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Background: Female representation varies geographically among orthopaedic residency programs, with the southern region of the United States reported as having relatively lower rates of female orthopaedic surgeons. Purpose: To determine the gender and geographic distributions of US-based orthopaedic sports medicine surgeons and analyze geographic patterns between their training locations and present-day practices. Study Design: Cross-sectional study. Methods: American Orthopedic Society of Sports Medicine (AOSSM) fellowship completion data from the 2016-2021 academic years were analyzed with regard to gender and fellowship location. Medical school, residency, and current practice locations were obtained via internet searches for all individuals identified within the databases. Locations were categorized into regions based on the US Census Bureau definitions. Descriptive statistical analysis was performed on the data. Results: A total of 1268 sports orthopaedic surgeons who graduated fellowship from 2016 to 2021 were analyzed: 141 (11%) were female and 1127 (89%) were male. The percentage of female sports medicine surgeons in fellowship remained constant (11%-12%) from 2016 to 2021. On average, the annual percentage of female orthopaedic sports medicine fellows was 7.2% in the South, 10.4% in the West, 14.2% in the Midwest, and 14.7% in the Northeast. Based on the orthopaedic sports medicine fellowship graduates from 2016 to 2021, the mean percentage of current female orthopaedic sports medicine surgeons in practice was 7.4% in the South, 11.7% in the Northeast, 12.8% in the Midwest, and 14.4% in the West. Conclusion: Approximately 11% of our sample was female; however, this percentage varied heavily by region, with the southern region having significantly lower rates of gender diversity.

Ankle fractures are common injuries treated by orthopedists. Indications for operative repair of deltoid ligament (DL) injuries in ankle fracture patients are debated. The purpose of this review is to determine the indications for operative DL repair. Ovid MEDLINE, CINAHL, and Scopus were searched up to December 2019. Web of Science was searched up to August 2018. Search terms included "Deltoid" and "Ligament" or "Ligaments." Comparative studies assessing conservative vs operative DL repair were searched for. Articles meeting inclusion criteria were screened in two stages to determine eligibility. Out of 1,542 articles, nine were included in our qualitative synthesis. These nine studies included 449 patients, of which 233 were treated with open reduction internal fixation (ORIF) with or without trans-syndesmotic (TS) screw fixation, and 205 of which were treated with ORIF with DL repair. The remaining 21 patients were managed nonoperatively, had no evidence of DL injury, or were lost to follow-up. There is a lower rate of malreduction associated with DL repair compared to TS screw fixation. Moreover, DL repair may be useful in treating patients with Weber Type C fractures, concomitant DL-syndesmotic disruption, or residual valgus instability following ORIF in isolated lateral malleolar fractures.

Hallux valgus is one of the most common conditions treated by foot and ankle orthopedists; over 140 surgical procedures have been developed for management of the condition. A rare complication of hallux valgus repair is nonunion, and the literature regarding nonunion after hallux valgus repair is correspondingly sparse. We present a 39-year-old active duty male who underwent operative management after developing nonunion and transfer metatarsalgia following a proximal oblique metatarsal osteotomy. The patient underwent nonunion correction and metatarsal lengthening via bone allografting. No complications were observed during the intra- or perioperative periods. At 2.5-years postoperatively, the patient’s symptoms had largely resolved. He expressed high satisfaction with his outcome and was able to continue activity duty. Our findings indicate that nonunion repair can have excellent clinical outcomes with high patient satisfaction, even in an active military population.

Background: The objective of this study was to evaluate sex differences in the incidence and risk of ankle–foot complex (AFC) stress fractures among U.S. military personnel, which could assist in d...

Vitamin D is critically important to numerous physiologic functions, including bone health. Poor vitamin D status is a common but underrecognized problem that predisposes the military population to stress fracture and completed fracture. This has significant implications for force health protection, warfighter readiness, attrition, and cost. Despite this, vitamin D deficiency is still underdiagnosed and undertreated in the military. This is a major hindrance to military readiness and one that could easily be modified with awareness, prevention, and early treatment. In this commentary, we review the literature on vitamin D deficiency and critically examine the current status of policies and clinical practice related to vitamin D in the military health system. We offer several practical recommendations to increase awareness and readiness while decreasing musculoskeletal injury and the associated costs.

Introduction: First metatarsal phalangeal joint (MTPJ) arthroplasty has a high failure rate due to aseptic loosening, which leads to bone loss. The salvage procedure is conversion to an arthrodesis, but bone loss can make obtaining screw fixation difficult. Herein, we report a unique case of revision first-metatarsal arthrodesis without the use of hardware after a failed arthroplasty. Case Report: A 60-year-old women presented to us with first MTPJ pain in the setting of failed arthroplasty. We performed an arthrodesis; however, intraoperatively, hardware fixation could not be obtained due to bone loss. We utilized allograft bone struts to maintain first ray length and to hold the correct hallux position during arthrodesis maturation. Conclusion: Bone loss is a frequently encountered problem in revision surgery to a first MTPJ arthrodesis. An arthrodesis can be obtained without the use of hardware in scenarios where bone loss precludes screw fixation. Keywords: Hallux rigidus, revision, bone loss, arthrodesis

We present a unique case of chronic deltoid ligament disruption in a 34-year-old high-level military operator with a 12-month history of acute-onset medial ankle pain. Magnetic resonance imaging showed an isolated chronic disruption of the superficial and deep deltoid ligament. The patient was managed operatively with a semitendinosus allograft. No complications were observed during the intra- or perioperative periods. At 12-month follow-up, the patient reported near-complete pain resolution and was able to return to unrestricted active duty. Use of allograft ligamentous reconstruction of the deltoid ligament in a highly active soldier was successful, allowing return to unrestricted active duty.

Category: Ankle; Bunion; Hindfoot; Lesser Toes; Midfoot/Forefoot Introduction/Purpose: There is a growing trend to perform surgical procedures at freestanding ambulatory surgical centers. No literature exists evaluating the rate of adverse events and overall safety of foot and ankle outpatient surgeries at a freestanding ambulatory surgery center (ASC). Methods: A retrospective review of all foot and ankle cases performed over a two year period at a single freestanding ASC. A total of 313 cases were performed. Adverse events are state-reported events that cause harm or lead to additional treatment. Using state-reported adverse events criteria and previous literature from hand and upper-extremity cases, we categorized our adverse events into seven categories: 1) infection requiring intravenous abx or return to the operating room, 2) postoperative transfer to a hospital, 3) wrong-site surgery, 4) retention of a foreign object, 5) postoperative symptomatic thromboembolism (DVT), 6) medication error, and 7) bleeding complications. Results: The overall rate of adverse events was 3.5% with 11 events identified over the two year period. There were a total of 10 infections and 1 symptomatic DVT. There were no cases that resulted in transfer to a hospital, hospital admission after discharge, medication error, bleeding complications, wrong-site procedures, or retained foreign bodies. Conclusion: Outpatient foot and ankle procedures are not without complications, but the overall rate of complications postoperatively is farly low (3.5%). Overall, foot and ankle surgeries can be performed safely in an outpatient setting at an ASC.

Introduction The medical device industry has grown substantially in recent years. There is limited research examining orthopedic subspecialties and the recall of orthopedic devices. We hypothesize that knee arthroplasty devices cleared through the Food and Drug Administration (FDA) 510(k)-notification process would have a higher recall rate than the premarket approval (PMA) process. Methods The FDA database was thoroughly queried for all knee arthroplasty surgical devices from January 1, 2007 through December 31, 2017. Recalled devices were analyzed by manufacturer, type of implant, recall class, manufacturer-determined reason, FDA-determined reason, quantity affected, submission type, and distribution within the United States or internationally. Results Out of over 30,000 medical devices on the market, a total of 300 knee arthroplasty devices from 18 different companies were recalled during the time frame of this study. Tibial components accounted for 35.33% of devices, polyethylene implants for 38.67%, and femoral components for 15%. The most common reason for recall was device design (n = 134, 44.67%), followed by process control (n = 32, 10.67%). Of the 300 knee arthroplasty devices recalled, 267 (89.0%) were cleared through the 510(k) premarket notification process and 33 (11.0%) devices were approved through the PMA process. Conclusions A larger proportion of knee arthroplasty surgical devices cleared through the 510(k) process were recalled compared to implants approved through the stricter PMA process. Changing the 510(k) process may enable manufacturers to improve upon the safety of their devices.

We present a unique case of chronic peroneal tendon dislocation in a 47-year-old active duty military member with a 2-mo history of acute onset lateral ankle pain due to sports injury. Magnetic resonance imaging revealed superficial peroneal retinaculum (SPR) disruption, a flattened retrofibular groove, dislocation of the peroneus longus tendon, and a tear of the peroneus brevis tendon. The patient was managed operatively with fibular groove deepening, SPR reconstruction, peroneus brevis debridement, and peroneus longus tubulurization. No complications were observed during the intra- or perioperative periods. At their 3-mo follow-up, the patient reported near complete resolution of pain and the ability to ambulate without any brace or support. He returned to running and was able to deploy fit for full duty 4.5 mo from injury.

Background This study evaluates the safety of foot and ankle outpatient surgeries at a freestanding ambulatory surgery centers. Methods A total of 1352 cases were evaluated for adverse events in a retrospective review of all foot and ankle cases performed over a 5-year period at a single center. Results The rate of adverse events was 2.3%, with 31 identified over the 5-year period (23 infections, 5 symptomatic thromboembolisms, 3 postoperative hospital transfers). Discussion The rate of postoperative adverse events in outpatient foot and ankle procedures is low. These surgeries can be performed safely in an outpatient setting at an ASC. Level of evidence Level IV, Case Series.

Category: Total Ankle Arthroplasty Introduction/Purpose: Although demand for total ankle arthroplasty (TAA) is increasing, access to high-volume TAA surgeons may vary in different geographic regions. Given that low-volume TAA surgeons have demonstrated higher revision rates compared to higher-volume surgeons, access to these high-volume centers is a matter of patient and public health interest. The recent public release of the Medicare Provider Utilization and Payment Public Use File (MPUP-PUF) now allows for identification of individual providers who perform specific procedures. This study analyzed surgeon prevalence, distribution and factors that correlate with higher or lower high-volume surgeon population in metropolitan areas. Methods: The MPUP-PUF was reviewed for the 2012-2015 calendar years and data were extracted for all physicians who performed a minimum of eleven TAA procedures among traditional Medicare patients. These physicians were grouped into major metropolitan areas (population of one million or more). Average reimbursement, number of high-volume TAA surgeons and number of total procedures were calculated per major metropolitan area. The presence of an American Orthopaedic Foot and Ankle Society (AOFAS) fellowship and mean geographic reimbursement were analyzed for correlation with number of high- volume TAA surgeons. Results: The MPUP-PUF for 2012 to 2015 included 58 unique surgeons who performed a minimum of 11 TAA procedures in any of those calendar years, with a combined total 2,281 Medicare TAA procedures. Of these surgeons, 81% practice within major metropolitan areas with population greater than one million. Distribution among major metropolitan areas is highly unequal and higher numbers of surgeons are present in cities with an AOFAS fellowship. Conclusion: Access to high-volume ankle replacement surgeons among the Medicare population is lacking in multiple major metropolitan areas in the United States due to the uneven distribution of these surgeons. This method of analysis allows for opportunities to target training programs as well as placement of physicians to ensure access to high-volume ankle arthroplasty surgeons.

Background: Inversion ankle injuries are extremely common, sometimes causing injury to the peroneus brevis tendon. If more than 50% of the tendon is injured, it oftentimes requires tenodesis to the adjacent peroneus longus tendon. Both Pulvertaft (PT) and side-to-side (SS) techniques have been used for joining the 2 tendons. The purpose of this study was to compare the strength and stiffness of these 2 techniques. Methods: Five matched pairs of cadaver ankle specimens were randomized to receive either an SS or PT tenodesis of the peroneus brevis to longus tendons. Following the tenodesis, the specimens were tested for failure load, displacement, energy absorbed at failure, and peak load. Stiffness was also calculated. Paired t tests were performed to detect differences between the 2 conditions. Results: There were no statistically significant differences between the SS and PT tenodesis for any of the metrics measured. For stiffness, the techniques were very similar (SS = 10.14 [4.35], PT = 12.85 [1.72]). Conclusion: There is no difference in failure load, displacement, energy absorbed at failure, peak load or stiffness between the PT and SS techniques for peroneal tenodesis. Level of Evidence: Level V, cadaver study.

Introduction Orthopaedic devices represent 12% of all medical device recalls. Products are approved through pre-market approval (PMA) or the 510(k) premarket notification process. No previous evaluation was found in the literature evaluating foot and ankle device recalls. The field of foot and ankle subspecialty has seen a rapid growth in innovation related to implants in recent years. Methods The Food and Drug Administration (FDA) Device Recall database was evaluated for all foot and ankle devices from 2007 through 2017 for the manufacturer, process of approval, type of implant, recall class, dates of initiation and termination of the recall, manufacturer determined reason, quantity affected, and distribution within the United States or internationally. Results A total of 161 products from 33 companies were identified with 158 (98.1%) approved through the 510(k) process. The most common reason for device recall was due to the device breaking intraoperatively or postoperatively. The average length of the recall was 487.5 days. Conclusions Device recall is not an uncommon event with the majority of products approved through the less demanding 510(k) process.

Lisfranc injuries are typically treated in the acute setting with open reduction and internal fixation (ORIF). The type of hardware that provides the best fixation for these injuries has not been definitively determined. Recently, dorsal bridge plating has increased in popularity. We report a case of partial extensor hallucis longus (EHL) injury after dorsal bridge plate fixation of a Lisfranc injury. The patient was successfully treated with hardware removal, tendon debridement, and tubularization. This case highlights a potential complication of dorsal bridge plating in the treatment of Lisfranc injuries.

Synovial chondromatosis of the ankle is rare and sparsely documented. Traditional surgical intervention is open loose body excision and synovectomy. Upon literature review, only two other cases were found to be managed arthroscopically. We report a case of synovial chondromatosis in a 54-year-old man leading to pain and limited range of motion of his ankle. This unique case of extensive nodule formation was treated via a three-port arthroscopic approach. Removal of loose bodies and synovectomy were successfully performed arthroscopically. A total of 76 loose bodies were removed and synovectomy performed using a 3.5 mm diameter full radius shaver. This case demonstrates that a three-port arthroscopic approach can provide adequate treatment while maintaining the superior risk profile inherent to arthroscopic intervention.

Background There is a noticeable lack of studies examining the connection between psychiatric illness and orthopaedic injury. The goal of this study is to determine if a relationship exists between calcaneus fracture and psychiatric illness or use of psychotropic medication. Methods A retrospective review was undertaken of calcaneus fracture patients at our institution from January 2011 through January 2014, and those with a diagnosis of psychiatric illness or history of psychotropic medication usage were identified. Medication records were analyzed along with medical histories taken during the initial encounter. If the patient was admitted, hospital notes for the hospitalization were reviewed to determine if any information was missed during the initial encounter. The date of injury, age, sex, insurance status at the time of initial encounter, psychiatric diagnoses or psychotropic medication use, and mechanism of injury were recorded. Any specific psychiatric diagnoses were collected from the patient charts, as was the presence of any specific prescribed psychotropic medications. After completion of the data collection, an attending psychiatrist verified the recorded data to ensure an accurate psychiatric assessment. Results A total of 85 calcaneus fractures met the inclusion criteria. In the population, there were 71 males and 14 females. The average age of the patients was 41.74 years, with 24% of patients having a diagnosis of psychiatric illness at the time of injury. The relative risk of a psychiatric illness in males compared to females was 0.31 (p = 0.009) while the relative risk of using psychotropic medication in males compared to females was 0.17 (p = 0.0007). Males were less likely to undergo operative intervention than females (p = 0.0001). The average age of a patient who either had a diagnosis or took medication for a psychiatric illness was 48.4 years, as compared to 39.7 years in those who did not (p = 0.014). Conclusion Males were less likely to have a psychiatric illness or be currently treated with psychotropic medications. A dedicated review of psychiatric history and prior medication may be useful during preoperative, perioperative, and postoperative treatment planning. Level of Clinical Evidence: 4.