Stephen Pinney

Followers

Following

Co-author

Public Views

Interests

Uploads

Papers by Stephen Pinney

Results of a Survey of the Use of Sciatic Nerve Blocks Amongst Foot and Ankle Surgeons in North America and the Uk

Orthopaedic Proceedings, Mar 1, 2010

Introduction: Sciatic nerve blocks have been used to reduce post-operative analgesia and allow ea... more Introduction: Sciatic nerve blocks have been used to reduce post-operative analgesia and allow early discharge for patients undergoing foot and ankle surgery. This study aims to identify utilisation of this procedure and to ascertain if there is a consensus amongst surgeons as to best practise with regards to who performs the block and how it is performed. Method: We surveyed current committee members of the American and members of the British orthopaedic foot and ankle surgery societies (AOFAS and BOFAS). Results: More than half of those who responded perform over 90% foot and ankle surgery. 77% performed sciatic nerve blockade through the popliteal approach (26% used the subgluteal approach). The most common position was supine with 80% being performed by the anaesthetist. 45% never used ultrasonography to detect the position of the nerve and variable levels of nerve stimulation were used. 30% used an infusion catheter with 20% allowing discharge to home with the catheter. 42% of surgeons where happy to have the block performed under full anaesthesia. The commonest complication cited was prolonged anaesthesia, the majority of which resolved. Performing the block awake or sedated did not seem to alter the number of complications seen. Discussion: This study represents a current practice review of sciatic nerve blocks performed in foot and ankle surgery and shows a variety of techniques used. Although this is now a widely used block, no consensus has been reached as to the use of ultrasound, level of nerve stimulation or whether the patient needs to be awake for the procedure. The use of infusion catheters (especially after discharge) has not been widely utilised, especially amongst UK surgeons.

Education to Teaching Orthopaedic Residents Orthopaedic Surgeons as Educators. Applying the Principles of Adult

Download

Educación para los estudiantes de medicina acerca de los problemas musculoesqueléticos

The Journal of Bone and Joint Surgery-American Volume, 2001

The influence of concomitant hammertoe correction on postoperative outcomes in patients undergoing hallux valgus correction

Foot and Ankle Surgery, Oct 1, 2022

Category: Bunion; Lesser Toes Introduction/Purpose: Patients with hallux valgus often develop sec... more Category: Bunion; Lesser Toes Introduction/Purpose: Patients with hallux valgus often develop secondary hammertoe deformities of the lesser toes. Chronic lateral deviation of the hallux leads to proximal interphalangeal joint flexion contracture, metatarsophalangeal joint subluxation and ultimately a cross-toe deformity. Operative management of bunions with hammertoe is more extensive since both the primary bunion deformity and the secondary defect have to be corrected simultaneously; however, it is unclear whether simultaneous bunion and hammertoe correction affects patient outcomes. The objective of this study was to compare postoperative patient reported outcomes using the patient-reported outcome measure information system (PROMIS) scores and radiographic outcomes between patients who underwent isolated bunion deformity correction and patients who underwent operative repair of hallux valgus with concomitant hammertoe correction. Methods: This retrospective cohort study included patients over the age of 18 who were treated operatively by 1 of 7 fellowship-trained foot and ankle surgeons for hallux valgus. Those with clinically symptomatic hammertoes were also corrected at the surgeon's discretion. All patients had minimum 1-year postoperative PROMIS scores and minimum 3-month postoperative radiographs. Preoperative, final postoperative and change in PROMIS scores from 6 domains (physical function, pain interference, pain intensity, global physical and mental health, and depression) were compared between the isolated bunion and bunion with hammertoe correction groups. Radiographic measurements compared between cohorts included hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal-articular angle (DMAA), and Meary's angle. Radiographic parameters were measured on anteroposterior (AP) and lateral weightbearing radiographs. Statistical analysis utilized targeted minimum-loss estimation (TMLE) to control for confounders (age, gender, BMI). Results: A total of 221 patients (134 with isolated bunion correction, 87 with concomitant hammertoe correction) with an average of 19.2 months follow-up were included in this study. Demographically, patients in the concomitant hammertoe cohort were older than the isolated bunion group (58.5 vs 53.1, p<0.01) and had a higher BMI (24.8 vs 58.5, p<0.05). Both cohorts demonstrated improvement in all PROMIS domains except for global mental health and depression. The isolated bunion cohort had significantly better improvements in pain interference and pain intensity when compared to the concomitant hammertoe group (p<0.01, p<0.05 respectively) (Table 1). The isolated bunion cohort had lower postoperative pain interference scores (p<.01). Radiographically, the concomitant hammertoe group had a higher preoperative HVA than the isolated bunion group (30 vs 27.6, p<.05). There were no statistically significant differences between the two cohorts in postoperative radiographic parameters, in addition to the probability of achieving normal postoperative radiographic measures. Conclusion: Patients undergoing simultaneous bunion and hammertoe correction experienced worse postoperative outcomes measured by PROMIS pain interference, had significantly less improvement in PROMIS pain interference and pain intensity scores, and had more severe preoperative radiographic deformity when compared to those who underwent isolated bunion correction. The relationship between hallux valgus and hammertoe development should be considered when counseling patients for surgery. Patients with hallux valgus who show early signs of hammertoe formation such as second toe elevation or pain under the second metatarsal head may benefit from earlier bunion correction before the hammertoe progresses to the point of needing surgical management.

Educating Medical Students About Musculoskeletal Problems

The Journal of Bone and Joint Surgery-American Volume, 2001

Background: Musculoskeletal problems are a common reason why patients present for medical treatme... more Background: Musculoskeletal problems are a common reason why patients present for medical treatment. The purpose of the present study was to review the curricula of Canadian medical schools to determine whether they prepare their students for the demands of practice with respect to musculoskeletal problems. Methods: The amount of time spent on musculoskeletal education at each of Canada's medical schools was reviewed by surveying the directors (or equivalents) of all sixteen undergraduate musculoskeletal programs. With use of data from this survey and the Association of American Medical Colleges' guide to curricula, the percentage of the total curriculum devoted to musculoskeletal education was determined. The prevalence of disorders related to the musculoskeletal system among patients of primary care physicians was determined on an international basis by reviewing the literature and on a local basis by surveying all primary care physicians affiliated with the University of British Columbia's Department of Family Medicine. Results: The curriculum analysis revealed that, on the average, medical schools in Canada devoted 2.26% (range, 0.61% to 4.81%) of their curriculum time to musculoskeletal education. The questionnaires completed by the directors of the undergraduate programs indicated widespread dissatisfaction with the musculoskeletal education process and, specifically, with the amount of time devoted to musculoskeletal education. Our literature review and survey of local family physicians revealed that between 13.7% and 27.8% of North American patients presenting to a primary care physician have a chief symptom that is directly related to the musculoskeletal system. Conclusion: There is a marked discrepancy between the musculoskeletal knowledge and skill requirements of a primary care physician and the time devoted to musculoskeletal education in Canadian medical schools.

Download

A Step-by-Step Guide to Understanding and Conducting Quality Improvement Initiatives in Orthopaedic Surgery

Journal of the Pediatric Orthopaedic Society of North America, Feb 23, 2023

Numerous frameworks have been developed as methods to address complex quality improvement (QI) pr... more Numerous frameworks have been developed as methods to address complex quality improvement (QI) problems. We aim to provide orthopaedic surgeons with a foundational understanding of QI in order to facilitate their engagement in QI initiatives. We begin by providing a broad overview of QI terms and frameworks and then present a step-bystep guide for conducting QI initiatives using a popular, intuitive, and practical method: Lean (A3). We accompany our descriptions with links to publicly accessible short QI videos developed by the Stanford Medicine Center for Improvement. Additionally, we list key educational resources offered by the American Academy of Orthopaedic Surgeons (AAOS) and the Pediatric Orthopaedic Society of North America (POSNA) as well as provide information on a recently published textbook devoted to QI and patient safety in orthopaedic surgery.

Download

Current Concept Review: Risk Factors for Infection Following Open Fractures

Orthopedic Research and Reviews

Infection following open fracture is a significant source of morbidity and mortality. Therefore, ... more Infection following open fracture is a significant source of morbidity and mortality. Therefore, a central tenet of treatment is to minimize the risk of infection. The initial risk of infection is determined by wound characteristics, such as size, soft tissue coverage, vascular injury, and contamination. While no consensus exists on optimal antibiotic regimen, early administration of prophylactic antibiotics, within an hour of injury, when possible, has been shown definitively to decrease the risk of infection. Infection risk is further reduced by early irrigation with normal saline and aggressive debridement of devitalized tissue. Patient factors that increase risk of infection following open fracture include diabetes mellitus, smoking, male gender, and lower extremity fracture.

Download

Surgical Treatment of Severe Hallux Valgus: The State of Practice among Academic Foot and Ankle Surgeons

Foot & Ankle International, 2006

Background: The purpose of this study was to evaluate the operative procedures used for treatment... more Background: The purpose of this study was to evaluate the operative procedures used for treatment of severe hallux valgus by academic foot and ankle surgeons practicing in the United States. Methods: A patient with severe hallux valgus deformity was developed as a hypothetical case: a 50-year-old woman with a severe deformity (intermetatarsal angle = 20 degrees; hallux valgus angle = 42 degrees). The patient was symptomatic with pain, did not improve with conservative measures, and wanted the deformity corrected. This case was sent to academic foot and ankle surgeons in a survey to determine their preferred operative treatment for this case. The overall response rate was 84% (128 of 153). To be included in the study group each surgeon had to have 1) foot and ankle patients comprising 50% or more of his clinical practice and 2) direct responsibility for teaching orthopaedic residents. One hundred and five respondents met the inclusion criteria and formed the study group; however, thr...

Surgical Treatment of Acquired Flatfoot Deformity: What is the State of Practice among Academic Foot and Ankle Surgeons in 2002?

Foot & Ankle International, 2003

Purpose:This study was performed to review the present approach to the surgical treatment of acqu... more Purpose:This study was performed to review the present approach to the surgical treatment of acquired flatfoot deformity among a cross section of academic foot and ankle surgeons in the United States.Methods:A typical case of stage II posterior tibial tendon dysfunction was developed. The hypothetical patient was a healthy 62-year-old male with a symptomatic acquired flatfoot deformity with posterior tibial tendon dysfunction. Nonoperative management had failed. A series of academic foot ankle surgeons were surveyed to identify their proposed operative treatment. Each surgeon surveyed was affiliated with an orthopaedic residency program and was directly responsible for teaching orthopaedic residents. Each surgeon had foot and ankle patients as the major component of their practice. The overall response rate was 81% (104/128).Results:Ninety-seven percent (101/104) of respondents reported that they would employ some type of bony procedure in their surgical treatment. Eighty-eight perc...

Strayer procedure (gastrocnemius recession)

Operative Techniques in Orthopaedics, 2004

The Strayer procedure is a treatment option for clinically relevant gastrocnemius equinus contrac... more The Strayer procedure is a treatment option for clinically relevant gastrocnemius equinus contracture. A posteromedial surgical approach is described. Identifying and protecting the sural nerve is an important component of the procedure. Accurately localizing the starting point and performing a meticulous closure will improve cosmesis.

Gastrocnemius Recession

Techniques in Foot & Ankle Surgery, 2003

Gastrocnemius equinus contracture is associated with the development of a variety of chronic prob... more Gastrocnemius equinus contracture is associated with the development of a variety of chronic problems of the foot and ankle, including plantar fasciitis, hallux valgus, symptomatic adult acquired flatfoot, metatarsalgia, diabetic forefoot ulcers, and synovitis of the metatarsophalangeal joints. Gastrocnemius recession has become an important component in the treatment of such problems aggravated or precipitated by a clinically evident gastrocnemius equinus contracture. With proper attention to surgical technique and a good postoperative program to allow the lengthened tendon to be maintained during the healing phase, the Strayer technique can produce excellent results with minimal complications.

Surgery in Rural Canada: Challenges and Possible Solutions

Rural Surgery, 2011

The provision of timely and quality surgical services is a persistent challenge in rural Canada. ... more The provision of timely and quality surgical services is a persistent challenge in rural Canada. Factors undermining the provision of surgical care in rural Canada include: an overall shortage of general surgeons; residency training programs that have relatively few role models for promoting the virtues of a rural practice; persistent difficulties in recruiting and retaining surgeons in rural communities; and limited resources for establishing and maintaining a coordinated surgical service. However, with these challenges come opportunities to develop creative solutions and the Canadian Health Care system in many ways is well positioned to enact these. Such solutions include better education and role modeling to promote rural surgery as a career choice; incorporation of telemedicine to expand and improve care in rural communities; making systematic organizational changes to improve the delivery of surgical care in rural areas; training GP surgeons to provide a set scope of basic surgical care; and utilizing physician extenders to expand the delivery of surgical services. Educational and health policy initiatives can help to explore these solutions further.

Ethical concerns in caring for elderly patients with cognitive limitations: a capacity-adjusted shared decision-making approach

The Journal of bone and joint surgery. American volume, Jan 4, 2015

Mrs. A is a pleasant seventy-seven-year-old widow with an increasingly symptomatic right knee tha... more Mrs. A is a pleasant seventy-seven-year-old widow with an increasingly symptomatic right knee that has markedly limited her activities in the past year. Mrs. A's daughter, who lives in town, urged her to seek treatment. History, physical examination, and radiographs confirmed the diagnosis of end-stage knee arthritis. Dr. Z, the orthopaedic surgeon, presented total knee arthroplasty as a potential treatment option and provided detailed information on the surgery and recovery. Mrs. A indicated that if Dr. Z thinks that total knee arthroplasty is a good idea, she would agree to have the surgery. She lives alone and goes grocery shopping once a week, but her pain makes such endeavors frustrating for her. Her daughter visits regularly, takes her to medical appointments, and helps her with medications. Mrs. A has returned for a preoperative visit with Dr. Z, and her total knee arthroplasty has been tentatively scheduled for the following month. At this visit, Mrs. A notes that she wa...

Download

Surgical anatomy of the gastrocnemius recession (Strayer procedure)

Foot & ankle international, 2004

The Strayer procedure (gastrocnemius recession) is a treatment option for patients with clinicall... more The Strayer procedure (gastrocnemius recession) is a treatment option for patients with clinically relevant gastrocnemius equinus contracture. The purpose of this study was to review the surgical anatomy of the Strayer procedure with specific reference to 1) the location of the sural nerve, and 2) the gastrocnemius tendon release point. Forty consecutive Strayer procedures in 33 patients (15 males, 18 females) served as the study group. Recorded measurements included: 1) the location of the sural nerve relative to the deep fascia, 2) the distance from the medial border of the gastrocnemius tendon to the sural nerve, and 3) the distance from the distal end of the gastrocnemius muscle belly (identified by surface landmarks) to the actual release site. At the point of the gastrocnemius release, the sural nerve was located superficial to the fascia in 17/40 legs (42.5%) and deep to the fascia in 23/40 legs (57.5%). In five legs (12.5%), the nerve was directly applied to the gastrocnemiu...

Foot and ankle experience in orthopaedic residency

Foot & ankle international, 2003

Dedicated orthopaedic residency training in the musculoskeletal discipline of foot and ankle is a... more Dedicated orthopaedic residency training in the musculoskeletal discipline of foot and ankle is an important contribution to the development of a well-rounded orthopaedic surgeon. Current residency training guidelines are vague and do not require specific experience or proficiency in this discipline. A one-page questionnaire on commitment to foot and ankle education in American Orthopaedic Surgery residency training programs was completed by all 148 program directors. Eighty of the programs (54.1%) had a single faculty member dedicated to foot and ankle orthopaedics, while 21 (14.2%) did not have a faculty member with a specific interest or commitment to problems related to the foot and ankle. Fifteen programs (10.1%) did not have a committed faculty member, nor did their residents have a clinical rotation dedicated to foot and ankle. Ninety-six programs (64.9%) had at least one clinical rotation dedicated to foot and ankle. Fifty-two (35.1%) did not. Thirty-three (34.7%) of those p...

The effect on ankle dorsiflexion of gastrocnemius recession

Foot & ankle international, 2002

Gastrocnemius equinus contracture has been suggested as an etiologic factor in mechanical disease... more Gastrocnemius equinus contracture has been suggested as an etiologic factor in mechanical diseases of the foot and ankle and in ulcer formation in the foot. The purpose of this study is to assess the correction in ankle dorsiflexion that can be achieved with a gastrocnemius recession. An isolated gastrocnemius release (Strayer procedure) was performed on 26 legs, in 20 consecutive patients, for clinically significant gastrocnemius equinus contracture. Ankle dorsiflexion was assessed using a validated electrogoniometer. Ankle dorsiflexion was recorded with the knee straight and with the knee bent. Measurements were recorded preoperatively, and immediately postoperatively. Measurements at an average of 55.0 days postsurgery (range, 37 to 128 days) were performed on 20 legs (15 patients). Average preoperative ankle dorsiflexion with the knee straight was 5.1 degrees. Average preoperative ankle dorsiflexion with the knee bent was 22.8 degrees. Immediately following surgery the average a...

Midfoot Injuries in Athletes: Fundamentals of Examination and Treatment

Operative Techniques in Sports Medicine, 2010

Orthopaedic Resident Education—It’s a Whole New Game<subtitle>“If I’m Going to Be a Spine Surgeon, Why Do I Need to Learn How to Reconstruct an Anterior Cruciate Ligament?”</subtitle><subtitle>AOA Critical Issues</subtitle>

The Journal of Bone and Joint Surgery (American), 2012

The evolving paradigm of orthopaedic resident education is a frequent area of discussion among th... more The evolving paradigm of orthopaedic resident education is a frequent area of discussion among those responsible for resident training. Although the body of knowledge and treatment options for patients with musculoskeletal disease steadily expand, the work-hour restrictions implemented within the past decade limit the actual experiential opportunity for residents. In addition, new expectations, based on the “core competencies”1 in the United States and the “CanMEDS”2 Physician Competency Framework in Canada, have been established for the educator. We appreciate the differences between these two philosophies of resident education but believe extensive common ground exists among the challenges. While attempting to adjust to these requirements, many believe the balance in the missions of the academic orthopaedist has changed. Declining professional fee reimbursement; changing practice models, including the integration of physicians into hospital employment relationships; and an increasing role of midlevel healthcare providers have the potential to de-emphasize our teaching focus and passion. Finally, in addition to orthopaedic knowledge and clinical skills, many differences exist between the educator and orthopaedic resident. Although it would be inappropriate to label any one individual with a collection of attributes related to birth year, sociologists and educators agree that the current generation views the balance between professional and work life differently than do most individuals in a position of senior leadership in academic orthopaedic departments3-6. Technology has become an integral component in the way in which residents learn, and residents often believe that they can use that technology to instantaneously find solutions to unanswered questions. There is also a perception that residents, during their training and on the basis of their fellowship match, begin to view themselves as future specialists who don’t really need to learn the fundamentals of orthopaedics beyond their anticipated area of discipline. Thus, a resident might ask, …

Orthopaedic Surgeons as EducatorsApplying the Principles of Adult Education to Teaching Orthopaedic Residents

The Journal of Bone and Joint Surgery (American), 2007

Download

$Research paper thumbnail of Fat embolism syndrome in isolated femoral fractures: does timing of nailing influence incidence?$

Fat embolism syndrome in isolated femoral fractures: does timing of nailing influence incidence?

Injury, 1998

In a consecutive series of 274 patients with isolated femoral shaft fractures 21 patients (4%) de... more In a consecutive series of 274 patients with isolated femoral shaft fractures 21 patients (4%) developed fat embolism syndrome. There were no cases offnt embolism syndrome in patients over the age of 35 years. Of fhe remaitzing patients, 60 operated on within 10 h of injury did uof dezlelop fat embolism. This left 109 patients who had nailing performed more than 10 h after irijury of whom elezlen (10%) developed fat embolism syndrome (p <0.027). Patients ulzder the age of 35 years with isolated femoral fractures should hazle nailiq performed as early as possible after injury to minimize fat embolism syndrome.

Download

Stephen Pinney

Uploads

Papers by Stephen Pinney

Log In