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Introduction This study sought to determine (1) incident risk, (2) chief report, (3) risk factors, and (4) total cost of unplanned healthcare visits to an emergency and/or urgent care (ED/UC) facility within 30 days of an outpatient orthopaedic procedure. Methods This was a retrospective database review of 5,550 outpatient surgical encounters from a large metropolitan healthcare system between 2012 and 2016. Statistical analysis consisted of measuring the ED/UC incident risk, respective to the procedures and anatomical region. Patient-specific risk factors were evaluated through multigroup comparative statistics. Results Of the 5,550 study patients, 297 (5.4%) presented to an ED/UC within 30 days of their index procedure, with 23 (0.4%) needing to be readmitted. Native English speakers, patients older than 45 years, and nonsmokers had significant reduced relative risk of unplanned ED or UC visit within 30 days of index procedure (P < 0.01). In addition, hand tendon repair/graft had the greatest risk incidence for ED/UC visit (11.0%). Unplanned ED/UC reimbursements totaled $146,357.34, averaging $575.65 per visit. Discussion This study provides an evaluation of outpatient orthopaedic procedures and their relationship to ED/UC visits. Specifically, this study identifies patient-related and procedural-related attributes that associate with an increased risk for unplanned healthcare utilization.

Case We present a long-term follow-up on a woman with otospondylomegaepiphyseal dysplasia (OSMED). At the age of 46 years, she is one of the oldest patients with the syndrome in the literature to date. We focus on the musculoskeletal anatomy and orthopaedic interventions over her lifetime. Conclusion OSMED is a very rare syndrome. Arthritis and joint pains presented in her early adolescence and progressed to the point of requiring joint replacements by her 20s. Early intervention and monitoring improved the quality of life for this patient.

IntroductionFemoral head collapse (FHC) is a rarely reported complication of hip intra-articular corticosteroid injection (IACSI). Upon observing a high rate of FHC after hip IACSI, we sought to (1) describe how we addressed the problem through a systematic evaluation of clinical data and institutional care practices followed by process improvement efforts; and (2) report our results.MethodsPatients receiving hip IACSI during a 27-month period underwent retrospective review to determine the rate of FHC and to identify associated patient factors or practice shortfalls. Findings led to institution-wide interventions: (1) to improve patient/provider awareness of this association; and (2) to develop/implement practice guidelines. Rates of FHC after hip IACSI and practice patterns among providers before and after intervention were compared.ResultsInitial FHC rate after hip IACSI was 20.4%. Patient-related factors included body mass index (p = 0.025), history of cancer therapy (p = 0.012), Vitamin D level (p = 0.030), and multiple injections (p = 0.004). Volume/dose of injectate and post-injection surveillance methods varied widely. Quality improvement (QI) intervention resulted in fewer treatment referrals (from 851 to 436), fewer repeat injections (mean = 1.61 to 1.37; p = 0.0006), and a 5% lower FHC rate (p = 0.1292). Variation in practice patterns persisted, so a systems-based Clinical Pathway was established.DiscussionWhen a high rate of FHC after hip IACSI was found to be associated with certain patient and practice factors, introduction of education materials and treatment guidelines decreased number of referrals, number of injections per patient, and FHC rate. In the absence of the systems-based Pathway, the type, dose, and volume of injectate and post-procedure follow-up remained variable.

Introduction The relative indications for removing symptomatic implants after osseous healing are not fully agreed on. The purpose of this study was to (1) determine whether patients showed improvement in functional outcomes after the removal of symptomatic orthopaedic implants, (2) compare the outcomes between upper and lower extremity implant removal, and (3) determine the rate of implant removal complications. Methods A prospective study was conducted between 2013 and 2016. Patients completed a Short Musculoskeletal Function Assessment outcome questionnaire before implant removal and at the 6-month follow-up. Demographic data were stratified and compared between upper and lower extremity groups and between preimplant removal and 6-month postremoval. Results Of the 119 patients included in the study, 85 (71.4%) were lower extremity and 34 (28.6%) were upper extremity. Significant improvement after implant removal was seen in the dysfunction index (P ≤ 0.001), bother index (P ≤ 0.001), and daily activities domain (P ≤ 0.001). Depression or anxiety (P = 0.016) were statistically significant predictors for an improved Short Musculoskeletal Function Assessment dysfunction index score at 6 months. The complication rate was 10.1% (n=12) for the cohort. Discussion Implant removal in both the upper and lower extremity presented notable improvement in dysfunction. Complications that require surgical intervention are extremely rare.

BACKGROUND The treatment of postoperative pain is an ongoing challenge for orthopaedic surgeons. Poorly controlled pain is associated with poorer patient outcomes, and the prescription of opioids may lead to prolonged, nonmedical use. Complementary and alternative medicine is widely adopted by the general public, and its use in chronic musculoskeletal pain conditions has been studied; however, its efficacy in a postoperative context has not yet been established. METHODS We conducted a systematic literature review of 10 databases to identify all relevant publications. We extracted variables related to pain measurement and postoperative opioid prescriptions. RESULTS We identified 8 relevant publications from an initial pool of 2,517 items. Of these, 5 were randomized studies and 3 were nonrandomized studies. All 8 studies addressed postoperative pain, with 5 showing significant decreases (p < 0.05) in postoperative pain. Also, 5 studies addressed postoperative opioid use, with 2 showing significant differences (p < 0.05) in opioid consumption. Substantial heterogeneity among the studies precluded meta-analysis. No articles were found to be free of potential bias. CONCLUSIONS Currently, there is insufficient evidence to determine the efficacy of complementary and alternative medicines for postoperative pain management or as an alternative to opioid use following orthopaedic surgery. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Laboratory workers are potentially exposed to a wide range of chemical hazards while performing experimental research. Moreover, unique combinations of chemicals can generate hazards that the indiv...

Background:Initial treatment for a displaced ankle fracture is closed reduction and splinting. This is typically performed in conjunction with either an intra-articular hematoma block (IAHB) or procedural sedation (PS) to assist with pain control. The purpose of this study was to compare the safety of IAHB to PS and evaluate the efficiency and efficacy for each method.Methods:A retrospective chart review for ankle fractures requiring manipulation was performed for patients seen in a level I trauma center from 2005 to 2016. The primary outcome was rate of successful reduction. Several secondary outcome measures were defined: reduction attempts, time until successful reduction, time spent in the emergency department (ED), rate of hospital admission, and adverse events. The analysis included 221 patients who received IAHB and 114 patients who received PS.Results:The demographics between the 2 groups were similar, with the exception that more patients with a dislocation received PS, which prompted a subgroup analysis. This analysis demonstrated that patients with an ankle fracture and associated tibiotalar joint subluxation underwent closed reduction in a shorter period of time with the use of an IAHB compared with those receiving PS. In patients sustaining a tibiotalar fracture dislocation, patients receiving PS were successfully reduced with 1 reduction attempt more frequently than those receiving IAHB. Orthopedic surgeons also had higher rates of success on first attempt compared with ED providers.Conclusion:Both IAHB and PS were excellent options for analgesia that resulted in high rates of successful closed reduction of ankle fractures with adequate safety. IAHB can be considered a first-line agent for patients with an ankle fracture and associated joint subluxation.Level of Evidence:Level III, retrospective comparative series.

Objective To determine journal publication rates of podium presentations from the OTA Annual Meetings between 2008 and 2012. Methods Podium presentations from the 2008 to 2012 OTA annual meeting were compiled from the Annual Meeting archives. During December 2016, and Google Scholar were performed using individual keywords in the abstract title and content. The results were reviewed for matches to the meeting abstracts with regard to the title, authors, and abstract content. Yearly publication rates were calculated, along with time to publication and common journals for publication. Results The publication rate for the 357 podium abstracts presented at the OTA between 2008 and 2012 was 72.8%. Eighty-one percent of abstracts were from the US institutions. The mean time to publication from podium presentation was 23.4 months, and the most common journals of publication were Journal of Orthopaedic Trauma (45.4%) and The Journal of Bone & Joint Surgery (15.3%). Conclusions The publication rate of the podium presentations at the OTA Annual Meeting from 2008 to 2012 has increased since previous years. Compared with other orthopaedic subspecialty and nonorthopaedic specialty meetings, the OTA publication rate is among the highest in the medical field. OTA annual meetings are an opportunity for early access to high-quality research in the area of orthopaedic trauma.

Background: Orthopedic implant removal following open reduction internal fixation of a fracture is a common procedure, especially in the foot and ankle. The purpose of this study was to evaluate functional change after the removal of symptomatic implants following ankle fracture open reduction internal fixation (ORIF) using the Short Musculoskeletal Function Assessment (SMFA) outcome score. We hypothesized that implant removal after ankle fracture would result in improved functional outcomes. Methods: Retrospective review of prospectively collected data on patients with a closed ankle fracture between 2013 and 2016 was performed. Inclusion criteria were skeletal maturity, symptomatic ankle implants and completion of the SMFA questionnaire prior to and 6 months after removal. Exclusion criteria were development of a nonunion, prior or current infection, peripheral neuropathy or ongoing litigation surrounding the surgery. The primary outcome was change in SMFA score from baseline to follow-up using Wilcoxon signed-rank test. Additional logistic regression models evaluated the effects of age, sex, body mass index, smoking status, and patient American Society of Anesthesiologists scores. Results: The study population consisted of 43 patients. There was a statistically significant improvement in function, represented by a decrease in SMFA scores from baseline to the 6-month follow-up period (∆ = −4.1 [95% confidence interval, −7.0, −1.3]; P = .003). Secondary outcome measures of the bother index and daily activities domain also demonstrated significant improvements ( P = .005 and P = .002, respectively). Additional logistical regression models identified no significant effects by assessed covariates for change in SMFA scores. Conclusion: Patients with symptomatic implants following ankle fracture ORIF had a statistically significant improvement in function following implant removal. There appears to be value in removing implants from the ankle in patients who report discomfort during daily activities. Further investigation into the specific indications for implant removal and the impact of injury and fracture pattern on outcomes is warranted. Level of Evidence: Level IV, case series.

Stopover sites provide crucial habitat for waterfowl to rest and refuel during migration. Knowledge of which land-cover types are of greatest importance to migrating waterfowl and how the surrounding landscape influences their use can inform management decisions and conservation plans to adequately meet resource requirements. Specifically, spring migration habitat is essential for waterfowl preparing for breeding yet is an understudied period of the life cycle. We placed radio-transmitters on Mallards (Anas platyrhynchos) and Green-winged Teal (Anas crecca) between January and April 2016–2017 in the Wabash River Valley of Illinois and Indiana to assess habitat use and movement patterns. Both Mallards and Green-winged Teal primarily used emergent and woody wetlands, with 89% of use points in these land-cover types even though they made up

BACKGROUND An increasing emphasis has been placed on developing value-based care delivery systems in orthopaedics to combat rising health care costs. The goal of these systems is to both measure and improve the provisional value of care. Patient-level value analysis creates a mechanism to quantify and optimize value within a procedure, in contrast to traditional methods, which only measures value. The purpose of this study was to develop a patient-level value analysis model and determine the efficacy of this model to improve value in orthopaedic care. METHODS Patients treated operatively for isolated closed ankle fractures at a single level 1 trauma center were prospectively identified. Short musculoskeletal function assessment was collected at the time of the initial clinical presentation and 6 months postoperatively. The cost of care was determined using time-driven activity-based costing, which included personnel, supplies, length of stay, implants, pharmacy, and radiology. Value was defined as each patient's change in the outcome score divided by their cost as determined by time-driven activity-based costing. A multiple linear regression was performed to determine which aspects of care significantly predicted value. RESULTS Forty-nine patients met inclusion/exclusion criteria. The multiple linear regression indicated treatment by physician D (β = -0.135, P = 0.04) and inpatient stay (β = -0.468, P < 0.01) were predictors of lesser value and represent areas for potential care pathway and value improvement. CONCLUSIONS Patient-level value analysis represents a paradigm shift in the quantification of value. We recommend surgeons, practices, and health care systems begin implementing a system to quantify and optimize the value of care provided. LEVEL OF EVIDENCE Level III. See Instructions for Authors for a complete description of levels of evidence.

The goal of this study was to compare immediate weightbearing (IWB) and traditional weightbearing (TWB) postoperative protocols in unstable ankle fractures, as this has not been compared in prior works. We hypothesize that an immediate weightbearing protocol after ankle fracture fixation will lead to an earlier return to work. An ankle fracture registry was reviewed for operatively treated unstable bimalleolar and trimalleolar ankle fractures at an ambulatory surgery center and followed up at associated outpatient clinics. All fracture cases reviewed occurred from 2009 to 2015. Immediate weightbearing patients were placed into a controlled ankle motion (CAM) boot and allowed to fully bear weight the day of surgery. Traditional weightbearing patients were placed into a CAM boot with 6 weeks of non-weightbearing. Demographics, fixation technique, and injury characteristics were surveyed. Physical job demand was stratified for 69 patients meeting the inclusion criteria (34 IWB and 35 TWB). The main outcome of this study was measured as the time to return to work. Subgroup analysis of patients with nonsedentary jobs demonstrated a significantly earlier return to work for the IWB group (5.7 versus 10.0 weeks, p = .04). Multivariate regression analysis identified a statistically significant 2.25-week (p = .05) earlier return to work for the IWB group after adjustment for occupational physical demand, demographics, fracture characteristics, and participation in a light work period before full work return. In patients with nonsedentary jobs, an IWB protocol after operative management of bimalleolar and trimalleolar ankle fractures resulted in an earlier return to work compared with traditional protocols.

Background: National orthopaedic meetings are used to disseminate current research through podium and poster abstract presentations. Not all of these abstracts go on to full-text journal publication. The purpose of this study was to determine the publication rates of podium and poster presentations from the American Orthopaedic Foot & Ankle Society (AOFAS) annual meetings between 2008 and 2012. Methods: All accepted podium and poster abstracts from the 2008-2012 AOFAS annual meetings were compiled from the AOFAS office, Physician Resource Center website, and hardcopy meeting programs. PubMed and Google Scholar searches were performed for journal publications using key words in the presentation abstracts and authors’ names. Full-text journal publication rates for the presentations were calculated per year, as were the most common journals of publication. Results: Overall full-text publication rate was 73.7% for podium presentations and 55.8% for posters. Podium presentations were published in a journal significantly more often than posters ( P < .0001; odds ratio 2.17 [95% confidence interval (CI), 1.64-2.86]). The mean time to publication was 1.5 and 1.4 years for podium and poster presentations, respectively ( P = .124). The most common journal for podium and poster publications was Foot & Ankle International. Conclusion: Podium abstracts were significantly more likely to be published compared to posters. The AOFAS overall full-text journal publication rate was one of the higher reported rates compared with other national orthopedic society meetings, which have ranged from 34% to 73%.

This case presents surgical treatment of a unique form of syndactyly: an isolated fenestrated, complex, crisscross syndactyly of the right middle and ring fingers. A 2-year-old boy presented with the ring finger lying dorsal and the middle finger lying volar, with the middle phalanges syndactylized. A surgical release was performed with a subsequent z-plasty, 2 years later, for scar elongation. At the age of 4, he has essentially full function of his hand with minimal limitations. This case demonstrates that 2 digits that were syndactylized in a coronal plane (ring finger dorsal and middle finger volar) can be successfully surgically separated.

The Accreditation Council for Graduate Medical Education (ACGME) requires orthopaedic residency programs to promote scholarship and research, which manifest differently among programs. We assess the impact of protected research time during orthopaedic residency on the number of resident publications.Rotation schedules and resident names were collected from 125 ACGME-accredited U.S. orthopaedic residency programs. Protected research time was classified as 1 of 3 types: (1) block time, (2) longitudinal time, or (3) no dedicated time. In April 2016, we searched residents in postgraduate year (PGY)-3 to PGY-5 on pubmed.gov to generate all orthopaedic publications with a PubMed identifier published during residency. Each publication's 2015 Thomson Reuters Journal Citation Reports 5-Year Journal Impact Factor and resident first authorship were noted. The number of PubMed identifiers for each program was summed and was divided by the number of residents in PGY-3 to PGY-5, giving a mean number of publications per resident. The relationship between output and program research time was compared using t tests and analysis of variance (ANOVA).A total of 1,690 residents were included, with an overall mean number (and standard deviation) of 1.2 ± 2.4 publications per resident. Eighty-seven programs reported block time, 14 programs reported longitudinal time, and 24 programs reported no time. There was a significant difference (p = 0.02) in the mean number of publications per resident when compared between programs with protected time (1.1 ± 1.2 publications) and programs with no protected time (0.6 ± 0.5 publication). One-way ANOVA demonstrated a significant mean difference across the 3 groups (p0.001), with longitudinal time correlating with significantly greater output at 1.9 ± 1.8 publications than block time at 1.0 ± 1.0 publication or no time at 0.6 ± 0.5 publication, a difference that persisted when adjusted to include only impact factors of0 and exclude case reports (p = 0.0015).Both the presence of and the type of dedicated research time correlate with residents' research productivity; further consideration of protected research time during residency is warranted.This article provides objective data with regard to research strategies in training orthopaedic surgeons.

Introduction. In the literature, there is conflicting data regarding the relationship between vitamin D and fractures. Reports on the effects of vitamin D levels on pathologies of the foot and ankle are limited. The purpose of this study is to assess the prevalence of vitamin D insufficiency in patients who have sustained low-energy metatarsal fractures compared to foot or ankle sprains without osseous involvement. Methods. Between May 2012 and August 2014, vitamin D levels and demographic data were collected prospectively in a total of 99 patients; 71 with metatarsal fractures and 28 with sprains, both from a low-energy mechanism of injury. Data between the metatarsal fracture group and sprain group were compared through univariate and multivariate analyses. Results. Mean vitamin D in the fracture group was 26.9 ng/mL (range = 78.0-4.3), and in the sprain group it was 27.1 ng/mL (range = 64.1-8.3; P = .93). Vitamin D insufficiency ( Levels of Evidence: Level III: Prospective, case-control study

Background: Lateral column lengthening (LCL) of the calcaneus is commonly performed as part of correction of the adult acquired flatfoot deformity. Increases in postoperative lateral plantar pressure associated with pain in the lateral aspect of the foot have been reported. The aim of this study was to investigate changes in pressures in the lateral aspect of the forefoot with increments of 6, 8, and 10 mm of LCL in a cadaveric flatfoot model. The hypothesis was that increasing the LCL incrementally by 2 mm will linearly increase the plantar pressures in the lateral aspect of the forefoot. Methods: Eight fresh-frozen cadaveric foot specimens were used. A robot compressively loaded the foot to 400 N with a 310-N tensile load applied to the Achilles tendon. A flatfoot model was created by resecting the medial and inferior soft tissues of the midfoot, followed by axial load of 800 N for 100 cycles. Kinematic and plantar pressure data were gathered after the different amounts of LCL (6, 8, and 10 mm) were achieved. Results: The talonavicular joint demonstrated a median abduction angle of 4.4° in the axial plane and −2.6° in the sagittal plane in the flatfoot condition as compared with the intact condition. The 6, 8, and 10-mm LCLs showed axial correction of talonavicular alignment by −1.4°, −4.9°, and −9.2° beyond that of the intact foot, and sagittal correction of −0.1°, 1.3°, and 2.9°, respectively. LCL of 6, 8, and 10 mm showed consistently increasing lateral forefoot average mean pressure, peak pressure, and contact area. Conclusions: LCL in 2-mm increments consistently reduced talonavicular abduction and consistently increased plantar pressure in the lateral aspect of the forefoot. Clinical Relevance: The lateral column should be lengthened judiciously, as a 2-mm difference leads to significant difference not only in angular correction of the talonavicular joint but also with regard to pressure in the lateral aspect of the forefoot.

National orthopaedic meetings are used to disseminate current research through podium and poster abstract presentations. Not all of these abstracts go on to full-text journal publication. The purpose of this study was to determine the publication rates of podium and poster presentations from the American Orthopaedic FootAnkle Society (AOFAS) annual meetings between 2008 and 2012.All accepted podium and poster abstracts from the 2008-2012 AOFAS annual meetings were compiled from the AOFAS office, Physician Resource Center website, and hardcopy meeting programs. PubMed and Google Scholar searches were performed for journal publications using key words in the presentation abstracts and authors' names. Full-text journal publication rates for the presentations were calculated per year, as were the most common journals of publication.Overall full-text publication rate was 73.7% for podium presentations and 55.8% for posters. Podium presentations were published in a journal significantly more often than posters ( P.0001; odds ratio 2.17 [95% confidence interval (CI), 1.64-2.86]). The mean time to publication was 1.5 and 1.4 years for podium and poster presentations, respectively ( P = .124). The most common journal for podium and poster publications was FootAnkle International.Podium abstracts were significantly more likely to be published compared to posters. The AOFAS overall full-text journal publication rate was one of the higher reported rates compared with other national orthopedic society meetings, which have ranged from 34% to 73%.

A host of observations demonstrating the relationship between nuclear architecture and processes such as gene expression have led to a number of new technologies for interrogating chromosome positioning. Whereas some of these technologies reconstruct intermolecular interactions, others have enhanced our ability to visualize chromosomes in situ. Here, we describe an oligonucleotide- and PCR-based strategy for fluorescence in situ hybridization (FISH) and a bioinformatic platform that enables this technology to be extended to any organism whose genome has been sequenced. The oligonucleotide probes are renewable, highly efficient, and able to robustly label chromosomes in cell culture, fixed tissues, and metaphase spreads. Our method gives researchers precise control over the sequences they target and allows for single and multicolor imaging of regions ranging from tens of kilobases to megabases with the same basic protocol. We anticipate this technology will lead to an enhanced ability to visualize interphase and metaphase chromosomes.

The syntheses and X-ray structures of two molybdenum pyranopterin dithiolene complexes in biologically relevant Mo(4+) and Mo(5+) states are reported. Crystallography reveals that these complexes possess a pyran ring formed through a spontaneous cyclization reaction of a dithiolene side-chain hydroxyl group at a C═N bond of the pterin. NMR data on the Mo(4+) complex suggest that a reversible pyran ring cyclization occurs in solution. These results provide experimental evidence that the pyranopterin dithiolene ligand in molybdenum and tungsten enzymes could participate in catalysis through dynamic processes modulated by the protein.

The synthesis, characterization, binding to calf thymus DNA, and plasmid DNA photocleavage studies of two ruthenium(II) pteridinylphenanthroline complexes are reported where the new pteridinylphenantholine ligands in these complexes are additions to a larger family designed to resemble DNA bases. [Ru(bpy)(2)(L-keto)](PF(6))(2)1 is synthesized from ligand substitution of Ru(bpy)(2)Cl(2) by 4-keto-pteridino[6,7-f]phenanthroline (L-keto). Increasing the reaction temperature during synthesis of 1 causes a ring scission of the L-keto ligand within the pyrimidine ring yielding a second Ru complex, [Ru(bpy)(2)(L-aap)](PF(6))(2)2 where L-aap is 2-amino-3-amidopyrazino[5,6-f]phenanthroline. The ring cleavage reaction is accompanied by the loss of one carbon in the pyrimidine ring. Complexes 1 and 2 are characterized by (1)H NMR, UV/visible absorption and FT-IR spectroscopies and by cyclic voltammetry, and these results are presented in comparison to the previously reported related complexes [Ru(bpy)(2)(L-allox)](PF(6))(2), [Ru(bpy)(2)(L-amino)](PF(6))(2), and [Ru(bpy)(2)(dppz)](PF(6))(2). In addition, 2 has been structurally characterized by X-ray diffraction. Both 1 and 2 are good intercalators of calf thymus DNA as determined by viscometry and binding constants obtained from absorption titrations. Only the ring-cleaved complex 2 exhibits a high degree of pBR322 plasmid photocleavage in contrast to the other pteridinyl-phenanthroline complexes, which exhibit no plasmid DNA photocleavage. Complex 1, however, decomposes in buffer forming the photocleaver 2, demonstrating that sample age and reactivity can affect observed photocleavage. Complex 2 appears to photocleave DNA through a singlet oxygen mechanism.

Background: One of the major concerns with lateral column lengthening (LCL) in symptomatic flatfoot deformity treatment is the risk of postoperative plantar lateral foot discomfort. We evaluated whether this risk can be minimized by using trial metal wedges. Using our study's evaluation tools, the incidence of postoperative plantar lateral foot discomfort before and after using trial metal wedges was determined. Materials and Methods: The incidence of plantar lateral foot pain after LCL was retrospectively assessed in 122 consecutive patients (132 feet) after they had undergone flatfoot reconstruction with LCL between 2001 and 2007. To determine if the incidence could be reduced, levels of pain or revision were compared before and after the use of trial metal wedges. The ratio of wedge size to preoperative radiographic calcaneal length was also determined. Results: The overall incidence of plantar lateral discomfort was 11.2%. The incidence of pain or revision was lower after the introduction of trial metal wedges (6.3% compared to 14.7%), but did not reach significance (p = 0.084). There was no significant difference found in the ratio of the size of bone graft wedge to calcaneal length between the two groups (p = 0.805). Conclusion: The incidence of plantar lateral foot discomfort overall was 11.2% after LCL. We believe this risk may be reduced using trial metal wedges, properly judging eversion stiffness and carefully assessing the position of the foot intraoperatively. Level of Evidence: III, Retrospective Comparative Study

Chronic ankle instability can be addressed surgically through direct lateral ligament repair, non-anatomic reconstruction, or anatomic reconstruction. The goal of this study was to assess the radiographic, functional, and clinical results of patients undergoing an anatomic lateral ankle ligament reconstruction using an anterior tibial tendon allograft. Eleven patients (12 feet; mean age, 48.9 ± 11.4 years) undergoing lateral ankle ligament reconstruction were followed at a mean of 3.5 ± 1.7 years after surgery (range, 1.2 to 5.0 years). Indications for surgery were previous failed repair (i.e., Broström; one case), hyperlaxity (seven cases), and high-demand patients (four cases). Subjective outcomes including the Foot and Ankle Outcome Score (FAOS), SF-36, and activity level were assessed. Mortise and lateral ankle stress radiographs were performed. The FAOS daily activity and sports activity subscores were 93.4 (range, 77.9 to 100) and 78.6 (range, 30 to 100), respectively. The SF-36v2 physical health and mental health components were 50.4 (range, 30.6 to 65.7) and 45.0 (range, 24.8 to 68.0), respectively. Four patients (five feet) reported no restriction; six patients reported mild restrictions, and one patient reported moderate activity restrictions. Tibiotalar tilt improved significantly from 20.2° to 4.6° after surgery (p

Patients with flexible stage IV flatfoot present with valgus ankle deformity in addition to medial arch collapse, resulting in hind foot valgus and midfoot abduction. The ankle deformity is best addressed at the time of flatfoot reconstruction. In this article, we describe a method of reconstructing the deltoid ligament complex by using an Achilles allograft tendon. The graft is prepared with a bone block that is placed in a talar tunnel and secured to a screw post in the lateral talar body. The graft is passed through an oblique tibial tunnel, drilled from medial to lateral starting at the medial malleolus and exiting out the lateral tibia above the level of the ankle. The reconstruction is indicated in cases in which ankle valgus can be passively reduced and there is no bone on bone contact in the ankle joint. A previous report showed promising results in a small cohort of patients using a peroneus longus autograft.

Patients with flexible flatfoot can present with a variety of deformities, including heel valgus, medial arch collapse, and midfoot abduction. The spring (calcaneonavicular) ligament plays a major role in stabilizing the medial longitudinal arch. Its compromise, when severe enough and accompanied by failure of other ligaments, is manifested by talonavicular collapse on lateral radiographs along with uncoverage of the talar head by the navicular on anteroposterior radiographs. In this article, we describe a method of reconstructing the spring ligament complex by using an Achilles allograft. This reconstruction is indicated in cases of severe talonavicular collapse manifested by forefoot abduction that persists despite appropriate lateral column lengthening. The decision to perform such reconstruction is supported by preoperative magnetic resonance imaging demonstrating severe compromise of the spring ligament and confirmed intraoperatively once it is determined that lateral column lengthening provides insufficient correction of the deformity.

The properties of carbonated hydroxyl and chloro lead apatites, Pb 10 (PO 4 ) 6 (OH) 2 and Pb 10 (PO 4 ) 6 Cl 2 , serve as models for the incorporation of carbonate into their medically important calcium analogs, and there is likely incorporation of carbonate in an insoluble lead phosphate phase during lead remediation. We have synthesized a series of carbonated lead hydroxyl- and lead chloro-apatites at 60–80 °C. The incorporation of carbonate into the apatite structure was documented by X-ray powder diffraction, IR and Raman spectroscopy, 207 Pb solid state NMR spectroscopy, and elemental analysis. The carbonate content was determined by combustion analysis and confirmed by Raman spectroscopic analysis. As carbonate content increases in hydroxyl lead apatite, Raman spectra show changes in the phosphate stretching modes at 925 and 950 cm −1 , an increase in intensity and downshift of a new peak at 1050 cm −1 , and changes in the spectral features of the O–H stretch at about 3560 cm −1 . The variation in unit cell parameters for the chloro lead apatite as a function of carbonate content is similar to that documented for B-type substitution in calcium apatites. The 207 Pb NMR spectra corroborate B-type substitution. For the hydroxyl lead apatite, the changes in cell parameters suggest a combination of A- and B-type substitution. Solubilities of the carbonated lead apatites, determined by ICP-MS, increase slightly at low to moderate carbonate content, but more strongly at ca. 5.0 wt.% carbonate content. K sp values extrapolated to zero carbonate content reveal that the chloro lead apatite is indeed less soluble than the hydroxyl analog.

Posterior tibial tendon insufficiency is characterized by the attenuation or degeneration of the dynamic and static supports of the foot and ankle. Flatfoot deformities have been divided into four different stages. Stage IIb deformity, a severe flexible flatfoot, is characterized by talonavicular un

Background: Stage II flatfoot secondary to posterior tibial tendon insufficiency may be subclassified into mild (IIa) and severe (IIb) deformity based on the degree of talonavicular abduction. Current assessment of this abduction is difficult. We hypothesized that two new anteroposterior radiographic parameters, the lateral talonavicular incongruency angle (IA) and incongruency distance (ID) would demonstrate good reliability, correlate with current abduction parameters, and differ in IIb deformity, IIa deformity, and controls. Materials and Methods: Preoperative radiographs for consecutive patients undergoing flatfoot reconstruction were reviewed and subdivided into those with a Stage IIb ( n = 32) or Stage IIa ( n = 8) deformity. A third group of patients without flatfoot served as control ( n = 30). Radiographs were measured blindly by two investigators. Reliability was assessed with intraclass correlation coefficients (ICC), correlation with existing parameters with Pearson coefficients, and comparison between groups with analysis of variance. Results: The mean intrarater and interrater ICC's for the IA (0.88 and 0.81, respectively) were high. The IA correlated well with the coverage angle ( r = 0.86) and uncoverage percent ( r = 0.76). The IA was higher in the IIb versus IIa patients ( p = 0.007) and in the IIb group versus control ( p < 0.001). The ID demonstrated excellent reliability (ICC's of 0.83 and 0.83), but correlated poorly with the two other abduction parameters ( r = −0.59 and −0.49) and failed to differentiate between the three groups ( p = 0.0528). Conclusion: This data suggests that the IA is reliable and may help subclassify Stage II flatfoot deformity. Level of Evidence: III, Retrospective Comparative Study

Objective The aims of this study were (1) to characterise the extent and nature of disrupted sleep in individuals with long-term sleep complaints subsequent to mild traumatic brain injury (MTBI), and (2) to determine whether sleep disturbances in MTBI subjects were more characteristic of psychophysiological, psychiatric, or idiopathic insomnia. Methods Nine MTBI patients (27.8 months post-injury; SD=15.5 months) and nine control subjects underwent polysomnographic testing and completed self-report questionnaires on sleep quality. Power spectral (FFT) analysis of the sleep onset period was conducted, with both the power and variability in power being quantified. Results Individuals with MTBI exhibited long-term sleep difficulties, along with various cognitive and affective abnormalities. The MTBI group had 4% less efficient sleep ( p =0.019), shorter REM onset latencies ( p =0.011), and longer sleep onset latencies, although the latter were highly variable in the MTBI group ( F -test: p =0.012). FFT analysis revealed greater intra-subject variability in the MTBI group in sigma, theta, and delta power during the sleep onset period. Conclusions MTBI patients with persistent sleep complaints differ significantly from controls on a number of electrophysiological outcomes, but could not be easily classified into existing insomnia subtypes. Significance Sleep disturbances can persist well after the injury in a subset of patients with MTBI.

The molybdenum cofactor at the catalytic heart of mononuclear molybdoenzymes comprises a molybdenum ion coordinated by one or two dithiolene ligands containing an N-heterocyclic structure known as pterin. Understanding the details of the unusual combination of molybdenum with pterin and dithiolene is the impetus behind employing model chemistry to investigate the cofactor’s broad redox capabilities. This chapter highlights the major efforts to synthesize pterin-containing models and study their chemical properties. The history of identification of the cofactor’s pyranopterin dithiolene ligand and the details of pterin redox chemistry are reviewed, followed by an account of the synthesis and analysis of pterin-inspired chemical models. The implications of these models’ chemical reactivity and redox features that provide a fundamental basis for understanding the molybdenum cofactor are included. In addition, we highlight the potential directions of the field.

Inconsistency across trials of 2-choice reaction time (RT) data was analyzed in 72 adolescents (age 12-17 years) within 4 groups differentiated by the presence or absence of attention deficit/hyperactivity disorder (ADHD) and reading difficulties (RD). ADHD participants were more inconsistent (across all trials, and in the slow portion of the RT distribution) than controls, but only when RD was present. Within the fast portion of the RT distribution, ADHD participants were more inconsistent than controls regardless of RD. The results highlight the importance of fluctuations in cognitive performance in ADHD and suggest that there may be independent sources of variation in inconsistency affecting the fast and slow portions of the RT distribution.

The conserved pterin dithiolene ligand that coordinates molybdenum (Mo) in the cofactor (Moco) of mononuclear Mo enzymes can exist in both a tricyclic pyranopterin dithiolene form and as a bicyclic pterin-dithiolene form as observed in protein crystal structures of several bacterial molybdoenzymes. Interconversion between the tricyclic and bicyclic forms via pyran scission and cyclization has been hypothesized to play a role in the catalytic mechanism of Moco. Therefore, understanding the interconversion between the tricyclic and bicyclic forms, a type of ring-chain tautomerism, is an important aspect of study to understand its role in catalysis. In this study, equilibrium constants (K(eq)) as well as enthalpy, entropy, and free energy values are obtained for pyran ring tautomerism exhibited by two Moco model complexes, namely, (Et4N)[Tp*Mo(O)(S2BMOPP)] (1) and (Et4N)[Tp*Mo(O)(S2PEOPP)] (2), as a solvent-dependent equilibrium process. Keq values obtained from (1)H NMR data in seven deuterated solvents show a correlation between solvent polarity and tautomer form, where solvents with higher polarity parameters favor the pyran form.

Inconsistency in latency across trials of 2-choice reaction time data was analyzed in 273 participants ranging in age from 6 to 81 years. A U-shaped curve defined the relationship between age and inconsistency, with increases in age associated with lower inconsistency throughout childhood and higher inconsistency throughout adulthood. Differences in inconsistency were independent of practice, fatigue, and age-related differences in mean level of performance. Evidence for general and specific variability-producing processes was found in those aged less than 21 years, whereas only a specific process, such as attentional blocks, was evident for those 21 years and older. The findings highlight the importance of considering moment-to-moment changes in performance in psychological research.

Inactivation of the maternal or paternal X chromosome in a mammalian embryonic XX cell is believed to involve random choice between the two X's. We propose two alternative models. One suggests that choice is not random, while the other is consistent with random choice, but not one between two X's.

Research is a foundational component of an orthopaedic residency. It fosters intellectual curiosity and pursuit of excellence, while teaching discipline and the scientific method. These are the key principles for careers in both community-based practice and academia. Currently, no consensus exists on how to best engage residents and support their research endeavors. In 2014, the American Academy of Orthopaedic Surgeons Board of Specialty Societies Research and Quality Committee convened a Clinician-Scientist Collaboration Workgroup. The workgroup's task was to identify barriers to clinical and basic science research, and to propose feasible recommendations to overcome these barriers. Herein, we have compiled the opinions of various stakeholder constituencies on how to foster scholarly pursuits during an orthopaedic residency. These opinions reflect the workgroup's conclusions that research is directly and indirectly influenced by funding, departmental support, and mentorship, and that early exposure and dedicated time to pursue scholarly activities may have a positive impact on lifelong research interests.

Category: Ankle, Trauma Introduction/Purpose: Orthopaedic hardware removal (HWR) is one of the most common orthopaedic procedures performed, with rates reported between 5% and 16%. Despite the high rates of HWR, there is still no consensus or guideline for removal after osseous healing without infection. Outcome studies for HWR are scarce, particularly in the lower extremity. The purpose of this study is to evaluate the effect of removal of symptomatic ankle hardware using the Short Musculoskeletal Function Assessment (SMFA) dysfunction index as the primary outcome. We hypothesize that HWR after ankle fracture will result in improved functional outcomes. Methods: Utilizing a prospectively collected ankle fracture registry, all patients that underwent HWR between 2013 and 2016 were retrospectively reviewed. Inclusion criteria were skeletal maturity, closed intra-articular ankle fracture, symptomatic ankle hardware and completion of the SMFA questionnaire prior to and 5-months after hardware removal. Exclusion criteria were development of a nonunion, infection or complex regional pain syndrome from initial surgery. The primary outcome was change in SMFA score from baseline. Paired t-test was used to compare baseline and follow-up SMFA scores. A multiple linear regression model evaluated the effects of age, sex, body mass index (BMI), smoking status, number of comorbidities, and Lauge-Hansen fracture classification on outcomes. Results: The study included 43 patients (31 females, 12 males), mean age 49.9 (range, 19 to 83). Mean time from initial surgery to HWR was 37±46 months (range, 2.2 to 209). Follow-up SMFA questionnaires were completed 5.7±0.5 months (range, 5.1 to 7.4) after HWR. The fractures were classified as 23 (53%) supination-external rotation, 6 (14%) pronation-external rotation, 2 (4.7%) pronation-abduction and 1 (2.3%) supination-adduction. Eleven fractures (26%) were classified as pilons. The SMFA dysfunction index improved significantly from baseline to follow-up (3.71±7.4, p=0.002). Significant improvement was seen in the secondary outcomes of SMFA bother index (4.40±8.9, p=0.003) and SMFA daily activities domain (4.12±9.1, p=0.006). Regression analysis revealed a significant improvement in the bother index correlating with female gender (p=0.01) and decreasing number of comorbidities (p=0.03). Conclusion: Our study demonstrates that patients with ankle fractures have a significant improvement in function following the removal of symptomatic ankle hardware. Patients also showed a significant improvement in the bother index and daily activities domain of the SMFA. Further investigation into the specific indications for HWR and the impact of injury and fracture pattern on outcomes is warranted.

Background and Purpose Reactive thrombocytosis (RT) is usually a benign process and is not associated with thrombotic or hemorrhagic events. Summary of Case We report a case of a young man who suffers a stroke caused by RT, which was secondary to splenectomy, iron deficiency, and infection. Conclusions Although rarely documented, RT can be the cause of a major vascular event.

Background: Successful correction of hindfoot alignment in adult acquired flatfoot deformity (AAFD) is likely influenced by the degree of medializing calcaneal osteotomy (MCO) performed, but it is not known if other reconstruction procedures significantly contribute as well. The purpose of this study was to evaluate the correlation between common preoperative and postoperative variables and hindfoot alignment. Methods: Thirty patients with stage II AAFD undergoing flatfoot reconstruction were followed prospectively. Preoperative and postoperative radiographs were reviewed to assess for correction in hindfoot alignment as measured by the change in hindfoot moment arm. Nineteen variables were analyzed, including age, gender, height, weight, body mass index (BMI), medial cuneiform-fifth metatarsal height, anteroposterior (AP) talonavicular coverage, AP talus-first metatarsal, lateral talus-first metatarsal and calcaneal pitch angles as well as intraoperative use of the MCO, lateral column lengthening (LCL), Cotton osteotomy, first tarsometatarsal fusion, flexor digitorum longus transfer, spring ligament reconstruction, and gastrocnemius recession or Achilles lengthening. Mean age was 57.3 years (range, 22-77). Final radiographs were obtained at a mean of 47 weeks (range, 25-78) postoperatively. Results: Seven variables were found to significantly affect hindfoot moment arm. These were gender ( P < .05), the amount of MCO performed (P < .001), LCL (P < .01), first tarsometatarsal fusion (P < .01), spring ligament reconstruction (P < .01), medial cuneiform-fifth metatarsal height (P < .001), and calcaneal pitch angle (P < .05). Multivariate regression analysis revealed that MCO was the only significant predictor of hindfoot moment arm. The final regression model for MCO showed a good fit (R2 = .93, P < .001). Conclusion: Correction of hindfoot valgus alignment obtained in flatfoot reconstruction is primarily determined by the MCO procedure and can be modeled linearly. We believe that the hindfoot alignment view can serve as a valuable preoperative measurement to help surgeons adjust the proper amount of correction intraoperatively. Level of Evidence: Level IV, prospective case series.

Category: Midfoot/Forefoot. Introduction/Purpose: Deficiency of vitamin D has been associated with a range of diseases, with hypovitaminosis D affect approximately 1 billion people worldwide. Among orthopaedic patients, insufficiency has been reported between 43% and 78%. Currently, the orthopaedic literature has conflicting evidence to associate vitamin D deficiency with acute fractures, stress fractures and nonunions. Furthermore, there is limited literature on vitamin D and its effects in foot and ankle patients. The purpose of this study is to determine the prevalence of vitamin D insufficiency in patients who have sustained low energy metatarsal fractures compared to non-osseous foot and ankle sprains. Methods: Data collection occurred from May 2012 to August 2014. Patients with low-energy closed metatarsal fractures or non-osseous ankle sprains, between 18 and 85 years old, were enrolled. Patient demographics for fracture and sprain groups were collected through chart review and included age (subdivided into categories: 18-54, 55-65, and >65), gender, race, BMI, mechanism of injury, smoking status, history of fractures, osteoporosis or osteopenia and a previous diagnosis of vitamin D deficiency were also noted. Sufficient, insufficient and deficient levels of vitamin D were defined as ≥ 30ng/ml, 20-30ng/ml, and < 20ng/ml, respectively. Categorical data was summarized using counts and percents then analyzed using Fisher’s Exact test. Serum vitamin D levels were reported in categories and as continuous data (mean ± standard deviation). ANOVA was used to assess between- group differences in vitamin D levels. Subgroup analysis was done to determine patient characteristics associated with differing vitamin D levels. Results: Of 71 fracture and 28 sprain patients, mean age was 51 and 41 years, respectively. Mean vitamin D level in the fracture group was 26.9±13.0ng/ml and in the sprain group was 27.1±12.8 (p=0.93). Between groups, the omnibus p-value for sufficient, insufficiency and deficiency was 0.81. Predictors of fracture risk were older age (p=0.001), white/non-Hispanic race (p=0.003), female gender (p=0.03), wintertime injury (p=0.02) and smoking (p=0.01). Variation in vitamin D levels, however, did not correlate to these differences. Subgroup analysis showed significantly higher vitamin D levels with calcium and/or vitamin D (p=0.001) supplementation, age >65 years old (p=0.01), non-Hispanic/white race (p=0.05) and a BMI < 30 (p=0.01). None of these characteristics independently predicted fracture risk, though the correlation with age may be explained by increased supplement use. Conclusion: There was no difference in the mean vitamin D level or incidence of vitamin D insufficiency between patients with metatarsal fractures versus sprains. No causal relationship was established between serum vitamin D levels and fractures. There was, however, an association found between higher vitamin D levels and vitamin D supplementation, white race and lower BMI. This is one of the first studies in the foot and ankle literature to find no association between vitamin D levels and risk fractures, demonstrating need for further study of the relationship between vitamin D deficiency and different types of fractures.

Hallux rigidus is the most common degenerative joint pathology of the foot. Untreated, it may result in notable limitations in gait, activity level, and daily function. Positive outcomes can be achieved with nonsurgical management; surgery is recommended for the sufficiently symptomatic patient for whom nonsurgical measures are unsuccessful. Surgery is selected based on grade of involvement. Early to mid-stage hallux rigidus is best managed with cheilectomy or cheilectomy and proximal phalanx osteotomy. Arthrodesis and arthroplasty are reserved for late-stage hallux rigidus.