approach for the past five years and found similar results in my practice,” says Dr. DeHeer. “The evidence continues to mount and is undeniable.”

What Is The Best Osteotomy For Hallux Valgus In Athletes?

By Brian McCurdy, Managing Editor

The chevron osteotomy can best get athletes back on their feet after suffering from mild to moderate hallux valgus, according to a recent review in the Journal of Foot and Ankle Surgery.

The authors reviewed five studies on the surgical correction of hallux valgus involving a total of 230 athletes. The review notes the literature supports the use of a chevron osteotomy for mild to moderate hallux valgus with a return to activity at three months post-op and advocates use of the Ludloff osteotomy for moderate to severe bunions.

Lead author Magali Fournier, DPM, calls the chevron osteotomy “an inherently stable osteotomy” that has a low complication rate. She notes the chevron procedure is technically easy to perform and allows athletes a rapid return to activity. It is indicated for mild to moderate deformities only. Dr. Fournier cautions the chevron is only indicated for mild to moderate hallux valgus. She notes the amount of correction the osteotomy offers is limited and surgeons should not use it to correct severe deformity.

Hallux valgus in athletes is no different than in non-athletes, notes Dr. Fournier, an attending physician at Gundersen Lutheran Health System in La Crosse, Wis. She says one should evaluate bunions in athletes and base the decision to perform a specific type of osteotomy (chevron or other) on the amount of deformity to correct among other factors. Although the chevron osteotomy does offer the quickest return to activity, she cautions that “this aspect alone should not be a reason to choose such an osteotomy.”

The study authors also found the Lapidus bunionectomy to permit, at best, 80 percent of athletes with hallux valgus to return to sports at a mean 2.8-year follow-up. However, Dr. Fournier suggests avoiding the Lapidus arthrodesis in athletes for several reasons. She notes the procedure itself can lead to a shortening of the first ray, which will affect the mechanics of the foot and lead to transfer lesions. In addition, Dr. Fournier says the Lapidus procedure has a high rate of non-union and overall low patient satisfaction in the athlete population.

Clarification

The Technology In Practice column in the December 2018 issue, “Polymerase Chain Reaction Test Can Accurately Diagnose Nail Dystrophy,” should have listed the nail dystrophy test as a DNA test, not a polymerase chain reaction (PCR) test. Additionally, the article misstated that 936 carcinomas, 191 melanomas and 58 sarcomas as of August 2018 were diagnosed with the DNA test referred to in the article. These diagnoses were made by the dermatopathologists at Bako Diagnostics. The correct version of the article is available at: https://www.podiatrytoday.com/polymerase-chain-reaction-test-can-accurately-diagnose-nail-dystrophy .