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Category: Ankle; Midfoot/Forefoot Introduction/Purpose: As medical and recreational cannabis use continues to increase in prevalence across the United States, it is important to understand the impacts of sustained cannabis use on one’s health. Previous literature has shown the potential for cannabidiol products to aid in the improvement of some osteoarthritic symptoms. However, there is a paucity of literature examining the relationship between cannabis use and postoperative medical outcomes for end stage osteoarthritis management, including procedures such as foot and ankle arthrodesis. Therefore, the purpose of this study was to investigate the relationship between cannabis use and the incidence of medical complications within 90 days of foot or ankle arthrodesis. Methods: A retrospective review of a national insurance claims database was performed from 2010 to 2022. CPT codes were used to identify patients who underwent arthrodesis of the ankle, subtalar, talonavicular, calcaneocuboid, naviculo-cuneiform, midtarsal, tarsometatarsal, metatarsophalangeal, or interphalangeal joints. Of those patients, those with established diagnoses of cannabis use disorder, cannabis dependency, or cannabis addiction were identified using ICD-9 and -10 codes. This cannabis cohort was matched 1:4 on the basis of age, sex, and Charlson Comorbidity Index (CCI) to a control cohort without a history of cannabis use to remove potential confounding upon comparison. Demographic and comorbidity profiles, as well as medical and surgical post-operative outcomes were compared using Chi-square tests. Results: Out of 192,162 patients undergoing foot or ankle arthrodesis, 6,387 had a documented history of cannabis use. Compared to controls, the cannabis cohort was significantly younger (mean age 44.1 vs. 56.5; p< 0.001), exhibited a higher comorbidity burden (mean CCI 1.59 vs. 1.38; p< 0.001), and had a greater proportion of male patients (48.2% vs. 31.9%; p< 0.001). Post-matching for age, CCI, and sex, cannabis users demonstrated a significantly higher incidence of medical complications within 90 days of their index ankle fracture ORIF procedure. Notably, cannabis users exhibited elevated rates of various complications, including pneumonia, deep venous thrombosis, pulmonary embolism, myocardial infarction, stroke, surgical site infection, cardiac arrest, acute kidney injury, urinary tract infection, sepsis, and hypoglycemia compared to matched controls (all p< 0.001). Conclusion: Cannabis use is associated with increased incidences of many serious medical complications within 90 days of foot or ankle arthrodesis. These results may help better inform physicians and patients about the increased postoperative risks cannabis users may face, which may lead to the implementation of tailored perioperative care. Further, these results emphasize the need for further research on the molecular mechanisms of cannabis to understand the risk-benefit ratio between the therapeutic effects of cannabidiol for arthritic pain relief, and the adverse outcomes that may result following surgical intervention.

Category: Ankle; Trauma Introduction/Purpose: As medical and recreational cannabis use continues to increase in prevalence across the United States, it is important to understand how cannabis can impact health. Though prior studies have shown that cannabis use can result in delayed bone healing, there is a paucity of literature examining the relationship between cannabis use and postoperative medical outcomes following fracture fixation. Therefore, the purpose of this study was to investigate the relationship between cannabis use and the incidence of medical complications within 90 days of surgical fixation of ankle fractures. Methods: A retrospective review of a national insurance claims database was performed from 2010 to 2022. Patients who underwent open reduction and internal fixation (ORIF) procedures for medial malleolus fractures, lateral malleolus fractures, distal fibula fractures, bimalleolar fractures, and trimalleolar fractures were identified using CPT codes. Of those patients, those with established diagnoses of cannabis use disorder, cannabis dependency, or cannabis addiction were identified using ICD-9 and -10 codes. This cannabis cohort was matched 1:4 on the basis of age, sex, and Charlson Comorbidity Index (CCI) to a control cohort without a history of cannabis use to remove potential confounding upon comparison. Demographic and comorbidity profiles, as well as medical and surgical post-operative outcomes were compared using Chi-square tests. Results: Out of 788,702 patients undergoing ankle fracture open reduction and internal fixation (ORIF) during the study period, 46,105 had documented cannabis use. Cannabis cohort, compared to controls, exhibited significant differences: younger age (mean 38.8 vs. 52.7 years; p< 0.001), lower comorbidity-burden (mean CCI 1.58 vs. 1.68; p< 0.001), and a higher proportion of male patients (51.1% vs. 33.2%; p< 0.001). Following age, CCI, and sex matching, patients with cannabis use histories showed a significantly increased incidence of medical complications within 90 days post ankle fracture ORIF. Cannabis users displayed elevated rates of various complications compared to matched controls, including pneumonia, deep venous thrombosis, pulmonary embolism, myocardial infarction, stroke, surgical site infection, cardiac arrest, acute kidney injury, urinary tract infection, sepsis, and hypoglycemia (all p< 0.001). Conclusion: Cannabis use is associated with increased incidences of many serious medical complications within 90 days of ankle fracture fixation procedures. These results underscore the importance of eliciting cannabis use history during preoperative patient evaluations so that physicians and patients can be better informed about the increased postoperative risks they may face, and so tailored perioperative care can be appropriately implemented. Further, these results emphasize the need for further research on the molecular mechanisms of cannabis to explain interactions that may predispose heavy cannabis users to this profile of adverse surgical outcomes.

Category: Ankle; Ankle Arthritis Introduction/Purpose: Obesity is an ongoing public health epidemic with wide-ranging implications for orthopaedic surgery. Bariatric surgery has been shown to be an effective method for weight reduction. This retrospective cohort study aimed to compare rates of reoperation between patients who underwent primary ankle arthrodesis (AA) and those who underwent total ankle arthroplasty (TAA) after undergoing bariatric surgery. Methods: Utilizing data from PearlDiver, patients who received primary AA or TAA with prior history of bariatric surgery to a cohort without prior bariatric surgery were retrospectively analyzed for reoperations. Both cohorts were propensity-matched based on age, sex and Charlson Comorbidity Index in a 1:4 ratio. Indications for reoperation included revision, prosthetic joint infection (PJI), hardware removal, adjacent joint fusion, and local open reduction internal fixation (ORIF). Kaplan-Meier survival analysis and hazard ratios were calculated for five years after the procedure. Results: Of the 801 patients with prior history of bariatric surgery, 519 (65%) underwent AA, while 282 (35%) underwent TAA. At 5 years post-operatively, patients who had undergone AA showed a higher incidence of adjacent joint fusion if they had prior history of bariatric surgery (Hazard ratio: 1.79, 95% Confidence Interval: 1.23 - 2.61, P-value < 0.001). No differences in reoperation rates were observed for PJI, hardware removal and ORIF. At 5 years, patients who had undergone TAA with history of bariatric surgery showed no difference in the incidence of revision, PJI, hardware removal, ORIF and adjacent joint fusion as compared to patients who underwent TAA with no history of bariatric surgery. Conclusion: Our findings suggest that patients undergoing primary TAA displayed comparable reoperation rates regardless of prior bariatric surgery history over a five-year post-procedure period. In contrast, patients undergoing primary AA exhibited an increased risk of adjacent joint fusions if they had history of bariatric surgery, although the rates of reoperation due to PJI, ORIF, and hardware removal remained comparable. Notably, our results do not position a prior history of bariatric surgery as a significant determinant in reoperation rates. These insights offer valuable guidance for orthopedic surgeons navigating the complexities of surgical interventions in the context of bariatric surgery.

Category: Ankle; Midfoot/Forefoot Introduction/Purpose: With the rising prevalence of cannabis consumption among individuals undergoing foot and ankle procedures, there is a critical need for a comprehensive investigation into the impact of cannabis use on post-operative outcomes. The shifting societal attitudes towards cannabis, coupled with legislative changes promoting increased accessibility, underscore the urgency of understanding the implications for both patients and surgeons. This study aims to address this gap in knowledge and provide insights that can guide pre-operative evaluations and post-operative care planning. Methods: Utilizing data from PearlDiver, patients who underwent interphalangeal fusion, arthrodesis, arthroscopy, total ankle arthroplasty, ankle fracture repair, lateral ankle ligament reconstruction, calcaneal tendon repair, bunionectomy and calcaneal osteotomy were identified. These patients with prior history of cannabis use were propensity-matched with a cohort without prior history of cannabis use based on age, sex and Charlson Comorbidity Index in a 1:4 ratio. Both cohorts were evaluated for 90-day occurrence of medical complications using univariate analysis. Results: In this study, we matched 59,797 patients with a history of cannabis use undergoing foot or ankle procedures with 239,086 without such history. Those with prior cannabis use showed significantly elevated rates of medical conditions compared to controls: pneumonia (6.1% vs. 2.2%, p < .001), deep vein thrombosis (1.5% vs. 0.8%, p < .001), pulmonary embolism (0.4% vs. 0.2%, p < .001), myocardial infarction (1.6% vs. 0.5%, p < .001), stroke (1.8% vs. 0.8%, p < .001), surgical site infections (4.0% vs. 2.2%, p < .001), acute kidney injury (6.8% vs. 3.0%, p < .001), urinary tract infections (9.0% vs. 3.5%, p < .001), sepsis (4.6% vs. 2.0%, p < .001), and hypoglycemia (1.2% vs. 0.5%, p < .001). Conclusion: This study highlights a compelling correlation between prior cannabis use and heightened risks of medical complications post foot and ankle surgeries. The findings emphasize the imperative for healthcare professionals to include cannabis use history in pre-operative assessments and post-operative care planning. Acknowledging the evolving landscape of cannabis use among surgical patients, further research is essential to refine clinical approaches and enhance patient outcomes in this context.

Background: There is a gap in the literature regarding musculoskeletal risk factors for concussion within the National Football League (NFL), which is an avenue that must be explored to promote player safety given the high incidence of both injury types. This study aims to observe if ankle injuries are associated with an increased risk of subsequent concussion in NFL players. Methods: The public online database ProFootballReference.com was used to identify ankle injuries and concussions in NFL players from the 2009-2010 to 2019-2020 seasons. Multivariable logistic regression for subsequent concussion and ankle injury was performed, adjusting for body mass index (BMI), age, and player position. For descriptive statistics, unpaired t tests with unequal variance were performed for continuous variables, including BMI and age. χ 2 testing was performed for categorical variables, including player position, and whether the position was offensive, defensive, or on special teams. Results: Of the 5538 NFL players included in the study, 941 had an ankle injury, 633 had a concussion, and 240 had both an ankle injury and a subsequent concussion. The adjusted odds ratio (aOR) for concussion following a single ankle injury was 0.90 (95% CI 0.72-1.14, P = .387); however, the aOR for concussion following multiple ankle injuries was 2.87 (95% CI 1.23-6.75, P = .015). Special teams players had the lowest risk for concussion (aOR 0.17, 95% CI 0.069-0.36, P

Category: Other Introduction/Purpose: Previous studies have reported conflicting data regarding 30-day readmission rates between patients of different races following orthopaedic surgery. Differences in specific reasons for 30-day readmission between races following orthopaedic surgery have yet to be explored. Methods: The ACS-NSQIP database was utilized to identify patients who underwent orthopaedic surgery and were readmitted within 30 days. Data was collected from 2015–2019, and patients were stratified into one of five race groups: American Indian/Alaskan Native, Asian, Black/African American, Native Hawaiian/Pacific Islander, and White. Analysis of variance (ANOVA) with Bonferroni post-hoc analysis for multiple comparisons was used to compare differences in continuous variables between racial groups. Chi-square analysis with post-hoc analysis of adjusted standardized residuals was used to compare differences in categorical variables between racial groups. Results: In total, 975,857 patients from the ACS-NSQIP database were included in the study. All-cause readmission rate was significantly different across races. Asian and Native Hawaiian/Pacific Islander patients had significantly lower readmission rates (2.7% and 2.8%, respectively), whereas Black patients had significantly greater readmission rates (3.9%) (p < 0.01). Black patients had significantly greater readmission rates for deep incisional SSI, wound disruption, renal insufficiency, and pulmonary embolism, and a lower readmission rate for pneumonia compared to other races. Asian patients had a lower readmission rate for pulmonary embolism, wound disruption, superficial incisional SSI, and vein thrombosis requiring therapy. Conclusion: Specific causes of 30-day readmission were significantly different between races, with Black patients experiencing higher readmission rates and Asian and Hawaiian/Pacific Islander patients experiencing lower readmission rates overall. Our findings can inform which complications should be more carefully monitored in certain patient populations, and how peri- and post-operative management can be adjusted accordingly.

Category: Sports; Ankle Introduction/Purpose: Ankle injuries are among the most common musculoskeletal injuries in National Football League (NFL) players. Concussions are also concerningly frequent, especially given increasing post-mortem observations of chronic traumatic encephalopathy (CTE) in former NFL players. There is a gap in the literature regarding musculoskeletal risk factors for concussion, which is an avenue that must be explored to promote player safety. The purpose of this study is to observe if ankle injuries, especially multiple ankle injuries, are associated with an increased risk of subsequent concussion in NFL players. Methods: The public online database ProFootballReference.com was utilized to identify ankle injuries and concussions in NFL players, as well as demographic variables such as BMI and age. Multivariable logistic regression for subsequent concussion and ankle injury was performed, adjusting for BMI and player position. For descriptive statistics, unpaired T-tests with unequal variance were performed for continuous variables, including BMI and age. Chi-squared testing was performed for categorical variables, including player position, and whether the position was offensive (quarterback, running back, tight end, wide receiver, offensive line), defensive (defensive back, defensive line, linebacker), or on special teams (kicker, punter, long snapper). Results: 5,538 NFL players from the 2009-2010 to 2019-2020 seasons were included in the study. The mean BMI and age of the cohort was 31.06 (SD 4.55) and 24.41 (SD 3.63), respectively. Of these players, 941 had an ankle injury, 633 had a concussion, and 240 had both an ankle injury and a subsequent concussion. The adjusted odds ratio (aOR) for concussion following a single ankle injury was 0.90 (95% CI 0.72 – 1.14, p = 0.387), however, the aOR for concussion following multiple ankle injuries was 2.88 (95% CI 1.28 – 6.74, p = 0.015). The kicker position was determined to have the lowest risk for concussion following ankle injury, and the positions with comparatively greater risk are outlined in Table 1. Conclusion: Multiple ankle injuries were associated with an increased risk of a subsequent concussion by 188% after adjusting for BMI, player position, and offense/defense/special teams designation. Special teams as a group and by position (kicker, long snapper, punter) had the lowest risk of concussion following ankle injury, likely owing to the lower-impact nature of these positions. These findings can inform injury prevention practices in the National Football League.

Introduction:. Orthopaedic surgery has the greatest degree of gender disparity among all medical specialties, presenting a little-explored opportunity to recruit women into orthopaedics early in the pipeline, particularly as undergraduate students. This study aimed to characterize the opinions of female premedical students regarding orthopaedic surgery as well as to assess the effectiveness of a virtual intervention in increasing interest in or improving attitudes toward the field. Methods:. In this prospective study, recruitment emails were sent to premedical advisors, who then circulated a survey that solicited responses from female-identifying premedical students. The survey consisted of questions about demographics, Likert scale questions about opinions of orthopaedic surgery, and an open-response section. At the end of the survey, respondents were provided the option to register for a Zoom panel, in which 4 female physicians described their experiences as women in orthopaedic surgery. Survey responses were analyzed using unpaired t tests for continuous variables and analysis of variance and Tukey's post hoc analysis for Likert scale responses. Results:. A total of 259 female premedical students completed the survey. Respondents most strongly agreed with the statements “orthopaedics is a male-dominated field” and “I wish I learned more about orthopaedics in college.” Interest in pursuing orthopaedic surgery was greater among respondents who had undergone orthopaedic surgery, personally knew an orthopaedic surgeon, personally knew a female orthopaedic surgeon, or had shadowed in orthopaedic surgery. After attending the panel, attendees' interest in orthopaedic surgery significantly increased (p < 0.001), and attendees disagreed significantly more strongly with the notion that gender would limit their opportunities in orthopaedics (p = 0.013). Conclusion:. Early exposure to orthopaedic surgery was consistently associated with increased interest among respondents. In addition, exposure to female orthopaedic surgeons was associated with more positive opinions of orthopaedics, and the mentorship intervention proved effective at increasing interest in the field. These results reinforce the need for targeted, early-exposure programs to recruit premedical women into orthopaedic surgery. Level of Evidence:. Level IV. See Instructions for Authors for a complete description of levels of evidence.