Improving Perioperative Care in Foot and Ankle Surgery

Doctor giving a patient foot treatment

For over a decade, the Foot and Ankle Service in the Department of Orthopaedic Surgery at Brigham and Women’s Hospital has conducted research that places a strong emphasis on optimizing perioperative care for foot and ankle surgery patients.

“For patients undergoing foot and ankle surgery, the perioperative space can be an important time to optimize care in order to reduce complications and improve outcomes,” says Christopher Chiodo, MD, Chief of the Foot and Ankle Service.

In an ongoing effort to improve perioperative care, faculty in the Foot and Ankle Service have examined—and subsequently changed—protocols specific to opioid prescriptions, weight-bearing compliance, and Vitamin D deficiency screening.

Limiting the use of opioids during foot and ankle surgery

Several years ago, when the opioid epidemic was beginning to surface, Dr. Chiodo worked with the Department of Psychiatry at Brigham and Women’s Hospital to better understand which factors were contributing to the increase in opioid addiction. They found that addiction often stemmed from a legal prescription for opioids.

After presenting these findings at an annual meeting of the American Psychiatric Association, Dr. Chiodo and colleagues at the Foot and Ankle Service changed how they prescribed opioids, resulting in a no-refill policy for most patients who underwent surgery.

“The longer a patient remains on an opioid, the greater the risk of addiction. If we avoid a refill, we help prevent dependency by avoiding long-term exposure to opioids,” says Dr. Chiodo.

To further reduce opioid use, the research team then developed a new evidence-based prescribing protocol that minimizes the amount of opioids patients receive. The statistically-based protocol more accurately prescribes amounts of opioids, thereby reducing amounts prescribed to the patient.

To create the protocol, the investigators studied patients who underwent various foot and ankle procedures, looking at the number of opioids they were safely using to manage their pain. The study was published in the July 2019 issue of Foot & Ankle International (FAI).

In a separate study, the team studied patient disposal methods of excess opioid medications. Instead of instructing patients to leave excess opioids at their local police or fire station, patients were given a commercially available charcoal-based disposal pouch after their operation.

“By measuring compliance, we found that the pouch significantly improved appropriate disposal of postoperative opioids. We now routinely give this pouch to patients following their surgery,” says Dr. Chiodo.

Improving weight-bearing compliance with crutch competence training

Making changes to post-operative opioid protocols is just one example of the Foot and Ankle Service’s efforts to optimize care in the perioperative space.

To continue improving post-operative outcomes, Dr. Chiodo and colleagues have also examined ways to improve weight-bearing compliance by training patients in crutch competence before surgery. Dr. Chiodo was prompted to study weight-bearing compliance after observing that a sizable portion of his patients were returning after surgery with worn-down casts.

Suspecting these patients were walking on their casts, Dr. Chiodo led a study in 51 adult patients with unilateral lower-extremity abnormality who had received non-weight-bearing instructions.

The study measured compliance by applying a pressure-sensitive film to casts. The results showed that 30 percent of these patients weren’t following weight-bearing instructions. The findings appeared in a recent issue of Journal of Bone and Joint Surgery.

“After this study, we spent more time educating patients on the rationale behind non-weight-bearing instructions,” says Dr. Chiodo. “When patients fully grasped that they could jeopardize their outcomes by putting weight on their casts, compliance increased dramatically.”

Seeing these results, his colleague and orthopaedic surgeon Eric M. Bluman, MD, PhD took it a step further, establishing a program at Brigham and Women’s Hospital for foot and ankle surgical patients to learn how to use crutches in physical therapy before their surgery.

“Our preoperative crutch competence training program makes patients more comfortable with crutches after their surgery. Not only are patients more weight-bearing compliant after training, they are more satisfied overall,” says Dr. Chiodo.

Vitamin D linked with decreased bone mineral density

As it turns out, that wouldn’t be the last time Dr. Chiodo and Dr. Bluman partnered to find ways to optimize perioperative care in foot and ankle patients.

Several years ago, they collaborated with their orthopaedic colleague Jeremy T. Smith, MD to examine Vitamin D levels in patients with low energy foot and ankle fractures. After finding a higher rate of Vitamin D deficiency in this population, they began routinely screening these patients in the office setting.

More recently, Dr. Chiodo and Dr. Bluman collaborated again with Dr. Smith, this time to study the impact of Vitamin D deficiency before foot and ankle surgery. In particular, they were looking to identify the prevalence and risk factors for Vitamin D deficiency in patients with osteochondral lesions of the talus (OLT).

Their research, published in Foot & Ankle International, ultimately identified a significantly higher rate of hypovitaminosis D in patients with an osteochondral lesions of the talus compared to a control group of acute ankle sprain patients.

As a result of this research, most patients who undergo foot or ankle fusion or fracture repair surgery at Brigham and Women’s Hospital are proactively screened for low Vitamin D. Those patients with low levels often receive supplementation as part of their perioperative care.

The future of perioperative care

Going forward, Brigham and Women’s Hospital will continue to investigate perioperative optimization for foot and ankle patients, including making sure that insights from their studies reach the clinical setting as soon as possible so that patients can reap the benefits.

“The perioperative space deserves more attention in orthopaedic research. Avoiding negative outcomes in the immediate term can be just as important as improving outcomes in the short or long-term,” says Dr. Chiodo.