Soft-Tissue Problems Top Foot and Ankle Complications

By: Terry Stanton

Terry Stanton

The most common foot and ankle procedures are associated with a higher rate of complications than orthopaedic procedures overall, according to Scientific Poster P207, on display in Academy Hall B, McCormick Place.

“The Most Common Patient Safety Problems in Orthopaedic Surgery of the Foot and Ankle” reports the results of a comprehensive review of more than 56,000 foot and ankle procedures as reported by CPT code. Although overall foot and ankle procedures were not associated with higher complications when compared with all orthopaedics (P = 0.11), the top 10 foot and ankle procedures (26,000 total) did have a higher complication rate (P = 0.02) than the approximately 429,000 total orthopaedic procedures.

The three most common complications in orthopaedic surgery of the foot and ankle were infection, wound dehiscence, and skin ulcer or blister. All had significantly higher complication rates than other orthopaedic procedures (P < 0.001) and all involved soft tissues. The fourth most common complication in foot and ankle surgery was nonunion or delayed union. Bone or implant fracture also occurred more frequently in foot and ankle surgery than in other orthopaedic surgeries.

The top 10 foot and ankle procedures were performed by 2,970 orthopaedic surgeons and accounted for 46 percent of all foot and ankle CPT codes. The most common procedure was open treatment of bimalleolar ankle fracture, followed by open treatment of distal fibular fracture (lateral malleolus) and intermedullary treatment of tibial shaft fractures, with or without interlocking screws.

Author Joshua Hunter, MD, observed that many studies on complication rates are from a restricted geographic location, based on reports from the experience of a single surgeon, or are low in overall volume. “This information, while useful, complicates the interpretation of their data,” he said.

In contrast, the findings in this presentation were obtained from a comprehensive, national volume of cases from the American Board of Orthopaedic Surgeons (ABOS) Database. “This provides a foundation for additional research, because it identifies the most common complications and their rates at a truly national level,” noted Dr. Hunter. “This knowledge can then be used to establish risk reduction programs and monitor improvement.”

However, these data also have limitations. They are obtained from relatively inexperienced, early-career surgeons, have short follow-up, and are self-reported with some variation in the definitions of complications.

Specifically, Dr. Hunter noted the finding regarding the higher frequency of soft-tissue complications. “Adequate time must be given to the soft tissues to heal from the initial insult, if traumatic in nature, before the second insult should be considered,” he said. “Waiting can be difficult for both the orthopaedic surgeon and the patient, who would like to begin rehabilitation as soon as possible. But we can do the patient a disservice by neglecting the soft tissues or by operating too quickly.”

Over all, he said, “Understanding the potential complications that can arise from any given surgical procedure is the first step to reduce their incidence. If we, as orthopaedic surgeons, are not actively thinking about potential complications during the procedure, then there is a good chance that we will be thinking about them as we treat them postoperatively.”

The authors concluded: “Improving patient safety and avoiding adverse events requires an accurate picture of the complication spectrum after individual procedures. Such knowledge can be an effective tool in designing customized risk-reduction programs and monitoring their impact. Comprehensive databases, such as the ABOS oral examination case list, can be valuable tools to direct current practice improvement initiatives such as the Maintenance of Certification and to improve patient care.”

Co-authors with Dr. Hunter on Scientific Poster P207, “The Most Common Patient Safety Problems in Orthopaedic Surgery of the Foot and Ankle,” are Joshua Olsen, MD; Christopher W. DiGiovanni, MD; Jeffrey Anglen, MD, FACS; and Judith F. Baumhauer, MD, MPH.

Disclosures: Dr. DiGiovanni—BioMimetic Extremity Medical, CuraMedix, Performance Orthotics, Saunders Elsevier, Foot and Ankle International, Techniques in Foot and Ankle Surgery (European), Journal of Foot and Ankle Surgery; Dr. Anglen—Journal of the AAOS, ABOS, American College of Surgeons; Dr. Baumhauer—DJ Orthopaedics, Carticept Medical, BioMimetic Therapeutics, Foot and Ankle International, Techniques in Foot and Ankle Surgery, Clinical Orthopaedics and Related Research, American Orthopaedic Foot and Ankle Society, Orthopaedic Research and Education Foundation, Orthopaedic Education Foundation, ABOS, American Board of Medical Specialties. Drs. Hunter and Olsen report no conflicts.