Clinical Orthopaedics
Clin Orthop Relat Res
DOI 10.1007/s11999-014-3733-4
CLINICAL RESEARCH
What are the Patterns of Prophylactic Postoperative Oral
Antibiotic Use After Foot and Ankle Surgery?
David J. Ruta MD, Anish R. Kadakia MD,
Todd A. Irwin MD
Received: 16 January 2014 / Accepted: 2 June 2014
Ó The Association of Bone and Joint Surgeons1 2014
Abstract
Background The CDC estimates 23% of healthcare-
associated infections to be surgical site infections, with
alarming prevalence of antibiotic-resistant organisms.
While there is consensus regarding preoperative prophy-
laxis, orthopaedic surgeons’ use of prophylactic
postoperative oral antibiotics is less defined.
Each author certifies that he or she, or a member of his or her
immediate family, has no commercial associations (eg, consultancies,
stock ownership, equity interest, patent/licensing arrangements, etc)
that might pose a conflict of interest in connection with the submitted
article.
All ICMJE Conflict of Interest Forms for authors and Clinical
Orthopaedics and Related Research1 editors and board members are
on file with the publication and can be viewed on request.
Clinical Orthopaedics and Related Research1 neither advocates nor
endorses the use of any treatment, drug, or device. Readers are
encouraged to always seek additional information, including FDA
approval status, of any drug or device before clinical use.
Each author certifies that the institution at which this work was
performed approved or waived approval for the human protocol for
this investigation, that all investigations were conducted in
conformity with ethical principles of research, and that informed
consent for participation in the study was obtained.
This work was performed at the University of Michigan Health
Systems in Ann Arbor, MI, USA.
D. J. Ruta, T. A. Irwin (&)
Division of Foot and Ankle Surgery, Department of Orthopaedic
Surgery, University of Michigan Health Systems, 2098 South
Main Street, Ann Arbor, MI 48103, USA
e-mail: tirwin@med.umich.edu
A. R. Kadakia
Division of Foot and Ankle Surgery, Department of Orthopaedic
Surgery, Northwestern Memorial Hospital, Chicago, IL, USA
and Related Research®
A Publication of The Association of Bone and Joint Surgeons®
Questions/purposes We investigated surgeons’ use of pro-
phylactic postoperative oral antibiotics after elective
outpatient foot or ankle procedures, identifying (1) frequency
of use, (2) regimen preferences, (3) personal indications, and
(4) associated experience and demographics.
Methods Using a cross-sectional survey design, a ques-
tionnaire was emailed to all active and candidate members
of the American Orthopaedic Foot and Ankle Society.
Supplementary questions captured demographic informa-
tion. We invited 1136 members to participate; 22 addresses
produced delivery failure messages, leaving 1114 members
as potential participants. After nonresponses and exclu-
sions, 312 (28%) responses were analyzed. Statistical
analysis used Pearson’s chi-square test, Fisher’s exact test,
and multivariate regression.
Results The majority (75%) of respondents reported use
of prophylactic postoperative oral antibiotics. Most users
(69%) prescribed to fewer than 25% of patients, although
16% prescribed for all elective cases. The most frequent
regimen was cephalexin 500 mg four times a day (63%)
and the most common duration was 5 to 7 days (50%).
Surgeons’ most common indications were previous infec-
tion (71%), medical comorbidities (65%), and previous
wound-healing difficulties (56%). Those who do and do not
prescribe prophylactic postoperative oral antibiotics
showed no difference in surgical site infection rate or any
demographic category.
Conclusions Surgeons’ reported use of prophylactic
postoperative oral antibiotics after elective foot or ankle
surgery was common, without demographic association.
Commonalities were identified in antibiotic regimen and
personal indications for this practice. Comparative clinical
studies are warranted to elucidate the efficacy of prophy-
lactic postoperative oral antibiotics and establish evidence-
based guidelines for their use.
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 Ruta et al.
Introduction
The risk of surgical site infection after orthopaedic surgery
remains a challenging issue [52, 57], often with greater
concern after foot and ankle surgery than at other sites
[29, 34, 47, 48, 58, 59, 61, 64]. Infection reportedly com-
plicates from 0.5% to 6.5% [66] of most clean orthopaedic
surgeries, although a much greater risk is found in the
population with neuropathic diabetes after foot and ankle
surgery [64]. The effects of surgical site infections can
range from minor to catastrophic in severity [2, 64]. Var-
ious preventive measures have been outlined by the
National Surgical Infection Prevention Project [10], the
Surgical Care Improvement Project [54], the American
Academy of Orthopaedic Surgeons Patient Safety Com-
mittee [2], and elsewhere [3, 52].
Investigation to decrease infectious risk in foot and
ankle surgery has been largely preoperative, including
preoperative risk stratification [17, 21, 59, 64] and evalu-
ation of antiseptic skin preparations [7, 12, 30, 47, 48]. An
additional measure taken by some foot and ankle surgeons
is planned use of a brief course of prophylactic postoper-
ative oral antibiotics after elective outpatient procedures.
Gaining insight into this practice is valuable. Judicious
use of antibiotics is recommended given the association
between increased use and the development of antibiotic-
resistant organisms [3, 46, 53], which are increasingly
prevalent [21, 52, 53]. Therefore, we investigated sur-
geons’ use of prophylactic postoperative oral antibiotics
after elective outpatient foot or ankle procedures, identi-
fying the (1) frequency of prescription, (2) regimen
preference, (3) indications, and (4) associated surgeon
experience, demographics, and reported surgical site
infections.
Materials and Methods
The study design was reviewed and granted exemption by
our institutional review board. A survey comprised of
17 questions was designed based on recommendations for
perioperative prophylactic antibiotic use in the orthopaedic
surgery literature [2, 52] (Appendix 1). Questions specific
to postoperative oral prophylaxis included frequency of
prescription, preferred regimen, duration, and personal
indications. The instructions indicated that the patient
population in question was that undergoing elective, out-
patient procedures on the foot and/or ankle. Furthermore,
the questions pertained only to antibiotics used postopera-
tively and for prophylaxis (as opposed to treatment for a
known infection). Supplementary questions were included
to collect additional demographic information. To encour-
age participation, questions were brief and worded clearly.
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Clinical Orthopaedics and Related Research1
Between December 2011 and February 2012, two emails
were sent from a secure account established for this survey
to the published addresses of all 1136 active and candidate
American Orthopaedic Foot and Ankle Society (AOFAS)
members. Twenty-two addresses produced delivery failure
messages, leaving 1114 members as potential participants.
The emails contained a link to the survey, housed on the
secured website of an independent, fee-based, online sur-
vey service (SurveyMonkey1; www.surveymonkey.com).
Included with the survey were a confidentiality statement
and an explanation of research. Completion of the ques-
tionnaire implied informed consent. Participants’ responses
were automatically deidentified and compiled by the online
service. A manual review of all deidentified surveys was
performed for analysis of free responses and to determine
question-specific response rates, given partially answered
surveys. Criteria for exclusion from analysis included
answer sets that clearly indicated reference to preoperative
antibiotic prophylaxis or inpatient procedures, or those that
were largely incomplete. Examples of excluded answers
included dosing specified as ‘‘intravenous piggy-back
within one hour of incision’’ or ‘‘x2 doses given while
admitted.’’ Response sets only indicating ‘‘Yes’’ or ‘‘No’’
to whether postoperative prophylactic antibiotics were ever
used by the participant, without any other question
answered, also were excluded given concern for potentially
unreliable information. Otherwise, all responses were
included in the analysis.
Three-hundred eighty members initiated the survey, a
response rate of 34%. Sixty-eight response sets were
excluded; 53 were deemed too incomplete for analysis, and
15 participants misunderstood the questions as referring to
preoperative prophylaxis or inpatient procedures. This left
312 (28%) responses for analysis.
Surgeons’ responses were reported using descriptive
statistics and figures created to summarize the findings.
Results were analyzed with Pearson’s chi-square test and
Fisher’s exact test. Significance was defined as probability
less than 0.05, for a 95% alpha level. Multivariate logistic
regression was used to analyze the effect of multiple payer
sources on antibiotic use. Collinearity among the various
payer sources was evaluated by correlation to ensure there
was no potential confounder. SPSS1 software (Version 18;
SPSS Inc, Chicago, IL, USA) was used for analyses.
Results
Two hundred thirty-five (75%) participants reported using
prophylactic postoperative oral antibiotics for at least some
patients, while 77 (25%) members reported never using
them. Of the 235 prescribers, 163 (69%) did so for less than
25% of the specified patient cohort. Thirty-eight (12%)

.
Fig. 1 Approximately 1 2 of the respondents prescribe prophylactic postoperative oral antibiotics after elective outpatient procedures on the foot
and/or ankle, typically for fewer than 25% of their patients. The pie chart is divided into the options listed in the questionnaire.
Fig. 2 Cephalexin 500 mg four times a day was the most frequently
used first-line prophylactic postoperative oral antibiotic. Trimetho-
prim/sulfamethoxazole was not an option included in the
reported routine use for all elective outpatient cases
(Fig. 1).
The most common antibiotic regimen was cephalexin
500 mg four times per day (146 of 233; 63%). This was
followed by cephalexin 500 mg three times per day (42 of
233; 18%). Ten responders (4.3%) selected clindamycin
and 14 (6.0%) wrote in trimethoprim/sulfamethoxazole as
their first-line choices (Fig. 2). Fifty percent (115 of 229)
prescribed their chosen regimen for 5 to 7 days postoper-
atively. Most remaining respondents prescribed for 2 to
4 days (52 of 229; 23%) or a single day (46 of 229; 20%).
Only 16 (7.0%) prescribed for more than 7 days.
All participants who selectively prescribed identified
their personal indications. Those reporting routine (100%)
use were not included in this subset analysis, as their
routine use suggests that they were not prescribing based
on identification of any specific indication(s). The most
Prophylactic Postoperative Oral Antibiotics
questionnaire, although it was written as a free response by some
participants. QID = four times per day; TID = three times per day;
TMP/SMX = trimethoprim/sulfamethoxazole.
common indications were history of infection (139 of 197;
71%), the patient’s medical comorbidities (129 of 197;
66%), and a history of difficulty with wound healing
(111 of 197; 56%). Other less common responses were
prolonged procedure duration (66 of 197; 34%), placement
of hardware (50 of 197; 25%), and multiple procedures
performed (39 of 197; 20%) (Fig. 3).
Respondents were asked to estimate the percentage of
patients given antibiotics at the first postoperative visit for
suspicion or diagnosis of a surgical site infection. A low
rate of surgical site infections was reported overall, with
87% (264 of 305) indicating fewer than 5% of patients with
infection on their first return visit. There was no difference
in reported rates of surgical site infections at the first
postoperative visit between participants who did and did
not prescribe prophylactic antibiotics. Eighty-five percent
(196 of 230) of prescribers indicated a surgical site
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 Ruta et al.
Fig. 3 Of respondents who prescribe prophylactic postoperative oral
antibiotics on a selective basis, the most commonly reported
indications were history of infection, the patient’s medical
infection rate less than 5% versus 91% of nonprescribers
(68 of 75) (relative risk = 0.93; 95% CI, 0.205–1.264;
p = 0.131). In comparing those who prescribed for all
elective outpatient cases and those who never prescribed
prophylactically, 87% (33 of 38) of prescribers reported a
surgical site infection rate less than 5% versus 91% of
nonprescribers (68 of 75) (relative risk = 0.96; 95% CI,
0166–2.048; p = 0.639). Comparing demographics
between respondents who did and did not prescribe pro-
phylactic postoperative antibiotics, no differences were
found in any analyzed category (Table 1).
Discussion
Although many studies support the benefit of preoperative
antibiotic prophylaxis for orthopaedic procedures [2, 9, 14,
24, 26, 46, 51, 52], few well-controlled studies have
examined their effects exclusively in foot and ankle sur-
gery, with several reporting a lack of efficacy. Zgonis et al.
[66] reviewed a series of elective, primary, nontraumatic,
outpatient surgeries on the foot or ankle and found no
significant difference in surgical site infection rates
between the 306 patients who received preoperative anti-
microbial prophylaxis (1.6%) and the 249 who did not
(1.4%). Paiement et al. [50] also found no significant dif-
ference in the rate of infection between patients who did
and did not receive preoperative prophylaxis in their pro-
spective, double-blind, randomized, placebo-controlled
series of 122 closed ankle fractures. Authors of both of
these analyses note that their studies were underpowered.
Use of prophylactic postoperative oral antibiotics is even
less defined. In the orthopaedic literature, there has been
greater concern for surgical site infections after foot and
ankle surgery than in other disciplines [29, 34, 47, 48, 58,
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Clinical Orthopaedics and Related Research1
comorbidities, and a history of difficulty with wound healing.
Respondents indicating routine use after all of their procedures were
not included in this analysis.
59, 61, 64], and many foot and ankle surgeries are per-
formed in an outpatient setting, precluding postoperative
intravenous prophylactic antibiotics while admitted. As
such, many surgeons elect to prescribe prophylactic post-
operative oral antibiotics. We investigated the current
practice to gain insight into frequency of prescription,
regimen preference, indications, and associated surgeon
experience and demographics.
Limitations of our study include collection of self-
reported data from a voluntary survey. Potential biases
inherent to this method include selection bias and nonre-
sponder bias. Participants were selected based on
membership in AOFAS, and we do not know the practices
of those who declined participation. After exclusions, our
response rate of 28% suggests that our data be interpreted
with caution. Self-administered surveys of orthopaedic
surgeons are a common technique to initially investigate an
issue and gauge surgeons’ practices [4–6, 18, 20, 22, 25,
27, 31, 33, 35, 37, 42, 44, 55, 56, 62]. The goal is to reflect
the current conceptualization of a controversial or debated
practice and the associated management strategies. The
initial survey often confirms a need for future randomized
studies, with the goal of practice standardization. Response
rates vary widely in orthopaedic questionnaire studies and
range from 15% to 72.7% for online surveys [4, 5, 18, 20,
25, 31, 35, 37, 55, 56]. While this method is valuable in
reaching a large population, relatively low response rates
similar to ours are common in the orthopaedic literature in
general [5, 18, 25, 31, 37, 56] and specifically in the same
population polled in our study [25, 31]. Our study design of
strict responder anonymity precluded sampling the nonre-
sponders to evaluate for nonresponder bias. We recognize
that nonresponder bias requires that the unobserved
respondents be different from participants. We believe that
participation of surgeons from all nine regions in the
 Prophylactic Postoperative Oral Antibiotics

Table 1. Selected demographic data of survey participants

Variable Response (number of respondents) Percentage of respondents p value
Prescribe Do not prescribe

Weekly caseload 304 of 312 (97%) 0.934

B5 22 24
6–10 55 55
11–15 18 16
[ 15 6 5
Fellowship in foot and ankle 304 of 312 (97%)
Yes 87 88 0.805
No 13 12
Time since fellowship 265 of 265 (100%) 0.236
B 5 years 25 30
6–10 years 16 23
[ 10 years 59 47
Rate of surgical site infection at 1st postoperative visit 305 of 312 (98%) 0.131
\ 5% 85 91
5%–10% 13 8
11%–20% 1 0
21%–40% 0 0
[ 40% 0 1
Practice setting 304 of 312 (97%) 0.067
Private–solo 7 4
Private–orthopaedic group 62 53
Private–multispecialty 9 13
Academic 21 21
Military 1 1
Public (nonmilitary) 1 7
Payer sources 309 of 312 (99%)
Private (self or insurance) 218 72 28 0.213
HMO/capitation 69 83 17 0.204
HMO/PPO/IPA (discounted fee for service) 168 79 21 0.150
Medicare 239 74 26 0.541
Medicaid 117 71 29 0.252
Workers’ compensation 173 74 26 0.766
Charity or pro bono 50 74 26 0.629
All data are self-reported; comparing between respondents who did and did not prescribe prophylactic postoperative oral antibiotics, no
difference was found in any analyzed demographic; HMO = health maintenance organization; PPO = preferred provider organization;
IPA = independent practice association.

United States and varied orthopaedic practice settings
provided a diverse population from which our data were
collected. Finding no associations between the collected
demographics and the practice and experience of prophy-
lactic postoperative oral antibiotics suggests a sense of
uniformity throughout these various environments. There is
also potential for recall bias regarding prescribing practices
and queried surgical site infection rate. As above, 18% of
initiated surveys were excluded for incompleteness or
answers indicative of preoperative prophylaxis, inpatient
surgery, or both. We attempted to prevent this with precise
wording regarding the intended cohort. Last, as 23% of
respondents reported a weekly schedule of greater than
10 foot and ankle surgeries, our data potentially are skewed
toward a less-busy group. However, it is unclear if this
surgical volume is representative of national average
caseloads for foot and ankle orthopaedic surgeons and
therefore is a potential limitation.
Our findings suggest that use of prophylactic postoper-
ative oral antibiotics is common, as 75% of respondents

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 Ruta et al.
reported prescribing for at least certain patients. Although
the majority prescribed for fewer than 25% of patients,
38 surgeons (12% of total participants) prescribed for all
patients. The use of prophylactic postoperative oral anti-
biotics after elective outpatient procedures has been
investigated in other surgical fields, especially plastic sur-
gery, with mixed conclusions regarding their efficacy and a
call for further evaluation of the practice [1, 15, 41].
Most surgeons preferred cephalexin 500 mg four times a
day, and the duration most commonly was 5 to 7 days.
Staphylococcus species is the most commonly isolated
organism in postoperative infections in patients having
general orthopaedic and foot and ankle surgery [3, 13, 21,
39, 46, 47, 52, 58, 61, 65]. This is consistent with the
recommendation for a first-generation cephalosporin as
preoperative prophylaxis for patients having orthopaedic
procedures [2, 3, 10, 52, 54], and our participants’
preferred cephalexin as their first-line prophylactic post-
operative oral antibiotic.
Respondents’ most common indications for prescribing
prophylactic postoperative oral antibiotics include the
patient’s medical comorbidities and a history of poor
wound healing, which are associated with increased risk of
surgical site infections. Wukich et al. [64] retrospectively
reviewed 1000 patients after foot and ankle procedures,
finding a significantly greater percentage of infections in
patients with diabetes (13.2% versus 2.8%), also with more
severe infections in patients with diabetes. Peripheral
neuropathy was the strongest predictor of infection [64].
Costigan et al. [17] reported infection in 83% of patients
with diabetes lacking preoperative pedal pulses and 92%
with peripheral neuropathy after surgical treatment for
ankle fractures. Numerous studies have supported associ-
ations with increased wound complications and surgical
site infections in patients with complicated diabetes,
peripheral vascular disease, and wound compromising
medications [8, 16, 23, 36, 43, 44, 59]. Other comorbidities
associated with increased risk of postoperative infection
include obesity, malnutrition, tobacco use, and immuno-
suppressive medication [11, 21, 43, 45]. Another potential
cause for greater concern for surgical site infections after
foot and ankle surgery is the persistent colonization of the
forefoot despite preoperative preparation [7, 12, 30, 47, 48,
63, 65]. Ostrander et al. [47] reported positive cultures after
application of surgical preparation solution in 125 patients,
ranging from 23% to 98% from the hallux nailfold and
second and third web spaces, compared with 10% to 35%
from the anterior tibia control. Multiple studies have
reported postpreparation forefoot cultures ranging from 0%
to 84%, most reporting greater than 50% [7, 12, 28, 30, 48,
63, 65]. Studies also have shown intraoperative forefoot
recolonization [12, 63, 65]. Interestingly, despite the
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Clinical Orthopaedics and Related Research1
reported increased surgical site infection rates, only 11% of
respondents reported an indication for prophylactic post-
operative oral antibiotics to be the forefoot as surgical site.
Early literature cited osteosynthesis as a risk factor for
surgical site infections [40, 60], although Jones et al. [32]
reported no difference in surgical site infections between
closed treatment and surgical fixation in 42 patients with
diabetes with closed ankle fractures. With modern opera-
tive technique, environment, and perioperative antibiotic
prophylaxis, the association between infection and ortho-
paedic implants has decreased [13]. Some authors reported
patient age to be an independent predictor for surgical site
infections [43, 45, 59]. Wukich et al. [64] did not find this
association in 1000 patients undergoing foot and ankle
procedures, nor have other studies [17, 23, 32, 36, 38, 49].
Consistent with the literature, age and hardware placement
were infrequent indications for use of prophylactic post-
operative oral antibiotics from our participants [13, 17, 23,
32, 36, 38, 49, 64].
There were no differences in the reported surgical site
infection rates between respondents who do and do not
prescribe prophylactic postoperative oral antibiotics,
regardless of regimen duration, although we acknowledge
that this study was not powered for prophylaxis efficacy.
Although there is potential for bias in this self-reported
outcome, it may question the efficacy of antibiotic use for
this purpose. Multiple studies showing a lack of benefit in
continuing prophylactic antibiotics beyond 24 hours, with
an increased threat of resistant bacterial strains, have
influenced surgical guidelines to recommend against
duration beyond that time [2, 3, 10, 19, 52, 54].
Routine use of prophylactic postoperative oral antibi-
otics after outpatient foot and ankle surgery is common
among responding members of the AOFAS. Surgeons’
preferred antibiotic regimens and indications showed some
uniformity and influence from the orthopaedic literature.
The most commonly reported indications suggest that the
impetus for prescription is the patient’s history and overall
health more than surgical site or intraoperative factors. Our
results may have implications in orthopaedic surgery,
infectious disease, and general medicine, given increasing
reports of antibiotic-resistant microbial strains and
emphasis on judicious antimicrobial use. Comparative
clinical studies are warranted to elucidate the efficacy of
prophylactic postoperative oral antibiotics and establish
evidence-based guidelines for this practice.
Acknowledgments We thank Thomas Cichonski BS, Department
of Orthopaedic Surgery, University of Michigan, for assistance in
preparing and editing this manuscript and Joel J. Gagnier ND, MSc,
PhD, Departments of Orthopaedic Surgery and Epidemiology, Uni-
versity of Michigan, for assistance with statistical analyses and
interpretation.

Appendix 1
Questionnaire administered to American Orthopaedic Foot
& Ankle Society (AOFAS) member participants.
The actual survey was accessed through an electronic
link embedded in an email sent to all members.
1) Do you ever prescribe prophylactic postoperative
antibiotics for patients undergoing elective outpatient
procedures on the foot and/or ankle?
h No
h Yes?
1a) What is the estimated percentage of this cohort
of patients to whom you prescribe postopera-
tive prophylactic antibiotics?
h \ 25%
h 25–50%
h 51–99%
h 100%
1b) If fewer than 100%, how do you determine
who receives postoperative prophylactic anti-
biotics? (please mark all that apply)
h Procedure only involves soft tissue
h Procedure includes any work
involving bone
h Procedure involves the placement
of hardware
h Multiple procedures are per-
formed at once
h Operative site involves forefoot
h Operative site involves hindfoot/
ankle
h Procedure was performed without
preoperative parenteral antibiotics
h Parenteral antibiotics were admin-
istered at the time of surgery but not
started until after incision was made
h Parenteral antibiotics were
administered preoperatively but with
[ 60 minutes between completed
administration and incision
h Prolonged duration of procedure
h Extremity tourniquet was used
h Extremity tourniquet was used
but with \ 10 minutes between
completed antibiotic administration
and tourniquet inflation
h Patient age [ 50 years old
h Patient age [ 75 years old
h History of previous infection in
the patient
Prophylactic Postoperative Oral Antibiotics
h History of wound healing diffi-
culties in the patient
h Medical comorbidities of the
patient (including diabetes, obes-
ity, systemic corticosteroid use,
peripheral arterial disease, smok-
ing, etc)
h Other: ___________________
1c) Which is your first line antibiotic for prophylaxis?
h Cephalexin (Keflex) 250 mg TID
h Cephalexin (Keflex) 250 mg QID
h Cephalexin (Keflex) 500 mg TID
h Cephalexin (Keflex) 500 mg QID
h Penicillin or cephalosporin other
than as shown above (please specify
name and dose): ____________
h Clindamycin (Cleocin) 300 mg
TID
h Clindamycin (Cleocin) 600 mg
TID
h Other (please specify name and
dose): _____________
1d) Which antibiotic do you prescribe if the patient
has a reported allergy to your first line
prophylactic antibiotic? (please specify name
and dose) _____________
1e) Which antibiotic do you prescribe if the patient
has a reported allergy to your first and second
line antibiotics? (please specify name and
dose)________
1f) Prophylactic antibiotics are prescribed for what
duration postoperatively?
h 1 day
h 2–4 days
h 5–7 days
h [ 7 days
2) What would you estimate to be the number of
elective outpatient foot and/or ankle procedures you
perform on a weekly basis?
hB5
h 6–10
h 11–15
h [ 15
3) On average, how soon following surgery is a
patient’s first postoperative visit?
h \ 5 days
h 5–7 days
h 8–14 days
h [ 14 days
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 Ruta et al.
4) Who typically sees the patient for their first postop-
erative visit?
h You (surgeon)
h Resident or fellow
h Midlevel provider (Physician’s Assistant, Nurse
Practitioner, etc)
5) What estimated percentage of patients is prescribed
oral antibiotics at the first postoperative visit (due to
suspected superficial or deep infection, including
those who require surgical intervention to address the
infection)?
h \ 5%
h 5–10%
h 11–20%
h 21–40%
h [ 40%
6) Have you completed a fellowship in foot and ankle
surgery at any point in your training?
h No
h Yes?
6a) How long has it been since the completion of
your fellowship in foot and ankle surgery?
h B 5 years
h 6–10 years
h [ 10 years
7) In which US region is your practice located?
h New England: Connecticut, Maine, Massachu-
setts, New Hampshire, Rhode Island, Vermont
h Mid-Atlantic: New Jersey, New York,
Pennsylvania
h East North Central: Illinois, Indiana, Michigan,
Ohio, Wisconsin
h West North Central: Iowa, Kansas, Minnesota,
Missouri, Nebraska, North Dakota, South Dakota
h South Atlantic: Delaware, District of Columbia,
Florida, Georgia, Maryland, North Carolina, South
Carolina, Virginia, West Virginia
h East South Central: Alabama, Kentucky, Mis-
sissippi, Tennessee
h West South Central: Arkansas, Louisiana,
Oklahoma, Texas
h Mountain: Arizona, Colorado, Idaho, Montana,
Nevada, New Mexico, Utah, Wyoming
h Pacific: Alaska, California, Hawaii, Oregon,
Washington
8) Which of the following best describes your practice?
h Private practice – solo
h Private practice – orthopaedic group
h Private practice – multispecialty group
h Academic practice
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Clinical Orthopaedics and Related Research1
h Military practice
h Public institution (nonmilitary)
9) Does your practice include Doctors of Podiatric
Medicine (DPMs)?
h Yes
h No
10) Which of the following best describe(s) the payer
source(s) for your practice (please mark only those
that contribute a substantial portion)?
h Private payer (self or insurance)
h HMO/Capitation
h HMO/PPO/IPA (discounted fee for service)
h Medicare
h Medicaid
h Workers’ Compensation
h Charity or Pro Bono
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