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Background Management of scaphoid fractures often requires advanced imaging to achieve accurate diagnoses and appropriate treatment. Digital tomosynthesis (DTS) is a cross-sectional imaging modality that may be used to substitute magnetic resonance imaging or computed tomographic scans. The purpose of this study is to: (1) determine the diagnostic accuracy of DTS in occult scaphoid fractures; and (2) report on the reduction of other advanced imaging when using DTS. Methods From May 2014 to October 2017, the charts of all patients who underwent scaphoid tomogram were retrospectively reviewed. The diagnostic accuracy of DTS for occult fracture was compared with 2-week follow-up plain films. To measure the reduction in utilization of advanced imaging, it was determined whether DTS eliminated the need for advanced imaging by providing adequate information regarding the clinical question. Results A total of 78 patients underwent scaphoid tomography in this time frame: 39 for occult fracture, 33 for fracture union, 5 for fracture morphology, and 1 for hardware positioning. For the detection of occult fracture, DTS had a sensitivity of 100%, specificity of 83%, positive predictive value of 64%, and negative predictive value of 100%. Advanced imaging was not used in 35 of the remaining 39 patients based on the results obtained by DTS. In patients who did receive advanced imaging, 83% of tomograms provided conclusive diagnostic information. Conclusions Digital tomosynthesis increases the diagnostic sensitivity of occult scaphoid fractures, reducing unnecessary immobilization and advanced imaging. Digital tomosynthesis provides clinical detail beyond plain film, which reduces the need to obtain advanced imaging when assessing union, fracture pattern, and hardware placement.

PURPOSE OF REVIEW: The use of cannabinoids has increased since legalization of recreational and medical use in the USA. It is likely that many orthopaedic patients consume cannabinoid products during the traumatic or perioperative period. The purpose of this study was to investigate the pre-clinical data evaluating the mechanism of action of cannabidiol (CBD) and Δ(9)-Tetrahydrocannabinol (Δ(9)-THC) and to evaluate the current clinical data on the use of cannabinoids in musculoskeletal illness. RECENT FINDINGS: Recent pre-clinical studies have demonstrated that cannabinoid use and the endocannabinoid system (ECS) has an important role in bone healing and bone homeostasis. There is data that suggests that the use of cannabidiol (CBD) may increase bone healing, whereas the use of Δ(9)-Tetrahydrocannabinol (Δ(9)-THC), the major psychoactive ingredient in marijuana, likely inhibits bone metabolism and repair. The clinical implications and consumption of marijuana by orthopaedic patients have not been thoroughly evaluated. Studies have demonstrated concern for negative cardiovascular and psychiatric effects caused by marijuana use, but have not yet elucidated outcomes in the orthopaedic literature. SUMMARY: With the recent increase in advertising of CBD products and legalization of marijuana, it is likely that many orthopaedic patients are consuming cannabinoid products. The clinical implications and consumption of these products are unclear. We need more robust and well-designed clinical studies prior to making further recommendations to our patients on the consumption of these products.

The bony and ligamentous structure of the foot is a complex kinematic interaction, designed to transmit force and motion in an energy-efficient and stable manner. Visible deformity of the foot or atypical patterns of swelling should raise significant concern for foot trauma. In some instances, disruption of either bony structure or supporting ligaments is identified years after injury due to chronic pain in the hindfoot or midfoot. This article will focus on injuries relating to the peritalar complex, the bony articulation between the tibia, talus, calcaneus, and navicular bones, supplemented with multiple ligamentous structures. Attention will be given to the five most common peritalar injuries to illustrate the nature of each and briefly describe methods for achieving the correct diagnosis in the context of acute trauma. This includes subtalar dislocations, chopart joint injuries, talar fractures, navicular fractures, and occult calcaneal fractures.

Category: Midfoot/Forefoot Introduction/Purpose: Hallux rigidus (HR) is the most common degenerative pathology of the foot, marked by degenerative osteoarthritis of the first metatarsophalangeal joint (MTPJ) and reduced sagittal motion. Cheilectomy remains the standard of treatment, with satisfactory pain relief and increases in MTPJ range of motion (ROM). While the majority of these patients have satisfactory outcomes, a subset remains dissatisfied with persistent pain and poor ROM. In this study, we aim to assess the effect of sesamoid pathology on the functional outcomes of those undergoing cheilectomy for hallux rigidus. Methods: Electronic medical records were retrospectively reviewed to identify patients who underwent cheilectomy, with or without a corrective osteotomy (Moberg or Akin) for a diagnosis of HR, identified through CPT code 28289. The data referenced was from November 2019 through November 2021, belonging to three fellowship-trained foot and ankle specialists at a single high volume orthopedic practice. Exclusion criteria included revision procedures, loss of follow-up prior to one year, and prior sesamoidectomy. Our assessment included the presence of sesamoid arthritis or degeneration, demographic data, stage of HR according to the Coughlin and Shurnas classification on preoperative plain radiographs, a patient-reported pain scale, postoperative satisfaction, ROM, and return to activity. Patients were followed at 6 weeks, 3 months, 6 months, and 1 year. Complications were recorded. Statistical analysis was performed using Pearson's chi-square analysis and a two-sample t-test with significance set at alpha Results: In this retrospective study, 74 patients who underwent cheilectomy for the treatment of hallux rigidus were examined; 1 with grade 0 HR, 7 with grade 1 HR, 51 with grade 2 HR, and 15 with grade 3 HR. There were 33 with radiographic evidence of sesamoid arthritis, 41 without. Those with sesamoid arthritis trended towards having less pain relief over the course of our study (p=0.290) and more restricted postoperative ROM (p=0.385), though neither reached significance. There was no difference in complication rates between the two groups (p=0.661). Conclusion: The presence of sesamoid pathology appears to trend towards worse outcomes after cheilectomy for the treatment of hallux rigidus. Patients with sesamoid pathology may go unrecognized and may warrant consideration for modalities of treatment beyond cheilectomy for hallux rigidus for more satisfactory outcomes. This study is limited in its power and would benefit from greater sample sizes and more objective parameters of measurement. Nonetheless, this data allows for recognition of these patients in whom cheilectomy does not result in pain relief with the goal of identifying factors to improve care and provide sufficient treatment.

Plantar fibromatosis (Ledderhose disease) is a rare, benign, hyperproliferative fibrous tissue disorder resulting in the formation of nodules along the plantar fascia. This condition can be locally aggressive, and often results in pain, functional disability, and decreased quality of life. Diagnosis is primarily clinical, but MRI and ultrasound are useful confirmatory adjuncts. Given the benign nature of this condition, treatment has historically involved symptomatic management. A multitude of conservative treatment strategies supported by varying levels of evidence have been described mostly in small-scale trials. These therapies include steroid injections, verapamil, radiation therapy, extracorporeal shock wave therapy, tamoxifen, and collagenase. When conservative measures fail, surgical removal of fibromas and adjacent plantar fascia is often done, although recurrence is common. This review aims to provide a broad overview of the clinical features of this disease as well as the current treatment strategies being employed in the management of this condition.

Perioperative management of orthopaedic patients with a hematologic disorder is a complex endeavor that requires a multidisciplinary team-based approach. A team composed of an experienced orthopaedic surgeon, an anesthesiologist, and a hematologist is necessary to achieve optimal outcomes. Patients with hemophilia and other complex hematologic disorders should be managed at, or in consultation with a hematologist at, a comprehensive hemophilia center. Bleeding disorders and inherited thrombophilia present unique challenges for the perioperative management of orthopaedic surgery. Comprehensive preoperative planning and familiarity with treatment guidelines can help to minimize these risks. Knowledge of the disease processes outlined in this article will provide orthopaedic surgeons with the requisite background knowledge that is needed to initiate safe and effective treatment strategies involving this high-risk patient population.

Increasing numbers of people are participating in the sport of rock climbing, and its growth is expected to continue with the sport's Olympic debut in 2020. Extreme loading of the upper extremities, contorted positioning of the lower extremities, rockfall, and falling from height create an elevated and diverse injury potential that is affected by experience level and quantity of participation. Injuries vary from acute traumatic injuries to chronic overuse injuries. Unique sport-specific injuries to the flexor tendon pulley system exist, but the remaining musculoskeletal system is not exempt from injury. Orthopaedic evaluation and surgery is frequently required. Understanding the sport of rock climbing and its injury patterns, treatments, and prevention is necessary to diagnose, manage, and counsel the rock-climbing athlete.

Background: Fractures of the proximal fifth metatarsal are one of the most common foot injuries in athletes. Repetitive stresses endured by the fifth metatarsal can lead to stress fracture, delayed union, and refracture, making optimal treatment challenging. A radiographic analysis of fifth metatarsal morphology and foot type in National Football League (NFL) players was performed to investigate morphologic risk factors for these injuries. Methods: This was a case-control study that looked at NFL players treated between 1992 and 2012, as well as participants at the NFL Combine. Ninety-six feet (51 athletes) were included. Fractures were present in 15 feet. Two reviewers assessed fifth metatarsal morphology and foot type on anteroposterior, lateral, and oblique radiographs. Differences in foot type and metatarsal morphology between athletes with and without fractures were determined. Results: On anteroposterior radiographs, significant differences in apex medullary canal width, 4-5 intermetatarsal angle, fifth metatarsal angle, and talar head uncovering were observed between fractured and non-fractured feet ( P = .001, .003, .004, .008, respectively). On lateral radiographs, significant differences in the fifth metatarsal length, distance to apex, apex height, fifth metatarsal angle, and talocalcaneal angle were observed between fractured and nonfractured feet ( P = .04, .01, .02, .01, .01, respectively). On oblique radiographs, a significant difference was observed in apex height between fractured and nonfractured feet ( P = .002). Conclusion: Individuals with long, narrow, and straight fifth metatarsals with an adducted forefoot were most at risk for fifth metatarsal fractures. With this insight, attempts at fracture prevention can be implemented via footwear modifications, orthoses, and off-loading braces that account for those aforementioned morphologic attributes that place athletes at risk. Level of Evidence: Level III, retrospective comparative study.

Background: The Centers for Medicare and Medicaid services (CMS) have implemented initiatives to improve postdischarge care and reduce unnecessary readmissions. Readmissions within 30 days are frequent and represent an economic burden on both patients and the healthcare system. The aim of this study was to evaluate the frequency and causes for urgent care visits within 30 days of discharge after ankle open reduction and internal fixation (ORIF) and determine factors correlated with such visits. Methods: This was a retrospective analysis of prospectively collected data. All patients who underwent ankle ORIF at our institution between July 1, 2016, and June 30, 2017, were included. Patients were identified using Current Procedural Terminology (CPT) codes for ankle ORIF. Patients’ demographics including age, sex, race, body mass index, occupation, insurance payer, and comorbidities were documented. Results: Thirty-five patients (10.51%) had urgent care visits within 30 days of discharge. Patients presented at a mean of 11.8 days after the day of surgery. Sixteen patients (45.71%) had cast/splint-related issues, 7 (20%) presented with pain, and 7 (20%) with increased operative site drainage. Univariate analysis demonstrated a statistically significant association between postoperative urgent care visits and patients with diabetes ( P = .03) or underlying psychiatric disorders ( P = .03). Conclusion: In this population study of patients undergoing ankle fracture surgery, we found that the rate of urgent care visits within 30 days of discharge exceeded the rate of inpatient readmission. Additionally, patients with diabetes and psychiatric disorders were significantly more likely to present to an urgent care facility postoperatively, potentially accounting for increased expenditures of the healthcare system. Level of Evidence: Level III, comparative series.

Wound management is a notable healthcare and financial burden, accounting for >$10 billion in annual healthcare spending in the United States. A multidisciplinary approach involving orthopaedic and plastic surgeons, wound care nursing, and medical and support staff is often necessary to improve outcomes. Orthopaedic surgeons must be familiar with the fundamental principles and evidenced-based concepts for the management of acute and chronic wounds. Knowledge of surgical dressings, negative pressure wound therapy, tissue expanders, dermal apposition, biologics, and extracellular matrices can aide practitioners in optimizing wound care.

HistoryAnkle fractures are common musculoskeletal injuries thatoccur in a bimodal distribution, with peaks in younger menand older women [2], the former related to high-energytrauma and the latter to osteopenia and osteoporosis.Although ankle fractures currently account for 9% offractures, incidence and severity are increasing [1]. This isattributed to the increased life expectancy among olderindividuals and improved survival of patients with severefoot and ankle trauma [23, 26].The first ankle fracture classification, credited to Perci-val Pott, described three types of ankle fractures based onthe number of malleoli involved: unimalleolar, bimalleolar,and trimalleolar [21]. Despite its ease of use and repro-ducibility, the classification did not effectively guidemanagement, as it failed to differentiate stable from un-stable injuries.This was the impetus for the work of Niel Lauge-Hansen(1899–1976), a Danish physician who studied ankle frac-tures during the 1940s and 1950s, ultimately creating aclassification system based on a rotational mechanism ofinjury [11–15]. Lauge-Hansen’s classification, which waspublished in a 1950 issue of Archives of Surgery, has be-come one of the most widely used ankle fractureclassification systems [12]. Although still considered alandmark work regarding the biomechanics and deformingforces of ankle fractures, the quality, validity, and repro-ducibility of the Lauge-Hansen classification have beenchallenged [17, 19, 22, 25].PurposeAn ideal fracture classification would be reproducible,widely recognized, relevant for prognosis, and useful interms of clinical decision-making, documentation, andresearch.The primary normal motion of the ankle is dorsiflexionand plantar flexion, with osseous anatomy and ligamentouscomplexes that provide stability in all planes and axes ofrotation. When these structures are injured, there is sub-stantial risk of instability. Appropriate reconstructiontherefore is important, and a classification scheme thatidentifies injury patterns and guides treatment would bedesirable.Description of the Lauge-Hansen SystemNiel Lauge-Hansen used freshly amputated limbs to de-velop an ankle fracture classification based on foot positionat the time of the traumatic event (supination or pronation)and the direction of the deforming forces (abduction, ad-duction, or external rotation) [12].Cadaveric tibias were fixed with a vice and nails while arotational deforming force was applied by hand with the

OBJECTIVE Dedicated orthopaedic operating rooms (DOORs) are increasingly popular solutions to reducing after-hours procedures, physician fatigue, and elective schedule disruptions. Although the benefits to surgeons are well understood, there are comparatively few studies that explore the effects of DOORs on patient care. We compared treatments and outcomes for all consecutive patients with femoral neck fractures, 4 years before and 4 years after implementation of a DOOR-based schedule. DESIGN Retrospective case-control study. SETTING Level 1 academic trauma center. PATIENTS A total of 111 consecutive trauma patients undergoing surgical management of isolated OTA group 31-B femoral neck fractures. INTERVENTION Based on individual patient factors and fracture characteristics, patients were managed with either hemiarthroplasty or open reduction internal fixation (ORIF). MAIN OUTCOME MEASURES Surgical timing, intervention type, perioperative complications, and postoperative length of stay. RESULTS Retrospective analysis revealed a significant decrease in after-hour surgery (4 PM-7:30 AM) for all femoral neck fractures (66.7%-19.3%; P < 0.001). No significant differences were found between the rates of arthroplasty versus those of open reduction internal fixation. Patients undergoing surgical treatment for femoral neck fractures after DOOR suffered significantly fewer morbidities, including significantly decreased rates of postoperative intensive care unit admissions, stroke, infections, and myocardial infarction or congestive heart failure exacerbations. We also observed a significant decrease in postoperative mortality (5.6% pre-DOOR vs. 0% post-DOOR; P = 0.04). Patients undergoing hemiarthroplasty experienced a significant shorter hospitalization (14.5 days pre-DOOR vs. 9.9 days post-DOOR; P = 0.04). CONCLUSIONS In our experience, a weekday DOOR is closely associated with improvements in both patient safety and outcomes. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background. Ankle frac- tures in diabetics are challenging to treat, and only generalized clini- cal guidelines specific to their treat- ment exist. As such, the American Orthopaedic Foot and Ankle Society (AOFAS) membership was polled regarding the management of different types of ankle fractures in this patient population. Methods. We developed a multiple-choice survey with 3 clinical scenarios involving diabetic ankle frac- tures that was sent via e-mail to the 895 active members of the AOFAS. In addi- tion to providing demographic infor- mation, respondents identified their preferred stabilization method, the need for supplemental fixation, and each patient's weight-bearing status. Results. Respondents' number of years in prac- tice, number of ankle fractures treated monthly, and type of fellowship train- ing did not correlate with management strategies. Enhanced fixation with syn- desmotic screws was advocated in the setting of displaced fractures without syndesmotic injury, while casting was selected as the treatment for those that were nondisplaced. Prolonged periods of non-weight bearing were chosen by survey participants in all cases. Conclusion. We identified several treat- ment trends among AOFAS membership regarding ankle fractures in diabet- ics. However, it is pivotal that further investigation evaluate both optimal fix- ation strategies and the factors that influence surgeon decision mak- ing in the setting of dia- betic ankle fractures, as the orthopaedic surgeon is encountering such patients more than ever before.

Background: Approximately 33% of Americans have inadequate health literacy, which is associated with infrequent use of preventative services, increased hospitalization and use of emergency care, and worse control of chronic diseases. In this study, the Literacy in Musculoskeletal Problems (LiMP) questionnaire was used to evaluate the prevalence of limited musculoskeletal literacy in patients undergoing carpal tunnel release (CTR), as these individuals may be at increased risk of inferior outcomes. Methods: This cross-sectional study included individuals older than or equal to 18 years of age who were scheduled for elective CTR. Participants completed a demographic survey and the LiMP questionnaire during their preoperative office visit. The prevalence of limited health literacy was determined, with chi-square analysis used to determine the influence of demographic parameters. Results: The mean LiMP score was 6 ± 1.40. Limited musculoskeletal literacy was seen in 34% of participants (22/65). Analysis identified race (Caucasian), gender (female), higher education levels (≥college), current or prior employment in a health care field, and a prior physician visit for a non–carpal tunnel musculoskeletal complaint as being associated with higher literacy rates. Conclusions: Approximately one-third of patients scheduled for elective CTR have limited musculoskeletal literacy and may lack the necessary skills required for making informed decisions regarding their care. This is concerning, as CTR is performed in the United States on roughly 500 000 individuals annually, at an estimated cost of 2 billion dollars. The identification of those most at risk is thus crucial, and will facilitate the development of education campaigns and interventions geared toward those who are most vulnerable.

Early stage adult acquired flatfoot deformity (AAFD) is traditionally treated with osteotomy and tendon transfer. Despite a high success rate, the long recovery time and associated morbidity are not sufficient. This study aims to evaluate the functional and radiological outcomes following the use of the arthroereisis screw with tendoscopic delivered PRP for early stage AAFD. Patients with stage IIa AAFD who underwent the use of the arthroereisis screw with tendoscopic delivered PRP with a minimum follow-up time of 24 months were retrospectively evaluated. Clinical outcomes for pain were evaluated with the Foot and Ankle Outcomes Score (FAOS) and Visual Analog Score (VAS). Radiographic deformity correction was assessed using weight-bearing imaging. Thirteen patients (13 feet) with mean follow-up of 29.5 months were included. The mean age was 37.3 years (range, 28–65 years). FAOS-reported symptoms, pain, daily activities, sports activities, and quality of life significantly improved from 52.1, 42.6, 57.6, 35.7, and 15.4 pre-operatively to 78.5, 68.2, 83.3, 65.0, and 49.6 post-operatively, respectively (p

The Institute of Medicine considers limited health literacy a “silent epidemic,” as approximately half of Americans lack the competencies necessary for making informed decisions regarding their health. Limited health literacy substantially impedes the effective dissemination and comprehension of relevant health information, and also complicates communication, compromises care, and leads to worse patient outcomes. Poor health, early death, and worse control of chronic conditions have also been associated with limited health literacy. Unfortunately, physicians often struggle to identify those with limited health literacy, which can have adverse effects on the physician-patient relationship. In this article, we discuss the meaning of health literacy, the risk factors for and consequences of limited health literacy, orthopaedic-specific implications and investigations, and the strategies orthopaedic surgeons can utilize to improve health literacy and communication.

The treatment of humeral shaft fractures ranges from conservative modalities to operative fixation, including plate osteosynthesis and intramedullary fixation. Nonunion is a complication of conservative and operative interventions but is more often associated with elastic nailing. This article discusses elucidates the successful outcomes achieved with flexible nailing of humeral shaft fractures.

c s b i t a e In B ri ef H IGH-PERFORMANCE musculoskeletal injuries in the instrumental musician stem from repetitive motions, awkward postures, and long practice hours. Although their precise prevalence in this population is unclear, many have attempted to quantify this number and delineate the specific problems. Although the musculoskeletal conditions affecting usicians have been acknowledged since the early 700s, the prevailing mantra has been that of “no pain, o gain.” Performing arts medicine developed as ealth care providers began to understand the anatomic nd physiologic stresses endured while playing an intrument and their associated injury patterns. It is a ollaborative field of both nonsurgical and surgical speialists devoted to understanding and treating injures hat frequently complicate musical practice and perforance.

Background:Percutaneous internal fixation is currently the method of choice treating proximal zone II fifth metatarsal fractures. Complications have been reported due to poor screw placement and inadequate screw sizing. The purpose of this study was to define the morphology of the fifth metatarsal to help guide surgeons in selecting the appropriate screw size preoperatively.Methods:Multiplanar analysis of fifth metatarsal morphology was completed using computed tomographic (CT) scans from 241 patients. Specific parameters were analyzed and defined in anteroposterior (AP), lateral, and oblique views including metatarsal length, distance from the base to apex of curvature, apex medullary canal width, apex height, and fifth metatarsal angle.Results:The average metatarsal length in the AP view was 71.4 ± 6.1 mm and in the lateral view 70.4 ± 6.0 mm, with 95% of patients having lengths between 59.3 and 83.5 mm and 58.4 and 82.4 mm, respectively. The average canal width at the apex of curvature was 4.1 ± 0.9 mm in the AP view and 5.3 ± 1.1 mm in the lateral view, with 95% of patients having widths between 2.2 and 5.9 mm and 3.2 and 7.5 mm, respectively. Average distance from apex to base was 42.6 ± 5.8 mm in the AP and 40.4 ± 6.4 mm in the lateral views. Every measurement taken in all 3 views had a significant correlation with height.Conclusions:When determining screw length, we believe lateral radiographs should be used since the distance from the base of the metatarsal to the apex was smaller in the lateral view. On average, the screw should be 40 mm or less to reduce risk of distraction. For screw diameter, the AP view should be used because canal shape is elliptical, and width was found to be significantly smaller in the AP view. Most canals can accommodate a 4.0- or 4.5-mm-diameter screw, and one should use the largest diameter screw possible. Larger individuals were likely to have more bowing in their metatarsal shaft, which may lead to a higher tendency to distract.Level of Evidence:Level III, comparative series.

The tarsometatarsal joint complex is an osseous and capsuloligamentous network that includes the 5 metatarsals, their articulations with the cuneiforms and cuboid, and the Lisfranc ligament, a strong interosseous attachment between the medial cuneiform and second metatarsal. A multitude of injury patterns exist involving the tarsometatarsal joint complex; a Lisfranc injury does not delineate a specific injury, but instead a spectrum of processes involving the tarsometatarsal joint complex.

Purpose. Approximately 33% of Americans have inadequate health literacy, which is associated with decreased medical knowledge, increased hospitalization and use of emergency care, and worse control of diseases. In this study, the Literacy in Musculoskeletal Problems (LiMP) questionnaire was used to evaluate the prevalence of limited musculoskeletal literacy in patients presenting to the emergency department (ED) with foot and ankle–related complaints, as these individuals may be at increased risk for inferior outcomes. Methods. In this cross-sectional study, individuals ≥18 years of age presenting with foot and ankle–related complaints to the ED were invited to participate. Participants completed a demographic survey and the LiMP questionnaire, with scores ≥6 indicative of adequate musculoskeletal literacy. The prevalence of adequate health literacy and the influence of demographic parameters was assessed. P values .05). However, Caucasians and those with higher levels of education (equal to or more than college) were significantly more likely to possess adequate literacy ( P = .008, P = .04, respectively). Conclusions. Approximately one third of patients presenting to the ED with foot and ankle–related complaints have limited musculoskeletal literacy and may lack the necessary skills required for making informed decisions regarding their care. This is concerning and has tremendous socioeconomic implications, as more than 23 000 people per day require medical care for ankle sprains in the United States, with average treatment costs for this injury in the ED setting estimated at $1498. Identification of those most at risk is thus crucial and will facilitate the development of interventions geared toward those most vulnerable. Levels of Evidence: Prognostic, Level IV study

Background. The Internet is one of the most widely utilized resources for health-related information. Evaluation of the medical literature suggests that the quality and accuracy of these resources are poor and written at inappropriately high reading levels. The purpose of our study was to evaluate the quality, accuracy, and readability of online resources pertaining to hallux valgus. Methods. Two search terms (“hallux valgus” and “bunion”) were entered into Google, Yahoo, and Bing. With the use of scoring criteria specific to hallux valgus, the quality and accuracy of online information related to hallux valgus was evaluated by 3 reviewers. The Flesch–Kincaid score was used to determine readability. Statistical analysis was performed with t tests and significance was determined by P values Levels of Evidence: Level IV

Tarsal bone injuries are most often incurred during motor-vehicle collisions and other high-energy trauma1. Although uncommon, they are being seen with increasing frequency. This trend is attributed to enhancements in automobile safety that have improved the protection of the abdomen, head, and neck but have left the feet unprotected in the pedal box area2,3. Despite the adverse impact of foot injuries on overall outcome and long-term function in patients with polytrauma, the diagnosis sometimes is not made or is made on a delayed basis as treating physicians focus on more obvious or life-threatening injuries1,4,5. The navicular is the most frequently injured tarsal bone3. In the acute setting, avulsion, tuberosity and body fractures, and comminuted fracture-dislocations can occur. Stress fractures of the navicular represent more chronic, low-energy injuries. They often present with an insidious onset of midfoot pain after an increase in the duration or intensity of exercise or other activity. It is important for orthopaedic surgeons to consider this injury when patients present with vague symptoms in the midfoot …

A 13-year-old boy presented to the emergency department with bilateral ankle pain and swelling following a 5-foot fall from a swing set.

The approach to skeletal lesions has been well described1-3. Nevertheless, these lesions remain intimidating to both clinicians and patients. This is particularly true in the setting of polyostotic lesions, which can represent a metastatic process. Although it is imperative to consider this diagnosis, especially in adults, multicentric skeletal lesions can be the manifestation of a plethora of processes, ranging from non-neoplastic and benign conditions to more devastating malignant lesions and metastatic disease (Table I). In order to ensure accurate diagnosis and treatment, orthopaedic surgeons must be familiar with these conditions and the necessary workup. This article presents the approach to polyostotic disease while also reviewing some of the more common conditions presenting as multicentric skeletal lesions. View this table: TABLE I Non-Neoplastic, Benign, and Malignant Conditions That Can Present As Polyostotic Disease* There are many ways in which patients with polyostotic lesions present to orthopaedic surgeons. Some patients already will have had imaging studies performed, whereas others are being seen for the first time. Regardless, a thorough history and physical examination must be performed as it is only with the combination of a history, physical examination, and imaging that a differential diagnosis can be appropriately formulated. Once a lesion is identified, a bone scan is useful for …

>> Adult-acquired flatfoot deformity is a complex process attributed mainly to posterior tibial tendon insufficiency.>> Thorough physical examination and radiographs of the foot and ankle are usually adequate to achieve diagnosis.>> Nonoperative management is the first line of treatment and has a re

The tarsal navicular plays an integral role in hind-foot motion and gait, and is the keystone of the foot’s medial longitudinal arch. As such, injuries to the navicular can be devastating. Acute avulsion, tuberosity, and body fractures have been described. Fractures of the body result from high-energy trauma and are often seen in conjunction with additional ipsilateral foot injuries. Plain radiographs are the gold standard for diagnosis, with computed tomography helpful in the presence of intra-articular fracture extension. Non-operative treatment is reserved for avulsion injuries and non-displaced body fractures. Open reduction and internal fixation must be performed for all other types, as failure to achieve an anatomic reduction can impede proper locomotion. Complications following operative intervention include pain, stiffness, posttraumatic arthritis, avascular necrosis, nonunion, and hindfoot deformity. [ Orthopedics. 2014; 37(8):541–546.]

Diabetes mellitus is a disease of uncontrolled hyperglycemia. Despite a more sophisticated understanding of the pathophysiology of diabetes mellitus and despite pharmacologic advancements that enable better glycemic control, the prevalence of this disease and its devastating sequelae continue to rise. The adverse effects of diabetes on the nervous, vascular, and immune systems render the musculoskeletal system vulnerable to considerable damage. Foot involvement has traditionally been thought of as the most severe and frequently encountered orthopaedic consequence. However, the upper extremity, spine, and muscles are also commonly affected. Orthopaedic surgeons are more involved than ever in the care of patients with diabetes mellitus, and they play a vital role in the multidisciplinary approach used to treat these patients. As a result, surgeons must have a comprehensive understanding of the musculoskeletal manifestations and perioperative considerations of diabetes in order to most effectively care for patients with diabetes mellitus.

Minor traumatic brain injury (mTBI) is a major public health problem. The Centers for Disease Control and Prevention and the National Center for Injury Prevention and Control label it a "silent epidemic." Subtle signs and symptoms of mTBI, including headache, fatigue, and memory loss, are often seen in conjunction with musculoskeletal trauma. Although sometimes evident immediately, mTBI may not manifest until patients return to work and their personal lives. In the patient with acute concurrent mTBI, skeletal management must be based on either a period of observation to rule out evolving neurologic symptoms or, when warranted, the recommendations of a neurosurgeon. Such input is particularly important when mTBI is associated with a prolonged loss of consciousness or posttraumatic amnesia. In the outpatient setting, when concern for mTBI exists weeks after an injury, familiarity with and referral to locally available mTBI specialists and programs can facilitate proper care. Armed with this knowledge, the orthopaedic surgeon has an opportunity to positively influence outcomes and help provide crucial care that extends beyond the management of musculoskeletal injuries.

The closure of the distal tibial physis occurs over an 18-month period between ages 12 and 15 years. During this time period, children are susceptible to several transitional fractures, so labeled because they are transitioning to skeletal maturity. In the setting of an external rotation force, triplane and Tillaux fractures can occur. These fractures, which present similarly to other Salter-Harris growth plate injuries, do not fit neatly into any 1 classification scheme and are not easily evaluated on plain radiographs. Computed tomography scans are required to optimally assess these fractures and to determine the need for closed vs open treatment. Regardless of which treatment modality is chosen, anatomic reduction is the goal. This article discusses the approach to these unique fractures.

Biomechanical studies suggest ulnohumeral chondral and ligamentous overload (UCLO) explains the development of posteromedial chondromalacia (PMC) in throwing athletes with ulnar collateral ligament (UCL) insufficiency. UCL reconstruction reportedly allows 90% of baseball players to return to prior or a higher level of play; however, players with concomitant posteromedial chondromalacia may experience lower rates of return to play.The purpose of this investigation is to determine: (1) the rates of return to play of baseball players undergoing UCL reconstruction and posteromedial chondromalacia; and (2) the complications occurring after UCL reconstruction in the setting of posteromedial chondromalacia.We retrospectively reviewed 29 of 161 (18%) baseball players who were treated for the combined posteromedial chondromalacia and UCL injury. UCL reconstruction was accomplished with the docking technique, and the PMC was addressed with nothing or débridement if Grade 2 or 3 and with débridement or microfracture if Grade 4. The mean age was 19.6 years (range, 16-23 years). Most players were college athletes (76%) and pitchers (93%). We used a modified four-level scale of Conway et al. to assess return to play with 1 being the highest level (return to preinjury level of competition or performance for at least one season after UCL reconstruction). The minimum followup was 24 months (mean, 37 months; range, 24-52 months).Return to play was Level 1 in 22 patients (76%), Level 2 in four patients (14%), Level 3 in two patients (7%), and Level 4 in one (3%) patient.Our data suggest baseball players with concomitant PMC, may have lower rates of return to the same or a higher level of play compared with historical controls.Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Background: There are several large series of outcomes after ulnar collateral ligament (UCL) reconstruction that have 1 or 2 javelin throwers included. To our knowledge, however, there are no reports that focus solely on the results of UCL reconstruction in this group of athletes. Hypothesis/Purpose: We hypothesize that by using modern UCL reconstruction techniques, javelin throwers can reliably expect to return to their sport. Additionally, we review the principles behind postoperative rehabilitation in these athletes, as it differs from the usual approach used with baseball players. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective review of 10 javelin throwers who underwent UCL reconstruction between 2006 and 2009 using the docking technique. There were 5 college and 5 high school javelin throwers. The average age was 18.5 years (range, 18-21 years). All patients, before being indicated for ligament reconstruction, failed a course of nonoperative management that included rest, physical therapy, and a structured attempt to return to throwing. Postoperatively, patients were evaluated using the Conway Scale and the Andrews-Timmerman Score. Results: Patients were evaluated at a minimum 2-year follow-up. The average follow-up was 28.9 months after surgery (range, 24-45 months). On the Conway Scale, 9 of the 10 players had excellent outcomes (90%). There was one fair (10%) outcome. Average time to return to previous level of competition was 15 months. The mean Andrews-Timmerman Score was 97 (range, 85-100). Overall, 100% (10/10) of the patients were subjectively satisfied with their clinical outcome. Conclusion: Similar to other overhand athletes with UCL insufficiency, javelin throwers can reliably expect to return to their previous level of play after surgical reconstruction. A thorough understanding of the unique demands placed on these athletes because of the different throwing motion is helpful when tailoring their postoperative rehabilitation protocol. Additionally, these athletes must be counseled that the postoperative course is associated with an extended period of time until return to previous level of competition when compared with baseball players.

Total knee arthroplasty (TKA) has become the predominant treatment modality for severe degenerative joint disease. With recent advancements in surgical and anesthetic technique, patients with severe comorbidities are able to have this procedure; they would have been precluded from TKA only a matter of years ago. Although many studies have investigated risk factors and the causes of perioperative morbidity and mortality in the arthroplasty patient, few have linked risk factors with specific outcomes. We present a case report that illustrates the link between the use of angiotensin-converting enzyme inhibitors and the development of postoperative acute kidney injury. While this relationship has been extensively studied in cardiac and gastric bypass patient populations, it has never been examined in the setting of joint replacement.

Much current research is focused on biologic enhancement of the tendon repair process. To evaluate the different methods, which include a variety of gene therapy and tissue engineering techniques, histological and biomechanical testing is often employed. Both modalities offer information on the progress and quality of repair; however, they have been historically considered as two separate entities. Histological evaluation is a less costly undertaking; however, there is no validated scoring scale to compare the results of different studies or even the results within a given study. Biomechanical testing can provide validated outcome measures; however, it is associated with increased cost and is more labor intensive. We hypothesized that a properly developed, objective histological scoring system would provide a validated outcome measure to compare histological results and correlate with biomechanics. In an Achilles tendon model, we have developed a histological scoring scale to assess tendon repair. The system grades collagen orientation, angiogenesis, and cartilage induction. In this study, histology scores were plotted against biomechanical testing results of healing tendons which indicated that a strong linear correlation exists between the histological properties of repaired tendons and their biomechanical characteristics. Concordantly, this study provides a pragmatic and financially feasible means of evaluating repair while accounting for both the histology and biomechanical properties observed in surgically repaired, healing tendon.