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Simulation-based surgical skills training addresses several concerns associated with the traditional apprenticeship model, including patient safety, efficient acquisition of complex skills, and cost. The surgical specialties already recognize the advantages of surgical training using simulation, and simulation-based methods are appearing in surgical education and assessment for board certification. The necessity of simulation-based methods in surgical education along with valid, objective, standardized techniques for measuring learned skills using simulators has become apparent. The most commonly used surgical skill measurement techniques in simulation-based training include questionnaires and post-training surveys, objective structured assessment of technical skills and global rating scale of performance scoring systems, structured assessments using video recording, and motion tracking software. The literature shows that the application of many of these techniques varies based on investigator preference and the convenience of the technique. As simulators become more accepted as a teaching tool, techniques to measure skill proficiencies will need to be standardized nationally and internationally.

Introduction Following successful closed reduction, the ideal timing of operative fixation for ankle fracture–dislocations is not well understood. We sought to describe the rate at which initial reduction is lost between the Emergency Department (ED) and clinic visits, and to identify factors associated with loss of reduction. Materials and methods We identified 30 patients with isolated, closed ankle fracture–dislocations that were successfully reduced and splinted in the ED prior to operative intervention. The maintenance of reduction at follow-up clinic visit was defined as a success, and loss of reduction was defined as a failure. Results There were 17 (57%) successes and 13 (43%) failures. When the ratio of posterior malleolus (PM) fracture fragment size to complete articular surface was >0.1, rate of failure was 65% compared with 18% when the ratio was ≤0.1 (p = 0.016). Conclusion Ankle fracture–dislocations with a larger PM fracture fragment size may warrant consideration of earlier operative intervention. Level of evidence IV, Case Series. Matson AP, Green CL, Hurwitz SR, Zura RD. Stability of Ankle Fracture–dislocations following Successful Closed Reduction. The Duke Orthop J 2017;7(1):58-63.

Outcomes following ankle fracture surgery have been well studied; however, factors associated with surgical wound healing specifically are less clear. We aimed to study the relationship between wound healing and body mass index, as well as other variables following surgical treatment of ankle fractures. There were 127 consecutive, isolated, closed, malleolar ankle fractures treated with open reduction and internal fixation at a level-1 trauma center from 2008 to 2012. Patient, injury, and treatment variables were recorded and clinical records were reviewed to identify wound complications. There were 6 major and 18 minor wound complications. The overall rate of wound complication of any type was significantly lower in obese patients at 11.7% (7/60) compared with 25.4% (17/67, P < .05) in nonobese patients. When controlling for other variables obesity was associated with a significantly lower risk of developing a wound complication (OR 0.267, 95% CI 0.087-0.822), as was low energy mechanism (OR 0.246, 95% CI 0.067-0.906). No other covariates tested were associated with an increased risk of a wound infection. Ankle anatomy may present a unique situation whereby obesity may be protective against wound complications. Further studies are needed to confirm this clinical observation, and to demonstrate the mechanism through which this may occur.Levels of Evidence: Therapeutic, Level IV: Retrospective

Simulation-based surgical skills training is recognized as a valuable method to improve trainees’ performance and broadly perceived as essential for the establishment of a comprehensive curriculum in surgical education. However, there needs to be improvement in several areas for meaningful integration of simulation into surgical education. The purpose of this focused review is to summarize the obstacles to a comprehensive integration of simulation-based surgical skills training into surgical education and board certification and suggest potential solutions for those obstacles. First and foremost, validated simulators need to be rigorously assessed to ensure their feasibility and cost-effectiveness. All simulation-based courses should include clear objectives and outcome measures (with metrics) for the skills to be practiced by trainees. Furthermore, these courses should address a wide range of issues, including assessment of trainees’ problem-solving and decision-making abilities and remediation of poor performance. Finally, which simulation-based surgical skills courses will become a standard part of the curriculum across training programs and which will be of value in board certification should be precisely defined. Sufficient progress in these areas will prevent excessive development of training and assessment tools with duplicative effort and large variability in quality.

Background: The indications and criteria for meniscal repair are expanding in parallel with new understanding in biomechanics, joint pathophysiology, and increased physician education. Purpose: To describe the practice patterns of arthroscopic meniscal treatment in recent years, compare the trends of arthroscopic meniscal repair versus arthroscopic meniscectomy, and compare sports fellowship–trained versus non–sports fellowship–trained surgeons in terms of arthroscopic meniscal treatment techniques among American Board of Orthopaedic Surgery (ABOS) candidates from 2004 to 2012. Study Design: Descriptive epidemiology study. Methods: The ABOS database was used to identify cases of meniscal repair, partial meniscectomy, and anterior cruciate ligament (ACL) reconstruction from 2004 to 2012. The number of surgeons contributing cases for each calendar year was also recorded, along with the number who had sports fellowship training. Rates were calculated as the number of procedures per surgeon per year. Trends were analyzed using Poisson regression analysis to model the rate of each procedure over time. Results: The rate of all meniscal procedures per surgeon decreased 12% from 18.4 cases per surgeon in 2004 to 16.2 cases per surgeon in 2012. There was a smaller decrease for sports fellowship–trained surgeons (7%) than for non–sports fellowship–trained surgeons (32%). The rate of meniscal repair cases per surgeon increased 37% from 1.6 to 2.2 cases per surgeon. The rate of meniscectomy cases decreased 17% from 16.8 to 14.0 cases per surgeon. When comparing fellowship-trained surgeons to non–fellowship-trained surgeons, there was no significant difference in meniscal repair rates over time. There was a decrease of 35% in rates of meniscectomy among non–fellowship-trained surgeons compared with 11% among fellowship-trained surgeons. Conclusion: This study provides insight into the current practice trends of recent orthopaedic training graduates in the treatment of meniscal tears. The results suggest that reported meniscal procedures have decreased overall among ABOS candidates but that meniscal repair cases have increased. The findings support the recent shift toward evidence-based medicine, with changing practice patterns that may reflect the dissemination of recent findings from large, high-quality research studies in this field.

Fractures of the proximal fifth metatarsal are relatively common and can be treated with a variety of treatment modalities. The goals of the current study were to answer the following questions: (1) Is there a difference in functional outcomes with different nonoperative treatment modalities for avulsion and Jones fractures? (2) What is the long-term functional impairment? This study included 53 patients who were treated for proximal fifth metatarsal fracture at 1 university health care system between 2004 and 2013. Treatment methods included shoe modification, cast, and boot. Patients completed a telephone questionnaire that included selected questions from the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS). Treatment groups were stratified as shoe modification or immobilization, and the results of the MODEMS survey were compared. At most recent follow-up, no significant difference was found between the 2 patient groups ( P =.062) for self-reported effects of the injury on work and quality of life. No significant difference was found for frequency of use of pain medication ( P =.157), patient satisfaction with current symptoms ( P =.633), ambulatory status ( P =.281), or pain level with strenuous activity ( P =.772). Obese patients were more likely to have severe pain with strenuous activity ( P =.015). Most (87%) patients were able to ambulate without the need for assistive devices. Of the study patients, 79% could wear dress shoes, excluding high heels, comfortably. The findings showed that patients who were treated with a variety of nonoperative methods for closed proximal fifth metatarsal fracture had acceptable functional outcomes, regardless of treatment method. [ Orthopedics. 2017; 40(6):e1030–e1035.]

BACKGROUND: The efficacy of vedolizumab, an α4β7 integrin antibody, in Crohn's disease is unknown. METHODS: In an integrated study with separate induction and maintenance trials, we assessed intravenous vedolizumab therapy (300 mg) in adults with active Crohn's disease. In the induction trial, 368 patients were randomly assigned to receive vedolizumab or placebo at weeks 0 and 2 (cohort 1), and 747 patients received open-label vedolizumab at weeks 0 and 2 (cohort 2); disease status was assessed at week 6. In the maintenance trial, 461 patients who had had a response to vedolizumab were randomly assigned to receive placebo or vedolizumab every 8 or 4 weeks until week 52. RESULTS: At week 6, a total of 14.5% of the patients in cohort 1 who received vedolizumab and 6.8% who received placebo were in clinical remission (i.e., had a score on the Crohn's Disease Activity Index [CDAI] of ≤150, with scores ranging from 0 to approximately 600 and higher scores indicating greater disease activity) (P=0.02); a total of 31.4% and 25.7% of the patients, respectively, had a CDAI-100 response (≥100-point decrease in the CDAI score) (P=0.23). Among patients in cohorts 1 and 2 who had a response to induction therapy, 39.0% and 36.4% of those assigned to vedolizumab every 8 weeks and every 4 weeks, respectively, were in clinical remission at week 52, as compared with 21.6% assigned to placebo (P

Background With the changing delivery of orthopaedic surgical care, there is a need to define the knowledge and competencies that are expected of an orthopaedist providing general and/or acute orthopaedic care. This article provides a proposal for the knowledge and competencies needed for an orthopaedist to practice general and/or acute care orthopaedic surgery. Methods Using the modified Delphi method, the General Orthopaedic Competency Task Force consisting of stakeholders associated with general orthopaedic practice has proposed the core knowledge and competencies that should be maintained by orthopaedists who practice emergency and general orthopaedic surgery. Results For relevancy to clinical practice, 2 basic sets of competencies were established. The assessment competencies pertain to the general knowledge needed to evaluate, investigate, and determine an overall management plan. The management competencies are generally procedural in nature and are divided into 2 groups. For the Management 1 group, the orthopaedist should be competent to provide definitive care including assessment, investigation, initial or emergency care, operative or nonoperative care, and follow-up. For the Management 2 group, the orthopaedist should be competent to assess, investigate, and commence timely non-emergency or emergency care and then either transfer the patient to the appropriate subspecialist's care or provide definitive care based on the urgency of care, exceptional practice circumstance, or individual's higher training. This may include some higher-level procedures usually performed by a subspecialist, but are consistent with one's practice based on experience, practice environment, and/or specialty interest. Conclusions These competencies are the first step in defining the practice of general orthopaedic surgery including acute orthopaedic care. Further validation and discussion among educators, general orthopaedic surgeons, and subspecialists will ensure that these are relevant to clinical practice. Clinical relevance These competencies provide many stakeholders, including orthopaedic educators and orthopaedists, with what may be the minimum knowledge and competencies necessary to deliver acute and general orthopaedic care. This document is the first step in defining a practice-based standard for training programs and certification groups.

Surgical skills education is in the process of a crucial transformation from a master-apprenticeship model to simulation-based training. Orthopaedic surgery is one of the surgical specialties where simulation-based skills training needs to be integrated into the curriculum efficiently and urgently. The reason for this strong and pressing need is that orthopaedic surgery covers broad human anatomy and pathologies and requires learning enormously diverse surgical procedures including basic and advanced skills. Although the need for a simulation-based curriculum in orthopaedic surgery is clear, several obstacles need to be overcome for a smooth transformation. The main issues to be addressed can be summarized as defining the skills and procedures so that simulation-based training will be most effective; choosing the right time period during the course of orthopaedic training for exposure to simulators; the right amount of such exposure; using objective, valid and reliable metrics to measure the impact of simulation-based training on the development and progress of surgical skills; and standardization of the simulation-based curriculum nationwide and internationally. In the new era of surgical education, successful integration of simulation-based surgical skills training into the orthopaedic curriculum will depend on efficacious solutions to these obstacles in moving forward.

Simulation-based surgical skills training has become essential in orthopaedic practice because of concerns about patient safety and an increase in technically challenging procedures. Surgical skills training in specifically designed simulation laboratories allows practice of procedures in a risk-free environment before they are performed in the operating room. The transferability of acquired skills to performance with patients is the most effective measure of the predictive validity of simulation-based training. Retention of the skills transferred to clinical situations is also critical. However, evidence of simulation-based skill retention in the orthopaedic literature is limited, and concerns about sustainability exist. Solutions for skill decay include repeated practice of the tasks learned on simulators and reinforcement of areas that are sensitive to decline. Further research is required to determine the retention rates of surgical skills acquired in simulation-based training as well as the success of proposed solutions for skill decay.

Orthopaedic research has advanced tremendously in parallel with accelerated progress in medical science. Possession of a fundamental understanding of basic and clinical science has become more essential than previously for orthopaedic surgeons to be able to translate advances in research into clinical practice. The number of medical graduates with prior education in scientific research who choose to pursue careers in orthopaedic surgery is small. Therefore, it is important that a core of research education be included during residency training to ensure the continued advancement of the clinical practice of orthopaedics. The authors examine some of the challenges to a comprehensive research experience during residency, including deficient priority, inadequate institutional infrastructure, financial strain on residency budgets, restricted time, and an insufficient number of mentors to encourage and guide residents to become clinician-scientists. They also present some strategies to overcome these challenges, including development and expansion of residency programs with clinician-scientist pathways, promotion of financial sources, and enhancement of opportunities for residents to interact with mentors who can serve as role models. Successful integration of research education into residency programs will stimulate future orthopaedic surgeons to develop the critical skills to lead musculoskeletal research, comprehend related discoveries, and translate them into patient care. Lessons learned from incorporating research training within orthopaedic residency programs will have broad application across medical specialties-in both primary and subspecialty patient care.

Background: Arthroscopic Bankart repair emerged in the 1990s as a minimally invasive alternative to open repair. The optimal technique of surgical stabilization of the unstable glenohumeral joint remains controversial. Hypothesis: A review of the American Board of Orthopaedic Surgery (ABOS) data would show a trend toward an increasing number of arthroscopic versus open Bankart procedures. Study Design: Descriptive epidemiology study. Methods: A query of the ABOS database for all cases of open or arthroscopic Bankart repair from 2003 through 2008 was performed, as the CPT (Current Procedural Terminology) codes for arthroscopic repair were introduced in 2003. All cases coded with CPT codes for arthroscopic Bankart repair (29806) or open Bankart repair (23455) were reviewed. Additional data were obtained on the surgeons (year of procedure, geographic location, fellowship training, subspecialty examination area) as well as the patients (age, gender, follow-up length, complications, objective outcome measures [pain, deformity, function, and satisfaction]). Results: From 2003 to 2008, a total of 4562 Bankart repair cases were reported, composing 8.6% of the total number of shoulder surgery cases in the ABOS database. From 2003 to 2005, 71.2% of Bankart repairs were arthroscopic, compared with 87.7% between 2006 and 2008 ( P < .0001). Surgeons having obtained subspecialty training in sports medicine performed the majority (65.3%) of Bankart repairs. Over the entire period, sports-trained surgeons also performed a higher proportion of arthroscopic repairs (84.1%) compared with surgeons without this training (71.9%) ( P < .0001). However, by 2008 both non-fellowship–trained and sports medicine fellowship–trained surgeons performed arthroscopic repair in 90% of cases. Surgeons in the Northeast region performed a significantly greater proportion of arthroscopic Bankart repairs (84.7%) than did surgeons in other regions (78.6%) ( P < .0001) from 2003 to 2008. The most commonly reported complications were nerve palsy/injury and dislocation, with a rate of nerve injury of 2.2% in the open group compared to 0.3% in the arthroscopic group ( P < .0001), and dislocation rate of 1.2% with open stabilization compared with 0.4% arthroscopically ( P = .0039). Conclusion: Review of the ABOS data shows a trend toward arthroscopic shoulder stabilization over time, with the use of open repair declining. Reported complications were lower overall in the arthroscopic stabilization group when compared with open surgeries.

The synthesis and organization of extracellular matrix (ECM) of tendon, in resting and states of repair, are governed by fibroblasts. Growth differentiation factor-5 (GDF-5) may enhance the cellular response to tendon injury, thus improving the structural outcome of the regenerative tissue. This study was an attempt to identify potential mechanisms controlling the response of fibroblasts to injury and GDF-5, in the pursuit of improved tissue regeneration. There were two sets of experiments. Isolated mice Achilles tendon fibroblasts were treated with different concentrations of rGDF-5 (0–100 ng/ml) for 0–12 days in cell culture. The temporal effect of rGDF-5 on ECM gene expression was analysed for type I collagen and aggrecan expression. Microarray and gene expression analysis were performed on cells treated with 100 ng/ml for 4 days. Forty-five mice underwent bilateral mid-substance Achilles tendon tenotomy and suture repair. Repair sites were injected with 10 µg rGDF-5 or saline. Tendons were assessed histologically at 2, 4 and 6 weeks. Expression of ECM genes procollagen IX, aggrecan, matrix metalloproteinase 9 and fibromodulin were upregulated. Proinflammatory reaction genes were downregulated. rGDF-5 led to an increase in total DNA, glycosaminoglycan (GAG) and hydroxyproline (OHP). The OHP:DNA ratio of fibroblast cultures was increased over all time points, with increased GAG:DNA at day 12. rGDF-5 treatment showed improved collagen organization over controls. The results delineate the mode of action of rGDF-5 at the cellular and gene level. rGDF-5 could play a role in tendon repair and be used for future therapies that promote tendon healing. Copyright © 2010 John Wiley & Sons, Ltd.

Background: Acromioplasty is considered a technically simple procedure but has become controversial with regard to its indications and therapeutic value. Methods: Two complementary databases were used to ascertain the frequency of acromioplasty over a recent span of time. In Part A, the New York Statewide Planning and Research Cooperative System (SPARCS) ambulatory surgery database was searched from 1996 to 2006 to identify all ambulatory surgery acromioplasties as well as all orthopaedic ambulatory surgery procedures. In Part B, the American Board of Orthopaedic Surgery (ABOS) database was searched from 1999 to 2008 to identify all arthroscopic acromioplasties as well as all orthopaedic procedures. Results: Part A revealed that in 1996 there were 5571 acromioplasties in New York State, representing a population incidence of 30.0 per 100,000. In 2006 there were 19,743 acromioplasties, representing a population incidence of 101.9 per 100,000. Over these eleven years, the volume of acromioplasties increased by 254.4%, compared with only a 78.3% increase in the volume of all orthopaedic ambulatory surgery procedures. In 2006, as compared with 1996, patients were 2.4 times more likely to have an acromioplasty compared with all other orthopaedic ambulatory procedures (p < 0.0001). Part B revealed that, in 1999, a mean of 2.6 arthroscopic acromioplasties were reported per candidate for Board certification. In 2008 a mean of 6.3 arthroscopic acromioplasties per candidate were reported. Over these ten years, the mean number of arthroscopic acromioplasties reported increased by 142.3%, compared with only a 13.0% increase in the mean number of all orthopaedic surgery procedures. In 2008, as compared with 1999, candidates were 2.2 times more likely to report an arthroscopic acromioplasty compared with all other orthopaedic procedures (p < 0.0001). Conclusions: There has been a substantial increase in the overall volume and the population-based incidence of acromioplasties in recent years on both the state and national levels in the United States. The reasons for this increase have yet to be determined and are likely multifactorial, with patient-based, surgeon-based, and systems-based factors all playing a role.

Burnout has many definitions but the most commonly accepted is “a state of physical, emotional or mental exhaustion caused by long-term involvement in situations that are emotionally demanding.”1 It tends to be most common among medical professionals as a result of long working hours, stresses associated with the responsibilities of patient care, and emotional contact with patients2. According to Jones, burnout—a syndrome of progressive emotional, attitudinal, and physical exhaustion—is a critical occupational hazard for people in a wide range of helping professions3. Those who are affected find themselves plagued by chronic fatigue, low energy, irritability, and a negative attitude toward themselves, toward others, and toward their jobs. Because they are emotionally depleted and cynical, they may have a negative impact on those around them, including the individuals with whom they work and the patients they treat. Among the members of the so-called helping professions, physicians are clearly most afflicted with burnout and, as we noted in our previous report4, they have by now been quite intensively studied. Characteristically, burnout syndrome involves the development of a cynical attitude and the loss of concern for people with whom one is working. In addition to physical exhaustion, which harms physical health through many pathways5, burnout is also characterized by an emotional exhaustion wherein the professional experiences growing negative feelings, cynicism, or disrespect for patients and colleagues. “A very cynical and dehumanized perception of these people often develops in which they are labeled in derogatory ways and therefore treated accordingly.”6 Gabbe et al.7 undertook a cross-sectional study, in which a questionnaire was sent to 131 chairs of academic departments of obstetrics and gynecology in the United States and Puerto Rico, and had a 91% response rate. The study found that 22% of the …

The objectives of this study were to quantitatively evaluate the articular cartilage layers of the ankle and describe the cartilage topographical distribution across the joint surfaces using high resolution MRI and image segmentation. An anisotropic diffusion noise reduction algorithm and a directional gradient vector flow (dGVF) snake segmentation algorithm were applied to cartilage sensitive MR images. Eight cadaveric ankles were studied. Six repeated data sets were acquired in five of the ankles. Quantitative parameters were calculated for each cartilage layer; coefficients of variation (CV) were calculated from the six repeated data sets; and 3D thickness distribution maps were generated. The noise reduction algorithm produced marked image enhancement. Mean cartilage thickness ranged from 0.91 ± 0.08 mm in the fibula to 1.34 ± 0.14 mm in the talus. Mean cartilage volume was 3.32 ± 0.55 ml, 1.72 ± 0.25 ml, and 0.35 ± 0.06 ml for the talus, tibia, and fibula, respectively. Mean CV ranged 2.82%–5.04% for quantitative parameters in the talus and tibia. The reported noise reduction and segmentation technique allow precise extraction of ankle cartilage and 3D reconstructions show that the thickest cartilage occurs over the talar shoulders, where osteochondritits dissecans (OCD) lesions commonly occur. © 2006 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 25:143–151, 2007

The formation of fibrous tissue during the healing of skeletal muscle injuries leads to incomplete recovery of the injured muscle. Platelet-rich-plasma (PRP) contains beneficial growth factors for skeletal muscle repair; however, it also contains deleterious cytokines and growth factors, such as TGF-β1, that can cause fibrosis and inhibit optimal muscle healing. Objective To test if neutralizing TGF-β1's action within PRP, through neutralization antibodies, could improve PRP's beneficial effect on skeletal muscle repair. Methods PRP was isolated from in-bred Fisher rats. TGF-β1 neutralization antibody (Ab) was used to block the TGF-β1 within the PRP prior to injection. The effects of customized PRP (TGF-β1 neutralized PRP) on muscle healing was tested on a cardiotoxin (CTX) induced muscle injury model. Results A significant increase in the numbers of regenerative myofibers was observed in the PRP and customized PRP groups compared to the untreated control. A significant decrease in collagen deposition was observed in customized PRP groups when compared to the control and PRP groups. Significantly enhanced angiogenesis and more Pax-7 positive satellite cells were found in the PRP and customized PRP groups compared to the control group. Macrophage infiltration was increased in the customized PRP groups when compared with the PRP group. More M2 macrophages were recruited to the injury site in the customized PRP groups when compared with the PRP and control groups. Conclusion Neutralizing TGF-β1 within PRP significantly promotes muscle regeneration while significantly reducing fibrosis. Not only did the neutralization reduce fibrosis, it enhanced angiogenesis, prolonged satellite cell activation, and recruited a greater number of M2 macrophages to the injury site which also contributed to the efficacy that the customized PRP had on muscle healing.

“... To fix a health care system distorted by spiraling costs... true reform needs to go farther. Certainly any farreaching reform must make greater use of evidence-based medicine...” —“Healing Health Care” The Washington Post, May 15, 2004 What is this “evidence-based medicine” that the editorial staff of The Washington Post feels is a cornerstone of health-care reform, and what, if anything, does it have to do with the current practice of orthopaedic surgery? Does the application of evidence-based medicine offer a way to reduce public expenditure on health care? The short answer is that evidence-based medicine is a process that uses truthful clinical information in addition to the practical experience of the surgeon to make medical decisions1. Also, in theory, the practice guidelines that are generated by scientific clinical studies can reduce the complications and bad surgical outcomes that drive health-care costs higher2. The long answer with regard to how evidence-based medicine works requires some rigorous learning about statistics, probability, clinical research, guided inquiry, systematic reviews, and levels of evidence. Fortunately, the short answer is enough to get started, and orthopaedic surgeons can get up to speed by reading about levels of evidence in peer-reviewed journals. The editors of peer-reviewed clinical journals have adopted a rating system that simplifies the process of rating articles for content3. Levels of evidence have been created to help clinicians to understand that evidence is created by scientific research that answers questions or solves problems. The application of journal articles into practice is the fourth stage of a problem-solving algorithm that starts with (1) formulating answerable questions, (2) gathering evidence, (3) evaluating the evidence, (4) putting evidence into practice, and (5) evaluating the results of putting evidence into practice. Surgeon-scientists have their articles published in journals that rate the …

To determine what fracture- and patient-specific variables affect outcome, 29 patients with 32 tibial plafond fractures were evaluated at a minimum of 2 years from the time of injury (range, 24-129 months; average, 46.5 months). The rank order method was used to assess severity of injury and accuracy of articular reduction on radiographs and agreement among the five surgeons was excellent with intraclass correlation coefficients of 0.93 and 0.94. Outcome was assessed by four independent measures: a radiographic arthrosis score, a subjective ankle score, the Short Form-36 (SF-36), and the patient's ability to return to work. The four outcome measures did not correlate with each other. Radiographic arthrosis was predicted best by severity of injury and accuracy of reduction. However, these variables did not show any significant relationship to the clinical ankle score, the SF-36, or return to work. These outcome measures were more influenced by patient-specific socioeconomic factors. Higher ankle scores were seen in patients with college degrees and lower scores were seen in patients with a work-related injury. The ability to return to work was affected by the patient's level of education. This study highlights the difficulties of predicting patient outcome, after these severe articular fractures.

Background: The safety and efficacy of corticosteroid injection for the treatment of Achilles tendinopathy is not known, with some reports indicating the hazard of tendon rupture and others extolling the efficacy of such injections. This study was undertaken to assess the safety of fluoroscopically guided corticosteroid injections into the peritendinous space for the treatment of Achilles tendinopathy. Methods: A series of patients was treated with fluoroscopically guided corticosteroid injections into the space surrounding the Achilles tendon. Major and minor complications were recorded, as were the number of repeat injections, the duration of symptomatic relief attained with the injection, and a subjective rating of symptoms related to the Achilles tendon. Results: Of eighty-three patients who had been treated, seventy-eight were available for follow-up and forty-three met our requirement for a minimum two-year follow-up (average duration of follow-up, 37.4 months). No major complications and one minor complication occurred in the forty-three patients. Seventeen (40%) of the patients reported improvement after the procedure, twenty-three (53%) thought that their condition was unchanged, and three (7%) felt that their condition was worse than it had been prior to the injection. Conclusions: This retrospective cohort study establishes the safety of low-volume injections of corticosteroids for the treatment of Achilles tendinopathy when the needle is carefully inserted into the peritendinous space under direct fluoroscopic visualization. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Computer simulations, dummy experiments with a new enhanced upper extremity and small female cadaver experiments were used to analyze the small female upper extremity response under side airbag loading. After establishing a worst case initial position, three tests were performed with the fifth percentile female hybrid III anthropometric test dummy and six experiments with small female cadaver subjects. A new fifth percentile female enhanced upper extremity was developed for the dummy experiments that included a two-axis wrist load cell in addition to the existing six-axis load cells in both the forearm and humerus. Forearm pronation was also included in the new dummy upper extremity to increase the biofidelity of the interaction with the handgrip. Instrumentation for both the cadaver and dummy tests included accelerometers and MHD angular rate sensors on the forearm, humerus, upper and lower spine. In order to quantify the applied loads to the cadaver hand and wrist from the door mounted handgrip, the handgrip was mounted to the door through a five-axis load cell and instrumented with accelerometers for inertial compensation. All six of the cadaver tests resulted in upper extremity injuries including comminuted mid-shaft humerus fractures, osteochondral fractures of the elbow joint surfaces, a transverse fracture of the distal radius and an osteochondral fracture of the lunate carpal bone. The results from the 6 cadaver tests presented in this study were combined with the results from 12 previous cadaver tests. A multivariate logistic regression analysis was performed to investigate the correlation between observed injuries and measured occupant response. Using inertially compensated force measurements from the dummy mid-shaft forearm load cell, the linear combination of elbow axial force and shear force was significantly (P=0.05) correlated to the observed elbow injuries.

Objective: To determine to the ability of systemically administered pluripotential mesenchymal stromal cells to localize to a fracture site and whether transduction with a therapeutic gene, insulin-like growth factor-I (D1-IGF-I), could potentiate healing. Design: Murine model, basic science study. Setting: Laboratory. Specimens: Closed, transverse, mid-shaft femur fractures were produced in 108 Balb/c mice after intramedullary stabilization. Interventions: A cloned, pluripotential, mesenchymal cell line, termed Dl, was stably transfected with either the gene (3-galactosidase (Dl-BAG) as a histologic marker or with the gene IGF-I (D1-IGF-I) growth factor. Mice received systemic injections of either D1-BAG cells for in vivo localization or Dl-IGF-I for therapeutic intervention. A third group received lactated Ringer's solution and served as control. Main Outcome Measurements: Sections obtained from the fracture site and contralateral femurs were examined histologically and by deoxyribonucleic acid-polymerase chain reaction (DNA-PCR) to detect the presence of transplanted cells at 2, 4, and 6 weeks after fracture. Matrix mineralization and callus maturation were evaluated by histology. Results: At all time points, using histologic staining with X-gal and deoxyribonucleic acid-polymerase chain reaction for marker genes, there was a statistically greater number of transplanted cells (p < 0.001) and significantly higher DNA-PCR for marker genes (p < 0.001) in the fractured femurs than in the nonfractured femurs. Mice receiving Dl-IGF-I cells demonstrated a greater percent of mineralized callus than controls at two weeks (p < 0.05). At 4 and 6 weeks, treated mice demonstrated on average greater mineralized matrix and accelerated progression to an osseous callus as compared with the control group. Conclusions: Cell-based gene therapy has the potential to deliver higher therapeutic levels of growth factors specifically at the site of cell localization while minimizing wider systemic side effects. This study demonstrates that systemically injected IGF-I transduced, mesenchymal cells are able to return to and repopulate the bone marrow. More importantly, these cells localize preferentially to a fracture site and accelerated fracture healing.

Complex regional pain syndrome, formerly known as reflex sympathetic dystrophy or causalgia, is a difficult therapeutic problem for the orthopaedic surgeon treating an affected lower extremity. Despite many divergent and often conflicting theories, the cause of the severe pain, alterations in regional blood flow, and edema is unknown. Interventions that have proved successful for treating similar conditions in the arm and hand frequently do not relieve pain similarly in the lower extremity. Common treatment regimens target individual components of this symptom complex, namely, sympathetic or afferent nerve hyperactivity, vasomotor instability, or regional osteoporosis. Despite widespread use of some of these treatments, few controlled clinical trials quantify their effectiveness. This challenging syndrome is best managed by a multidisciplinary team, including chronic pain management specialists, physical therapists, and orthopaedic surgeons.

This study aims to investigate changes in frequency, risk, and patterns of lower limb injuries due to vehicle and occupant parameters as a function of vehicle model year. From the National Automotive Sampling System-Crashworthiness Data System, 10,988 observations were sampled and analyzed, representing 4.7 million belted drivers involved in frontal crashes for the years 1998-2010. A logistic regression model was developed to understand the association of sustaining knee and below knee lower limb injuries of moderate or greater severity with motor vehicle crash characteristics such as vehicle type and model years, toepan and instrument panel intrusions in addition to the occupant's age, gender, height and weight. Toepan intrusion greater than 2cm was significantly associated with an increased likelihood of injury (odds ratio: 9.10, 95% confidence interval 1.82-45.42). Females sustained a higher likelihood of distal lower limb injuries (OR: 6.83, 1.56-29.93) as compared to males. Increased mass of the driver was also found to have a positive association with injury (OR: 1.04, 1.02-1.06), while age and height were not associated with injury likelihood. Relative to passenger cars, vans exhibited a protective effect against sustaining lower limb injury (OR: 0.24, 0.07-0.78), whereas no association was shown for light trucks (OR: 1.31, 0.69-2.49) or SUVs (OR: 0.76, 0.28-2.02). To examine whether current crash testing results are representative of real-world NASS-CDS findings, data from frontal offset crash tests performed by the Insurance Institute for Highway Safety (IIHS) were examined. IIHS data indicated a decreasing trend in vehicle foot well and toepan intrusion, foot accelerations, tibia axial forces and tibia index in relation to increasing vehicle model year between the year 1995 and 2013. Over 90% of vehicles received the highest IIHS rating, with steady improvement from the upper and lower tibia index, tibia axial force and the resultant foot acceleration considering both left and right extremities. Passenger cars received the highest rating followed by SUVs and light trucks, while vans attained the lowest rating. These results demonstrate that while there has been steady improvement in vehicle crash test performance, below-knee lower extremity injuries remain the most common AIS 2+ injury in real-world frontal crashes.

Purpose The purpose of this study was to summarize the recent developments in the field of tissue engineering as they relate to multilayer scaffold designs in musculoskeletal regeneration. Methods Clinical and basic research studies that highlight the current knowledge and potential future applications of the multilayer scaffolds in orthopaedic tissue engineering were evaluated and the best evidence collected. Studies were divided into three main categories based on tissue types and interfaces for which multilayer scaffolds were used to regenerate: bone, osteochondral junction and tendon-to-bone interfaces. Results In vitro and in vivo studies indicate that the use of stratified scaffolds composed of multiple layers with distinct compositions for regeneration of distinct tissue types within the same scaffold and anatomic location is feasible. This emerging tissue engineering approach has potential applications in regeneration of bone defects, osteochondral lesions and tendon-to-bone interfaces with successful basic research findings that encourage clinical applications. Conclusions Present data supporting the advantages of the use of multilayer scaffolds as an emerging strategy in musculoskeletal tissue engineering are promising, however, still limited. Positive impacts of the use of next generation scaffolds in orthopaedic tissue engineering can be expected in terms of decreasing the invasiveness of current grafting techniques used for reconstruction of bone and osteochondral defects, and tendon-to-bone interfaces in near future.

Primary glenohumeral osteoarthritis is a common indication for shoulder arthroplasty. Historically, both total shoulder arthroplasty (TSA) and hemi-shoulder arthroplasty (HSA) have been used to treat primary glenohumeral osteoarthritis. The choice between procedures is a topic of debate, with HSA proponents arguing that it is less invasive, faster, less expensive, and technically less demanding, with quality of life outcomes equivalent to those of TSA. More recent evidence suggests TSA is superior in terms of pain relief, function, ROM, strength, and patient satisfaction. We therefore investigated the practice of recently graduated orthopaedic surgeons pertaining to the surgical treatment of this disease.We hypothesized that (1) recently graduated, board eligible, orthopaedic surgeons with fellowship training in shoulder surgery are more likely to perform TSA than surgeons without this training; (2) younger patients are more likely to receive HSA than TSA; (3) patient sex affects the choice of surgery; (4) US geographic region affects practice patterns; and (5) complication rates for HSA and TSA are not different.We queried the American Board of Orthopaedic Surgery's database to identify practice patterns of orthopaedic surgeons taking their board examination. We identified 771 patients with primary glenohumeral osteoarthritis treated with TSA or HSA from 2006 to 2011. The rates of TSA and HSA were compared based on the treating surgeon's fellowship training, patient age and sex, US geographic region, and reported surgical complications.Surgeons with fellowship training in shoulder surgery were more likely (86% versus 72%; OR 2.32; 95% CI, 1.56-3.45, p0.001) than surgeons without this training to perform TSA rather than HSA. The mean age for patients receiving HSA was not different from that for patients receiving TSA (66 versus 68, years, p=0.057). Men were more likely to receive HSA than TSA when compared to women (RR 1.54; 95% CI, 1.19-2.00, p=0.0012). The proportions of TSA and HSA were similar regardless of US geographic region (Midwest HSA 21%, TSA 79%; Northeast HSA 25%, TSA 75%; Northwest HSA 16%, TSA 84%; South HSA 27%, TSA 73%; Southeast HSA 24%, TSA 76%; Southwest HSA 23%, TSA 77%; overall p=0.708). The overall complication rates were not different with the numbers available: 8.4% (15/179) for HSA and 8.1% (48/592) for TSA (p=0.7555).The findings of this study are at odds with the recommendations in the current clinical practice guidelines for the treatment of glenohumeral osteoarthritis published by the American Academy of Orthopaedic Surgeons. These guidelines favor using TSA over HSA in the treatment of shoulder arthritis. Further investigation is needed to clarify if these practice patterns are isolated to recently graduated board eligible orthopaedic surgeons or if the use of HSA continues with orthopaedic surgeons applying for recertification.Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Peter J. Stern, MD, is Norman S. & Elizabeth C.A. Hill Professor and Chairman of Orthopaedic Surgery at the University of Cincinnati College of Medicine; Stephen Albanese, MD, is Professor and Chair of Orthopedic Surgery and Medical Director of Orthopedic Surgery Clinic at SUNY Upstate Medical University; Mathias Bostrom, MD, is Residency Program Director and Academic Director of Orthopaedics at Hospital for Special Surgery and Professor of Orthopaedic Surgery, Weill Cornell Medical College, Helen Hayes Hospital; Charles S. Day, MD, MBA, is Rabkin Fellow in Medical Education, Associate Professor of Orthopedic Surgery at Harvard Medical School, and Chief/Program Director of Hand and Upper Extremity Surgery at Beth Israel Deaconess Medical Center; Steven L. Frick, MD, is Chairman of Orthopedic Surgery at Nemours Children’s Hospital and Professor of Orthopedic Surgery at the University of Central Florida College of Medicine; William Hopkinson, MD, is Professor, Vice-Chair, and Program Director of Orthopaedic Surgery & Rehabilitation at Loyola University Stritch School of Medicine; Shepard Hurwitz, MD, is Executive Director of the American Board of Orthopaedic Surgery and Professor of Orthopaedics at the University of North Carolina; Keith Kenter, MD, is Director of the Orthopaedic Surgery Residency Program, Associate Professor of Orthopaedic Surgery, and Associate Professor of Physical Medicine and Rehabilitation at the University of Cincinnati College of Medicine; John S. Kirkpatrick, MD, is Professor and Chair of Orthopaedic Surgery and Rehabilitation and Program Director of Orthopaedic Surgery Residency at the University of Florida College of Medicine; J. L. Marsh, MD, is Program Director of Residency Training Program and Professor and Carroll B. Larson Chair of Orthopaedics and Rehabilitation at the University of Iowa; Anand M. Murthi, MD, is Chief of Shoulder and Elbow Surgery and Fellowship Director at MedStar Union Memorial Hospital; Lisa A. Taitsman, MD, MPH, is Associate Professor of Orthopaedics and Sports Medicine at the University of Washington; Brian C. Toolan, MD, is Associate Professor of Surgery and Director of the Residency Program of Orthopaedic Surgery at the University of Chicago Medicine; Kristy Weber, MD, is Virginia & William Percy Professor of Orthopaedic Surgery, Division Chief of Orthopaedic Oncology, and Director of the Sarcoma Center at Johns Hopkins School of Medicine; Rick W. Wright, MD, is Dr Asa C. Dorothy W. Jones Professor of Orthopaedic Surgery, Residency Program Director, and Co-Chief of Sports Medicine at Washington University School of Medicine; Pamela L. Derstine, PhD, MHPE, is Executive Director of the Review Committees for Colon and Rectal Surgery, Neurological Surgery, Orthopaedic Surgery, and Otolaryngology at the Accreditation Council for Graduate Medical Education; and Laura Edgar, EdD, CAE, is Senior Associate Director of Outcome Assessment at the Accreditation Council for Graduate Medical Education.

Background: Amputations are rarely performed solely for pain relief because of concerns regarding the persistence of pain and disability after the procedure. The purpose of this study was to assess the outcome of below-the-knee amputations performed to relieve intractable foot and ankle pain. Methods: A chart review was conducted to identify all below-the-knee amputations that had been performed for the treatment of chronic foot and ankle pain by three orthopaedic foot and ankle specialists at three institutions. The inclusion criteria included (1) intractable foot or ankle pain as the surgical indication, (2) failure of maximal medical therapy, (3) failure of prior surgical reconstruction, and (4) a minimum follow‐up period of twenty‐four months after below-the-knee amputation. Patients with diabetes mellitus, peripheral vascular occlusive disease, or peripheral neuropathy were excluded. Each participant completed a two-part questionnaire with regard to the levels of disability, function, pain, and recreational activity both before and after the amputation. Results: Twenty patients met the inclusion criteria, and eighteen completed the study. The study group included four women and fourteen men who had an average age of forty‐two years (range, twenty‐six to sixty‐one years) and were followed for an average of forty‐one months (range, twenty‐five to eighty‐five months) after the amputation. When asked whether they would have the below-the-knee amputation done again under similar circumstances, sixteen patients said yes, one was unsure, and one said no. The same distribution was observed when the patients were asked whether they were satisfied with the outcome: sixteen said yes, one was unsure, and one said no. Disability, pain, and recreational status were assessed with a 10-cm visual analog scale. After the amputation, the patients reported a decrease in both pain frequency (with the average score improving from 9.8 to 1.7; p < 0.0001) and pain intensity (with the average score improving from 8.4 to 2.6; p < 0.0001). Ten patients discontinued the use of narcotics, and seven decreased the level and/or dosage. Three patients worked before the amputation, and eight worked after the amputation. The average walking distance increased from 0.3 to 0.8 mile (p = 0.0034). Conclusion: In selected patients, a below-the-knee amputation may be a good salvage procedure for intractable foot and ankle pain that is unresponsive to all medical and local surgical reconstructive techniques.

What information consumes is rather obvious: it consumes the attention of its recipients. Hence a wealth of information creates a poverty of attention, and a need to allocate that attention efficiently among the overabundance of information sources that might consume it. -Herbert Simon, Nobel Laureate Economist, 1971 Knowledge is power. -Sir Francis Bacon, 1597 Some books are to be tasted, others to be swallowed, and some few to be chewed and digested. -Sir Francis Bacon Medical information that is relevant to orthopaedic surgeons is continuously expanding and changing, while older information is expiring24,25. The speed at which new information is generated and disseminated challenges us to adopt new strategies for acquiring useful knowledge and leaving unusable information aside. Reading faster or spending more time reading does not ensure that one is gaining more relevant orthopaedic knowledge. In addition to the challenge of processing ever-increasing amounts of orthopaedic information, there exists the timeless problem of discriminating "the truth" from that which is "not-truth" (incorrect or not clinically useful). The ability to sift through large amounts of written material to uncover a few useful truths that will improve one's practice is a skill that busy orthopaedists and current residents should learn19,21. We live in an electronic information age in which patients often have more citations at their command than do practitioners15,16. Our present dilemma is that a large quantity of information is quickly available, yet more and faster information services have not translated into better care for patients15,20,21. The management or application of information related to orthopaedic care, combined with the skill of treating musculoskeletal disease, is what will set the orthopaedic surgeon apart from the educated lay public and from physicians who are …

This study characterizes the interaction between a small female upper extremity and a deploying side air bag. Results are based on 12 tests with small female cadavers, and 15 tests with the instrumented SAE 5th percentile female upper extremity attached to the 5th percentile Hybrid III dummy. The upper extremity was loaded by a deploying seat mounted thoracic side air bag in a static test environment. Three types of inflators were used varying in peak pressure and pressure onset rate. Three upper extremity positions were chosen that maximized loading to the humerus and elbow joint. Upper extremity instrumentation for the tests included accelerometers and angular rate sensors. Strain gage rosettes were also used on the cadaver anterior and posterior humerus. The SAE 5th percentile female instrumented upper extremity included 6 axis load cells in both the forearm and humerus. Peak humerus moments were calculated for the cadaver tests and compared to the peak humerus moments recorded by the dummy in similar positions. The moments recorded in the cadaver and dummy were similar, despite kinematic differences. Chondral and osteochondral fractures in the elbow joint were recorded for 7 of 12 cadaver tests, while a simple fracture of the distal humerus head was observed in 1 test. Linear regression was performed to correlate occurrence of recorded injury and test parameters. Injury risk functions were constructed for age, forearm acceleration, elbow moment, and air bag inflator level. The dynamic injury tolerance for the 5th percentile female humerus of 128 Nm was recommended for use with the dummy.

Background and Purpose. Several studies have demonstrated that patients with knee injury scored within a normal range during onelegged hop tests yet showed quadriceps femoris muscle weakness with non‐weight-bearing isokinetic testing. This study evaluated lowerextremity kinetics while subjects performed a single-leg vertical jump (VJ) and a lateral step-up (LSU) in an attempt to explain this phenomenon. Subjects and Methods. Using a motion analysis and force platform system, hip, knee, and ankle extension moments of 20 subjects with anterior cruciate ligament (ACL) reconstructions and 20 matched subjects were measured while they performed an LSU and a VJ. Results. An analysis of variance revealed that the knee extension moment of the ACL-reconstructed extremity was lower than that of the uninjured and matched extremities during the LSU, VJ take-off, and VJ landing. However, there was no difference in summated extension moment (hip 1 knee 1 ankle) among extremities during the LSU and VJ take-off. The summated extension moment of the ACLreconstructed extremity during VJ landing was less than that of the uninvolved and matched extremities. Conclusions and Discussion. These results suggest that the hip or ankle extensors may compensate for the knee extension moment deficit. The decrease in summated extension moment in the ACL-reconstructed extremity during VJ landing represents inadequate attenuation of landing forces, which may expose the skeleton and joint structures to injury. [Ernst GP, Saliba E, Diduch DR, et al. Lower-extremity compensations following anterior cruciate ligament reconstruction. Phys Ther. 2000;80:251‐ 260.]

Diabetes mellitus has been shown to alter the properties of bone and impair fracture healing in both humans and animals. The objective of this study was to document changes in the structural and material properties of intact bone and bone with healed fractures in diabetic rats compared with nondiabetic controls after 3 and 4 weeks of healing. Rods were inserted in the right femurs of control rats and rats with streptozotocin-induced diabetes, and the femurs were fractured in a standardized procedure and then allowed to heal for 3 and 4 weeks. After death, all femurs were mechanically tested to failure in torsion. The degree of healing was quantified for each animal by normalizing mechanical parameters for the femur with a healed fracture with those for the intact contralateral femur. At both time points of healing, diabetic rats exhibited inferior healing compared with that of control animals in terms of failure torque, failure stress, structural stiffness, and material stiffness of the femur with the healed fracture relative to the intact contralateral femur (p < 0.05). Our results demonstrate that the recovery of structural and material strength in femurs with healed fractures in diabetic rats is delayed by at least 1 week compared with that in controls.

We investigated alterations in the expression of mRNA for type II and type X collagen in fracture callus of experimentally induced diabetic animals compared with controls and performed radiographic, histological, immunocytochemical and biomechanical studies. Experimentally induced diabetic rats exhibited an alteration in the temporal expression of type II and type X collagen mRNA and a decrease in type X mRNA expression as compared to controls. Radiographs showed a more intense periosteal reaction and a more rapid reconstitution of cortices in control versus diabetic animals. Histologically there was a delay in chondrocyte maturation and hypertrophy seen in diabetics. Immunolocalization of type X collagen demonstrated a delay in type X collagen expression around the hypertrophic chondrocytes. Biomechanical analysis showed a decrease in the strength of healing fractures in diabetic animals. Fracture healing in diabetic patients is compromised and may lead to delays in bone union. Though the exact mechanisms are unknown, we present evidence of decreased mechanical strength of the fracture and suggest that associated changes in collagen expression and chondrocyte maturation are mechanisms leading to delayed healing in untreated and poorly controlled diabetes.

Orthopaedic graduate medical education includes evaluation and treatment of problems of the foot and ankle. The challenges of managed care, podiatry, and institutional resources have reshaped the way we educate orthopaedic residents as managers of disorders of the foot and ankle. The most useful tools acquired in residency will be those that establish a strong medical and surgical foundation in problems of the foot and ankle and foster lifelong adaptation of new knowledge and techniques.

We investigated the effects of severity of initial injury pattern and the quality of the articular reduction on outcome of displaced intra-articular distal tibial fractures, using a series of 25 patients who were treated with articulated external fixation and limited internal fixation, which provided a spectrum of reduction quality. Outcome was assessed by clinical ankle scores and radio-graphic arthrosis. The results demonstrate the rank order method to be a reliable means of stratifying severity of injury and quality of reduction. Neither injury nor reduction correlated with clinical ankle score. Reduction had a significant correlation with radiographic arthrosis. We conclude that the rank order method is useful in stratification of fracture patients, and that factors other than injury pattern and quality of articular reduction are important in determining outcome of patients with this severe articular injury.

The effects of surgical repair versus non-repair on cell morphology and type X collagen expression were investigated using a rat model of Achilles tendon avulsion. The animals were divided into four groups. In Group 1, tendon was reattached to the original attachment site by suturing through a drill hole in the calcaneus; in Group II, tendon was not reattached and a drill hole was not made; in Group III, tendon was not reattached but a drill hole was made; and the animals in Group IV were sham operated. In Group I (tendon reattached), at 2 weeks postoperatively, many hypertrophic chondrocytes appeared at the reattachment site adjacent to bone and type X collagen was detected immunologically both in the cells and in the extracellular matrix. After 4 weeks, the cells at the original site of attachment were arranged in rows along the newly formed tendon fibers and were stained with type X collagen antibody. By contrast, when tendon was not reattached (Groups II and III), a gap between the original attachment site and the tendon stump was observed through the entire postoperative period. At 8 weeks, the original attachment site was covered by fibrocartilaginous tissue and tendon became attached to the calcaneal fibrocartilage area, which is proximal to the original attachment site. Type X collagen was detected in the cells which were adjacent to bone. In Group IV (sham operation), there were no changes in histology or type X collagen distribution, either at the attachment site or in tendon and bone, compared with the non-operated control rats. These results suggest that surgical reattachment of tendon to the original site is important to help reorganize cells during the repair process. Type X collagen was identified immunohistochemically in the cells adjacent to bone in all the groups, suggesting that it may play a role in maintaining distinct areas of calcified and non-calcified fibrocartilage.

A series of 50 amputated human lower limbs were tested to determine the injury tolerance of the ankle and foot structure to kinematic and kinetic parameters that could be used to describe the impact environment The test apparatus consisted of a pendulum-driven plate constrained to move longitudinally while simulating the motion of the toepan structure in an automobile. The leg specimens were amputated at the midshaft of the femur and attached to a device simulating the hip joint. The legs were mounted to the plate in a position approximating the geometry typical for drivers and were constrained with a spring loaded tether and knee hamess which simulated the action of the leg muscles. Pendulum speed, foot plate acceleration and loads, leg and foot angular velocities and accelerations, and tibia internal loads were measured directly for each test. The lower limb trauma included fractures of the calcaneus, talus, malleoli, and ligamentous tears identified from radiography and detailed necropsy. Logi...

This study histologically and immunohistochemically demonstrated developmental changes in cell morphology and expression of type-X collagen in the attachment of the Achilles tendon to the calcaneus in the rat. Although the site of attachment in the mature rat showed a well organized, direct insertion that was composed of tendon, fibrocartilage, calcified fibrocartilage, and bone, this four-zone structure was not observed in the immature 1-week-old rat. Formation of fibrocartilage was observed at 2 weeks, together with the hypertrophy of chondrocytes and the appearance of the secondary center of ossification. Type-X collagen was not detected either in chondrocytes in the attachment area at 1 week or in hypertrophic chondrocytes at the attachment at 2 weeks. In the 3-week-old rat, the secondary center of ossification extended to the area of attachment and type-X collagen was detected both in cartilage spicules within the secondary center of ossification and in cells found at the attachment adjacent to the secondary center of ossification. A four-zone structure had been established by 6 weeks and remained through 20 weeks. After 6 weeks, type-X collagen was identified both in the attachment of the tendon and beneath the calcaneal fibrocartilage. Type-X collagen is produced by cells in transitional zones between calcified and noncalcified tissue, such as the interface between articular cartilage and subchondral bone. In these areas, the expression of this protein persists through maturity and is not transient.

The foot and ankle are among the hardest of all areas to image because of the complex three-dimensional anatomy. Magnetic resonance imaging (MRI), with its multiplanar capabilities, excellent soft-tissue contrast, ability to image bone marrow, noninvasiveness, and lack of ionizing radiation, has become a valuable tool in evaluating patients with foot and ankle problems. MRI is more specific than bone scintigraphy and provides more information than ultrasound and computed tomography. Arthroscopy of the ankle is limited to the articular surface and joint space. MRI allows a global evaluation of the bones, tendons, ligaments, and other structures with a single examination that exceeds the capabilities of all other available techniques. This monograph was written to provide a useful guide to basic technique, indications, positioning, anatomy, and interpretation of foot and ankle MRI. The first part describes the performance of the MRI examination with reference to the positioning of the foot, types of coils, and advantages and disadvantages of the different sequences and imaging planes. The next section was written by an experienced foot and ankle orthopedic surgeon and outlines the indications for MRI for the common foot and ankle symptom complexes and the information that the surgeon hopes to obtain from the study. This is followed by a review of pertinent anatomy, as it applies to imaging, with emphasis on osseous structures, ligaments, tendons, and muscles. The final section is a comprehensive review of the common pathologic conditions encountered in the foot and ankle. We hope that radiologists and radiologists-in-training find this article a useful reference tool and gain a better understanding of this complex area of musculoskeletal imaging.

To determine the value of injections of local anesthetic and steroids in the foot and ankle in localizing the source of pain and their effect on clinical confidence and decision making.In 47 patients, fluoroscopically guided injections of local anesthetic and steroid into the foot and ankle were performed in 106 intra- and extraarticular sites. Questionnaires were completed by the referring surgeon before and after injections to evaluate the level of confidence with regard to the source of pain for each site injected and the proposed treatment plan.Forty-three (91%) patients reported pain relief after injections. The level of confidence that the site injected was the source of pain increased in 68 (64%) sites, decreased in 19 (18%) sites, and remained unaltered in 19 (18%) sites (P.01). The treatment plan was changed from nonsurgical initially to surgical in three (8%) of 36 patients and was changed from surgical to nonsurgical in three (27%) of 11 patients after injections. Of the remaining eight patients, treatment was altered in three (37%) as a result of pain relief after the injections.Fluoroscopically guided injections of local anesthetic and steroid in the foot and ankle can improve clinical confidence with regard to the site of pain and may be valuable in clinical decision making and patient treatment.

Category: Trauma Introduction/Purpose: Ankle fractures are among the most common injuries treated by Orthopaedic Surgeons. Complications following surgical treatment of ankle fractures have been well described, however less is known about the risk factors for postoperative wound complications specifically. The purpose of the present study was to evaluate the incidence of wound complications following open reduction and internal fixation of ankle fractures in obese and non-obese patients. Methods: We retrospectively identified 127 consecutive patients who underwent open reduction and internal fixation for an isolated, closed ankle fracture from 2008-2012. The age, sex, height, weight, diabetes status, and tobacco use of each patient were recorded. Time from injury to surgical fixation, use of external fixation, presence of initial dislocation, energy of mechanism, and injury pattern were also recorded. Patients’ records were reviewed to identify any postoperative wound complications. Complications were categorized as major or minor based on need for subsequent surgical intervention. Complication rates were compared between groups using the chi square test, and significant results were followed up with calculation of odds ratios and 95% confidence intervals using multivariate logistic regression. Results: The overall rate of wound complication was 18.9% (24/127), consisting of 6 major and 18 minor complications. The rate of wound complication of any type was significantly lower in obese patients at 11.7% (7/60) compared to 25.4% (17/67) in non- obese patients (P = 0.049). Obesity was associated with a significantly lower risk of developing a wound complication (OR 0.267, 95% CI 0.087 - 0.822), even when controlling for age, sex, diabetes status, tobacco use, surgical delay, external fixation, and injury pattern. No other covariates were associated with an increased risk of a wound infection. Conclusion: In the present study obese patients were less likely than non-obese patients to have a postoperative wound complication following internal fixation of an ankle fracture. Obesity may be protective against wound complications following surgical treatment of ankle fractures given the additional soft-tissue overlying the ankle.