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Background: Tobacco use significantly increases the rate of wound complications in patients undergoing total ankle arthroplasty (TAA). Preoperative optimization through smoking cessation programs significantly minimizes the rate of infection and improves wound healing in arthroplasty procedures. Despite its utility, minimal research has examined the cost-effectiveness of preoperative smoking cessation programs to reduce the need for extracapsular irrigation and debridement (I&D) due to wound complications following TAA. Methods: The cost of an I&D procedure was obtained from our institution’s purchasing records. Baseline wound complication rates among tobacco users who have undergone TAA and smoking cessation program cost were obtained from literature. A break-even economic analysis was performed to determine the absolute risk reduction (ARR) to economically justify the implementation of preoperative smoking cessation programs. Different smoking cessation program and I&D costs were tested to account for variations in each factor. ARR was then used to calculate the number needed to treat (NNT) to prevent a single I&D while remaining cost-effective. Results: Smoking cessation programs were determined to be economically justified if it prevents 1 I&D surgery out of 8 TAAs among tobacco users (ARR = 12.66%) in the early postoperative period (

Background: Lisfranc fracture-dislocation is an uncommon but serious injury that currently lacks universal consensus on optimal operative treatment. Two common fixation methods are open reduction and internal fixation (ORIF) and primary arthrodesis (PA). The objective of this study is to analyze the cost difference between ORIF and PA of Lisfranc injuries, along with the contribution of medical services to overall costs. Methods: This was a retrospective cost analysis of the MarketScan database from 2010 to 2020. MarketScan is an insurance and commercial claims database that integrates deidentified patient information. It captures person-specific clinical utilization, expenditures, and enrollment across inpatient and outpatient services. Patients undergoing primary ORIF ( CPT code 28615) vs PA (28730 and 28740) for Lisfranc fracture-dislocation were identified. The primary independent variable was ORIF vs PA of Lisfranc injury. Total costs due to operative management was the primary objective. The utilization of and costs contributed by medical services was a secondary outcome. Results: From 2010 to 2020, a total of 7268 patients underwent operative management of Lisfranc injuries, with 5689 (78.3%) ORIF and 1579 (21.7%) PA. PA was independently associated with increased net and total payment and coinsurance, clinic visits, and imaging, and patients attended significantly more PT sessions. Conclusion: Using this large database that does not characterize severity or extent of injury, we found that treatment of Lisfranc fracture-dislocation with ORIF was associated with substantially lower initial episode of treatment costs compared with PA. Specific excessive cost drivers for PA were clinic visits, PT sessions, and imaging. Level of Evidence: Level III, retrospective cohort study.

Category: Other Introduction/Purpose: Previous studies have reported conflicting data regarding 30-day readmission rates between patients of different races following orthopaedic surgery. Differences in specific reasons for 30-day readmission between races following orthopaedic surgery have yet to be explored. Methods: The ACS-NSQIP database was utilized to identify patients who underwent orthopaedic surgery and were readmitted within 30 days. Data was collected from 2015–2019, and patients were stratified into one of five race groups: American Indian/Alaskan Native, Asian, Black/African American, Native Hawaiian/Pacific Islander, and White. Analysis of variance (ANOVA) with Bonferroni post-hoc analysis for multiple comparisons was used to compare differences in continuous variables between racial groups. Chi-square analysis with post-hoc analysis of adjusted standardized residuals was used to compare differences in categorical variables between racial groups. Results: In total, 975,857 patients from the ACS-NSQIP database were included in the study. All-cause readmission rate was significantly different across races. Asian and Native Hawaiian/Pacific Islander patients had significantly lower readmission rates (2.7% and 2.8%, respectively), whereas Black patients had significantly greater readmission rates (3.9%) (p < 0.01). Black patients had significantly greater readmission rates for deep incisional SSI, wound disruption, renal insufficiency, and pulmonary embolism, and a lower readmission rate for pneumonia compared to other races. Asian patients had a lower readmission rate for pulmonary embolism, wound disruption, superficial incisional SSI, and vein thrombosis requiring therapy. Conclusion: Specific causes of 30-day readmission were significantly different between races, with Black patients experiencing higher readmission rates and Asian and Hawaiian/Pacific Islander patients experiencing lower readmission rates overall. Our findings can inform which complications should be more carefully monitored in certain patient populations, and how peri- and post-operative management can be adjusted accordingly.

Category: Trauma; Other Introduction/Purpose: Racial and ethnic disparities remain a major problem in orthopaedic surgery, driving inequitable resource distribution, disparate clinical outcomes, and increased healthcare costs. The objective of this study was to investigate potential racial/ethnic disparities in the incidence and injury patterns of orthopaedic lower extremity trauma (LET) in the U.S. over the last 10 years, as well as differences in final disposition outcomes. Methods: The National Electronic Injury Surveillance System (NEISS) database was queried for all orthopaedic LET presenting to U.S Emergency Departments (ED) from 2010–2020. Incidence rate ratios (IRR) were used to compare incidence rates between racial/ethnic groups at the population level. To compare outcomes specifically among patients with LET, adjusted odds ratios (aOR) were calculated for each racial/ethnic group using multivariate logistic regression. Results: Black/African Americans (Black/AAs) consistently experienced the highest incidence of LET over the ten-year period analyzed (709.108 per 100,000 person-years), followed by Whites (547.159 per 100,000 person-years) (Figure 1). Furthermore, Black/AAs had the highest incidence of polytrauma (114.19 per 100,000 person-years), over 1.7x greater than Whites (IRR: 1.73 [95% CI: 1.72–1.75]). Black/AAs had over 2-fold higher odds of death after LET compared to Whites (aOR 2.15 [95% CI: 1.78– 2.59]) (Figure 2). By 2019–2020, the incidence of deaths among Black/AAs reached more than triple that of Whites (IRR: 3.50 [95% CI: 2.74–4.46]). Black/AAs were also the most likely to be discharged AMA (aOR: 1.94 [95% CI: 1.92–1.96]), and the least likely to be admitted as inpatients (aOR: 0.683 [95% CI: 0.679–0.688]). Conclusion: Despite Black/AAs experiencing a disproportionately higher incidence of LET and over 2-fold greater odds of death compared to Whites, they were also the most likely to be discharged AMA and least likely to be admitted as inpatients. Improved patient education and more effective communication may help ensure that injuries in this patient population are not prematurely discharged, potentially improving clinical outcomes and reducing mortality.

Category: Other Introduction/Purpose: The purpose of this study is to characterize out-of-pocket (OOP) cost trends in both elective and trauma foot and ankle surgeries for commercially insured patients. Secondarily, we sought to compare the OOP costs of these surgeries between hospital-based outpatient departments (HOPDs) and ambulatory surgical centers (ASCs), as well as insurance plan types. Methods: Adult patients who underwent elective or trauma foot and/or ankle surgeries between 2010 and 2020 were identified using the MarketScan Database. Demographic, procedural, and financial data were recorded. The primary outcome was OOP costs, which were defined as the sum of the deductible, coinsurance, and copayment for each episode of care. Monetary data were adjusted to 2020 dollars. General linear regression, Kruskal-Wallis test, and Wilcoxon-Mann-Whitney test were used for analysis, as appropriate. Alpha was set at 0.05. Results: A total of 966,095 patients (806,707 elective and 159,388 trauma) underwent common outpatient foot and ankle surgeries between 2010 and 2020. Trauma surgeries generated significantly higher mean OOP costs than elective procedures ($1438.79 versus 1058.53, P< 0.001). OOP costs were significantly lower for procedures performed in ASCs compared to HOPDs ($1071.09 vs $1126.96, P< 0.001). This trend was driven by significantly higher coinsurance for HOPDs ($727.98) versus ASCs ($622.95) (P < 0.001). Of the insurance plans studied, high deductible health plans had the highest average OOP costs. Average OOP costs for common outpatient foot and ankle surgeries increased by 55.2% from $875.11 in 2010 to $1357.86 in 2020. Conclusion: OOP costs for foot and ankle surgeries have increased significantly since 2010. Average OOP costs from surgeries performed in ASCs were less than in HOPDs. Patients enrolled in HDHPs tended to incur the greatest average OOP costs. As direct costs for patients increase over time, it is critical to be aware of this financial burden and work towards improving access to necessary care.

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: First ray or medial column instability has been linked to the development of hallux valgus deformity (HVD), in part due to potential instability of Lisfranc joints and ligamentous complex. However, no study has assessed the 3D weight- bearing (WB) relationship of the Lisfranc complex in patients with confirmed hallux valgus, particularly at the articulating surface of the first tarsometatarsal joint and the second metatarsal and medial cuneiform space, commonly described as the primary region- of-interest of the Lisfranc complex. In this case-control study, we aimed to assesses WB 3D volumetric measurements in the entire Lisfranc joint, as well as in between first and second rays, and to compare HVD patients and controls. We hypothesized that volumes would be increased in HVD patients. Methods: In this IRB-approved, retrospective case-control study, we analyzed weight-bearing Computed Tomography (WBCT) data of 20 consecutive HVD patients and 20 healthy control patients. Using an automated segmentation method (DISIOR Bonelogic 2.0, Paragon28, USA), 3D volumetric models of the bones of the foot were created from WBCT data. Opposing articular spaces in the Lisfranc joint were selected on the STL models of the bones. Interarticular distance mapping was then performed to characterize the joint space width (JSW) in each of the articulations. Interarticular volume was then assessed using an area-weighted volume measurement. Areas of each triangle from the triangulated surface were multiplied by the JSW at each triangle. The sum of individual volumes was then normalized by the total surface area. The final volume was estimated using the product of the normalized summation and average area of both surfaces. Comparisons were performed with independent t-tests. P-Values < 0.05 were considered significant. Results: Estimates of volumetric assessment of the Lisfranc Complex were obtained using the automated method written in MATLAB. These outputs are reported in Table 1. As expected, the first tarsometatarsal joint volumes were the highest for both HVD patients and controls. No significant differences in the volumes were observed when comparing HVD patients and controls for any of the joints or spaces assessed (Figure). Particularly, no differences in the volumetric analysis of the first tarsometatarsal joint, 1-2 intercuneiform space or Lisfranc space (medial cuneiform-second metatarsal) were confirmed. Conclusion: In this retrospective case-control study, we hypothesized that joint volumes of the articulating surfaces and spaces-of- interest within the Lisfranc complex would be higher in HVD patients, consistent with first ray/medial column instability. Our study results demonstrated however no significant volume increases in Lisfranc joints or spaces assessed, particularly with no increases in the volumetric measurements at the first tarsometatarsal joint or between first and second rays. Even though our study could be underpowered to demonstrate potential differences between HVD and controls, our results support that no significant first ray instability in present when volumetric WBCT assessment is used.

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Lisfranc fracture-dislocation is an uncommon but serious injury that currently lacks universal consensus on optimal operative treatment. Two common fixation methods are open reduction and internal fixation (ORIF) and primary arthrodesis (PA). The objective of this study is to analyze the cost difference between ORIF and PA of Lisfranc injuries, along with the contribution of medical services to overall costs. Methods: This was a retrospective cost analysis of the MarketScan database from 2010-2020. Patients undergoing primary ORIF (CPT code 28615) versus PA (28730 and 28740) for Lisfranc fracture-dislocation were identified. The primary independent variable was ORIF versus PA of Lisfranc injury. Costs accrued due to operative management was the primary objective, and was analyzed according to net payment, total payment, coinsurance, copayment, deductible, and coordination of benefits per savings (COB/savings) amounts. Outpatient surgery setting (hospital versus ambulatory surgical center (ASC)) and requirement for secondary arthrodesis within the primary ORIF group were secondary independent variables. The utilization of and costs contributed by medical services were secondary outcomes. These included outpatient clinic visits, foot radiographs, lower extremity magnetic resonance imaging (MRI), lower extremity computed tomography (CT), physical therapy (PT), and opioid prescriptions. Student’s t-test, chi-squared test, and Poisson multivariable regression were used for statistical analysis, with significance set as P < 0.05. Results: From 2010 to 2020, 7,268 patients underwent operative management of Lisfranc injuries, with 5,689 (78.3%) ORIF and 1,579 (21.7%) PA. Of those undergoing initial ORIF, 22 (0.39%) were converted to secondary arthrodesis at a mean ± standard deviation of 10.2 ± 12.1 months after the index surgery. PA was independently associated with increased net payment, total payment, and coinsurance. When compared to primary ORIF, patients undergoing PA utilized more clinic and PT visits and imaging sessions. However, primary ORIF with secondary arthrodesis was associated with more clinic visits, imaging, and generated higher costs from these medical services compared to PA alone. Within hospital and ASCs, PA was associated with increased net and total payments. However, out-of-pocket (OOP) costs were found to be higher in ASCs. Conclusion: Treatment of Lisfranc fracture-dislocation with PA is associated with higher initial costs compared to ORIF with subsequent secondary arthrodesis. Conversely, secondary arthrodesis demonstrated significantly higher costs and resource utilization compared to primary procedures. Specific cost drivers for PA and secondary arthrodesis were clinic visits and perioperative imaging.

Category: Sports; Ankle Introduction/Purpose: Ankle injuries are among the most common musculoskeletal injuries in National Football League (NFL) players. Concussions are also concerningly frequent, especially given increasing post-mortem observations of chronic traumatic encephalopathy (CTE) in former NFL players. There is a gap in the literature regarding musculoskeletal risk factors for concussion, which is an avenue that must be explored to promote player safety. The purpose of this study is to observe if ankle injuries, especially multiple ankle injuries, are associated with an increased risk of subsequent concussion in NFL players. Methods: The public online database ProFootballReference.com was utilized to identify ankle injuries and concussions in NFL players, as well as demographic variables such as BMI and age. Multivariable logistic regression for subsequent concussion and ankle injury was performed, adjusting for BMI and player position. For descriptive statistics, unpaired T-tests with unequal variance were performed for continuous variables, including BMI and age. Chi-squared testing was performed for categorical variables, including player position, and whether the position was offensive (quarterback, running back, tight end, wide receiver, offensive line), defensive (defensive back, defensive line, linebacker), or on special teams (kicker, punter, long snapper). Results: 5,538 NFL players from the 2009-2010 to 2019-2020 seasons were included in the study. The mean BMI and age of the cohort was 31.06 (SD 4.55) and 24.41 (SD 3.63), respectively. Of these players, 941 had an ankle injury, 633 had a concussion, and 240 had both an ankle injury and a subsequent concussion. The adjusted odds ratio (aOR) for concussion following a single ankle injury was 0.90 (95% CI 0.72 – 1.14, p = 0.387), however, the aOR for concussion following multiple ankle injuries was 2.88 (95% CI 1.28 – 6.74, p = 0.015). The kicker position was determined to have the lowest risk for concussion following ankle injury, and the positions with comparatively greater risk are outlined in Table 1. Conclusion: Multiple ankle injuries were associated with an increased risk of a subsequent concussion by 188% after adjusting for BMI, player position, and offense/defense/special teams designation. Special teams as a group and by position (kicker, long snapper, punter) had the lowest risk of concussion following ankle injury, likely owing to the lower-impact nature of these positions. These findings can inform injury prevention practices in the National Football League.

Background: Primary Achilles tendon repair (ATR) can be performed in ambulatory surgery centers (ASCs) or hospitals. We compared costs and complication rates of ATR performed in these settings. Methods: We retrospectively queried the electronic medical record of our academic health system and identified 97 adults who underwent primary ATR from 2015 to 2021. Variables were compared between patients treated at ASCs vs those treated in hospitals. We compared continuous variables with Wilcoxon rank-sum tests and categorical variables with χ 2 tests. We used an α of 0.05. Multivariable logistic regression was performed to determine associations between surgical setting and costs. Linear regression was performed between each charge subtype and total cost to identify which charge subtypes were most associated with total cost. Results: Patients who underwent ATR in hospitals had a higher rate of unanticipated postoperative hospital admission (13%) than those treated in ASCs (0%) ( P = .01). We found no differences with regard to postoperative complications, emergency department visits, readmission, rerupture, reoperation/revision, or death. Patients treated in hospitals had a higher mean (±SD) implant cost ($664 ± $810) than those treated in ASCs ($175 ± $585) ( P 25 (odds ratio = 1.2 [95% CI: 1.0-1.5]). Operating room costs were strongly correlated with total costs ( R 2 = .94). Conclusion: The overall cost and complication rate of ATRs were not significantly different between ASCs and hospitals. ATRs performed in hospitals had higher implant costs and higher rates of postoperative admission than those performed in ASCs. Level of Evidence: Level III, retrospective comparative study.

Background: Achilles tendon rupture (ATR) is a common injury with a growing incidence rate. Treatment is either operative or nonoperative. However, evidence is lacking on the cost comparison between these modalities. The objective of this study is to investigate the cost differences between operative and nonoperative treatment of ATR using a large national database. Methods: Patients who received treatment for an ATR were abstracted from the large national commercial insurance claims database, Marketscan Commercial Claims and Encounters Database (n = 100 825) and divided into nonoperative (n = 75 731) and operative (n = 25 094) cohorts. Demographics, location, and health care charges were compared using multivariable regression analysis. Subanalysis of costs for medical services including clinic visits, imaging studies, opioid usage, and physical therapy were conducted. Patients who underwent secondary repair were excluded. Results: Operative treatment was associated with increased net and total payments, coinsurance, copayment, deductible, coordination of benefits (COB) / savings, greater number of clinic visits, radiographs, magnetic resonance imaging (MRI) scans, and physical therapy (PT) sessions, and with higher net costs due to clinic visits, radiographs, MRIs, and PT ( P

Background: Plantar fasciitis (PF) is the most common cause of heel pain and can be a source of extensive physical disability and financial burden. Platelet-rich plasma (PRP) offers a potentially definitive, regenerative treatment modality that, if effective, could change the current paradigm of PF care. However, randomized controlled trials (RCTs) on the clinical benefits of PRP for refractory PF offer inconsistent conclusions, potentially because of the broader limitations of using P value thresholds to declare statistical and clinical significance. In this study, we use the Continuous Fragility Index (CFI) and Quotient (CFQ) to appraise the statistical robustness of data from RCTs evaluating PRP for treatment of PF. Methods: RCTs comparing outcomes after PRP injection vs alternative treatment in patients with chronic PF were evaluated. Representative simulated data sets were generated for each reported outcome event using summary statistics. The CFI was determined by manipulating each data set until reversal of significance (α=0.05) was achieved. The corresponding CFQ was calculated by dividing the CFI by the sample size. Results: Of 259 studies screened, 20 studies (59 outcome events) were included in this analysis. From these simulations, the median CFI for all events was 9, suggesting that varying the treatment of 9 patients would be required to reverse trial significance. The corresponding CFQ was 0.177. Studies with reported P value .05 (CFI=5, CFQ=0.179). Of 36 outcome events reporting lost to follow-up data, 10 events (27.8%) lost ≥9 patients. Conclusion: Our findings suggest that, on average, the statistical fragility of RCTs evaluating PRP for nonoperative PF therapy is at least comparable to that of the sports medicine literature. However, several included studies had concerningly low simulated fragility scores. Orthopaedic surgeons may benefit from preferentially relying on studies with higher CFI and CFQ values when evaluating the utility of PRP for chronic PF in their own clinical practice. Given the importance of RCT data in clinical decision making, fragility indices could help give context to the stability of statistical findings. Level of Evidence: Level I, systematic review.

Category: Trauma; Ankle; Hindfoot; Other Introduction/Purpose: Race-based differences in the surgical management of hip fractures are well-established. Studies assessing these disparities for below-knee fractures have yet to be conducted despite their high volume. Our purpose was to determine whether 1) early postoperative complications and 2) time to surgery for operative fixation of below-knee fractures differ for black versus white patients, and to assess whether disparities exist between fracture subtypes. Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for patients (>=18 years) undergoing open fixation of below-knee fractures between 2010-2019. This yielded 9,172 patients; 1,120 (12%) were black. We collected patient demographics and preoperative risk factors. Primary outcomes were 30-day postoperative complications and time to surgical fixation. Fractures were further subclassified as tibia and/or fibula shaft, isolated malleolar, bi/trimalleolar, and pilon fractures. Nearest-neighbor propensity score matching in a 1:1 ratio was applied to compare outcomes by race. Alpha = 0.05. Results: After matching, we identified 1,120 white patients with equal propensity scores as our black patients. Black patients had 1.5 times higher odds (95% confidence interval [CI]: 1.0-2.0) of experiencing any early adverse event when compared with matched white counterparts. Blacks also had 1.9 times higher odds (95% CI: 1.2-3.0) of requiring unplanned readmission within 30 days of operative fixation. Fifty-eight black patients (5.3%) required short-term readmission, compared with 351 white patients (4.5%) - 32 (2.9%) in the matched cohort. The most common reasons for readmission were wound, gastrointestinal, thromboembolic, and recurrent musculoskeletal complications for both races. There were no significant differences by race in time to surgery. Fracture subtype was not associated with postoperative complications or time to surgery in the multivariable analysis. Conclusion: Racial disparities in the early postoperative course after open fixation of below-knee fractures exist, with significantly higher rates of early adverse events and unplanned readmission for black versus white patients that persist after propensity matching. These trends may be secondary to a host of community- and hospital-level factors, illustrating the importance of interventions that consider the differences between hip and non-hip fractures and increase resources to vulnerable areas.

Category: Basic Sciences/Biologics; Hindfoot; Sports Introduction/Purpose: Randomized controlled trial (RCT) outcomes reaching statistical significance, frequently determined by p

Category: Trauma; Ankle; Hindfoot Introduction/Purpose: The standardized identification of patients who are at higher risk of early postoperative adverse events has implications for quality improvement, preoperative medical optimization, and cost reduction through bundled payments. The purpose of the present study was to develop points-based risk stratification systems for predicting 30-day adverse events (AEs) and mortality after open fixation of periarticular hip, knee, and ankle fractures. Methods: Query of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database yielded 65,529 patients who underwent periarticular hip, knee, and ankle fracture repair from 2010-2019. We collected patient demographics and preoperative risk factors. To generate our risk stratification systems, 60% of patients were randomly designated as the development cohort and analyzed with multivariable regression plus bootstrap modeling to identify independent risk factors for early AE and mortality. A nomogram analysis was then conducted to assign scores for each risk factor and generate two points-based risk stratification systems, for AE and mortality. To validate our models, the systems were applied to the remaining 40% of patients (the validation cohort) and tested for predictive ability. Results: In total, 13,212 patients (20.2%) experienced any AE and 3,613 patients (5.5%) mortality within 30 days of fracture fixation. Patients were assigned points for each of the following in both risk stratification systems: fracture type (+4 hip, +2 knee, +0 ankle), male gender (+1), age (>=80 years +5, 60-79 years +3, 40-59 years +2), functionally dependent (+2), anemia (+2 for AE, +1 for mortality), pulmonary disease (+3 for AE, +1 for mortality), congestive heart failure (+3 for AE, +2 for mortality), and end- stage renal disease (+3 for AE, +1 for mortality). Corticosteroid use (+1), hypertension (+1), and insulin-dependent diabetes (+2) were additional predictors for only AEs. The AE and mortality models had maximum scores of 27 and 17 points, and Harrell C statistics of 0.66 and 0.75, respectively. The estimated risk of developing early AE ranged from 3.4-79.5% and mortality from 0.08- 54.4%. Conclusion: Fracture type, male gender, age >=40 years, corticosteroid use, functional dependence, anemia, hypertension, insulin-dependent diabetes, pulmonary disease, congestive heart failure, and end-stage renal disease can be used in the prediction of early AE or mortality following open fixation of periarticular lower extremity fractures, with a marked disparity in estimated risks depending on the number of risk factors possessed by a patient.

Category: Other; Trauma Introduction/Purpose: Orthopaedic surgeons are at high risk for experiencing work-related musculoskeletal injuries and chronic pain. This is largely due to daily exposure to repetitive large magnitude forces, altered posture from the use of leaded vests, and prolonged standing often in irregular body positions. We sought to synthesize available evidence regarding 1) the biomechanics of orthopaedic surgery and 2) musculoskeletal injuries sustained by orthopaedic surgeons with subsequent treatment and consequences. Methods: To conduct this systematic review, we queried four databases (PubMed, Embase, MEDLINE, and Web of Science) for original research studies presenting on the biomechanics of orthopaedic surgery or musculoskeletal injuries sustained by orthopaedic surgeons. Studies were excluded if they were not original research (i.e., reviews) or reported on injuries to patients, non-musculoskeletal injuries, or non-orthopaedic subspecialties. The literature search yielded 3,202 publications, 36 of which were included in the final analysis. Results: Eight studies reported on the biomechanics of orthopaedic surgery. Surgeons spent an average 41.6% of time slouched during surgeries. Head and whole spine angles were closest to natural standing position when using a microscope for visualization and with higher surgical field heights. Use of lead aprons resulted in a shifted weight distribution on the forefoot, gain in thoracic kyphosis, and increase in lateral deviation from postural loading. Twenty-eight studies reported on musculoskeletal conditions experienced by orthopaedic surgeons. The overall prevalence of musculoskeletal symptoms or injury involving any body region ranged from 44-97%. Prevalence by body region in decreasing order were as follows: lower back (15.2-89.5%), hip/thigh (4.4- 86.6%), neck (2.4-74%), hand/wrist (10.5-54%), shoulder (7.1-48.5%), elbow (3.1-28.3%), knee/lower leg (7.9-27.4%), and foot/ankle (7-25.7%). Of surgeons with any reported musculoskeletal symptom or injury, 27-65.7% required nonoperative treatment, 3.2- 34.3% required surgery, and 33.3-59.3% indicated that their operative performance was affected. Conclusion: The orthopaedic surgeon population experiences a high prevalence of musculoskeletal symptoms and injuries, likely secondary to the biomechanical burdens of tasks required of them during strenuous operations. Ergonomic interventions must be taken within the operating room to reduce this prevalence, increase the physical well-being of orthopaedic surgeons, and reduce the healthcare costs associated with time off work and early retirement as a result of musculoskeletal conditions.

Category: Trauma; Ankle Introduction/Purpose: Isolated ankle dislocations (IADs) are rare type of dislocation associated with significant morbidity. Prompt reduction is indicated to prevent negative sequelae. Considering the potential negative outcomes associated with this injury, we sought to identify populations at increased risk. Methods: The National Electronic Injury Surveillance System (NEISS) database was queried to identify patients who presented to Emergency Departments (EDs) in the U.S. for IADs between 2001-2019. NEISS codes indicating ankle dislocation as the primary diagnosis were utilized. Population estimates were derived from the U.S. Census Bureau for calculation of incidence in person- years. Chi-square analysis and Wald chi-square tests were performed to assess differences between subgroups. Results: An estimated 52,520 IADs (2,862 per year) were identified among a population at risk of 5,853,993,882 person-years. The estimated incidence of IADs in the general population presenting to EDs was 0.90 per 100,000 person-years. Patients with IADs were most commonly male (61.6%), white (71.9%), and between 15-35 years old (60.1%). Patients aged 15-20 years comprised the highest proportion of IADs (19.6%). Surprisingly, sport-related activities accounted for a minority of injuries (38.2%), with most of these occurring during basketball (47.8%), football (12.9%), and soccer (9.8%). Most IADs were due to non- athletic activity, with falls from stairs (30.8%) and ladders (13.4%), and skateboarding (5.0%) being the most common mechanisms. When comparing injured male and female patients, female patients were older (45.2 vs 32.0 years; P

Category: Trauma; Ankle Introduction/Purpose: Preoperative anemia has been associated with significant postoperative morbidity following various types of orthopaedic procedures. However, to our knowledge, there is no study assessing postoperative outcomes following open reduction internal fixation (ORIF) of ankle fractures with varying severity of anemia. The purpose of this study was to determine the influence of preoperative anemia severity on 30-day postoperative outcomes following ankle fracture ORIF. Methods: The American College of Surgeons National Surgical Quality Improvement Program registry was queried from 2005 to 2019 for patients undergoing ankle fracture ORIF. Patients were stratified into 3 cohorts: non-anemic (hematocrit > 36% for women, >39% for men), mildly anemic (hematocrit 33%-36% for women, 33%-39% for men), and moderately to severely anemic (hematocrit

Category: Other Introduction/Purpose: There is little consensus on the effects of vitamin D on fracture healing. This review aims to clarify that effect in addition to determining trends in the classification of deficiency and supplementation. Methods: This systematic review searched Pubmed, Embase, and Web of Science for manuscripts related to vitamin D status/deficiency and fracture healing. Two independent reviewers screened articles, graded evidence quality, and extracted data. A total of 38 human studies, 11 in vivo studies and 14 systematic reviews were analyzed. Results: The median vitamin D deficiency prevalence reported amongst the human studies was 41.2% which is comparable to subset of patients with deficiency defined as 30 ng/mL for sufficiency. Although there is no radiographic evidence, daily smaller doses of vitamin D supplementation seem to have a stronger impact on clinical fracture healing than large boluses.

Category: Trauma; Ankle Introduction/Purpose: It has been suggested that the COVID-19 pandemic has led to patients deferring evaluation and treatment of injuries due to fear of contagion. This, in addition to lockdowns and avoidance of outside activities, may have led to a decrease in the recorded incidence of activity-related injuries. The purpose of this study was to evaluate the effect of the 2020 COVID-19 period on Emergency Department (ED) visits for ankle sprains in the United States, including incidence, demographics, and etiology. Methods: The National Electronic Injury Surveillance System (NEISS) database was queried to identify patients who presented to EDs in the U.S. for ankle sprains between 2001-2020. Population estimates were derived from the U.S. Census Bureau from 2001- 2020 for calculation of incidence in person-years. Chi-square analysis and Wald chi-square tests were performed to assess differences between pre-pandemic (2001-2019) and during-pandemic (2020) periods. Results: Between 2001 and 2020, a total of 315,545 actual ankle sprains were identified in the NEISS database for an estimated 11,904,243 ankle sprains (610,445.2 per year) among a population at risk of 6,185,494,962 person-years. The estimated incidence of ankle sprains in the general population presenting to EDs was 1.92 per 1000 person-years. When analyzing pre- and during- pandemic cohorts, ankle sprain incidence was significantly lower during-pandemic (1.98 vs 0.89 per 1000 person-years; P

Category: Other Introduction/Purpose: Not only is poor nutritional status common amongst the elderly, but its incidence is also high amongst orthopedic trauma patients as injuries, and fractures more specifically, cause hypermetabolic states. The purpose of this review was to perform the most comprehensive analysis of literature published within the last decade to determine the effect of nutritional status on fracture healing, as well as outlining the effects of specific herbal supplements, vitamins and minerals. Methods: Following PRISMA guidelines, PubMed, Embase and Web of Science databases were searched using variations of the terms nutrition and malnutrition along with vitamins, minerals and proteins as well as fractures and fracture healing. Two independent reviewers screened articles, graded evidence quality, and extracted data. A total of 31 studies were related to nutritional status - 22 human studies and 9 animal studies - and 45 studies were related to specific herbs or food products - 2 human studies, 36 animal studies, and 7 review articles. Results: There is substantial variability in the definitions of nutritional status, with some quantitative measures including serum albumin and lymphocyte count being the most popular, and questionnaires like the Mini Nutritional Assessment (MNA) and the Malnutrition Universal Screening Tool (MUST). Published human studies predominately studied the effects of nutrition on traumatic fractures in the elderly or bone healing after spinal surgery. Consistently, hypoalbuminemia was found to be an independent risk factor of post-operative complications and longer hospital stays. Few studies reported on nutritional supplementation, but those that did found supplementation to be associated with lower rates of postoperative complications and wound infection, as well as shorter hospital stays. Although there is much evidence published on herbal supplements and food products in animals, there is a dearth of evidence of their benefits to humans with only two RCTs included in this analysis (demonstrating the benefits of Momiai and lactobacillus casei Shirota). Conclusion: Nutrition remains an easily targetable factor that can significantly improve fracture healing, especially amongst elderly populations. Although proper adherence to supplementation is rare, when attained its benefits are profound. To demonstrate that the beneficial effects of herbal supplements and food products on fracture healing seen in animal models persist in humans, future placebo-controlled trials are needed.

Category: Trauma; Ankle Introduction/Purpose: Due to the rapid expansion of scooter sharing companies in recent years, there has been a dramatic increase in the number of electric scooter injuries. The purpose of our study was to conduct a systematic review to characterize the demographics, most common injuries, and management of patients injured from electric scooters. Methods: This systematic review searched PubMed, EMBASE, Scopus, and Web of Sciences databases using variations of the terms 'motorized scooter', 'electric scooter', etc. Exclusion criteria included studies prior to 2015, study population less than 50, case reports, presentations or posters only, and studies focused on other devices. Two independent reviewers screened articles and data was analyzed using t-tests with Welch's correction. Sub-group analyses were performed to address data heterogeneity. Results: 5550 patients from 34 studies were included. The median age was 33.07 years, and 58.3% (n=3325) of the patients were male. The most common mechanism of injury was falling (n=3595, 67.3%). Injured patients were more likely to not have been wearing a helmet at the time of injury (70.3%, p

Category: Trauma; Other Introduction/Purpose: Increase in opioid use has been associated with a higher incidence of compartment syndrome. To our knowledge, there is no long-term or large database study that analyzes this unique patient population. We sought to compare the clinical outcomes of opioid-related compartment syndrome (ORCS) and non-opioid related compartment syndrome (NORCS), and assess risk factors for amputation in ORCS. Methods: Data on 154 patients (132 NORCS and 22 ORCS patients) from January 1, 2016 to December 31, 2021 who presented with compartment syndrome was collected through a multicenter billing database. We analyzed demographic and clinical findings, including cause of compartment syndrome, time until initial evaluation, length of hospital stay, number of surgeries, rate of amputation, and peak creatinine kinase (CK) and lactate levels. Bivariate statistics were used to assess the data. Results: The most common cause of compartment syndrome was trauma (62%) in the lower leg (79%). Twenty-one ORCS patients (96%) had a delayed presentation after immobilization in dependent position for >=8 hours. ORCS patients had significantly higher mean peak CK and lactate levels (p

Category: Ankle Introduction/Purpose: Ankle fractures are common and can potentially lead to devastating consequences if not treated appropriately. The aim of this study was to assess trends in incidence, presentation, causes, and final disposition of emergency department visits for ankle fractures from 2019 to 2020. Methods: The National Electronic Injury Surveillance System (NEISS) database is a probability sample of hospitals in the United States. This sample was stratified and weighted based on ED size, which was used to generate national estimates (NE). The NEISS databases contains variables such as age, race, drug use, alcohol use, location, disposition, cause, body part, and injury type. The NEISS database from 2001 to 2020 was queried for patients who sustained an ankle fracture. Two cohorts: before COVID-19 (BC) (July 2019 - Dec 2019) and during COVID-19 (DC) (July 2020 - Dec 2020) were compared. Results: This study assessed 3,350 (NE: 131, 672) total patients who presented to emergency departments around the United States. 1,683 (NE: 17,936) patients presented BC and 1,667 (NE: 64,380) DC, representing a 4% decrease compared to the year before. The median age was 44 (Interquartile Range (IQR) 24-62), with 60% (NE: 79,051) females. On bivariate analysis, the rate of alcohol related ankle fractures increased (1.9% BC vs. 2.6% DC; p

Category: Other Introduction/Purpose: As both fellowship training and opportunities for leadership's popularity increase, understanding a Foot and Ankle Fellowship Directors' (FD's) necessary components is crucial for evaluating Orthopaedic improvement methods and providing a template for the field's aspiring leaders. However, despite a FD's significance in trainee's development, future success, and careers in Foot and Ankle via Orthopaedic Surgery, no literature analyzing Foot and Ankle FD's demographics, surgical training, nor experience currently exists. This article aims to illustrate the trends in the characteristics and qualifications needed for leadership as an Orthopaedic Surgery Foot and Ankle FD. Methods: The American Orthopaedic Foot and Ankle Society (AOFAS) identified the FDs for all 2021 participating Orthopaedic Foot and Ankle fellowship programs in the United States. The characteristics, demographics, and educational background data for each fellowship director was gathered and consolidated by author review of available curricula vitae (CV's). Information that could not be obtained from the CV's were then further gathered from resources such as Scopus web of science, institutional biographies, and emailed questionnaires. To ensure adequate response and data points, with absence of email response, information not readily available was obtained through telecommunications. These data points were then consolidated into 1 database. The information gathered to be used as data points were: Age, sex, race/ethnicity, residency/fellowship training location and graduation year, name of current institution, length of time at current institution, time since training completion until being appointed fellowship director, length in fellowship director role, and personal research H-index. Results: 51 Foot and Ankle FDs were appraised. The mean age of Current FD's was 51.27 years old with a mean H-Index of 14.69. 94.1% of these FD's were male and 5.9% were female; 90.2% were Caucasian, 5.9% were Asian American, and 3.9% were African American. The mean residency graduation year was 2001.31; and the most attended Residency program was the Harvard Combined Orthopaedic Residency Program. The mean fellowship graduation year was 2002.30; and the most attended fellowship program was the MedStar Union Memorial Foot and Ankle Fellowship. The time from completion of fellowship until FD appointment was 11.42 years; the mean number of years spent as a FD is 4.37. 19.61% of FD's work at the same institution where they completed residency; 9.8 % of FD's currently work at the same institution where they completed fellowship. The FD with the highest research impact displayed a Scopus H-index of 48. Conclusion: This study serves as an objective summary and analysis of the current leadership within Foot and Ankle Fellowship Programs in the US. Orthopaedics sees a large disparity in diversity in percentage of women and minorities within the field as compared to several different specialties; however, that same disparity is further pronounced amongst leadership as lower percentages of women and minorities hold leadership positions within orthopaedics compared to other specialties. This study provides data to be used as a template for candidates aspiring for leadership while displaying trends that establish a more comprehensive sense of diversity and equality.

Category: Ankle; Trauma Introduction/Purpose: Patients treated operatively for foot and ankle fractures may be at higher risk of undertreated pain as well as overuse of opioid medications. We sought to synthesize the recent literature investigating use of opioids for analgesia following foot and ankle fracture surgery. To accomplish this, we aimed to determine the patterns of opioid use and prescription (e.g., quantity, duration, incidence of persistent use), risk or protective factors for persistent opioid use, and clinical outcomes (e.g., relief of pain, adverse events) associated with opioid use in this population. Methods: We followed PRISMA guidelines for our review. We systematically searched PubMed, Embase, Scopus, Cochrane, and Web of Science. We included studies published from 2010 to present that assessed patterns of opioid use, risk factors for increased opioid use, and outcomes associated with opioid use following foot/ankle fracture surgery. Two reviewers performed title/abstract screening and full-text review. The quality of included studies was evaluated using MINORS criteria. Results: In our review, 1713 articles were assessed and 18 were included (Figure 1). MINORS scores ranged from 13 to 18, indicating moderate study quality. Overall, there was wide variability in opioid use between and within studies. Rates of postoperative persistent opioid use ranged from 7-39%. Risk factors for increased opioid use included preoperative opioid exposure, mental health disorders, tobacco consumption, and certain injury patterns. Protective factors were spinal anesthesia, peripheral nerve block, and postoperative ketorolac. Opioid use was not associated with decreased pain or improved satisfaction. Opioid use was associated with increased rates of pain-related emergency department visits and readmission. Preoperative opioid use was associated with the greatest odds of increased postoperative use. Conclusion: There is a high incidence of persistent opioid use after foot and ankle fracture surgery. Opioid use was associated with negative health outcomes without decreasing pain levels or increasing patient satisfaction after foot/ankle fracture surgery. The wide variability of reported opioid use emphasizes the need for standardized guidelines for postoperative opioid use in this patient population, and our findings suggest that lower opioid prescription may be advisable.

Category: Basic Sciences/Biologics; Hindfoot; Sports Introduction/Purpose: Plantar fasciitis (PF) is estimated to account for 8% of all running-related injuries, affecting nearly 1 out of every 10 adults aged 50 and older. Recent randomized controlled trials (RCTs) suggest platelet-rich plasma (PRP) injection may be an effective non-operative treatment option for chronic, refractory PF. However, RCTs in general have come under scrutiny due to a frequent lack of reproducibility, which is largely attributable to shortcomings of the commonly used p=9 patients. Outcome events that were originally reported as significant (p

Background: Randomized controlled trial (RCT) outcomes reaching statistical significance, frequently determined by P

Category: Ankle; Ankle Arthritis; Trauma Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is a routinely utilized salvage procedure that treats patients with severe talar and subtalar joint disease. Unfortunately, nonunion is a relatively common complication postoperatively which can increase risks and costs for patients. The goal of this study is to review the literature to identify risk factors for nonunion post TTC arthrodesis and stratify them based on strength of evidence. A meta-analysis will be performed on risk factors when appropriate to establish values based on pre-existing studies. Methods: Five databases (CINAHL, Cochrane Library, EMBASE, MEDLINE, and Web of Science) were searched from inception to May 17th, 2020. Two independent reviewers screened abstracts and full-text articles for those that included risk factors predictive of nonunion for TTC arthrodesis. Any disagreements were discussed between the two reviewers and a third reviewer served as the ultimate decision maker if a consensus could not be reached. Relevant data regarding participants’ characteristics, study design, follow-up time, statistical tests and identified risk factors were extracted from the included studies. The two reviewers independently appraised the methodological quality of the studies using the Quality In Prognosis Studies tool. Those risk factors described in multiple studies were included in the meta-analysis. Random effects meta-analyses were summarized as forest plots of individual study and pooled random effect results. Results were reported as odds ratios (OR) with 95% confidence intervals (CI). Results: Database search identified 428 articles, of which 113 were screened for full text. Eight studies involving 607 patients were included and 33 potential risk factors for nonunion were identified. Risk factors were stratified into demographic, preoperative, intraoperative and postoperative. Results of the meta-analysis established two significant risk factors for nonunion following TTC arthrodesis. Strong evidence supports that prior neurological deficits, such as Charcot neuroarthropathy and diabetes neuropathy, are associated with nonunion following surgery (OR: 2.86, 95% CI: 1.56 - 5.23). There was moderate evidence to suggest that preoperative infection was predictive for nonunion (OR: 3.99, 95% CI: 1.26 - 12.68). Although our meta- analysis did not find smoking (OR: 1.75, 95% CI: 0.90 - 3.38) or diabetes (OR: 2.28, 95% CI: 0.98 - 5.34) to be significant risk factors, multiple high quality studies support these as comorbidities that increase the likelihood of nonunion. Conclusion: TTC arthrodesis can be an effective salvage procedure but is associated with high nonunion rates. The results of our meta-analysis suggest that prior neurological deficits, such as Charcot neuroarthropathy or diabetes neuropathy, have strong evidence for failure to achieve union. Although our meta-analysis did not find other statistically significant risk factors, the findings of individual studies in our review suggest that diabetes mellitus and smoking are both factors which can lead to failure of fusion. Surgeons should be cognizant of these risks when performing TTC arthrodesis and carefully monitor patients with the aforementioned comorbidities to achieve successful results.

Category: Sports; Ankle Introduction/Purpose: Achilles tendon ruptures are devastating injuries highly prevalent among athletes. Despite our understanding of the impact of Achilles tendon rupture in professional athletes, and in particular its relationship to basketball, no study has examined the effect of Achilles tendon rupture on performance metrics in National Collegiate Athletic Association (NCAA) Division I basketball players. Methods: NCAA Division I basketball players who sustained a surgically repaired Achilles tendon rupture between the 2000 and 2019 seasons were identified by systematic evaluation of individual injury reports from the NCAA career statistics and individual school statistics databases. 65 male and 41 female players were identified. Athletes were included if they participated in at least one collegiate season before tearing their Achilles tendon, and at least one season after operative repair. A total of 50 male and 30 female athletes were ultimately included in the analysis. Each injured athlete was matched to a healthy control by conference, position, starter-status at time of injury, class year, and number of games played. Matched controls were healthy players and experienced no significant injuries during their NCAA careers. Results: Following Achilles tendon rupture and subsequent surgical repair, male athletes played significantly more minutes per game (19.7 vs. 22.6, p=0.017), scored more points per game (6.7 vs 7.9, p=0.024), and had more assists per game (1.4 vs. 1.7, p=0.036), when compared to their pre-injury statistics. The only area of worsened athletic performance following injury was total blocks, which significantly decreased post-injury (18.1 vs. 10.2, p=0.004). Matched healthy controls demonstrated a higher percent change in assists per game (+39.0% vs +21.8%, p=0.036) and total blocks (+55.1% vs -43.5%, p=0.031) between the matched pre- injury and post-injury periods. Female athletes scored significantly more points per game after returning from injury (7.6 vs 6.3, p=0.032) but demonstrated a significantly lower 3-point shooting percentage (10% vs. 20%, p=0.047). Conclusion: Male athletes who returned to play following Achilles tendon rupture demonstrated significant increases in various offensive performance metrics, while suffering a significant decrease in total blocks. Female athletes demonstrated a significant improvement in points per game following Achilles tendon rupture, but suffered a significant decline in 3-point shooting percentage. Despite suffering an Achilles tendon rupture, 14% of the male cohort reached the NBA, and 16.7% of the female cohort reached the WNBA.

Category: Sports; Ankle Introduction/Purpose: Achilles tendon ruptures are devastating injuries in elite athletes. Current literature shows poor prognosis following Achilles tendon rupture in professional male basketball players, however there are currently no studies examining the effects of Achilles tendon rupture on performance outcomes in the Women's National Basketball Association (WNBA). Understanding the impact Achilles tendon rupture has on return to play and performance metrics in the WNBA will provide valuable information to players, team personnel, and medical professionals on post-injury expectations. Methods: 17 WNBA players who sustained an Achilles tendon rupture from 2000-2019 were identified from publicly available injury reports and player profiles. Demographic information collected included age, body mass index (BMI), position, and service in the WNBA when the tear occurred. Statistics were collected for the season before the injury, and two seasons after the injury, and the Player Efficiency Rating (PER) was calculated. PER is defined as ([points + rebounds + assists + steals + blocks] - [(field goals attempted - field goals made) + (free throws attempted - free throws made) + turnovers]) / games. Controls were matched by service in the WNBA, position, and PER. Results: Following Achilles tendon rupture, four players never returned to play in the WNBA, while seven players failed to play >1 season. Players who returned saw a significant decrease in the number of minutes played per game in both their first and second seasons post-injury (mean differences -6.11 and -6.54, respectively, p1 season after returning from injury.

Category: Hindfoot; Ankle Introduction/Purpose: Achilles Tendon (AT) rupture is the most common tendon rupture in the lower extremity with an incidence of 2.1 AT ruptures per 100,000 person years. Due to the non-emergent nature of this injury, a delay in presentation may occur leading to delays in diagnosis and treatment; which may alter both nonoperative and operative management. Health insurance status may directly impact time to presentation for many patients. To our knowledge, no study has evaluated the effect of insurance status on delay in diagnosis and treatment of AT rupture. Methods: From December 2013 to December 2018, 89 patients with AT ruptures who underwent surgical management were identified by CPT code in a dual-institution retrospective chart analysis. Demographic and injury-specific data were obtained with attention to the date of injury, date of diagnosis, location of initial presentation (clinic vs. emergency room), and number of medical visits. A univariate two tail t test was used to compare various groups. Statistical significance was set at p < 0.05 to determine the effects of insurance type on the time to diagnosis and treatment of acute AT ruptures. Results: When compared to adequately insured patients (private and Medicare), underinsured patients (uninsured and Medicaid) experienced a significantly greater time from the date of: injury to first clinic visit (14.5 days versus 5.2 days, p < 0.001), first clinic visit to surgery (34.6 days versus 4.8 days, p < 0.002), injury to surgery date (48.9 days versus 9.8 days, p < 0.001), initial presentation to when magnetic resonance imaging (MRI) was obtained (48.1 days versus 1.9 days, p < 0.002), and initial presentation to diagnosis (22.8 days versus 1.71 days, p < 0.029). Conclusion: Disparities in access to care are intimately related to insurance status. Uninsured and medicaid patients are subject to institutional delays and decreased access to care when compared to patients with private insurance. Under and uninsured patients are significantly more likely to present to the emergency department for their initial visit, potentially resulting in increased healthcare costs. Emergency department visits as well as difficulty in obtaining an appointment with an orthopedic surgeon may directly contribute to delay in diagnosis.

Category: Ankle; Ankle Arthritis; Arthroscopy; Basic Sciences/Biologics; Bunion; Diabetes; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports; Trauma; Other Introduction/Purpose: The topics, articles and discussions that arise within Foot and Ankle Orthopaedic literature are increasingly determined by their presence on social media outlets. The influence of social media mentions on Foot and Ankle Orthopaedic literature has not yet been investigated. The primary purpose of this study is to identify the social media outlets that were most associated with the Altmetric attention score (AAS). The secondary aim is to characterize the top 100 most highly cited articles within Foot and Ankle literature with the top 100 scoring Altmetric articles. Methods: We conducted a query of the Altmetric database for all journal titles containing the words ‘Foot’ and ‘Ankle.’ In accordance with other investigations, articles were only included after 2010, since this was beginning of academic social media participation. We assessed the frequency and percent of articles by journal, collecting variables including impact factor, AAS, along with average mentions within news, blogs, policy, patents, Twitter, peer review, Weibo, Facebook, Wikipedia, Google+, LinkedIn, Reddit, Pinterest, F1000, Q&A, online video, Syllabi, and traditional metrics such as number of Mendeley readers and citations (Table 1). We used a Spearman, semi-partial, and partial correlation test to detect the association between AAS and media outlet mentions, Mendeley readers or Dimensions citations. Finally, we ranked one article list with the 100 most popular articles on social media and one with the 100 most cited articles. Articles were examined for overlap, topic, article type, and level of evidence. Results: Our search returned 4,365 articles. Foot and Ankle International had the highest frequency of articles, though the Journal of Foot and Ankle Research had the highest AAS (Table 1). News and Twitter mentions had the greatest association with AAS. The top study designs for the AAS articles were prospective (n=35), retrospective (n=25), and systematic reviews (n=17), compared to the most highly cited articles which had retrospective (n=32), review (n=31), and observational studies (n=26) (p

Category: Ankle; Ankle Arthritis; Arthroscopy; Bunion; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports Introduction/Purpose: With the development of the COVID-19 pandemic, elective foot and ankle surgeries were delayed throughout the U.S. to divert healthcare resources and limit exposure. Little is known about the impact of COVID-19 on patient’s willingness to proceed with elective procedures once restrictions are lifted and factors contributing to such decision. Methods: Patients across six U.S. Orthopedic Institutions who had their elective foot and ankle surgeries cancelled secondary to the pandemic were given a questionnaire. Specifically, patients were asked about their willingness to move forward with surgery once restrictions were lifted and if not why. Pain-level and pain medication use were also assessed. Univariate analysis was used to identify factors that contribute to patient’s decisions. Results: A total of 150 patients participated in this study. N=21 (14%) opted not to proceed with surgery once restrictions were lifted. 43% (N=9) listed concern for COVID infection as the reason, however, 14% of them would proceed if procedures were performed in surgery center. Twenty-nine (19% of the total cohort) patients had increased pain and 11% of patients were taking more pain meds because of the delay to their procedure. Patients who decided not to proceed with surgery reported pain reduction (3% vs. 14%) and lower increase in pain medication used (5% vs. 12%). Conclusion: COVID-19 has made a significant impact on the healthcare. Delay of elective foot and ankle procedures impact patient quality of life and outcomes. Access to surgery centers may provide a partial solution during the pandemic.

Category: Ankle; Other Introduction/Purpose: Ankle fractures are common injuries that may require surgical treatment consisting of open reduction and internal fixation (ORIF). Injuries associated with increased pain levels are also correlated with increased opioid use, which is also recognized as a risk factor for bone fracture. There is a paucity of literature evaluating the impact of patients with a history of opioid use disorder (OUD) on postoperative complications following ORIF for ankle fracture. This study aims to investigate whether OUD patients are at greater odds of: 1) readmission rates, 2) emergency room visits, and 3) costs of care. Methods: Patients undergoing ORIF for ankle fracture with a 90-day history of OUD prior to the procedure were identified using national health insurance claims database. We selected patients that underwent surgical corrections as recorded by the following current procedural terminology (CPT) medical codes: 27792, 27814, 27822, 27823, 27766, 27829, and 27769. We matched cases with OUD to controls with a 1:4 of OUD to non-OUD controls. Variables that were matched between non-controls and controls included age, sex, Elixhauser- Comorbidity Index (ECI), in addition to comorbidities including diabetes, hyperlipidemia, hypertension, and tobacco usage. Logistic regression analysis was used to calculate odds-ratios (OR) for outcomes of 90-day readmission rates and emergency room visits. Welch’s t-test was used to test for significance of outcomes of cost of care and ECI between the cohorts. A p-value less than 0.001 was statistically significant. Results: A total of 2,198 patients were included with (n= 485) and without (n = 1,698) OUD undergoing ORIF for ankle fracture (Table 1). OUD patients undergoing ORIF for ankle fractures were found to have a higher incidence and odds of 90-day readmission rates compared to controls (8.65 vs. 7.30%; OR: 1.20, 95%CI: 0.83 - 1.73, p=0.320), but failed to reach statistical significance. OUD patients were found to have a higher incidence and odds of emergency room visits compared to controls (3.50 vs. 0.64%; OR: 5.57, 95% CI: 2.59 - 11.97, p

Category: Basic Sciences/Biologics; Bunion Introduction/Purpose: Hallux valgus is one of the most common surgically corrected forefoot deformities. Compared to open procedures, minimally invasive treatment of hallux valgus has resulted in decreased operative time, reduced complication rates, and greater patient satisfaction. Until recently in the United States, distal chevron osteotomies have been the standard for hallux valgus correction of moderate deformity. To the best of the authors’ knowledge, no studies have evaluated biomechanical strength of transverse and chevron distal metatarsal osteotomy constructs. The purpose of this study was to evaluate the biomechanical strength of transverse and chevron minimally invasive osteotomy techniques using 9 matched cadaveric pairs. Methods: A total of nine matched cadaveric specimens were randomized to transverse or chevron distal metatarsal osteotomies. Each minimally invasive surgical technique was performed by a fellowship trained orthopedic foot and ankle surgeon. Anterior- posterior and lateral radiographic images were obtained following surgical fixation. Biomechanical testing was performed on an Instron Mechanical System. Ultimate load to failure, yield load, and stiffness were assessed across the fixation construct with fulcrum within the metatarsal shaft proximal to screw fixation and compression load at the sesamoid bones. A pre-load of 10N was applied to the sesamoid bones by the compression post to stabilize the sample. Subsequently, a compression rate was applied to the sample at 10mm/min until failure was observed. Mean and standard deviations were assessed and compared across cohorts. Results: All nine cadaveric specimens were male. There was no difference in average percent metadiaphyseal shift among transverse (36%) and chevron (38%) osteotomies. The most common mode of failure among transverse and chevron osteotomies was fracture at screw insertion site (55.6%), followed by failure at osteotomy site (44.4%). One paired sample was noted to have poor bone quality prior to biomechanical testing. There was a trend towards increased ultimate load to failure (p=0.480) and stiffness (p=0.438) among transverse osteotomy compared to chevron osteotomy, however, no statistically significant difference was observed. Conclusion: Biomechanical testing demonstrates no statistical difference in ultimate load to failure and stiffness between minimally invasive transverse and chevron distal metatarsal osteotomy constructs. A trend towards increased ultimate load and stiffness in the transverse osteotomy cohort was observed. Chevron osteotomies violate the entire plantar cortex and may result in early failure by relative ease of cutout through cancellous bone compared to transverse osteotomies in which failure would require cortical bone cutout. Future studies are required to evaluate strength of construct in a larger sample. Analysis is limited, healing may provide additional strength that is not simulated in cadaveric studies.

Category: Ankle; Bunion; Midfoot/Forefoot; Other Introduction/Purpose: Patients with a history of opioid use disorder (OUD) have been shown to incur more severe medical complications, higher readmission rates, and increased cost following various orthopedic procedures. There is a scarcity in the literature investigating the effects of OUD following a hallux valgus procedure. Therefore, the purpose of this study was to evaluate whether OUD patients undergoing a hallux valgus correction are at greater odds of: 1) readmission rates, 2) emergency room (ER) visits, and 3) costs. Methods: Patients undergoing a hallux valgus correction with a history of OUD were identified using a health insurance claims database. To search for patients undergoing hallux valgus surgical corrections the following current procedural terminology (CPT) medical codes were used: 28290, 28292, 28293, 28294, 28296, 28297, 28298, 28299, 28306, and 28307. To include all eligible patients the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes were also utilized, including: 77.51 and 77.59. OUD patients were matched to non-opioid use disorder (NUD) patients in a 1:4 ratio by age, sex, Elixhauser-Comorbidity Index (ECI), diabetes mellitus, hyperlipidemia, hypertension, and tobacco use. Primary outcomes analyzed included odds of 90-day readmission rates, 30-day emergency room visit, and 90-day episode of care costs. Pearson’s chi-squared test was used to compare demographics. Logistic regression analysis calculated odds-ratios for readmission and ER visits. Welch’s t-test was used for significance in ECI and cost between cohorts. Results: The query yielded 6,318 patients (OUD=1,276; NUD=5,042) who underwent a hallux valgus correction. There were no significant difference between any of the compared age ranges (p=0.859, p=0.952, p=0.909, p=0.961), ECI (p=1.000) and comorbidities between OUD and NUD patients. OUD patients had higher incidence and odds of 90-day readmission rates (9.56 vs. 6.04%; OR: 1.55, p

Category: Ankle Arthritis Introduction/Purpose: The ankle is at greatest risk for post-traumatic osteoarthritis (PTOA) in comparison to the hip or knee. Adaptive changes to the cartilaginous topography may be a marker for where cartilage damage poses the greatest risk of development of osteoarthritis. The objective of this study was to elucidate the mechanism of PTOA by analyzing the changes in regional genetic expression of inflammatory markers after impact injury in an ex-vivo porcine model. Methods: Talus bones were recovered from 5 porcine ankles. A drop tower was used to induce injury by dropping a 1000 g weight from a height of 15 cm on the talus. Following the injury the bone was cultured for 24 hours. Four 6-mm cartilage plugs were harvested from the inferior aspect of each talus bone and a small slice of each plug was used for cell imaging. The remaining cartilage plugs were flash frozen with liquid nitrogen and stored at -80°C for ribonucleic acid (RNA) extraction and analysis of gene expression. Expression of inflammatory and catabolic genes (IL1-ß, TNF-a, ADAMTS-5, ADAMTS-4, MMP-3 and MMP-13) was compared among the samples obtained from the non-impacted and impacted sites of the anterior and posterior regions. Student t-test was performed to examine the differences between the control (non-impact) and impacted samples from each region and between the control samples from the anterior and posterior regions. Results: The current porcine impact model demonstrated significant up-regulation of several inflammatory cytokines and metalloproteinases by impact force. Among the genes tested, TNF-a, ADAMTS-4, and MMP-3 showed increased expression at impact sites (p

Category: Midfoot/Forefoot, Healthcare economics Introduction/Purpose: Hallux rigidus is the most prevalent arthritic condition of the foot. Treatment of end-stage disease traditionally consists of a first metatarsophalangeal joint (MTPJ) arthrodesis, however the use of a synthetic cartilage implant is becoming more common. With the high prevalence of disease and implementation of new treatment modalities, healthcare consumers should be aware of the costs associated with management. The purpose of this study was to determine access to the cost and variability in price of first MTPJ arthrodesis and synthetic cartilage implantation. Methods: Forty academic centers were contacted using a standardized patient script. The patient was a 59-year-old female who had failed conservative treatment of hallux rigidus. Each institution was contacted up to three times in an attempt to obtain a full bundled operative quote for a first MTPJ arthrodesis and synthetic cartilage implantation. Results: Twenty centers (50%) provided a quote for first MTPJ arthrodesis and 15 centers (38%) provided a quote for synthetic cartilage implantation. Only 14 centers (35%) were able to provide a quote for both procedures. The mean bundled price for MTPJ arthrodesis was $21,767 (range, $8,417 – $39,265). The mean bundled price for synthetic cartilage implantation was $21,546 (range, $4,903 – $74,145). There was no statistically significant difference between the bundled price for first MTPJ arthrodesis and synthetic cartilage implantation. Conclusion: There was limited availability of consumer prices for first MTPJ arthrodesis and synthetic implantation, therefore impeding healthcare consumers’ decision making. There was a wide range of quotes for both procedures, indicating potential cost savings.

Category: Ankle, Ankle Arthritis Introduction/Purpose: A major complication of total ankle replacement (TAR) is a periprosthetic joint infection (PJI). The reported rate of this complication ranges between 2.4 – 8.9%. Identifying preoperative patient characteristics that correlate with an increased risk of PJI is of great interest to orthopaedic surgeons, as this may assist with appropriate patient selection. The purpose of this study is to systematically review the literature to identify risk factors that are associated with PJI following TAR. Methods: Utilizing the terms “(risk factor OR risk OR risks) AND (infection OR infected) AND (ankle replacement OR ankle arthroplasty)” we searched the PubMed/MEDLINE electronic databases. Using the PRISMA guidelines, studies were selected for inclusion if they assessed clinical risk factors for developing a PJI following TAR. In addition, the reference lists of included studies were also reviewed and compared to the collected studies to ensure that no pertinent papers were omitted. The quality of the included studies was then assessed using the American Academy of Orthopaedic Surgeons Clinical Practice Guideline and Systematic Review Methodology. Recommendations were made using the overall strength of evidence. Results: Eight studies met the inclusion criteria, totaling 12,704 patients who underwent a TAR. A limited strength of recommendation can be made that the following preoperative patient characteristics correlate with an increased risk of PJI following TAR: inflammatory arthritis, prior ankle surgery, age greater than 65 years, body mass index less than 19, peripheral vascular disease, chronic lung disease, hypothyroidism, and low preoperative AOFAS hindfoot scores. There is conflicting evidence in the literature regarding the effect of obesity, tobacco use, diabetes, and duration of surgery. Conclusion: Several risk factors were identified as having an association with PJI following TAR. These factors may alert surgeons that a higher rate of PJI is possible. However, because of the low level of evidence of reported studies, only a limited strength of recommendation can be ascribed to regard these as risk factors for PJI at this time.

Introduction:. The role of elective rotations in the orthopaedic residency selection process varies between programs. Our study aims to identify factors associated with residency programs that interview and match a greater proportion of applicants who have completed an elective rotation with their program. Methods:. Data were collected through the American Orthopaedic Association's Orthopaedic Residency Information Network database. Bivariate correlations and multivariate regression models were used to identify independent predictors of programs with a greater proportion of interviewees or residents who completed an elective rotation at the respective program. Results:. One hundred seventy-eight of the 218 existing residency programs were included in this study. Programs that offered fewer interviews and more away rotation positions per year were associated with a greater odds of its interviewees (OR = 0.36, p = 0.01; OR = 4.55, p < 0.001, respectively) and residents (OR = 0.44, p = 0.04; OR = 4.23, p < 0.001, respectively) having completed an elective rotation with the program. In addition, programs with fewer attendings (OR = 0.39, p = 0.03) and in-person interviews (OR = 3.04, p = 0.04) matched a greater proportion of their rotators. However, programs that interviewed applicants during the elective rotation were less likely to match their rotators (OR = 0.35, p = 0.04). Conclusion:. Certain program characteristics independently predict the likelihood of a program interviewing and matching their rotators. These findings may provide information for applicants and programs regarding the rotation process. Level of Evidence:. III.

Abstract. Objectives:. To determine whether (1) early postoperative complications and (2) time to surgery for operative fixation of fractures distal to the knee differ for Black versus White patients and to assess whether disparities exist within fracture subtypes. Design:. Retrospective database review. Setting:. Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program database. Patients/Participants:. Patients (18 years or older) undergoing open fixation of fractures distal to the knee between 2010 and 2019 (n = 9172 patients). Intervention:. Open reduction and internal fixation of fractures distal to the knee. Main Outcome Measurements:. Thirty-day postoperative complications and time to surgery by race, as compared by multivariable regression with nearest-neighbor propensity score matching. Results:. Of the 9172 patients in our cohort, 1120 (12%) were Black. After matching, we identified 1120 White patients with equal propensity scores as our Black patients. Black patients had 1.5 times higher odds (95% confidence interval [CI]: 1.0–2.0) of experiencing any early adverse event when compared with matched White counterparts. Black patients also had 1.9 times higher odds (95% CI: 1.2–3.0) of requiring unplanned readmission within 30 days of operative fixation. There were no significant differences by race in time to surgery. Fracture subtype (tibia/fibula shaft, isolated malleolar, bi/trimalleolar, and pilon fractures) was not associated with postoperative complications or time to surgery in the multivariable analysis. Conclusion:. Racial disparities in the early postoperative course after open fixation of fractures distal to the knee exist, with significantly higher rates of early adverse events and unplanned readmission persist for Black versus White patients after propensity matching. Level of Evidence:. Prognostic level III.

Background:. Orthopaedic surgeons are at increased risk for many occupational hazards, both physical and mental. The aim of this study was to evaluate a wide range of work-related injuries among orthopaedic surgeons in the United States. Methods:. An electronic survey was developed to assess both physical and mental occupational hazards among orthopaedic surgeons. Descriptive statistics were analyzed for all survey items and compared using chi-square and paired t tests, as appropriate. Results:. The 1,645 responding orthopaedic surgeons (7% response rate) reported a total of 2,702 work-related musculoskeletal injuries, 17.9% of which required surgical treatment. Of the 61 who filed a disability claim, only 66% returned to work and 34% retired early. Additionally, 17.4% of respondents reported having been diagnosed with cancer since starting practice, and 93.8% reported experiencing a finger stick at some point in their career. Over one-half (55.8%) had experienced feelings of psychological distress since beginning practice, and nearly two-thirds (64.4%) reported burnout from work. Conclusions:. This study captured a spectrum of occupational injuries that pose longitudinal risks to an orthopaedic surgeon’s physical and mental well-being. Our hope is that this analysis of occupational hazards will help to raise awareness among the orthopaedic and medical communities and lead to efforts to reduce these risks. Level of Evidence:. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background:. Greater faculty diversity within orthopaedic residency programs has been associated with an increased application rate from students of similarly diverse demographic backgrounds. It is unknown whether these underrepresented student populations have an equitable likelihood of being highly ranked and matching at these programs. Thus, we sought to evaluate the relationship between faculty and resident diversity, with a specific focus on sex, racial/ethnic groups that are underrepresented in medicine (URiM), and international medical graduates (IMGs). Methods:. The American Orthopaedic Association's Orthopaedic Residency Information Network database was used to collect demographic data on 172 US residency programs. Linear regression analyses were performed to determine the relationship between the proportion of female or URiM attendings at a program and the proportion of female, URiM, or IMG residents or top-ranked applicants (≥25 rank). URiM was defined as “racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.” Results:. A mean of 13.55% of attendings were female and 14.14% were URiM. A larger fraction of female attendings was a positive predictor of female residents (p < 0.001). Similarly, a larger percentage of URiM attendings was a positive predictor of URiM residents (p < 0.001), as well as of URiM (p < 0.001) and IMG (p < 0.01) students being ranked highly. There was no significant association between URiM attendings and female residents/overall top-ranked applicants, or vice versa. Conclusions:. Residency programs with more female attendings were more likely to match female residents, and programs with more URiM attendings were more likely to highly rank URiM and IMG applicants as well as match URiM residents. Our findings indicate that orthopaedic surgery residencies may be more likely to rank and match female or URiM students at similar proportions to that of their faculty. This may reflect minority students preferentially applying to programs with more diverse faculty because they feel a better sense of fit and are likely to benefit from a stronger support system. Level of Evidence:. III.

Background:. In May 2022, the Association of American Medical Colleges (AAMC) published guidelines regarding interviews for the 2022-2023 residency application cycle. These guidelines recommended virtual interviews and discouraged “hybrid” interviewing. We conducted a survey of orthopaedic program directors (PDs) to understand their perspectives on these new guidelines and their plans for the upcoming cycle. Methods:. A 19-question multicenter, cross-sectional research survey was emailed to 98 PDs (38.8% response rate) through Qualtrics XM. Contact information was obtained from a public national database. Results:. Most orthopaedic residency programs (60.5%) were planning on conducting in-person interviews before any AAMC and hospital guidelines, and most (65.8%) will likely be conducting virtual interviews post-guidelines. PDs voiced mixed opinions about virtual interviews (39.4% in favor vs. 47.4% against). PDs were also split on whether forgoing the AAMC guidance would be irresponsible for residency programs (47.4% believe it would be irresponsible vs. 44.8% believe it would not); however, a plurality are in favor of the AAMC's guidance (42.1%). Furthermore, PDs agreed that virtual interviews have disadvantages including favoring top-tier applicants, students from home institutions, and in-person rotators, making ranking applicants and learning about a program's culture more difficult. Most PDs (84.2%) felt that hybrid interviews would disadvantage applicants who would choose the virtual option. Conclusion:. AAMC guidance seems to be influencing how most orthopaedic surgery programs will conduct residency interviews for the 2022-2023 cycle. Most PDs agreed with the AAMC guidelines but voiced concerns regarding several disadvantages for all 3 proposed interview options (virtual, in-person, and hybrid). Our results indicate that the recent AAMC guidelines may have contributed to a shift in opinions among PDs but are not sufficient to create a consensus on the best practices for residency interviews. Our findings should encourage solutions focused on the deeper systemic issues within the orthopaedic application process in the post-coronavirus 2019 pandemic era.

Background:. The purpose of this study was to assess the influence of the COVID-19 pandemic on the 2021 orthopaedic surgery residency match outcomes. Because in-person away rotations and interviews were canceled during the 2020 to 2021 application cycle, we hypothesized that applicants would match at their home program at a higher rate in 2021 than in previous years. Methods:. We queried allopathic orthopaedic surgery residency websites and social media accounts for names of residents and medical school information for cohorts matching from 2017 through 2021. To assess availability of and participation in virtual away rotations, we administered a survey to Accreditation Council for Graduate Medical Education–accredited allopathic orthopaedic surgery residency programs. The primary outcome was the annual proportion of applicants matching at the program affiliated with their medical school (“home program”). Subgroup analyses were stratified by Doximity reputation ranking and availability of a virtual away rotation. Results:. We identified 2,632 residents who matched between 2017 and 2020 and 698 residents who matched in 2021. Overall home program match rate and likelihood of home matching were higher in 2021 compared with 2017 to 2020 (28% vs. 20%; odds ratio [OR] = 1.51, 95% confidence interval [CI] 1.24-1.82, p < 0.001). The increase in the home match rate at programs ranked in the top 30 (27% vs. 20%, p = 0.034) was similar to the increase at programs ranked outside the top 30 (28% vs. 20%, p < 0.001). Of the 66 (48%) programs that responded to the survey, 16 (24%) offered a virtual away rotation. Programs with a higher Doximity ranking were more likely than lower-ranked programs to offer a virtual away rotation (OR = 6.75, 95% CI 1.95-23.4, p = 0.003). Home match rates did not differ significantly between programs that offered a virtual away rotation and those that did not (26% vs. 32%, p = 0.271). Conclusions:. A higher proportion of orthopaedic surgery residency applicants matched at their home program in 2021 compared with previous years. Limitations on in-person activities due to the COVID-19 pandemic may have contributed to this rise. Level of Evidence:. N/A.

Background:. Amid the COVID-19 pandemic, medical education and residency application have faced unprecedented changes. This has forced residency directors to alter their selection criteria in the absence of away rotations and the implementation of nationwide virtual interviews. Purpose:. The purpose of this study was to assess how residency directors have adapted their selection criteria in light of this unique application cycle and to look at the effect, and future, of the different changes. Methods:. A 16-question online survey was disseminated to 31 residency programs gathering data about new opportunities offered this cycle, changes to selection criteria, match outcomes, as well as the number of applicants to their program. Results:. Twenty-nine respondents completed the survey (94% response rate). There was a significant rise in the number of applications received by programs this cycle (p < 0.05). Programs have unanimously altered their selection processes. The biggest changes in selection criteria were putting more weight into communication from mentors, emails from the applicants, home applicant status, and virtual information session attendance. Some programs used additional application requirements beyond Electronic Residency Application Service, which were often uncompleted, and cut the number of eligible applications by up to 46%. Among the new opportunities offered this cycle, virtual information sessions and social media platforms seem to be the most commonly offered and are anticipated to grow. Discussion and Conclusion:. Orthopaedic surgery residency continues to become more competitive with a significant rise in the number of applications during the COVID-19 pandemic. Amid this increasingly demanding virtual application cycle, a holistic application review was more challenging. More weight was put that cycle into communication from faculty mentors, emails from the applicants, home applicant status, and virtual information session attendance. Supplementary applications and virtual informative opportunities are likely to last and change the future of the orthopaedic surgery residency application process.