Search

Introduction: Private equity (PE) investment in health care has increased more than 250% between 2010 and 2020. This is mirrored by an increasing number of published materials in medical journals. The objective of our study was to identify and characterize trends and key themes seen within publications discussing the topic of PE investment into orthopaedic surgery practices and bias within those publications., Methods: The inclusion criteria for our study required an article to be published between the years 2003 and June 2024 and to contain the phrase "orthopaedic surgery" or "orthopedics" in addition to "PE" or "PE investment." Based on these parameters, 15 articles met the criteria for inclusion. Articles were then evaluated to assess various themes related to general views expressed regarding PE firms, reasons for PE attraction to orthopaedics, and most cited positives/negatives of PE investment and potential conflicts of interest with respect to underlying relationships/associations with PE firms at the time of publication., Results: Of the 15 publications meeting the inclusion criteria, 4 (26.7%) expressed positive views on the topic of PE ownership of orthopaedic practices, while 4 (26.7%) expressed a neutral view and 7 (46.7%) expressed a negative outlook. Four (26.7%) of the articles had authors who were either employed or had ownership in a practice that was purchased by a PE firm. Of these 4 articles, none disclosed this potential conflict of interest. Three of the 4 articles had either a positive or neutral view of PE. The most cited reason for PE attraction to orthopaedics was revenue from ancillary services. The most cited upside of PE transactions was the possibility of benefiting from economies of scale, while the most cited downside was the misalignment of incentives., Conclusion: The plurality of present studies views PE transactions negatively (46.7%). Our research unveiled 4 studies with undisclosed conflicts of interest (26.7%). In addition, orthopaedic surgeons should be wary of the numerous downsides of PE transactions, such as the misaligned incentives between themselves and PE firms., Clinical Relevance: Independent orthopaedic practices should be critical of the literature when evaluating the merits of potential partnerships with PE firms., Competing Interests: Of the 15 articles that met our inclusion criteria, 4 expressed generally positive views on the topic, 7 expressed generally negative views, and 4 expressed primarily neutral views (Table II). Four of the articles had authors who were either employed or had ownership in a practice that was purchased by a PE firm. Of these 4 articles, none disclosed this potential conflict of interest4,11-13. TABLE IIGeneral Views Toward Private Equity Firms Expressed by Selected Articles*Author ListGeneral Views on Private Equity FirmsPositiveNeutralNegativeAuthor With Conflict of InterestDisclosure of Conflict of Interest? (Yes/No)Galetta et al.xLundyxxNoMoses et al.xPatel et al.xBoddapati et al.xMikhail et al.xHenretty et al.xxNoGeymanxMcKeon et al.xxNoBorsa et al.xSievers et al.xLachiewiczxRickertxRahman et al.xLundy et al.xxNon (%) articles citing factor4 (26.7%)4 (26.7%)7 (46.7%)4 (26.7%)*An “x” indicates endorsement of a view or possession of a conflict of interest.*An “x” indicates endorsement of a view or possession of a conflict of interest.Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A718)., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Background: Nitinol compression staples have been increasingly used in foot and ankle orthopaedic surgery because of simple implantation, reproducibility, and favorable biomechanical features. Compared with traditional implants (i.e., plates and screws), nitinol staple use in foot and ankle orthopaedics has not been extensively described. This systematic review aims to describe the current clinical outcomes of nitinol staple use in forefoot and midfoot surgery., Methods: A search was conducted using PubMed, Web of Science, and Embase. All studies that included clinical outcomes of nitinol in foot surgery were evaluated for their demographics, outcome scores, or complication rates. Biomechanical studies and studies investigating nitinol nails in the hindfoot were excluded. Two reviewers screened titles, abstracts, and full texts., Results: Of the 198 total articles from the search, 9 articles met the inclusion criteria. Of the 9 articles, 4 articles investigated outcomes of nitinol in the forefoot, 3 articles in the midfoot, 1 article in the forefoot and midfoot, and 1 article in the midfoot and hindfoot. This systematic review included articles that were retrospective in nature and thus subject to selection bias. The mean follow-up ranged from 6 to 35.9 months. The included studies demonstrated significantly improved postoperative visual analog scale pain score ( P  < .001), Ankle Osteoarthritis Scale scores ( P  < .001), and Foot and Ankle Ability Measure activities of daily living scores ( P  < .001). Of the 6 studies that report union for patients receiving purely nitinol staple constructs or nitinol staples in combination with another construct, the overall fusion rate was 94.6% and the overall complication rate was 11.25%., Conclusion: This systematic review demonstrates that nitinol staples in foot surgery, whether alone or in combination with another construct, can achieve an acceptable fusion rate. However, currently we found highly limited clinical study data directly comparing nitinol staples to traditional implants. The current literature is heterogenous in its discussion of nitinol staple configurations and designs., Level of Evidence: Level IV, Systematic Review., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr R. James Toussaint is a paid consultant for Medline Industries. The other authors have not received any financial payments or other benefits from any commercial entity. Disclosure forms for all authors are available online., (© The Author(s) 2024.)

With over 400 harmful immigration policy changes in the past 4 years, Latinx adolescents and families nationwide are developing within a context of extreme anti-immigrant sentiment (Dismantling and reconstructing the U.S. immigration system: A catalog of changes under the Trump presidency, Migration Policy Institute, 2020). This paper introduces the Multitiered Model of Oppression and Discrimination (MMOD), a conceptual model for understanding the impacts of multiple levels of discrimination on the well-being and development of Latinx immigrant adolescents. Interpersonal discrimination (Hispanic Journal of Behavioral Sciences, 2010, 32, 259), community-held stereotypes (Social Psychology of Education, 2001, 5, 201), institutional policies (Children and Youth Services Review, 2018, 87, 192), and structural practices (Journal of Criminal Justice, 2020, 66, 1) can negatively impact well-being and development among these adolescents. Culturally sustaining interventions, civic engagement and mobilization, and policies targeting inequitable policies and practices will provide healing and an avenue for liberation., (© 2022 The Authors. Journal of Research on Adolescence published by Wiley Periodicals LLC on behalf of Society for Research on Adolescence.)

Background: Bohler's angle (BA) is the most commonly utilized radiographic measurement in the study of calcaneus fractures and has been shown to be prognostic in nature. Therefore, it is critical that the measurement of BA be accurate as both therapeutic and prognostic information relies on it. Oblique lateral radiographs can be a cause of error in BA measurements. However, measurement error and the effects of X-ray beam obliquity on BA have not been established in the literature. The purpose of this study was to determine measurement error and understand the effects of X-ray beam's obliquity on the measurement of BA., Methods: A cadaver specimen was imaged using a C-arm to obtain a perfect lateral radiograph of the ankle and slightly oblique lateral views in the anterior, posterior, cephalad, and caudad directions in 5° increments (21 images). Metallic beads were then placed on the anterior calcaneal process, posterior facet, and the superior aspect of the posterior tuberosity, and the same 21 images were then obtained. The metallic beads placed on the reference radiographs allowed the authors to accurately measure BA for each image and served as reference for the corresponding test radiographs. Thirty-four orthopaedic staff members participated in the study and used DICOM measurement tool to measure BA on each of the 21 test radiographs. The measurements were then compared to the measurements of BA from the reference radiographs to determine error in measurement., Results: A total of 714 different measurements were obtained. Average measurement error was 6° (95% confidence interval = -4° to 15°). The difference between the observed BA measurements compared to the true BA measurements increased with increasing X-ray obliquity., Conclusions: Measurement error for BA is ±6° and increases most with cephalad oblique radiographs. Orthopaedic surgeons' ability to accurately measure BA significantly decreases with increasing obliquity of the lateral radiograph., Levels of Evidence: Level V: Cadaver bench study., (© 2016 The Author(s).)

Background: The purpose of this study was to evaluate prognostic predictors of complications and need for secondary surgery in a series of calcaneal avulsion fractures., Methods: Thirty-three patients who sustained extra-articular calcaneal avulsion fractures from 2002 to 2011 were retrospectively identified. Main outcome measurement was need for secondary surgical procedures. Secondary complications such as soft tissue complications and loss of fixation were noted. Prognostic factors for outcome measures were identified., Results: There was a need for secondary operations in 12 cases. Of those, 10 (83%) had wound complications and 5 (41.7%) had failure of fixation. Two subjects required below knee amputation. Of the entire cohort of 33 patients, 13 (39.4%) had soft tissue complications. Of the 22 that underwent surgery, 6 (27%) had failure of fixation. Increased age was significantly associated with wound complications (P = .029). Hypothyroidism (P = .003), peripheral vascular disease (P = .022), and presence of more than one comorbidity (P = .005) were significantly associated with need for secondary surgical intervention. Skin compromise at presentation was significantly associated with soft tissue complication (P = .036) and failure of fixation (P = .046)., Conclusions: Calcaneal avulsion fractures have a high incidence of soft tissue problems, failure of fixation, and need for additional surgeries. Comorbid conditions and increased age portend a poor prognosis with a significant association with wound complications and need for additional surgeries., Levels of Evidence: Prognostic, Level II: Retrospective Analysis., (© 2014 The Author(s).)

Unlabelled: The distal tibial blind spot represents an area where improperly measured long screws may pose a risk to surrounding anatomic structures and is not well visualized on AP, mortise, and lateral radiographs. Awareness of this area as well as the use of a 45° external rotation oblique view when placing fixation in this area may prevent iatrogenic injury., Levels of Evidence: Level V, Expert Opinion., (© 2014 The Author(s).)

Background: The 2006 Massachusetts Healthcare Reform (MHR) has resulted in health coverage for 98.1% of residents in Massachusetts. The purpose of this study was to evaluate the effect of MHR on the actual rate of uninsured individuals in the orthopaedic trauma population in the largest metropolitan area of Massachusetts. We also sought to measure the change in uncompensated care following the implementation of MHR., Methods: We performed a retrospective review of all patients treated by the orthopaedic trauma services at three of the four level-I trauma centers in Boston from 2003 to 2010. The primary study cohort consisted of all uninsured patients, while the remaining patients were considered to have insurance. The study population was divided into two groups to compare the uninsured rate before and after MHR. Patients from 2006 to 2007 were excluded from the analysis to allow for an enrollment period in subsidized health insurance., Results: A total of 16,338 patients with extremity and pelvic fractures and dislocations were treated from 2003 to 2010. There was a significant decrease in the uninsured rate from 23.8% to 14.4% following MHR (p < 0.001). The post-MHR risk of being uninsured is approximately 0.6 times the pre-MHR risk, with a 95% confidence interval of 0.56 to 0.65. There was also a reduction in the proportion of uncompensated care from 16.7% to 11.5% after MHR., Conclusions: There was an estimated 40% reduction in risk of uninsured individuals in the orthopaedic trauma population in the metropolitan Boston area following MHR. Despite a significant improvement, these results reveal a rate of uninsured individuals fivefold greater than currently reported by the state of Massachusetts and the U.S. government., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: In an intra-articular calcaneal fracture, the sustentaculum tali is generally thought to remain tightly bound to the talus by the interosseous talocalcaneal ligaments, spring ligament, and deltoid ligament, providing a "constant" fragment that remains anatomically aligned. The extensile lateral approach is commonly used for reduction based on this assumption, but because it provides only limited access to the medial aspect of the calcaneus, indirect fracture reduction is required to restore an anatomic relationship of these fragments to the sustentacular fragment. The purpose of this study was to determine the prevalence and displacement of sustentacular fractures in patients with an intra-articular calcaneal fracture, and thus determine whether the sustentacular fragment can be accurately considered as constant and can be consistently relied on to maintain anatomic alignment., Methods: All patients with an intra-articular calcaneal fracture who presented to two level-I trauma centers from 2006 to 2012 were included in the study if computed tomography scanning was performed. The presence or absence of a sustentacular fracture was documented, along with the displacement and the comminution of any such fracture and the subluxation or dislocation of the sustentaculum tali., Results: Sustentacular fractures were present in ninety-four (44.3%) of the 212 patients who met the inclusion criteria. Seventy-two (76.6%) of the sustentacular fractures were nondisplaced, eleven (11.7%) were displaced, and ten (10.6%) were comminuted. The articulation between the sustentaculum tali and the talus was anatomically aligned in 166 (78.3%) of the calcaneal fractures, subluxated in forty-three (20.3%), and dislocated in two (0.9%)., Conclusions: This study provides a detailed description of the frequency of sustentacular fractures, the displacement of such fractures, and articular subluxation or dislocation associated with intra-articular calcaneal fractures. Fixation by means of a lateral approach may be compromised when the sustentaculum tali is fractured or subluxated. A medial approach or combined medial and lateral approaches may be considered in such circumstances. Special attention should be paid to the integrity and alignment of the sustentacular fragment prior to surgical fixation., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)

Unlabelled: We describe a simple technique using dual C-arms (large and mini C-arm together) for open reduction internal fixation of calcaneal fractures in the lateral decubitus position that (1) decreases the difficulty of obtaining proper intraoperative imaging; (2) limits C-arm movement, which decreases risk of contamination and operative time; and (3) minimizes the drawbacks of each imaging fluoroscopic modality., Levels of Evidence: Level V, Technical tip, Expert opinion.

Background: Peroneal tendon displacement (subluxation or dislocation) accompanying an intra-articular calcaneal fracture is often undetected and under-treated. The goals of this study were to determine (1) the prevalence of peroneal tendon displacement accompanying intra-articular calcaneal fractures, (2) the association of tendon displacement with fracture classifications, (3) the association of tendon displacement with heel width, and (4) the rate of missed diagnosis of the tendon displacement on radiographs and computed tomography (CT) scans and the resulting treatment rate., Methods: A retrospective radiographic review of all calcaneal fractures presenting at three institutions from June 30, 2006, to June 30, 2011, was performed. CT imaging of 421 intra-articular calcaneal fractures involving the posterior facet was available for review. The prevalence of peroneal tendon displacement was noted and its associations with fracture classification and heel width were evaluated., Results: Peroneal tendon displacement was identified in 118 (28.0%) of the 421 calcaneal fracture cases. The presence of tendon displacement was significantly associated with joint-depression fractures compared with tongue-type fractures (p < 0.001). Only twelve (10.2%) of the 118 cases of peroneal tendon displacement had been identified in the radiology reports. Although sixty-five (55.1%) of the fractures with tendon displacement had been treated with internal fixation, the tendon displacement was treated surgically in only seven (10.8%) of these cases., Conclusions: Analysis of CT images showed a 28% prevalence of peroneal tendon displacement accompanying intra-articular calcaneal fractures. Surgeons and radiologists are encouraged to consider this association.

Background: Many articles have been published to address the topic of in-hospital falls; however, there is considerably less literature that focuses specifically on the topic of falls from the operating room table. The lay press and legal filings contain reports of such incidents, which can result in considerable morbidity, lawsuits, and occasional death., Technique: When tilting the operating table, a simple technique for preventing falls is through the use of posts. Posts are regularly used during knee and hip arthroscopy to facilitate valgus positioning or access into the joint. These posts can be positioned below the axilla and at the level of the greater trochanter to supplement patient safety straps when tilting the table., Discussion: Falls that occur during a hospital admission can lead to serious injury and prolonged hospital stays. Furthermore, falls that occur off the operating table are particularly disastrous and in some cases have resulted in death. Our proposed technique is simple and particularly useful for patients with large or small body habitus or when operating procedures necessitate significant tilting of the operating table., Levels of Evidence: Level V.

Background: The aim of this study was to determine the ability of the Harris heel view to confirm placement of the sustentacular screw during calcaneal fixation., Methods: A 4.0 cancellous screw was placed in a cadaveric specimen, from lateral to medial in 5 configurations: (1) within the sustentaculum, (2) misdirected inferiorly to sustentaculum, (3) misdirected superiorly to sustentaculum, (4) misdirected anteriorly to sustentaculum, and (5) misdirected posteriorly to sustentaculum. Harris heel views were obtained at 5 angulations and were analyzed to determine screw placement., Results: A screw placed anatomically was radiographically confirmed by the Harris heel view to be within the sustentaculum in all views. An inferiorly misdirected screw appeared radiographically within the sustentaculum at 30, 40 and 50 degrees but was confirmed misplaced on the 10- and 20-degree views. A posteriorly misdirected screw was confirmed misplaced on all 5 views. An anteriorly misdirected screw appeared radiographically within the sustentaculum on the 10-degree view but was confirmed misplaced on all other views. A superiorly misdirected screw was confirmed misplaced on all views., Conclusions: Clinicians should be aware that several specific axial heel views are required to verify placement of the sustentacular screw. An inferiorly misdirected screw will appear to be within the sustentaculum with the standard Harris heel view., Clinical Relevance: Heel views should be obtained from a range of 10 to 50 degrees to confirm accurate placement of the sustentacular screw.

In the aftermath of the devastating Haitian earthquake, we became the primary relief service for a large group of severely injured earthquake victims. Finding ourselves virtually isolated with extremely limited facilities and a group of critically injured patients whose needs vastly outstripped the available resources we employed a disaster triage system to organize their clinical care. This report describes the specific injury profile of this group of patients, their clinical course, and the management philosophy that we employed. It provides useful lessons for similar situations in the future., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Postoperative medical complications after total hip arthroplasty (THA) and total knee arthroplasty (TKA) may occur in patients of any age. However, percentage of adverse events increases with increasing patient age and can cause significant morbidity and even mortality. It is important that the orthopedist identify risk factors and symptoms and be knowledgeable in the treatment of nonsurgical postoperative complications. Nonsurgical complications after THA and TKA include pulmonary embolism, fat embolism syndrome, pneumonia, myocardial infarction, postoperative delirium, cerebrovascular accident, urinary retention, urinary tract infections, and deep vein thrombosis.