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Category: Ankle; Midfoot/Forefoot Introduction/Purpose: As medical and recreational cannabis use continues to increase in prevalence across the United States, it is important to understand the impacts of sustained cannabis use on one’s health. Previous literature has shown the potential for cannabidiol products to aid in the improvement of some osteoarthritic symptoms. However, there is a paucity of literature examining the relationship between cannabis use and postoperative medical outcomes for end stage osteoarthritis management, including procedures such as foot and ankle arthrodesis. Therefore, the purpose of this study was to investigate the relationship between cannabis use and the incidence of medical complications within 90 days of foot or ankle arthrodesis. Methods: A retrospective review of a national insurance claims database was performed from 2010 to 2022. CPT codes were used to identify patients who underwent arthrodesis of the ankle, subtalar, talonavicular, calcaneocuboid, naviculo-cuneiform, midtarsal, tarsometatarsal, metatarsophalangeal, or interphalangeal joints. Of those patients, those with established diagnoses of cannabis use disorder, cannabis dependency, or cannabis addiction were identified using ICD-9 and -10 codes. This cannabis cohort was matched 1:4 on the basis of age, sex, and Charlson Comorbidity Index (CCI) to a control cohort without a history of cannabis use to remove potential confounding upon comparison. Demographic and comorbidity profiles, as well as medical and surgical post-operative outcomes were compared using Chi-square tests. Results: Out of 192,162 patients undergoing foot or ankle arthrodesis, 6,387 had a documented history of cannabis use. Compared to controls, the cannabis cohort was significantly younger (mean age 44.1 vs. 56.5; p< 0.001), exhibited a higher comorbidity burden (mean CCI 1.59 vs. 1.38; p< 0.001), and had a greater proportion of male patients (48.2% vs. 31.9%; p< 0.001). Post-matching for age, CCI, and sex, cannabis users demonstrated a significantly higher incidence of medical complications within 90 days of their index ankle fracture ORIF procedure. Notably, cannabis users exhibited elevated rates of various complications, including pneumonia, deep venous thrombosis, pulmonary embolism, myocardial infarction, stroke, surgical site infection, cardiac arrest, acute kidney injury, urinary tract infection, sepsis, and hypoglycemia compared to matched controls (all p< 0.001). Conclusion: Cannabis use is associated with increased incidences of many serious medical complications within 90 days of foot or ankle arthrodesis. These results may help better inform physicians and patients about the increased postoperative risks cannabis users may face, which may lead to the implementation of tailored perioperative care. Further, these results emphasize the need for further research on the molecular mechanisms of cannabis to understand the risk-benefit ratio between the therapeutic effects of cannabidiol for arthritic pain relief, and the adverse outcomes that may result following surgical intervention.

Category: Ankle; Trauma Introduction/Purpose: As medical and recreational cannabis use continues to increase in prevalence across the United States, it is important to understand how cannabis can impact health. Though prior studies have shown that cannabis use can result in delayed bone healing, there is a paucity of literature examining the relationship between cannabis use and postoperative medical outcomes following fracture fixation. Therefore, the purpose of this study was to investigate the relationship between cannabis use and the incidence of medical complications within 90 days of surgical fixation of ankle fractures. Methods: A retrospective review of a national insurance claims database was performed from 2010 to 2022. Patients who underwent open reduction and internal fixation (ORIF) procedures for medial malleolus fractures, lateral malleolus fractures, distal fibula fractures, bimalleolar fractures, and trimalleolar fractures were identified using CPT codes. Of those patients, those with established diagnoses of cannabis use disorder, cannabis dependency, or cannabis addiction were identified using ICD-9 and -10 codes. This cannabis cohort was matched 1:4 on the basis of age, sex, and Charlson Comorbidity Index (CCI) to a control cohort without a history of cannabis use to remove potential confounding upon comparison. Demographic and comorbidity profiles, as well as medical and surgical post-operative outcomes were compared using Chi-square tests. Results: Out of 788,702 patients undergoing ankle fracture open reduction and internal fixation (ORIF) during the study period, 46,105 had documented cannabis use. Cannabis cohort, compared to controls, exhibited significant differences: younger age (mean 38.8 vs. 52.7 years; p< 0.001), lower comorbidity-burden (mean CCI 1.58 vs. 1.68; p< 0.001), and a higher proportion of male patients (51.1% vs. 33.2%; p< 0.001). Following age, CCI, and sex matching, patients with cannabis use histories showed a significantly increased incidence of medical complications within 90 days post ankle fracture ORIF. Cannabis users displayed elevated rates of various complications compared to matched controls, including pneumonia, deep venous thrombosis, pulmonary embolism, myocardial infarction, stroke, surgical site infection, cardiac arrest, acute kidney injury, urinary tract infection, sepsis, and hypoglycemia (all p< 0.001). Conclusion: Cannabis use is associated with increased incidences of many serious medical complications within 90 days of ankle fracture fixation procedures. These results underscore the importance of eliciting cannabis use history during preoperative patient evaluations so that physicians and patients can be better informed about the increased postoperative risks they may face, and so tailored perioperative care can be appropriately implemented. Further, these results emphasize the need for further research on the molecular mechanisms of cannabis to explain interactions that may predispose heavy cannabis users to this profile of adverse surgical outcomes.

Category: Ankle; Ankle Arthritis Introduction/Purpose: Obesity is an ongoing public health epidemic with wide-ranging implications for orthopaedic surgery. Bariatric surgery has been shown to be an effective method for weight reduction. This retrospective cohort study aimed to compare rates of reoperation between patients who underwent primary ankle arthrodesis (AA) and those who underwent total ankle arthroplasty (TAA) after undergoing bariatric surgery. Methods: Utilizing data from PearlDiver, patients who received primary AA or TAA with prior history of bariatric surgery to a cohort without prior bariatric surgery were retrospectively analyzed for reoperations. Both cohorts were propensity-matched based on age, sex and Charlson Comorbidity Index in a 1:4 ratio. Indications for reoperation included revision, prosthetic joint infection (PJI), hardware removal, adjacent joint fusion, and local open reduction internal fixation (ORIF). Kaplan-Meier survival analysis and hazard ratios were calculated for five years after the procedure. Results: Of the 801 patients with prior history of bariatric surgery, 519 (65%) underwent AA, while 282 (35%) underwent TAA. At 5 years post-operatively, patients who had undergone AA showed a higher incidence of adjacent joint fusion if they had prior history of bariatric surgery (Hazard ratio: 1.79, 95% Confidence Interval: 1.23 - 2.61, P-value < 0.001). No differences in reoperation rates were observed for PJI, hardware removal and ORIF. At 5 years, patients who had undergone TAA with history of bariatric surgery showed no difference in the incidence of revision, PJI, hardware removal, ORIF and adjacent joint fusion as compared to patients who underwent TAA with no history of bariatric surgery. Conclusion: Our findings suggest that patients undergoing primary TAA displayed comparable reoperation rates regardless of prior bariatric surgery history over a five-year post-procedure period. In contrast, patients undergoing primary AA exhibited an increased risk of adjacent joint fusions if they had history of bariatric surgery, although the rates of reoperation due to PJI, ORIF, and hardware removal remained comparable. Notably, our results do not position a prior history of bariatric surgery as a significant determinant in reoperation rates. These insights offer valuable guidance for orthopedic surgeons navigating the complexities of surgical interventions in the context of bariatric surgery.

Category: Ankle; Midfoot/Forefoot Introduction/Purpose: With the rising prevalence of cannabis consumption among individuals undergoing foot and ankle procedures, there is a critical need for a comprehensive investigation into the impact of cannabis use on post-operative outcomes. The shifting societal attitudes towards cannabis, coupled with legislative changes promoting increased accessibility, underscore the urgency of understanding the implications for both patients and surgeons. This study aims to address this gap in knowledge and provide insights that can guide pre-operative evaluations and post-operative care planning. Methods: Utilizing data from PearlDiver, patients who underwent interphalangeal fusion, arthrodesis, arthroscopy, total ankle arthroplasty, ankle fracture repair, lateral ankle ligament reconstruction, calcaneal tendon repair, bunionectomy and calcaneal osteotomy were identified. These patients with prior history of cannabis use were propensity-matched with a cohort without prior history of cannabis use based on age, sex and Charlson Comorbidity Index in a 1:4 ratio. Both cohorts were evaluated for 90-day occurrence of medical complications using univariate analysis. Results: In this study, we matched 59,797 patients with a history of cannabis use undergoing foot or ankle procedures with 239,086 without such history. Those with prior cannabis use showed significantly elevated rates of medical conditions compared to controls: pneumonia (6.1% vs. 2.2%, p < .001), deep vein thrombosis (1.5% vs. 0.8%, p < .001), pulmonary embolism (0.4% vs. 0.2%, p < .001), myocardial infarction (1.6% vs. 0.5%, p < .001), stroke (1.8% vs. 0.8%, p < .001), surgical site infections (4.0% vs. 2.2%, p < .001), acute kidney injury (6.8% vs. 3.0%, p < .001), urinary tract infections (9.0% vs. 3.5%, p < .001), sepsis (4.6% vs. 2.0%, p < .001), and hypoglycemia (1.2% vs. 0.5%, p < .001). Conclusion: This study highlights a compelling correlation between prior cannabis use and heightened risks of medical complications post foot and ankle surgeries. The findings emphasize the imperative for healthcare professionals to include cannabis use history in pre-operative assessments and post-operative care planning. Acknowledging the evolving landscape of cannabis use among surgical patients, further research is essential to refine clinical approaches and enhance patient outcomes in this context.

Category: Other; Midfoot/Forefoot Introduction/Purpose: The advent of minimally invasive percutaneous foot and ankle surgery techniques has helped lower certain complication rates, including wound infection and nonunion. The percutaneous burr is the working horse to perform these procedures. One concern with using the burr is that heat generated from prolonged use may induce bone thermal necrosis, affecting healing and outcomes. It is in contention whether further chilling the irrigation fluid may affect postoperative complication rates. Thus, the objective of this study is to assess the impact of chilled vs non-chilled saline during burr use on percutaneous foot surgery. Methods: Data was prospectively collected for 384 consecutive patients undergoing percutaneous foot and ankle surgeries at two separate facilities, treated with either non-chilled saline or chilled saline. Age, sex, complication rates, union rates and time to union data were collected. Categorical and numerical statistical analysis was performed. Results: 384 patients (chilled = 191, non-chilled = 193) were included. The mean age (SD) for all patients was 50.82 (14.28). Time to union took an average (SD) of 9.87 (3.59) weeks for the chilled saline group and 9.27 (2.91) weeks for the non-chilled saline group (P = .07). Union rates were 100% in the chilled saline group and 99.5% in the non-chilled saline group (P = .50). Complication rates were 1.6% in both the chilled and non-chilled saline groups (P = .65). The complications seen in the chilled saline group included one superficial wound dehiscence, and two delayed unions. The non-chilled saline group saw one non-union, one case of sural neuritis and one case of painful hardware removal. Conclusion: Based on the available data, no significant difference could be detected between chilled saline and non-chilled saline groups during burr use for percutaneous foot surgery when comparing union times, union rates and complication rates.

Category: Ankle; Trauma Introduction/Purpose: Syndesmotic injuries are commonly treated with syndesmotic screws, with subsequent screw removal routinely scheduled during the postoperative period. Recent studies have raised doubts about the necessity of routine removal, highlighting the lack of change in functional outcomes and the risks posed by a second surgery. Previous systematic reviews on this topic have not limited their inclusion criteria to Randomized Controlled Trials (RCTs), consequently lowering their level of evidence (LOE). Our study aimed to compare the functional outcomes and complication rates in patients undergoing routine syndesmotic screw removal versus those managed with an on-demand approach while providing a higher LOE than previous studies. Methods: In accordance with the guidelines on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) we conducted a systematic search of seven databases (MEDLINE, Embase, Cochrane CENTRAL, CINAHL, Web of Science, PubMed, and ClinicalTrials.gov) for comparative studies on routine syndesmotic screw removal versus an on-demand approach to removal following acute ankle fractures or isolated syndesmotic injuries. Only prospective RCTs were considered for inclusion. Data reported by at least 2 studies were pooled for meta-analysis using Review Manager Software (RevMan 5.4.1). Mean differences were calculated for continuous outcomes while risk ratios were calculated for dichotomous outcomes; all measures were calculated with their respective 95% confidence intervals (CIs). Two-tailed tests of significance were performed with a value of 0.05. Heterogeneity was calculated using I2 index, Random-effect models were used for groups with high heterogeneity (I2 > 51%) while common-effect models were used for groups with low heterogeneity (I2 < 50%). Results: Of 630 potential articles, only 3 studies were ultimately chosen for inclusion. Pooled data analysis showed no significant difference in Olerud-Molander ankle scores (mean difference [MD] -2.36, 95% confidence interval [CI] -6.50 to 1.78, p = 0.26), American Orthopedic Foot and Ankle Hindfoot Score (MD -0.45, 95% CI -1.59 to .69, p = 0.44), or dorsiflexion (mean difference 2.20, 95% CI -0.50 to 4.89, p = 0.11) between the routine removal and on-demand removal groups at the one-year mark postoperatively. However, routine removal was associated with a significantly higher rate of overall complications compared to on-demand removal (risk ratio 3.02, 95% CI 1.64 to 5.54, p = 0.0004). Respectively, none of the included studies reported a significant difference in pain scores or range of motion. Conclusion: Our results did not show any significant difference in functional outcome scores between routine removal and on-demand removal of syndesmotic screws at 1-year postoperatively, suggesting that neither removal strategy significantly impacts functional recovery. However, the significantly higher incidence of complications in the routine removal group, raises important considerations regarding the potential disadvantages of this approach. Consequently, given the elevated risk of complications associated with routine removal and the lack of superior functional outcomes, we recommend adopting an as-needed approach to syndesmotic screw removal.

Background: Research experience is mandatory for all Orthopaedic Surgery residency programs. Although the allocation of required protected time and resources varies from program to program, the underlying importance of research remains consistent with mutual benefit to both residents and the program and faculty. Authorship and publications have become the standard metric used to evaluate academic success. This study aimed to determine if there is a correlation between the research productivity of Orthopaedic Surgery trainees and their subsequent research productivity as attending Orthopaedic Surgeons. Methods: Using the University of Mississippi Orthopaedic Residency Program Research Productivity Rank List, 30 different Orthopaedic Surgery Residency Programs were analyzed for the names of every graduating surgeon in their 2013 class. PubMed Central was used to screen all 156 physicians and collect all publications produced by them between 2008 and August 2022. Results were separated into two categories: Publications during training and Publications post-training. Results: As defined above, 156 Surgeons were analyzed for publications during training and post-training. The mean number of publications was 7.02 ± 17.819 post-training vs. 2.47 ± 4.313 during training, P

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.

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.

Background: There is a gap in the literature regarding musculoskeletal risk factors for concussion within the National Football League (NFL), which is an avenue that must be explored to promote player safety given the high incidence of both injury types. This study aims to observe if ankle injuries are associated with an increased risk of subsequent concussion in NFL players. Methods: The public online database ProFootballReference.com was used to identify ankle injuries and concussions in NFL players from the 2009-2010 to 2019-2020 seasons. Multivariable logistic regression for subsequent concussion and ankle injury was performed, adjusting for body mass index (BMI), age, and player position. For descriptive statistics, unpaired t tests with unequal variance were performed for continuous variables, including BMI and age. χ 2 testing was performed for categorical variables, including player position, and whether the position was offensive, defensive, or on special teams. Results: Of the 5538 NFL players included in the study, 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 = .387); however, the aOR for concussion following multiple ankle injuries was 2.87 (95% CI 1.23-6.75, P = .015). Special teams players had the lowest risk for concussion (aOR 0.17, 95% CI 0.069-0.36, P

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.

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:. 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:. 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.

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: 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:. 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: 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.

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.

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

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: 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: 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: 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

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: 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: 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: 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: 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: 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: 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: 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

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

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.