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Objectives: While rates of post-traumatic osteoarthritis after acetabulum fracture have been thoroughly studied, there has been less emphasis on hip osteoarthritis after pelvic ring injuries. The objective of this study was to determine the frequency of post-traumatic hip osteoarthritis in pelvic ring injury patients. It was hypothesized that more severe pelvic ring injuries would be associated with greater rates of post-traumatic hip osteoarthritis., Methods: Design : Retrospective Cohort., Setting: Urban/Suburban Academic Level I Trauma Center., Patient Selection Criteria: Subjects were identified using a retrospective search for AO/OTA type A, B, and C pelvic ring injuries. Patients were included if they were age 18 or greater, had a pelvic ring injury, and one year or more of radiographic follow-up. Patients were excluded if they had prior total or hemi-arthroplasty of either hip, femoral neck fracture, acetabulum fracture, femoral head fracture, or inadequate radiographic follow-up., Outcome Measures and Comparisons: Both hips were graded using the Tönnis classification at the time of injury and available follow-up pelvis films. Comparison of rate of osteoarthritis progression was made between stable (LC I injuries stable on examination under anesthesia, all APC I injuries) and unstable (APC II, APC III, LC II, LC III, LC I injuries unstable on examination under anesthesia) pelvic ring injury patients, as well as severity of injury using the Young-Burgess classification., Results: Two hundred and eleven patients were included for final analysis. Average age was 58.8 years (SD 28.1 years, range 18-100 years). Eighty-eight patients (41.7%) were male. 127 patients underwent non-operative management, and 84 underwent surgical stabilization. 34.5% (29/84) of patients with unstable pelvic ring injuries and 6.2% (8/127) of patients with stable pelvic ring injuries demonstrated progression of osteoarthritis on the ipsilateral side of their injury (p < 0.001). More severe pelvic ring injury patterns had a greater rate of post-traumatic osteoarthritis (PTOA) based on the Young-Burgess injury classification (44.4% of LC III versus 11.1% of LC I pelvic ring injury patients, p < 0.001)., Conclusions: A significant frequency of post-traumatic osteoarthritis after pelvic ring injuries was identified. A higher rate of preogression to PTOA was found with unstable injuries compared with stable pelvic injuries., Level of Evidence: III, Retrospective Cohort Study., Competing Interests: The authors report no conflicts of interest related to this work., (Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: This study explored the hypothesis that social determinants of health, including racial and economic differences, may impact orthopaedic trauma outcomes in patients undergoing open reduction and internal fixation of humeral shaft fractures., Design: Retrospective., Setting: Single, academic, tertiary level I trauma center., Patient Selection Criteria: Adults with midshaft humerus fractures (Orthopaedic Trauma Association/Association of Osteosynthesis 12) were treated operatively with plate fixation from May 2011 to May 2021 with a minimum follow-up of 9 months., Outcome Measures and Comparisons: Radiographic fracture healing, complication rates, and patient-reported outcomes were investigated. Social determinants of health were assessed using the Area Deprivation Index (ADI). Demographics, complication rates, and patient-reported clinical outcomes were compared between the first and fourth ADI quartiles., Results: One hundred ninety-six patients fit the study criteria. The average age of the cohort was 47 years with 100 women (51%). Comparisons of the least deprived quartile (n = 49) with the most deprived quartile (n = 49) yielded similar sex distribution (59% vs. 43% females, P = 0.15), fewer non-White patients (8% vs. 51%, P < 0.01), older average age (51 vs. 43 years, P = 0.05), similar body mass index (30.5 vs. 31.8, P = 0.45), and higher Charlson Comorbidity Index (2.2 vs. 1.1, P = 0.03). While nonunion rates were similar ( P = 0.20) between groups, the most deprived quartile had 2.3 times greater odds of postoperative complications ( P = 0.04). Patients in the most deprived group exhibited higher Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference scores ( P < 0.01) and PROMIS Depression (D) scores ( P = 0.01), with lower PROMIS Physical Function scores ( P < 0.01) at 6-month follow-up than the least deprived cohort. The most deprived cohort had 3 times higher odds of missing scheduled appointments within the first postoperative year ( P < 0.01), resulting in a significantly higher no-show rate ( P < 0.01) than the least deprived cohort. Regression analysis including several demographic and injury factors identified that ADI was significantly associated with the occurrence of any missed appointments ( P < 0.01), no-show rates ( P = 0.04), and experiencing one of the following postoperative complications during recovery: nonunion, radial nerve injury, or dysfunction ( P = 0.03)., Conclusions: Patients experiencing greater resource deprivation faced increased odds of complications, missed appointments, and poorer PROMIS outcomes following humeral shaft fracture fixation. These findings suggest that baseline socioeconomic disparities predict unfavorable postoperative outcomes even given favorable baseline health status according to the Charlson Comorbidity Index score., Level of Evidence: Prognostic, Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To determine if rates of pin site infection and surgical site infection among patients managed with primary closure after external fixator removal were similar to those allowed to heal secondarily., Design: Retrospective cohort., Setting: Urban/Suburban Academic Level I Trauma Center., Patient Selection Criteria: Patients who had received a lower extremity external fixator for provisional management before definitive fixation of lower extremity fractures were included with pin site wounds closed primarily or allowed to heal by secondary intention., Outcome Measures and Comparisons: The rate of pin tract infection and surgical site infection following primary closure of external fixator pin sites relative to patients whose pin sites were allowed to heal through secondary intention., Results: In total, 256 patients were evaluated: 143 patients (406 pin sites) in the primary closure group and 113 patients (340 in sites) in the secondary closure group. The average age was 49 ± 16 years. Sixty-five percent of included patients were male. There was no difference in pin tract infections between cohorts (primary = 0.5%, secondary = 1.5%, P = 0.26). External fixator duration in the primary closure group was 11.5 ± 8.4 days and 13.0 ± 8.1 days in the secondary closure group (P = 0.15). There was a greater rate of surgical site infections in the secondary intention cohort (15.9% vs. 7.7%, P = 0.047)., Conclusions: There was no difference in pin site infection rate after primary pin site closure relative to patients who were allowed to heal through secondary intention. Furthermore, there was a lower rate of surgical site infection after primary closure. These results challenge the dogma of secondary closure for ex fix pin sites, suggesting that debridement and primary closure is a safe option for management of external fixator pin sites and may impart benefit in decreasing infection risk., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To test the hypothesis that primary osteosynthesis of humeral shaft fractures may lead to more favorable clinical, functional, and patient-reported outcomes than fixation following a trial of nonoperative management., Design: Retrospective cohort review., Setting: Academic level I trauma center., Patient Selection Criteria: Adult patients who presented with humeral shaft fractures and ultimately underwent open reduction and internal fixation (ORIF) from May 2011 to May 2021. Patients who underwent ORIF within 2 weeks of injury were grouped into the primary osteosynthesis cohort, and patients who underwent ORIF >4 weeks from the date of injury were grouped into the trial of nonoperative cohort., Outcome Measures and Comparisons: Postoperative complications, elbow arc of motion, time to radiographic union, and patient-reported outcomes were investigated and compared between the primary osteosynthesis and trial of nonoperative management cohorts., Results: One hundred twenty-seven patients fit the study criteria, 84 underwent primary osteosynthesis and 43 trialed initial nonoperative treatment. No differences were found in patient demographics between the primary osteosynthesis and trial of nonoperative management cohorts, including age (53 ± 19 vs. 57 ± 18; P = 0.25), sex (39% vs. 44% male, 61% vs. 56% female; P = 0.70), and Body Mass Index (BMI) (30 ± 6 vs. 32 ± 9; P = 0.38). The average time to operative intervention in the primary osteosynthesis group was 4 days (0-14 days) and 105 days (28-332 days) in the trial of nonoperative treatment group ( P < 0.01). No differences were found with regard to intraoperative blood loss, total operative time, time to radiographic union (determined using the Radiographic Union Scores for Humeral scoring system), or overall complication rates, including primary and secondary radial nerve injuries ( P = 0.23 and 0.86, respectively). Patients reported similar patient-reported outcomes measurement information system pain interference ( P = 0.73), depression (D) ( P = 0.99), and physical function ( P = 0.66) scores at their 6-month postsurgical follow-up visits., Conclusions: Patients who attempted a trial of nonoperative management for humeral shaft fractures before ORIF had similar clinical, functional, and patient-reported outcomes as those who underwent primary osteosynthesis., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The purpose of this study was to understand the role of social determinants of health assessed by the Area Deprivation Index (ADI) on hospital length of stay and discharge destination following surgical fixation of pelvic ring fractures., Methods: A retrospective chart analysis was performed for all patients who presented to our level-I trauma center with pelvic ring injuries that were treated with surgical fixation. Social determinants of health were determined via use of the ADI, a comprehensive metric of socioeconomic status, education, income, employment, and housing quality. ADI values range from 0 to 100 and are normalized to a U.S. mean of 50, with higher scores representing greater social deprivation. We stratified our cohort into 4 ADI quartiles. Statistical analysis was performed on the bottom (25th percentile and below, least deprived) and top (75th percentile and above, most deprived) ADI quartiles. Significance was set at p < 0.05., Results: There were 134 patients who met the inclusion criteria. Patients in the most deprived group were significantly more likely to have a history of smoking, to self-identify as Black, and to have a lower mean household income (p = 0.001). The most deprived ADI quartile had a significantly longer mean length of stay (and standard deviation) (19.2 ± 19 days) compared with the least deprived ADI quartile (14.7 ± 11 days) (p = 0.04). The least deprived quartile had a significantly higher percentage of patients who were discharged to a resource-intensive skilled nursing facility or inpatient rehabilitation facility compared with those in the most deprived quartile (p = 0.04). Race, insurance, and income were not significant predictors of discharge destination or hospital length of stay., Conclusions: Patients facing greater social determinants of health had longer hospital stays and were less likely to be discharged to resource-intensive facilities when compared with patients of lesser social deprivation. This may be due to socioeconomic barriers that limit access to such facilities., Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosures: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H698 )., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Operative decision making between approaches to posterior malleolus reduction remains a challenge. The purpose of this study is to compare the quality of reduction between percutaneous and open reduction of posterior malleolus fractures and to identify factors associated with malreduction., Methods: Operatively managed ankle fractures that included posterior malleolus fixation were reviewed. Fracture characteristics were determined on preoperative CT scans. Initial postoperative radiographs were used to measure reduction of the posterior malleolus articular surface and graded as satisfactory (<2 mm step-off) or malreduced (≥2 mm step-off). Final postoperative PROMIS scores and 1-year complications were compared between percutaneous and open cohorts. A multivariate stepwise regression model was used to evaluate predictors for malreduction., Results: A total of 120 patients were included. Open reduction was performed in 91 (75.8%) compared with 29 (24.2%) who underwent percutaneous reduction. Malreduction (≥2-mm articular step-off) occurred in 11.7% of patients. Malreduction rates were significantly higher with percutaneous fixation than open fixation (24.1% vs 7.7%, P  = .02). Multiple fragments and those with ≥5 mm of displacement demonstrated higher malreduction rates with percutaneous fixation ( P  < .05 for both), whereas single fragments and those with <5 mm of displacement experienced similar malreduction rates with percutaneous or open fixation. Initial displacement ≥5 mm (relative risk [RR] = 3.8, 95% CI = 1.2-11.5, P  = .02) and percutaneous treatment (RR = 4.1, 95% CI = 1.6-10.5, P  < .01) were identified as independent risk factors for malreduction. There were no significant differences in 1-year complication rates or final PROMIS scores between groups., Conclusion: Open reduction of the posterior malleolus may lead to improved fracture reduction compared to percutaneous reduction without significant increase in complications. Open fixation improves reduction among fractures with multiple fragments or ≥5 mm of displacement, whereas fractures with a single fragment or <5 mm of displacement achieve similar reductions regardless of approach. Initial displacement ≥5 mm and percutaneous reduction are independent risk factors for malreduction., Level of Evidence: Level III, therapeutic., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2023.)

Objective: To evaluate early outcomes (within 1 year) for geriatric proximal humerus fractures managed nonoperatively or with reverse shoulder arthroplasty (RSA)., Design: Retrospective cohort., Setting: Academic level 1 trauma center, level 2 trauma/geriatric fracture center., Patients/intervention: Seventy-one patients with proximal humerus fractures that underwent nonoperative management or RSA, matched by age, comorbidity burden, and fracture morphology., Main Outcome Measurements: Patient-reported outcomes, range of motion, and complications rates within 1 year of treatment., Results: RSA patients demonstrated greater active forward flexion (aFF) and external rotation compared with nonoperative patients throughout the first 6 months after treatment ( P < 0.05 for all). RSA patients achieved satisfactory ROM (>90 degrees aFF) at higher rates than nonoperative patients (96.2% vs. 62.2%, P < 0.01). RSA led to significantly lower shoulder pain and PROMIS pain interference scores throughout the first year post-treatment ( P < 0.05). PROMIS physical function scores were also higher in the RSA group at 3 months, 6 months, and 1 year compared with the nonoperative group ( P < 0.05 for all). Similar complication rates were experienced in both groups (nonoperative = 8.9%, RSA = 7.7%; P = 0.36)., Conclusions: In an age, comorbidity and fracture morphology matched analysis, treatment of proximal humerus fractures with RSA is associated with greater shoulder ROM throughout the first 6 months of treatment, decreased pain, and improved physical function compared with nonoperative management, without significant differences in short-term complications. These results suggest that RSA may be superior to nonoperative management during the early recovery period for proximal humerus fractures., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To compare patient-reported outcomes (PROs), range of motion (ROM), and complication rates for proximal humerus fractures managed nonoperatively or with open reduction internal fixation (ORIF)., Design: Retrospective cohort., Setting: Academic level 1 trauma center., Patients/participants: Four hundred thirty-one patients older than 55 years were identified retrospectively. 122 patients were excluded. 309 patients with proximal humerus fractures met inclusion criteria (234 nonoperative and 75 ORIF). After matching, 192 patients (121 nonoperative and 71 ORIF) were included in the analysis., Intervention: Nonoperative versus ORIF (locked plate) treatment of proximal humerus fracture., Main Outcome Measurements: Early Visual Analog Score (VAS), ROM, PROs, complications, and reoperation rates between groups., Results: At 2 weeks, ORIF showed lower VAS scores, better passive ROM, and patient-reported outcomes measurement information system (PROMIS) scores ( P < 0.05) compared with nonoperative treatment. At 6 weeks, open reduction internal fixation (ORIF) had lower VAS scores, better passive ROM, and PROMIS scores ( P < 0.05) compared with nonoperative treatment. At 3 months, ORIF showed similar PROMIS scores ( P > 0.05) but lower VAS scores and better passive ROM ( P < 0.05) compared with nonoperative treatment. At 6 months, ORIF showed similar VAS scores, ROM, and PROMIS scores ( P > 0.05) compared with nonoperative treatment. There was no difference in secondary operation rates between groups ( P > 0.05). ORIF patients trended toward a higher secondary reoperation rate (15.5% vs. 5.0%) than nonoperative patients ( P = 0.053)., Conclusions: In an age-, comorbidity-, and fracture morphology-matched analysis of proximal humerus fractures, ORIF led to decreased pain and improved passive ROM early in recovery curve compared with nonoperative treatment that normalized after 6 months between groups., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: I. Voloshin, MD is a paid presenter or speaker for Arthrex, Arthrosurface, FH Orthopaedics, and Zimmer and receives IP royalties from Innomed. G. Soles, MD is a paid consultant for Depuy, A Johnson & Johnson Company. The remaining authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To identify characteristics associated with loss of reduction following open reduction and locked plate fixation (ORIF) of proximal humerus fractures in older adults and determine if loss of reduction affects patient reported outcomes (PROs), range of motion (ROM), and complication rates during the first postoperative year., Methods: Patients >55 years old who underwent proximal humerus ORIF were reviewed. Patient and fracture characteristics were recorded. Fixation characteristics were measured on the initial postoperative AP radiograph including humeral head height (HHH) relative to the greater tuberosity (GT), head shaft angle (HSA), screw-calcar distance, and screw tip-joint surface distance. Loss of reduction was defined as GT displacement >5 mm or HSA displacement >10° on final follow up radiographs. Patient, fracture, and fixation characteristics were tested for association with loss of reduction. Outcomes including ROM, visual analog scale pain and PROMIS scores, and complication/reoperation rates during the first postoperative year were compared between those with or without loss of reduction., Results: A total of 79 patients were identified, 23 (29.1%) of which had a loss of reduction. Calcar comminution (relative risk [RR]=2.5, 95% Confidence Interval [CI]=1.3-5.0, p<0.01), HHH <5 mm above GT (RR=2.0, CI=1.0-3.9, p = 0.048), and screw-calcar distance ≥12 mm (RR=2.1, CI=1.1-4.1, p = 0.03) were risk factors for loss of reduction. Upon multivariate analysis, calcar comminution was determined to be an independent risk factor for loss of reduction (RR=2.4, CI=1.2-4.7, p = 0.01). Loss of reduction led to higher complication (44% vs 13%, p<0.01) and reoperation rates (30% vs 7%, p<0.01), and decreased achievement of satisfactory ROM (>90° active forward flexion, 57% vs 82%, p = 0.02) compared to maintained reduction, but similar PROs., Conclusions: Calcar comminution, decreased HHH, and increased screw-calcar distance are risk factors for loss of reduction following ORIF of proximal humerus fractures. These morphologic and technical factors are important considerations for prolonged reduction maintenance., (Copyright © 2022. Published by Elsevier Ltd.)

Background: Understanding the recovery trajectory following operative management of ankle fractures can help surgeons guide patient expectations. Further, it is beneficial to consider the impact of mental health on the recovery trajectory. Our study aimed to address the paucity of literature focused on understanding the recovery trajectory following surgery for ankle fractures, including in patients with depressive symptoms., Methods: From February 2015 to March 2020, patients with isolated ankle fractures were asked to complete Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Pain Interference (PI), and Depression questionnaires as part of routine care at presentation and follow-up time points. Linear mixed effects regression models were used to evaluate the patient recovery pattern, comparing the preoperative time point to <3 months, 3-6 months, and >6 months across all patients. Additional models that included the presence of depression symptoms as a covariate were then used., Results: A total of 153 patients met inclusion criteria. By 3-6 months, PROMIS PF (β: 9.95, 95% CI: 7.97-11.94, P  < .001), PI (β: -10.30, 95% CI: -11.87 to -8.72, P  < .001), and Depression (β: -5.60, 95% CI: -7.01 to -4.20, P  < .001) improved relative to the preoperative time point. This level of recovery was sustained thereafter. When incorporating depressive symptoms into our model as a covariate, the moderate to high depressive symptoms were associated with significantly and clinically important worse PROMIS PF (β: -4.00, 95% CI: -7.00 to -1.00, P  = .01) and PI (β: 3.16, 95% CI: -0.55 to 5.76, P  = .02) scores., Conclusion: Following ankle fracture surgery, all patients tend to clinically improve by 3-6 months postoperatively and then continue to appreciate this clinical improvement. Although patients with moderate to high depressive symptoms also clinically improve following the same trajectory, they tend to do so to a lesser level than those who have low depressive symptoms., Level of Evidence: Level III, case-control study., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2023.)

Objective: (1) To present an effective surgical technique for the treatment of open and high-energy calcaneal fractures with significant soft tissue injuries. (2) To present complications with this technique and to evaluate patient-reported outcomes of staged external fixation followed by delayed reconstruction with open reduction internal fixation (ORIF) and subtalar arthrodesis., Design: Retrospective case series., Setting: Level I trauma center., Patients/participants: Twelve patients with 13 calcaneus fractures associated with open traumatic wounds (10 patients) or other severe soft tissue injury (ie, fracture blisters) between April 2013 and December 2019., Intervention: All patients were treated with staged ankle-spanning external fixation and delayed reconstruction with ORIF with subtalar arthrodesis., Main Outcome Measures: Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes are presented via the domains of physical function (PF), pain interference (PI), and depression (D) in addition to visual analog score. Complications with the injury and surgical procedure were reported as well., Results: Patients underwent initial stabilization on average 1.3 days (range, 0-12 days) from injury with stage II occurring on average 31.1 days (range, 18-42 days) from external fixation. Mean time to radiographic union was 5.6 months (range, 4-10 months). One-year mean PROMIS outcomes were as follows: PF final average of 37.4 with an average improvement of 12.2 (P < 0.01), PI final average of 62.2 with average improvement of 5.6 (P = 0.01), and D final average of 52.1 with average improvement of 6 (P = 0.12). Mean final visual analog score pain score was 3.6 with an average improvement of 2.25 (P = 0.01)., Conclusion: Staged treatment with initial external fixation followed by ORIF and subtalar arthrodesis in the setting of highly comminuted calcaneus fractures with significant soft tissue compromise effectively addresses both bony and soft tissue concerns while providing for positive outcomes postoperatively with regards to pain and function. There were minimal complications noted for this complex injury., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: This study compares patient-reported outcomes and range of motion (ROM) between adults with an AO Foundation/Orthopaedic Trauma Association type C proximal humerus fracture managed nonoperatively, with open reduction and internal fixation (ORIF), and with reverse shoulder arthroplasty (RSA)., Methods: This is a retrospective cohort study of patients >60 years of age treated with nonoperative management, ORIF, or RSA for AO Foundation/Orthopaedic Trauma Association type 11C proximal humerus fractures from 2015 to 2018. Visual analog scale pain scores, Patient-Reported Outcomes Measurement Information System (PROMIS) scores, ROM values, and complication and reoperation rates were compared using analysis of variance for continuous variables and chi square analysis for categorical variables., Results: A total of 88 patients were included: 41 nonoperative, 23 ORIF, and 24 RSA. At the 2-week follow-up, ORIF and RSA had lower visual analog scale scores and lower PROMIS pain interference scores ( P  < .05) than nonoperative treatment. At the 6-week follow-up, ORIF and RSA had lower visual analog scale, PROMIS pain interference, and PF scores and better ROM ( P  < .05) than nonoperative treatment. At the 3-month follow-up, ORIF and RSA had better ROM and PROMIS pain interference and PF scores ( P  < .05) than nonoperative treatment. At the 6-month follow-up, ORIF and RSA had better ROM and PROMIS PF scores ( P  < .05) than nonoperative treatment. There was a significantly higher complication rate in the ORIF group than in the non-operative and RSA groups ( P  < .05)., Conclusion: The management of AO Foundation/Orthopaedic Trauma Association type 11C proximal humerus fractures in older adults with RSA or ORIF led to early decreased pain and improved physical function and ROM compared to nonoperative management at the expense of a higher complication rate in the ORIF group.

Background: Hallux rigidus is a common and painful degenerative condition of the great toe limiting a patient's physical function and quality of life. The purpose of this study was to investigate pre- and postoperative physical function (PF) and pain interference (PI) levels of patients undergoing synthetic cartilage implant hemiarthroplasty (SCI) vs arthrodesis (AD) for treatment of hallux rigidus using the Patient-Reported Outcomes Measurement Information System (PROMIS)., Methods: PROMIS PF and PI t scores were analyzed for patients who underwent either SCI or AD. Postoperative final PROMIS t scores were obtained via phone survey. Linear mixed model analysis was used to assess differences in PF and PI at each follow-up point. Final follow-up scores were analyzed using independent sample t tests., Results: Total 181 (59 SCI, 122 AD) operatively managed patients were included for analysis of PROMIS scores. Final phone survey was performed at a minimum of 14 (mean 33, range, 14-59) months postoperatively, with 101 patients (40 SCI, 61 AD) successfully contacted. The mean final follow-up was significantly different for SCI and AD: 27 vs 38 months, respectively ( P < .01). The mean age of the SCI cohort was lower than the AD cohort (57.5 vs 61.5 years old, P = .01). Average PF t scores were higher in the SCI cohort at baseline (47.1 and 43.9, respectively, P = .01) and at final follow-up (51.4 vs 45.9, respectively, P < .01). A main effect of superior improvement in PF was noted in the SCI group (+4.3) vs the AD group (+2) across time intervals ( P < .01). PI t scores were similar between the 2 procedures across time points., Conclusion: The SCI cohort reported slightly superior PF t scores preoperatively and at most follow-up time points compared with the arthrodesis group. No differences were found for PI or complication rates between the 2 treatment groups during this study time frame., Level of Evidence: Level IV, case series.

Canonical nuclear factor κB (NF-κB) signaling mediated by homo- and heterodimers of the NF-κB subunits p65 (RELA) and p50 (NFKB1) is associated with age-related pathologies and with disease progression in posttraumatic models of osteoarthritis (OA). Here, we established that NF-κB signaling in articular chondrocytes increased with age, concomitant with the onset of spontaneous OA in wild-type mice. Chondrocyte-specific expression of a constitutively active form of inhibitor of κB kinase β (IKKβ) in young adult mice accelerated the onset of the OA-like phenotype observed in aging wild-type mice, including degenerative changes in the articular cartilage, synovium, and menisci. Both in vitro and in vivo, chondrocytes expressing activated IKKβ had a proinflammatory secretory phenotype characterized by markers typically associated with the senescence-associated secretory phenotype (SASP). Expression of these factors was differentially regulated by p65, which contains a transactivation domain, and p50, which does not. Whereas the loss of p65 blocked the induction of genes encoding SASP factors in chondrogenic cells treated with interleukin-1β (IL-1β) in vitro, the loss of p50 enhanced the IL-1β–induced expression of some SASP factors. The loss of p50 further exacerbated cartilage degeneration in mice with chondrocyte-specific IKKβ activation. Overall, our data reveal that IKKβ-mediated activation of p65 can promote OA onset and that p50 may limit cartilage degeneration in settings of joint inflammation including advanced age.

Background: Double hindfoot arthrodesis is a reliable treatment option in lower extremity deformity and arthritis. Single (medial) and 2-incision techniques have been described. The purpose of this study was to evaluate the extent of cartilage debrided in each approach and to evaluate the competency of the deltoid ligament., Methods: Eight matched pairs of cadaveric specimens were acquired. One limb from each pair was randomly assigned to the single medial incision and the other to the 2-incision technique. Stress radiographs were obtained prior to dissection to evaluate for valgus tibiotalar tilt. The talonavicular and subtalar articular surfaces were denuded of cartilage and the joints disarticulated. The percentage of cartilage debrided was determined using ImageJ software. Postoperative tibiotalar tilt was measured with a technique and threshold previously described by our group. The intraclass correlation coefficient was calculated to determine inter- and intraobserver reliability., Results: The single medial incision demonstrated significantly less cartilage denuded than the 2-incision technique at the talar head (61.1% ± 20.4% vs 88.1% ± 6.1%, P < .001), and the posterior facets of the talus (53.5% ± 7.6% vs 73.6% ± 7.0%, P < .001) and calcaneus (55.3% ± 16.5% vs 81.0% ± 7.4%, P = .001). Overall, 75% of specimens that underwent a single medial incision approach demonstrated increased valgus tibiotalar tilt postdissection, whereas none that underwent the 2-incision technique developed increased tibiotalar tilt ( P < .01). The average tibiotalar tilt among these specimens was 4.6 ± 1.3 degrees (range 2.5-5.7 degrees). For all measurements, the intraclass correlation coefficient was greater than 0.8., Conclusion: The posterior facet of the subtalar joint and talar head are at risk of subtotal debridement, as well as increased tibiotalar tilt with the single medial incision technique. Adequate debridement may require greater soft tissue dissection, possibly at the expense of medial ankle stability., Level of Evidence: Level III, retrospective cohort study.

Objectives: To evaluate and compare femoral neck shortening and varus collapse in stable pertrochanteric femur fractures treated with sliding hip screws (SHSs) or cephalomedullary nails (CMNs)., Design: Retrospective review., Setting: Academic medical center., Patients: A total of 290 patients were included in the study. The average age was 82 years, and most were women. All sustained low-energy pertrochanteric femur fractures (OTA/AO A1.1, 1.2, 1.3, 2.2) treated operatively with SHSs or CMNs. Minimum radiographic follow-up was 3 months, with an average of 28 (range 3-162) months., Intervention: CMN or SHS fixation., Main Outcome Measures: Varus collapse of the femoral neck-shaft angle and proximal femoral shortening., Results: Both implants allowed some varus collapse. Univariate analysis demonstrated a significantly greater portion of patients with SHSs progressed to varus collapse >5 degrees (P = 0.02), mild horizontal shortening >5 mm (P < 0.01), and severe horizontal shortening >10 mm (P < 0.01). There was no statistical difference in vertical shortening (P = 0.3). There was no difference in implant failure (P = 0.5), with failure rates of 3% for cephalomedullary implants and 5% for SHS constructs., Conclusions: The SHS group experienced greater varus collapse and horizontal shortening. There was no difference in overall implant failure. These findings suggest that the CMN is a superior construct for maintenance of reduction in stable pertrochanteric fractures, which may lead to improved functional outcomes as patients recover., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Adult acquired flatfoot deformity (AAFD) is a complex and progressive deformity involving the ligamentous structures of the medial peritalar joints. Recent anatomic studies demonstrated that the spring and deltoid ligaments form a greater medial ligament complex, the tibiocalcaneonavicular ligament (TCNL), which provides medial stability to the talonavicular, subtalar, and tibiotalar joints. The aim of this study was to assess the biomechanical effect of a spring ligament tear on the peritalar stability. The secondary aim was to assess the effect of TCNL reconstruction in restoration of peritalar stability in comparison with other medial stabilization procedures, anatomic spring or deltoid ligament reconstructions, in a cadaveric flatfoot model., Methods: Ten fresh-frozen cadaveric foot specimens were used. Reflective markers were mounted on the tibia, talus, navicular, calcaneus, and first metatarsal. Peritalar joint kinematics were captured by a multiple-camera motion capture system. Mild, moderate, and severe flatfoot models were created by sequential sectioning of medial capsuloligament complex followed by cyclic axial loading. Spring only, deltoid only, and combined deltoid-spring ligament (TCNL) reconstructions were performed. The relative kinematic changes were compared using 2-way analysis of variance (ANOVA)., Results: Compared with the initial condition, we noted significantly increased valgus alignment of the subtalar joint of 5.1 ± 2.3 degrees ( P = .031) and 5.8 ± 2.7 degrees ( P < .01) with increased size of the spring ligament tear to create moderate to severe flatfoot, respectively. We noted an increased tibiotalar valgus angle of 5.1 ± 2.0 degrees ( P = .03) in the severe model. Although all medial ligament reconstruction methods were able to correct forefoot abduction, the TCNL reconstruction was able to correct both the subtalar and tibiotalar valgus deformity ( P = .04 and P = .02, respectively)., Conclusion: The TCNL complex provided stability to the talonavicular, subtalar, and tibiotalar joints. The combined deltoid-spring ligament (TCNL) reconstructions restored peritalar kinematics better than isolated spring or deltoid ligament reconstruction in the severe AAFD model., Clinical Relevance: The combined deltoid-spring ligament (TCNL) reconstruction maybe considered in advanced AAFD with medial peritalar instability: stage IIB with a large spring ligament tear or stage IV.

Background: Diabetic foot ulcers with associated infection and osteomyelitis often lead to partial or complete limb loss. Determination of the appropriate level for amputation based on the patient's baseline physical function, extent of infection, vascular patency, and comorbidities can be challenging. Although Chopart amputation preserves greater limb length than more proximal alternatives such as Syme or below-the-knee amputations (BKA), challenges with wound healing and prosthesis fitting have been reported. We aimed to investigate the functional and clinical outcomes of Chopart amputation combined with tendon transfers., Methods: We identified patients who underwent Chopart amputations for diabetic foot infections by an academic orthopaedic group between August 2013 and September 2018. Subjects completed three Patient-Reported Outcomes Measurement Information Systems (PROMIS) instruments. Incidence of postoperative complications and change in patient-reported outcomes before and after surgery were recorded., Results: Eighteen patients with an average age of 60.8 (range, 44 to 79) years were identified. The mean follow-up was 22.8 months (range, 6.7 to 51.0). Seventeen of the 18 total patients developed postoperative wound complications. These lead to revision amputations in 10 Chopart amputees, consisting of two Syme and eight BKAs. Half of the Chopart patients never received a prosthesis because of delayed wound healing and revision amputation. PROMIS physical function (PF) (31.1 pre-op and 28.6 post-op), pain interference (63.1 pre-op and 59.4 post-op), and depression (53.0 pre-op and 54.8 post-op) did not show significant change (P-values = 0.38, 0.29, 0.72, respectively). Pre- and post-op the PROMIS physical function scores were well below the US average., Discussion: In our patient cohort, 94% of patients developed postoperative wound complication. Only 44% of patients ever successfully ambulated with a prosthesis after Chopart amputation, and the others (56%) required revision amputations such as a BKA. Even after wound healing, Chopart amputees may struggle with obtaining a prosthesis suitable for ambulation. Surgeons should exercise judicious patient selection before performing Chopart amputation., Level of Evidence: IV, Case Series.

Objectives: Most patients can tolerate a hemoglobin (Hgb) > 8 g per deciliter. In some cases, however, transfusion will delay physical therapy and hospital discharge. This study aims to review Hgb and transfusion data for a large volume of recent hip fracture patients in order to identify new opportunities for decreasing the length of hospital stay. Our hypotheses are that in some cases, earlier transfusion of more blood will be associated with shorter hospital stays, and that Hgb levels consistently decrease for more than 3 days postoperatively., Design: Retrospective chart review., Setting: Two academic medical centers with Geriatric Fracture Programs., Patients: Data was collected from patients 50 years and older with hip fractures April 2015 and October 2017., Intervention: Operative stabilization of the hip fractures according to standard of care for the fracture type and patient characteristics. Transfusion according to established standards., Main Outcome Measurements: Electronic records were retrospectively reviewed for demographic information, Hgb levels, and transfusion events., Results: One thousand fifteen patients with femoral neck or intertrochanteric hip fractures were identified. Eight hundred sixty met the inclusion criteria. The average length of hospital stay was 6.7 days. The mean patient age was 82 years. The average American Society of Anesthesiologists score was 2.9. The average Hgb level consistently decreased for 5 days postoperatively before beginning to increase on day 6. There was poor consistency between intraoperative Hgb levels and preoperative or postoperative Hgb levels. Three hundred sixty-eight (42.8%) patients were transfused an average of 1.9 (range 1-6) units. One hundred five patients required a transfusion on postoperative day (POD) 1: 72 received only 1 unit of blood: 36 (50%) of the 72 required a second transfusion in the following days, compared to 9 of 33 (27%) who received 2 units on POD 1 (χ2 = 3.8898; P  < .05). Patients who received transfusions on POD 3 or later had an average length of stay >2.5 days longer than those who received a transfusion earlier ( P  = 0.005)., Conclusions: Our findings do not support earlier transfusion of more blood. Although in some cases, there is an association between earlier transfusion of more blood and shorter hospital stay, routine transfusion of more blood would incur higher transfusion risks in some patients who would not otherwise meet criteria for transfusion. After hip fracture surgery, the Hgb usually decreases for 5 days and does not begin to increase until POD 6. This information will provide utility in the population health management of hip fracture patients., Level of Evidence: Level III, Retrospective Cohort Study., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Objective: To investigate the immediate impact of removing symptomatic syndesmotic screws on PROMIS outcomes and ankle range of motion (ROM) in patients who had previously undergone ankle fracture open reduction and internal fixation (ORIF) and syndesmotic fixation and later experienced functional limitations., Design: Prospective cohort study., Setting: Level 1-trauma center., Patients/participants: Fifty-eight patients with ankle fractures with syndesmotic instability that required ORIF with syndesmotic fixation who underwent syndesmotic screw removal (SSR) and 71 patients who underwent ankle ORIF with syndesmotic fixation, but without screw removal during the same study period., Intervention: Symptomatic SSR for patients with functional limitations and decreased ankle ROM., Main Outcome Measurements: PROMIS physical function (PF) and pain interference T-scores and ankle ROM before and after screw removal., Results: Patients who underwent SSR had a statistically significant improvement in the PF T-score to 44.5 (P < 0.01) in the early postoperative period (mean 48 days) after screw removal. The screw removal occurred an average of 184 days after initial ORIF. This PF T-score change also met the minimally clinically important difference. There was a trend toward a significant improvement in PF T-scores for the SSR group as compared to the cohort group (44.5 vs. 41.6; P = 0.06) after screw removal. Removal of symptomatic implants resulted in an early mean improvement of total arc ankle ROM by 17 degrees (P < 0.01)., Conclusions: Patients experienced an immediate and significant improvement in PF outcomes and ankle ROM after symptomatic SSR for ankle fracture ORIF with syndesmotic fixation., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Research on outcomes after ankle fusion focuses on basic activities of daily living, fusion rates, and gait parameters. Little has been reported on the patient's perspective after surgery. The purpose of this study was to determine the change in patient reported physical function and pain interference after ankle fusion surgery to guide patient expectations and improve provider communication., Methods: This was a retrospective review of prospectively collected patient reported outcome measurement information system (PROMIS) data in 88 ankle arthrodesis procedures performed from May 2015 to March 2018. The PROMIS Physical function (PF) and pain interference (PI) measures were collected as routine care. Linear mixed models were used to assess differences at each follow-up point for PF and PI. Preoperative to last follow-up in the 120-365 day interval was assessed using analysis of variance. Outcomes included T-scores, z-scores, and PROMIS-Preference (PROPr) utility scores for PF and PI and the percentage of patients improving by at least 4 T-score points., Results: The linear mixed model analysis for PF after the 120-149 days, and for PI, after 90-119 days, indicated recovery plateaued at 39-40 for PF and 57-59 for PI T-scores. The change in the PI T-score was the greatest with a mean T-score improvement of - 5.4 (95% CI - 7.7 to - 3.1). The proportion of patients improving more than 4 points was 66.2% for either PF or PI or both. The change in utility T-scores for both PF (0.06, 95% CI 0.02 to 0.11) and PI (0.15, 95% CI 0.09 to 0.20) was significantly improved, however, only PI approached clinical significance., Conclusion: Average patients undergoing ankle fusion experience clinically meaningful improvement in pain more so than physical function. Average patient recovery showed progressive improvement in pain and function until the four-month postoperative time point. Traditional dogma states that recovery after an ankle fusion maximizes at a year, however based on the findings in this study, 4 months is a more accurate marker of recovery. A decline in function or an increase in pain after 4 months from surgery may help to predict nonunion and other complications after ankle arthrodesis., Level of Evidence: Level II, prospective single cohort study.

Objectives: To evaluate the rate of, and reasons for, conversion of closed treatment of humeral shaft fractures using a fracture brace, to surgical intervention., Design: Multicenter, retrospective analysis., Setting: Nine Level 1 trauma centers across the United States., Patients: A total of 1182 patients with a closed humeral shaft fracture initially managed nonoperatively with a functional brace from 2005 to 2015 were reviewed retrospectively from 9 institutions., Intervention: Functional brace., Main Outcome Measurements: Conversion to surgery., Results: A total of 344 fractures (29%) ultimately underwent surgical intervention. Reasons for conversion included nonunion (60%), malalignment beyond acceptable parameters (24%), inability to tolerate functional bracing (12%), and persistent signs of radial nerve palsy requiring exploration (3.7%). Univariate comparisons showed that females and whites were significantly (P < 0.05) more likely to be converted to surgery. The multivariate logistic regression identified females as being 1.7 times more likely and alcoholics to be 1.4 times more likely to be converted to surgery (P < 0.05). Proximal shaft as well as comminuted, segmental, and butterfly fractures were also linked to a higher rate of conversion., Conclusions: This large multicenter study identified a 29% surgical conversion rate, with nonunion as the most common reason for surgical intervention after the failure of functional brace. These results are markedly different than previously reported. These results may be helpful in the future when counseling patients on the choice between functional bracing and surgical intervention in managing humeral shaft fractures., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Introduction: Syndesmotic injury alters joint mechanics, which may fail to be restored unless an anatomic reduction is obtained., Methods: A minimally invasive method of measuring joint forces was utilized that does not require significant dissection or intraarticular placement of sensory instruments. Steinmann pins were placed in the tibia and talus of eight fresh-frozen human cadaveric lower extremities and a baseline joint reaction force was determined. A syndesmotic injury was created and reduction (anatomic and anterior malreduction) performed with one or two quadricortical screws and joint reaction forces were measured after the injury and subsequent repairs., Findings: Baseline mean tibiotalar joint reaction force was 31.4 (SD 7.3 N) and syndesmotic injury resulted in a 35% decrease (mean 20.3, SD 8.4 N, p < 0.01). Fixation of the injury using one or two syndesmotic screws resulted in significant increase compared to the injury state (mean 28.7, SD3.9 N, and mean 28.3, SD 6.4 N, p < 0.05), however there was no significant difference between the two methods of fixation. Malreduction of the fibula also increased joint reaction force compared to the injury state (mean 31.5, SD 5.2 N, p < 0.01), however a significant difference was not detected between malreduction and anatomic reduction., Interpretation: The present study demonstrates that syndesmotic injury decreases joint reaction force within the tibiotalar joint, suggesting ankle joint instability. Tibiotalar force was restored with anatomic reduction with either a 1 or 2 quadricortical syndesmotic screws. Furthermore, anterior malreduction restored joint reaction force to levels similar to those observed at baseline and with anatomic reduction., Level of Evidence: Level V: biomechanical/cadaver study., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

RUNX2 is a transcription factor critical for chondrocyte maturation and normal endochondral bone formation. It promotes the expression of factors catabolic to the cartilage extracellular matrix and is upregulated in human osteoarthritic cartilage and in murine articular cartilage following joint injury. To date, in vivo studies of RUNX2 overexpression in cartilage have been limited to forced expression in osteochondroprogenitor cells preventing investigation into the effects of chondrocyte-specific RUNX2 overexpression in postnatal articular cartilage. Here, we used the Rosa26 Runx2 allele in combination with the inducible Col2a1 CreERT2 transgene or the inducible Acan CreERT2 knock-in allele to achieve chondrocyte-specific RUNX2 overexpression (OE) during embryonic development or in the articular cartilage of adult mice, respectively. RUNX2 OE was induced at embryonic day 13.5 (E13.5) for all developmental studies. Histology and in situ hybridization analyses suggest an early onset of chondrocyte hypertrophy and accelerated terminal maturation in the limbs of the RUNX2 OE embryos compared to control embryos. For all postnatal studies, RUNX2 OE was induced at 2 months of age. Surprisingly, no histopathological signs of cartilage degeneration were observed even 6 months following induction of RUNX2 OE. Using the meniscal/ligamentous injury (MLI), a surgical model of knee joint destabilization and meniscal injury, however, we found that RUNX2 OE accelerates the progression of cartilage degeneration following joint trauma. One month following MLI, the numbers of MMP13-positive and TUNEL-positive chondrocytes were significantly greater in the articular cartilage of the RUNX2 OE joints compared to control joints and 2 months following MLI, histomorphometry and Osteoarthritis Research Society International (OARSI) scoring revealed decreased cartilage area in the RUNX2 OE joints. Collectively, these results suggest that although RUNX2 overexpression alone may not be sufficient to initiate the OA degenerative process, it may predetermine the rate of OA onset and/or progression following traumatic joint injury. © 2019 American Society for Bone and Mineral Research., (© 2019 American Society for Bone and Mineral Research.)

Background. Achilles tendinopathy is a common clinical disorder. Utilizing the Patient-Reported Outcomes Measurement Information System, we aim to determine clinical response to nonoperative achilles tendinopathy rehabilitative care of insertional achilles tendinopathy compared to non-insertional achilles tendinopathy. Methods. Prospective Patient-Reported Outcomes Measurement Information System Physical Function, Pain Interference, and Depression scores were collected for patients with achilles tendinopathy at presentation and following a standard course of nonoperative care. A distribution-based method was used to determine the minimal clinically important difference. Descriptive statistics were reported and bivariate analysis was used to compare insertional achilles tendinopathy and non-insertional achilles tendinopathy. Receiver operating characteristic curve analysis was used to predict clinical improvement. Results. A total of 102 patients with an average follow-up of 68 days were included. For the non-insertional achilles tendinopathy group: Fifteen (46%), 12 (36%) and 9 (27%) patients reached clinical improvement for Physical Function, Pain Interference and Depression, respectively. For the insertional achilles tendinopathy group: Seventeen (25%), 20 (29%) and 22 (32%) patients reached clinical improvement for Physical Function, Pain Interference and Depression, respectively. Physical Function scores improved more in non-insertional achilles tendinopathy patients (4.0 vs. -0.046; p = 0.035) and more patients clinically improved (45.5% vs. 24.6%; p = 0.034). Patients with non-insertional and insertional achilles tendinopathy clinically improved functionally when initial Physical Function scores were equal to or lower than 40.25 and 38.08, respectively. Conclusions. Nonoperative care in achilles tendinopathy is often successful. The Patient-Reported Outcomes Measurement Information System can be used to evaluate and help determine clinical success. Levels of Evidence: Level II: Prospective comparative study.

Introduction: Multiple studies have shown the impact of hip fractures on geriatric mortality. Few evaluate mortality after proximal humerus (PH) or distal humerus (DH) fractures, and fewer determine differences in mortality based on management. We aim to evaluate a statewide cohort of elderly patients with PH or DH fractures to evaluate mortality, length of stay, discharge data, readmission, and differences based on management., Methods: The New York Statewide Planning and Research Cooperative System database was used to identify patients 60 years and older admitted with a PH or DH fracture. Patient demographics, including age, gender, sex, race, weight, and insurance status, along with comorbid conditions using the Charlson Comorbidity Index, were determined. Seven-day, 30-day, and 1-year mortality was determined for operative and nonoperative cohorts. Logistic regression determined the competing risk of mortality when controlling for patient demographics, comorbid conditions, and treatment., Results: Forty-two thousand five hundred eleven PH and 7654 DH fractures were evaluated. PH fractures had higher mortality than DH. Nonoperative treatment occurred in 76.2% of PH fractures and 53% of DH fractures. There were more comorbid conditions, longer length of stay, and higher mortality at 7 days, 30 days, and 1 year in patients treated nonoperatively. After controlling for patient demographics and comorbid conditions, there was no difference in mortality between PH and DH fractures, but operative treatment for either PH or DH was associated with lower mortality at all time points., Discussion: Fewer PH than DH fractures were treated operatively. Operative treatment was associated with improved survival in patients hospitalized with PH or DH fracture even after controlling for patient demographic and comorbid factors., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background:: The Numeric Pain Rating Scale (NPRS) is a popular method to assess pain. Recently, the Patient-Reported Outcomes Measurement Information System (PROMIS) has been suggested to be more accurate in measuring pain. This study aimed to compare NPRS and PROMIS Pain Interference (PI) scores in a population of foot and ankle patients to determine which method demonstrated a stronger correlation with preoperative and postoperative function, as measured by PROMIS Physical Function (PF)., Methods:: Prospective PROMIS PF and PI and NPRS data were obtained for 8 common elective foot and ankle surgical procedures. Data were collected preoperatively and postoperatively at a follow-up visit at least 6 months after surgery. Spearman correlation coefficients were calculated to determine the relationship among NPRS (0-10) and PROMIS domains (PI, PF) pre- and postoperatively. A total of 500 patients fit our inclusion criteria., Results:: PROMIS PF demonstrated a stronger correlation to PROMIS PI in both the pre- and postoperative settings (preoperative: ρ = -0.66; postoperative: ρ = -0.69) compared with the NPRS (preoperative: ρ = -0.32; postoperative:ρ = -0.33). Similar results were found when data were grouped by Current Procedural Terminology (CPT) code., Conclusion:: PROMIS PI was a superior tool to gauge a patient's preoperative level of pain and functional ability. This information may assist surgeons and patients in setting postoperative functional expectations and pain management., Level of Evidence:: Level II, prognostic.

Background: Spring ligament tear is often found in advanced adult acquired flatfoot deformity and its reconstruction in conjunction with the deltoid ligament has been proposed to restore the tibiotalar and talonavicular joint stability. The aim of the present study is to determine the effect of spring ligament injury and subsequent reconstruction on static joint reactive force using a non-invasive method of measurement., Methods: Ten fresh-frozen human cadaveric lower legs were disarticulated at the knee joint. Static joint reactive force of the tibiotalar and talonavicular joint were measured at baseline, after spring ligament injury, and after ligament reconstruction. Reconstruction consisted of a forked semitendinosis allograft with dual limbs to reconstruct the tibionavicular and tibiocalcaneal ligaments., Findings: The mean baseline joint reactive force of the tibiotalar and talonavicular joints were 37.2 N + 8.1 N and 13.4 N + 4.2 N, respectively. The spring ligament injury model resulted in a significant 29% decrease in tibiotalar joint reactive force. Reconstruction of the tibionavicular limb resulted in a significant increase in tibiotalar and talonavicular joint reactive force compared to those seen in the injury state. Furthermore, the addition of the tibiocalcaneal limb significantly increased tibiotalar joint reactive force compared to those results obtained from the injury state and the tibionavicular limb alone., Interpretation: This is the first study to demonstrate diminished tibiotalar static joint reactive force in a spring ligament injury model with subsequent joint reactive force restoration using two-limbed reconstruction of the deltoid and spring ligament., Level of Evidence: Biomechanical Study., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Talar head fractures represent a rare subtype of injury to the talus. Clinical series of talar head fractures are nonexistent in the current literature, and treatment of these injuries is based on expert opinion. Many authors recommend a single-incision approach to open reduction and internal fixation of talar head fractures; however, we have found that a 2-incision approach allows for optimal visualization while facilitating proper implant placement. We present a description of our technique and our clinical experience treating 8 of these rare injuries.

Background: As the role of generic patient-reported outcomes (PROs) expands, important questions remain about their interpretation. In particular, how the Patient Reported Outcome Measurement Instrumentation System (PROMIS) t score values correlate with the patients' perception of success or failure (S/F) of their surgery is unknown. The purposes of this study were to characterize the association of PROMIS t scores, the patients' perception of their symptoms (patient acceptable symptom state [PASS]), and determination of S/F after surgery., Methods: This retrospective cohort study contacted patients after the 4 most common foot and ankle surgeries at a tertiary academic medical center (n = 88). Patient outcome as determined by phone interviews included PASS and patients' judgment of whether their surgery was a S/F. Assessment also included PROMIS physical function (PF), pain interference (PI), and depression (D) scales. The association between S/F and PASS outcomes was evaluated by chi-square analysis. A 2-way analysis of variance (ANOVA) evaluated the ability of PROMIS to discriminate PASS and/or S/F outcomes. Receiver operator curve (ROC) analysis was used to evaluate the ability of pre- (n = 63) and postoperative (n = 88) PROMIS scores to predict patient outcomes (S/F and PASS). Finally, the proportion of individuals classified by the identified thresholds were evaluated using chi-square analysis., Results: There was a strong association between PASS and S/F after surgery (chi-square <0.01). Two-way ANOVA demonstrated that PROMIS t scores discriminate whether patients experienced positive or negative outcome for PASS ( P < .001) and S/F ( P < .001). The ROC analysis showed significant accuracy (area under the curve > 0.7) for postoperative but not preoperative PROMIS t scores in determining patient outcome for both PASS and S/F. The proportion of patients classified by applying the ROC analysis thresholds using PROMIS varied from 43.0% to 58.8 % for PASS and S/F., Conclusions: Patients who found their symptoms and activity at a satisfactory level (ie, PASS yes) also considered their surgery a success. However, patients who did not consider their symptoms and activity at a satisfactory level did not consistently consider their surgery a failure. PROMIS t scores for physical function and pain demonstrated the ability to discriminate and accurately predict patient outcome after foot and ankle surgery for 43.0% to 58.8% of participants. These data improve the clinical utility of PROMIS scales by suggesting thresholds for positive and negative patient outcomes independent of other factors., Level of Evidence: II, prospective comparative series.

Obesity is a risk factor for osteoarthritis (OA), the greatest cause of disability in the US. The impact of obesity on OA is driven by systemic inflammation, and increased systemic inflammation is now understood to be caused by gut microbiome dysbiosis. Oligofructose, a nondigestible prebiotic fiber, can restore a lean gut microbial community profile in the context of obesity, suggesting a potentially novel approach to treat the OA of obesity. Here, we report that - compared with the lean murine gut - obesity is associated with loss of beneficial Bifidobacteria, while key proinflammatory species gain in abundance. A downstream systemic inflammatory signature culminates with macrophage migration to the synovium and accelerated knee OA. Oligofructose supplementation restores the lean gut microbiome in obese mice, in part, by supporting key commensal microflora, particularly Bifidobacterium pseudolongum. This is associated with reduced inflammation in the colon, circulation, and knee and protection from OA. This observation of a gut microbiome-OA connection sets the stage for discovery of potentially new OA therapeutics involving strategic manipulation of specific microbial species inhabiting the intestinal space.

Objectives: To evaluate the association of cephalomedullary nail cutout in trochanteric femur fractures with the presence of the following radiographic variables: lateral wall fracture, posteromedial fragment, angular malreduction, residual basicervical fracture gapping, screw placement, and tip-apex distance., Design: Retrospective review., Setting: Academic medical center., Patients: A total of 362 patients were included in the study. The average age was 83 years and the majority was female. All sustained low-energy trochanteric femur fractures treated operatively with cephalomedullary nails. Minimum radiographic follow-up was 3 months, with an average of 11 (range 3-88) months., Intervention: Cephalomedullary nailing with either a lag screw or helical blade., Main Outcome Measures: Cutout of the lag screw or helical blade., Results: A total of 22 (6%) cutouts occurred. Univariate analysis showed significantly (P ≤ 0.01) more frequent cutout with fracture of the lateral wall, posteromedial fragment, residual gapping (>3 mm) at basicervical component, neck-shaft malreduction >5 degrees varus or 15 degrees valgus, and tip-apex distance >25 mm, and superior screw/blade positioning. There was no difference with unstable fracture pattern (P = 0.58) or fellowship training (P = 0.21). Multivariate regression analysis demonstrates that lateral wall fracture (Odds ratios [OR] = 8.0, 95% confidence interval [CI], 2.4-27.1), neck-shaft malreduction (OR = 4.3, CI, 1.3-14.7), and residual basicervical gapping (OR = 3.6, CI, 1.0-13.0) were associated with fixation cutout., Conclusions: Risk factors for cutout of trochanteric fractures in our study can be viewed as modifiable or nonmodifiable factors. Statistically significant factors included lateral wall fracture (nonmodifiable) as well as basicervical gapping and malreduction (modifiable)., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: The development of valgus tibiotalar tilt following hindfoot arthrodesis is rarely discussed in the literature. The purpose of this study was to determine the incidence of valgus tibiotalar tilt and to evaluate if there were any radiographic predictors for the development of valgus tibiotalar tilt., Methods: Patients who underwent hindfoot fusion between January 1, 2004 and December 31, 2013 were identified. Charts were reviewed for demographic information and operative details. Preoperative and postoperative radiographs were reviewed for the development of tibiotalar tilt, and standardized measurements and angles were calculated. A total of 187 patients were included. There were 106 (56.7%) females and 81 (43.3%) males. The average age was 52 years (range, 11-82 years). The most common indication for surgery was adult-acquired flatfoot deformity (n = 92, 49.2%), followed by arthritis (n = 83, 44.4%). The most common procedure was triple arthrodesis (n = 101, 54%). Twenty-seven patients demonstrated tibiotalar tilt preoperatively., Results: A total of 51 patients (27.3%) developed valgus tibiotalar tilt postoperatively at an average of 3.6 months after surgery. We found that an increase in the preoperative Meary (lateral talar-first metatarsal) angle (hazard ratio, 1.039; 95% confidence interval, 1.002-1.077; P < .05) was associated with the development of tibiotalar tilt. An increase in the postoperative Meary angle (hazard ratio, 1.052; 95% confidence interval, 0.999-1.108; P = .0528) approached significance for the development of tibiotalar tilt., Conclusion: The development of valgus tibiotalar tilt following hindfoot fusion was a notable phenomenon, occurring in 27% of our patient population. The preoperative Meary angle was the only radiographic measurement that was significantly associated with the development of valgus tibiotalar tilt, although the postoperative Meary angle approached significance. These findings should encourage surgeons to be aware of patients with large deformities and of their propensity to develop a valgus deformity about the ankle., Level of Evidence: Level III, retrospective comparative series.

Osteoarthritis (OA) is a degenerative joint disease for which there are no disease modifying therapies. Thus, strategies that offer chondroprotective or regenerative capability represent a critical unmet need. Recently, oral consumption of a hydrolyzed type 1 collagen (hCol1) preparation has been reported to reduce pain in human OA and support a positive influence on chondrocyte function. To evaluate the tissue and cellular basis for these effects, we examined the impact of orally administered hCol1 in a model of posttraumatic OA (PTOA). In addition to standard chow, male C57BL/6J mice were provided a daily oral dietary supplement of hCol1 and a meniscal-ligamentous injury was induced on the right knee. At various time points post-injury, hydroxyproline (hProline) assays were performed on blood samples to confirm hCol1 delivery, and joints were harvested for tissue and molecular analyses were performed, including histomorphometry, OARSI and synovial scoring, immunohistochemistry and mRNA expression studies. Confirming ingestion of the supplements, serum hProline levels were elevated in experimental mice administered hCol1. In the hCol1 supplemented mice, chondroprotective effects were observed in injured knee joints, with dose-dependent increases in cartilage area, chondrocyte number and proteoglycan matrix at 3 and 12 weeks post-injury. Preservation of cartilage and increased chondrocyte numbers correlated with reductions in MMP13 protein levels and apoptosis, respectively. Supplemented mice also displayed reduced synovial hyperplasia that paralleled a reduction in Tnf mRNA, suggesting an anti-inflammatory effect. These findings establish that in the context of murine knee PTOA, daily oral consumption of hCol1 is chondroprotective, anti-apoptotic in articular chondrocytes, and anti-inflammatory. While the underlying mechanism driving these effects is yet to be determined, these findings provide the first tissue and cellular level information explaining the already published evidence of symptom relief supported by hCol1 in human knee OA. These results suggest that oral consumption of hCol1 is disease modifying in the context of PTOA.

Extracting high-quality RNA from articular cartilage is challenging due to low cellularity and high proteoglycan content. This problem hinders efficient application of RNA sequencing (RNA-seq) analysis in studying cartilage homeostasis. Here we developed a method that purifies high-quality RNA directly from cartilage. Our method optimized the collection and homogenization steps so as to minimize RNA degradation, and modified the conventional TRIzol protocol to enhance RNA purity. Cartilage RNA purified using our method has appropriate quality for RNA-seq experiments including an RNA integrity number of ∼8. Our method also proved efficient in extracting high-quality RNA from subchondral bone., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: To determine if hospital arthroplasty volume affects patient outcomes after undergoing total hip arthroplasty (THA) for displaced femoral neck fractures., Methods: The Statewide Planning and Research Cooperative System database from the New York State Department of Health was used to group hospitals into quartiles based on overall THA volume from 2000 to 2010. The database was then queried to identify all patients undergoing THA specifically for femoral neck fracture during this time period. The data were analyzed to investigate outcomes between the 4 volume quartiles in 30-day and 1-year mortality, 1-year revision rate, and 90-day complication rate (readmission for dislocation, deep vein thrombosis, pulmonary embolism, prosthetic joint infection, or other complications related to arthroplasty in the treatment of femoral neck fractures with THA)., Results: Patients undergoing THA for femoral neck fracture at hospitals in the top volume quartile had significantly lower 30-day (0.9%) and 1-year (7.51%) mortality than all other volume quartiles. There were no significant differences on pairwise comparisons between the second, third, and fourth quartiles with regard to postoperative mortality. There was no significant difference in revision arthroplasty at 1 year between any of the volume quartiles. On Cox regression analysis, THA for fracture at the lowest volume (fourth) quartile [hazard ratio (HR), 1.91; P = 0.016, 95% confidence interval (CI), (1.13-3.25)], second lowest volume (third) quartile (HR, 2.01; P = 0.013, 95% CI, 1.16-3.5) and third lowest volume (second) quartile (HR, 2.13; P = 0.005, 95% CI, 1.26-3.62) were associated with increased risk for a 1-year postoperative mortality event. Hospital volume quartile was also a significant risk factor for increased 90-day complication (pulmonary embolism/deep vein thrombosis, acute dislocation, prosthetic joint infection) following THA for femoral neck fracture. Having surgery in the fourth quartile (HR, 2.71; P < 0.001, 95% CI, 1.7-4.31), third quartile (HR, 2.61; P < 0.001, 95% CI, 1.61-4.23), and second quartile (HR, 2.41; P < 0.001, 95% CI, 1.51-3.84), all were significant risk factors for increased 90-day complication risk., Conclusions: The results of this population-based study indicate that THA for femoral neck fractures at high-volume arthroplasty centers is associated with lower mortality and 90-day complication rates but does not influence 1-year revision rate. THA for femoral neck fractures at top arthroplasty volume quartile hospitals are performed on healthier patients more quickly. Patient health is a critical factor that influences mortality outcomes following THA for femoral neck fractures., Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Conflicts of Interest: None declared

Objectives: To assess the healing and radiographic outcomes of displaced and comminuted talar neck fractures treated with medial position screws augmented with lateral minifragment plate fixation., Design: Retrospective case series., Setting: Two level I trauma centers., Patients: The records of 26 patients with displaced and comminuted talar neck fractures who underwent open reduction and internal fixation with medial-sided position screws augmented with lateral minifragment plates., Intervention: Surgery consisted of medial and lateral approaches to the talus, fixation with a laterally placed minifragment plate, and screw construct augmenting sagittal-plane-oriented, medial-sided position screws., Main Outcome Measurements: The incidences of nonunion, malunion, avascular necrosis, post-traumatic arthritis, and symptomatic implants., Results: Nonunion occurred in 3/26 (11.5%) displaced and comminuted talar neck fractures. There were no instances of malunion. Avascular necrosis developed in 7/26 (27%) cases. Post-traumatic arthritis was the most common complication affecting 10/26 (38%) tali. The subtalar joint was most commonly affected. There were no instances of hardware removal due to symptomatic medial impingement., Conclusions: Lateral minifragment plate fixation augmenting medially placed sagittal plane position screws provides a length stable construct that prevents talar neck shortening and malunion. Medial position screws can help avoid secondary surgeries for removal of symptomatic implants due to medial impingement as is common with medially based minifragment plates. This fixation strategy should be considered in the setting of displaced and comminuted talar neck fractures., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objective: Obesity is a state of chronic inflammation that is associated with insulin resistance and type 2 diabetes mellitus (DM), as well as an increased risk of osteoarthritis (OA). This study was undertaken to define the links between obesity-associated inflammation, insulin resistance, and OA, by testing the hypotheses that 1) tumor necrosis factor (TNF) is critical in mediating these pathologic changes in OA, and 2) insulin has direct effects on the synovial joint that are compromised by insulin resistance., Methods: The effects of TNF and insulin on catabolic gene expression were determined in fibroblast-like synoviocytes (FLS) isolated from human OA synovium. Synovial TNF expression and OA progression were examined in 2 mouse models, high-fat (HF) diet-fed obese mice with type 2 DM and TNF-knockout mice. Insulin resistance was investigated in synovium from patients with type 2 DM., Results: Insulin receptors (IRs) were abundant in both mouse and human synovial membranes. Human OA FLS were insulin responsive, as indicated by the dose-dependent phosphorylation of IRs and Akt. In cultures of human OA FLS with exogenous TNF, the expression and release of MMP1, MMP13, and ADAMTS4 by FLS were markedly increased, whereas after treatment with insulin, these effects were selectively inhibited by >50%. The expression of TNF and its abundance in the synovium were elevated in samples from obese mice with type 2 DM. In TNF-knockout mice, increases in osteophyte formation and synovial hyperplasia associated with the HF diet were blunted. The synovium from OA patients with type 2 DM contained markedly more macrophages and showed elevated TNF levels as compared to the synovium from OA patients without diabetes. Moreover, insulin-dependent phosphorylation of IRs and Akt was blunted in cultures of OA FLS from patients with type 2 DM., Conclusion: TNF appears to be involved in mediating the advanced progression of OA seen in type 2 DM. While insulin plays a protective, antiinflammatory role in the synovium, insulin resistance in patients with type 2 DM may impair this protective effect and promote the progression of OA., (© 2016 The Authors. Arthritis & Rheumatology published by Wiley Periodicals, Inc. on behalf of the American College of Rheumatology.)

Purpose: To determine if residual angular deformity following non-operative treatment of humeral diaphyseal fractures correlates with patient reported outcomes., Methods: Skeletally mature patients treated by one of three orthopaedic trauma surgeons at a level 1 trauma centre with humeral shaft fractures treated without surgery were retrospectively identified over a 7 year period. After inclusion and exclusion criteria, 42 patients were eligible for the study. Disabilities of the Arm, Shoulder, and Hand (DASH); Simple Shoulder Test (SST); General health questionnaire SF-12 physical component summary (SF-12 PCS) and mental component summary (SF-12 MCS) were obtained from study participants. Healed angular deformity was obtained from patient charts., Results: Thirty two subjects were successfully recruited (32/42 or 76%). Average age was 45 ± 22 with average study follow up being 47 ± 29 months. Average outcome scores were DASH 12 ± 16, SST 10 ± 2.7, SF-12 PCS 50 ± 7.9, and SF-12 MCS 54 ± 8.8. Healed sagittal plane deformity averaged 8 ± 5.7° [range 0-18], and 15 ± 7.9° [range 2-27] in the coronal plane. There was no correlation between residual sagittal or coronal plane deformity and outcome scores (DASH and SST for both p>0.05). Patients with at least 20° (n=7; 22%) of healed coronal deformity had similar outcomes to those with <20° ([DASH (13.2 ± 18.7 vs 11.7 ± 16.1; p=0.83]; [SST (10.3 ± 2 vs 10.0 ± 2.9; p=0.81]). Higher SF-12 PCS and MCS scores correlated with better DASH and SST scores (p<0.05 for all)., Conclusion: Residual angular deformity ranging from 0 to 18° in the sagittal plane and from 2 to 27° in the coronal plane after non-operative treatment for humeral shaft fractures had no correlation with patient reported DASH scores, SST scores, or patient satisfaction. Instead, overall physical and mental health status as measured by the SF-12 significantly correlated with patient reported outcomes., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: To compare the prevalence of peroneal tendon instability as determined by intraoperative evaluation versus preoperative computed tomography (CT) scans, and to identify specific risk factors that correlate with tendon instability., Design: Retrospective comparative study., Setting: Level 1 trauma hospital., Patients: Patients with operatively treated intra-articular calcaneus fractures managed between January 1, 2002 and December 31, 2012 were reviewed for evidence of peroneal tendon instability. Of 254 fractures, 155 intra-articular calcaneus fractures met inclusion criteria and were available for final analysis., Intervention: Operative notes were reviewed to confirm intraoperative testing for superior peroneal retinaculum (SPR) integrity and peroneal tendon stability. Preoperative CT scan and plain radiographs were evaluated for presence of peroneal tendon dislocation, fibular fracture or "fleck" sign, excessive lateral wall displacement, and/or calcaneal fracture-dislocation., Main Outcome Measures: Peroneal tendon stability was determined with intraoperative assessment of the intact SPR and its confluence with the peroneal tendon sheath. The incidence of peroneal tendon instability on intraoperative assessment was compared with preoperatively identified tendon dislocation on CT scan. Prevalence of peroneal tendon dislocation was determined using each diagnostic method. Risk factors for tendon instability were identified using a multivariate regression model., Results: There was significantly higher prevalence of peroneal tendon instability as determined by preoperative imaging (30%; n = 47/155) compared with intraoperative retinaculum testing (11.6%; n = 18/155) (P < 0.001). Intraoperative tendon instability was significantly associated with increased fracture classification severity, fibular fracture/"fleck" sign, and fracture-dislocation., Conclusions: Intraoperative evaluation of the SPR should be used in conjunction with preoperative imaging for diagnosis of peroneal instability in the setting of operatively treated, intra-articular calcaneus fractures., Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives: Medial talar body pins may be inserted to provide points of fixation in the hindfoot when applying external fixators. Because of the proximity to the ankle joint, there is a risk of intracapsular pin placement. We hypothesized that intracapsular placement is common when inserting medial talar body pins., Methods: Medial talar body pins were inserted in 12 fresh frozen cadaver ankles. Arthrography of each ankle was then performed to determine whether the pin was intracapsular. Each pin was then removed, and fluoroscopy was repeated to evaluate for contrast extravasation from the pin insertion site. The distance from the apex of the talar head to the anterior extent of the ankle capsule was measured to determine a safe area for extracapsular pin placement., Results: Arthrograms of all 12 ankles demonstrated that the pins were intracapsular. After pin removal, there was contrast extravasation from the pin insertion site in all specimens. Contrast was present in the pin tract in all specimens. Mean distance from the talar head to the anterior ankle capsule was 20.95 ± 4.8 mm (range, 12.2-27.3 mm) on the lateral view and 15.5 ± 1.8 mm (range, 12.4-20.0 mm) on the anteroposterior view of the foot., Conclusions: There is a high rate of intracapsular pin placement when inserting medial talar body pins. Pin placement within the joint capsule risks seeding a sterile joint with bacteria and fistula formation when the pin remains in place for prolonged periods. For this reason, talar body pins should be avoided in temporizing external fixation frames.

Background: Patients who undergo internal fixation of ankle fractures commonly have postoperative imaging performed immediately after surgery. As these patients typically are typically immobilized, radiographs provide limited visualization. The purpose of this study was to evaluate the utility and quality of formal radiographs performed immediately following ankle fracture surgery., Methods: Ankle fractures undergoing open reduction and internal fixation at a single institution from January 1, 2011, to January 1, 2013, were reviewed. Intraoperative and formal postoperative radiographs were evaluated using defined parameters. The postoperative images were compared with the intraoperative fluoroscopic images in terms of quality. Postoperative complications were evaluated in terms of fracture displacement, hardware malpositioning, and need for return to the operating room. A total of 411 patients with 413 ankle fractures underwent surgical fixation, with 271 patients undergoing formal postoperative radiographs., Results: Twenty-eight patients (10.3%) had 3 good quality postoperative views of the ankle, with the lateral (35.2%) and mortise (41.3%) views least commonly performed with good technique. None of the patients without radiographs had a complication that could have been detected earlier using postoperative radiographs. No patients required return to the operating room based on immediate postoperative radiographs. Postoperative radiographs cost $191 per patient., Conclusion: The routine use of formal postoperative radiographs prior to discharge from the hospital did not provide additional value to the patient or orthopedic surgeon. The quality of these images was generally inferior to the quality of those obtained and saved intraoperatively due to malrotation and overlying cast material. To reduce cost and radiation exposure, formal postoperative radiographs should be obtained only in specific circumstances, such as increasing postoperative pain, marginal fixation, or instability., Level of Evidence: Level III, retrospective cohort study., (© The Author(s) 2015.)

The authors report the case of a patient who sustained traumatic two-level noncontiguous ligamentous flexion-distraction injuries in the thoracolumbar spine. To the best of their knowledge, this is the first reported case of this combined injury pattern.