Single-bone versus both-bone plating of unstable paediatric both-bone forearm fractures. A randomized controlled clinical trial.

PURPOSE: This clinical trial compares the functional and radiological outcomes of single-bone fixation to both-bone fixation of unstable paediatric both-bone forearm fractures. METHODS: This individually randomized two-group parallel clinical trial was performed following the Consolidated Standards of Reporting Trials (CONSORT) statement at a single academic tertiary medical centre with an established paediatric orthopaedics unit. All children aged between nine and 15 years who presented to the emergency department at Assiut university with unstable diaphyseal, both-bone forearm fractures requiring surgical intervention between November 1, 2018, and February 28, 2020, were screened for eligibility against the inclusion and exclusion criteria. Inclusion criteria were diaphyseal unstable fractures defined as shaft fractures between the distal and proximal metaphyses with an angulation of > 10°, and/or malrotation of > 30°, and/or displacement > 10 mm after attempted closed reduction. Exclusion criteria included open fractures, Galeazzi fractures, Monteggia fractures, radial head fractures, and associated neurovascular injuries. Patients who met the inclusion criteria were randomized to either the single-bone fixation group (intervention) or the both-bone fixation group (control). Primary outcomes were forearm range of motion and fracture union, while secondary outcomes were forearm function (price criteria), radius re-angulation, wrist and elbow range of motion, and surgical time RESULTS: A total of 50 children were included. Out of these 50 children, 25 were randomized to either arm of the study. All children in either group received the treatment assigned by randomization. Fifty (100%) children were available for final follow-up at six months post-operatively. The mean age of single-bone and both-bone fixation groups was 11.48 ± 1.93 and 13 ± 1.75 years, respectively, with a statistically significant difference (p = 0.006). There were no statistically significant differences in gender, laterality, affection of the dominant hand, or mode of trauma between single-bone and both-bone fixation groups. All patients in both groups achieved fracture union. There mean radius re-angulation of the single-bone fixation groups was 5.36 ± 4.39 (0-20) degrees, while there was no radius re-angulation in the both-bone fixation group, with a statistically significant difference (p < 0.001). The time to union in the single-bone group was 6.28 ± 1.51 weeks, while the time to union in the both-bone fixation group was 6.64 ± 1.75 weeks, with no statistically significant difference (p = 0.44). There were no infections or refractures in either group. In the single-bone fixation group, 24 (96%) patients have regained their full forearm ROM (loss of ROM < 15°), while only one (4%) patient lost between 15 and 30° of ROM. In the both-bone fixation group, 23 (92%) patients have regained their full forearm ROM (loss of ROM < 15°), while only two (8%) patients lost between 15 and 30° of ROM. There was no statistically significant difference between groups in loss of forearm ROM (p = 0.55). All patients in both groups regained full ROM of their elbow and wrist joints. On price grading, 24 (96%) and 23 (92%) patients who underwent single bone fixation and both-bone fixation scored excellent, respectively. Only one (4%) patient in the single-bone fixation group and two (8%) patients in the both-bone fixation group scored good, with no statistically significant difference in price score between groups (p = 0.49). The majority of the patients from both groups had no pain on the numerical pain scale; 22 (88%) patients in the single-bone fixation group and 21 (84%) patients in the both-bone fixation groups, with no statistically significant difference between groups (p = 0.38). The single-bone fixation group had a significantly shorter mean operative time in comparison to both-bones plating (43.60 ± 6.21 vs. 88.60 ± 10.56 (min); p < 0.001). CONCLUSION: Single-bone ulna open reduction and plate fixation and casting are safe and had a significantly shorter operative time than both-bone fixation. However, single-bone ORIF had a higher risk radius re-angulation, alas clinically acceptable. Both groups had equally excellent functional outcomes, forearm ROM, and union rates with no complications or refractures. Long-term studies are required.

Donor site morbidity of calcaneal, distal tibial, and proximal tibial cancellous bone autografts in foot and ankle surgery. A systematic review and meta-analysis of 2296 bone grafts.

PURPOSE: This study aims to report on the safety and donor site morbidity of the distal lower extremity (calcaneal, proximal, and distal tibial) cancellous bone autografts. We summarized the findings in a comprehensive infographic illustration. We are unaware of any similar meta-analyses to date. METHODS: Following the PRISMA guidelines, two independent investigators searched MEDLINE (PubMed), EMBASE, SCOPUS, Google Scholar, and Cochrane databases in December 2020 using the following keywords and their synonyms: ("bone graft", "donor site morbidity", "calcaneal graft", "proximal tibia graft", and "distal tibia graft"). Besides, the reference lists from previous review articles were searched manually for eligible studies. The primary outcomes of interest were (1) chronic pain, (2) fracture, and (3) infection, whereas the secondary outcomes were (1) neurological complications, (2) sensory disturbance and hypertrophic scars, (3) other complications such as shoe-wear difficulties and gait disturbance. Inclusion criteria were: studies on complications and adverse events of lower extremity bone autografts (calcaneal, proximal tibial, and distal tibial bone autografts) reporting at least one of the desired outcomes. Studies not reporting any of the outcomes of interest or if the full text is not available in English were excluded. Studies reporting on bone marrow aspirate or autografts for non-orthopedic indications were also excluded. RESULTS: After the removal of duplicates, a total of 5981 studies were identified. After screening those records, 85 studies remained for full-text assessment. Out of those, 15 studies qualified for the meta-analysis with a total of 2296 bone grafts. Out of those grafts, 1557(67.8%) were calcaneal grafts, 625 (27.2%) were proximal tibial grafts, and 114 (5%) were distal tibial grafts. In calcaneal bone grafts, there were 28 cases of chronic pain [1.97%, CI:1.10-2.50%, I2 = 66%], 5 fractures [0.32%, CI: 0.10-0.60%,I2 = 0%], 20 sural neuritis [1.28%, CI:0.70-1.80%, I2 = 0%), and no wound infections. In proximal tibial grafts there were 13 cases of chronic pain [2.08%, CI: 1.01-3.2%, I2 = 34.5%], 1 fracture [0.16%, CI:0.10-0.50%, I2 = 0%], and 3 superficial wound infections [0.48%, CI: 0.10-1.01, I2 = 0%]. In the distal tibial grafts there were no cases of chronic pain or wound infections, 1 fracture [0.90%, CI: 0.80-2.6%, I2 = 0%], and 5 saphenous neuritis [4.5%, CI: 0.70-8.40%, I2 = 65%]. CONCLUSION: Calcaneal, distal tibial, and proximal tibial bone autografts are safe with a low rate of overall and major complications. We report an overall complication rate of 6.8%, which is less than half of that previously reported for iliac crest grafts. The authors recommend using distal lower extremity grafts for foot and ankle primary surgeries instead of iliac crest grafts when indicated. Clinical trials with a large sample size are required.

Locked intramedullary nailing provides superior functional outcomes and lower complication rates than plate fixation of distal fibula fractures. A systematic review and meta-analysis of comparative studies.

PURPOSE: This study aims to provide an updated systematic review and meta-analysis of comparative studies on the outcomes and complications of locked IMNs in comparison to ORIF using plates and screws, while avoiding limitations of similar published reviews. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two independent team members electronically searched MEDLINE (PubMed), EMBASE, Google Scholar, SCOPUS, and Cochrane databases throughout May 2021 using the following keywords with their synonyms: "Ankle fracture fixation" AND "Open reduction and internal fixation", "locked intramedullary nail", or "complications". The primary outcomes were (1) functional outcomes, (2) complications, and (3) reoperation, while the secondary outcomes were: (1) union rate, and (2) cost. INCLUSION CRITERIA: comparative studies on outcomes and complications of plate open reduction and internal fixation (ORIF) vs. locked intramedullary nailing (IMN) of ankle fractures reporting at least one of the following parameters: functional outcomes, complications (infection, dehiscence, reoperation etc.), union, and cost. Studies reporting on non-locked intramedullary fibular nails were also excluded. RESULTS: After the removal of duplicates, a total of 1461 studies were identified. After screening those records, 63 studies remained for full-text assessment. Out of those, four comparative studies with a total of 262 ankle fractures met the inclusion criteria for this meta-analysis. The mean 12 months postoperative Olerud and Molander Ankle Scores (OMAS) were reported by two studies, with a statistically significant difference in favor of IMNs (MD= 6.72, CI: 3.77-9.67, p<0.001, I2= 94%). In the ORIF group, the overall complication rate was 39/134 (29.1%) vs. 10/128 (7.8%) in the IMN group, with a statistically significant difference in favor of the IMN group (RR=3.23, CI:1.71-6.11, p<0.001, I2=34%). In the ORIF group, the overall infection rate was 11/134 (8.2%), while there were no infections in the IMN group, with a statistically significant difference in favor of the IMN group (RR=8.05, CI:1.51-42.82, p=0.01, I2=0%). In the ORIF group, the overall reoperation rate was 10/134 (7.5%) while the overall reoperation rate was 6/128 (4.7%) in the IMN group, with no statistically significant difference between groups (RR=1.49, CI: 0.60-3.70, p = 0.39, I2=0%). CONCLUSION: Locked intramedullary nail fixation of distal fibula fractures could provide superior functional outcomes and lower complication rates in comparison to open reduction and plate fixation. Despite the high incidence of ankle fractures, the number of high-quality comparative studies remains limited in literature, especially on newer locked fibular nails, and large multicentric clinical trials are required before recommending locked IMNs as the new standard of care in distal fibula fractures.

Return to sport following navicular stress fracture: a systematic review and meta-analysis of three hundred and fifteen fractures.

PURPOSE: This meta-analysis aims to provide updated evidence on the success rate, return to play (RTP) rate, time to RTP, and complications of operatively and conservatively managed navicular stress fractures (NSFs) as well as delays in diagnosis while avoiding limitations of previous similar studies. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two independent team members electronically searched MEDLINE (PubMed), EMBASE, Google Scholar, SCOPUS, and Cochrane databases throughout February 2021 using the following keywords with their synonyms: "Navicular stress fracture," "return to play," and "athletes." The primary outcomes were (1) management success rate, (2) RTP rate, and (3) time to RTP. The secondary outcomes were (1) non-union, (2) time to diagnosis, (3) refracture, and (4) other complications. Inclusion criteria were clinical studies on NSFs reporting at least one of the desirable outcomes. Studies not reporting any of the outcomes of interest or the full text was not available in English, German, French, or Arabic were excluded. Case reports, case series with less than ten cases, and studies reporting exclusively on navicular non-union management were also excluded. The Newcastle-Ottawa scale was used for quality assessment while Review Manager (RevMan) Version 5.4 was used for the risk of bias assessment. Data were presented by type of treatment (surgical or conservative). If enough studies were present that were clinically and statistically homogeneous and data on them adequately reported, a meta-analysis was performed using a fixed-effects model. In case of statistical heterogeneity, a random-effects model was used. If meta-analysis was not possible, results were reported in a descriptive fashion. The need to explore for statistical heterogeneity was determined by an I2 greater than 40%. RESULTS: Eleven studies met the inclusion criteria with a total of 315 NSF. Out of those, 307 (97.46%) NSFs were in athletes. One hundred eight (34.29%) NSFs were managed operatively, while 207 (65.71%) NSFs were managed conservatively. Successful outcomes were reported in 104/108 (96.30%) NSF treated operatively with a mean success rate of 97.9% (CI: 95.4-100%, I2 = 0%). Successful outcomes were reported in 149/207 (71.98%) NSF treated conservatively, with a mean success rate of 78.1% (CI: 66.6-89.6%, I2 = 84.93%). Successful outcome differences were found to be significant in favor of operative management (OR = 5.52, CI: 1.74-17.48, p = 0.004, I2 = 4.6%). RTP was noted in 97/98 (98.98%) NSF treated operatively and in 152/207 (73.43%) NSF treated conservatively, with no significant difference between operative and conservative management (OR = 2.789, CI: 0.80-9.67, p = 0.142, I2 = 0%). The pooled mean time to RTP in NSF treated operatively was 4.17 months (CI: 3.06-5.28, I2 = 92.88%), while NSF treated conservatively returned to play at 4.67 months (CI: 0.97-8.37, I2 = 99.46%) postoperatively, with no significant difference between operative and conservative management (SMD = - 0.397, CI: - 1.869-1.075, p = 0.60, I2 = 92.24). The pooled mean duration of symptoms before diagnosis was 9.862 (3.3-123.6) months (CI: 6.45-13.28, I2 = 94.92%), reported in ten studies. Twenty (23.53%) refractures were reported after conservative management of 85 NSFs, while one (1.28%) refracture was reported after operative management of 78 NSFs, with a significant difference in favor of operative management (OR = 0.083, CI: 0.007-0.973, p = 0.047, I2 = 38.78%). CONCLUSION: Operative management of NSF provides a higher success rate, a lower refracture rate, and a lower non-union rate as compared to other non-operative management options. While not significant, there is a notable trend towards superior RTP rates and time to RTP following operative management. Therefore, we recommend operative fixation for all NSFs type I through III in athletes. Athletes continue to exhibit an alarmingly long duration of symptoms before diagnosis is made; a high index of suspicion must be maintained, therefore, and adjunct CT imaging is strongly recommended in the case of any work-up. Unfortunately, the published literature on NSFs remains of lower level of evidence and high-quality studies are needed.

Double versus triple arthrodesis for adult-acquired flatfoot deformity due to stage III posterior tibial tendon insufficiency: a prospective comparative study of two cohorts.

PURPOSE: The study aims to prospectively compare double and triple arthrodesis in terms of functional outcomes and deformity correction. To the best of our knowledge, this is the first prospective comparative study in the literature to date. METHODS: This is a prospective comparative cohort study carried out between May 2017 and May 2019. The study was approved by the IRB at Assiut University and done according to the Helsinki declaration. Patients with AAFD stage III aged between 15 and 40 years old were assigned to double arthrodesis or triple arthrodesis. The groups were prospectively followed for one year. Primary outcomes were union rates, AOFAS scores, and radiological parameters of deformity correction on AP and lateral plain radiographs. Secondary outcomes were operative time, time to union, and complications. The double arthrodesis was done through the medial approach, while the triple arthrodesis was done through dual medial and lateral approaches. The post-operative protocol was standardized for both groups. RESULTS: A total of twenty-three patients matched the inclusion criteria and provided their consent to participate in the study. Thirteen (all males) patients underwent double arthrodesis, while ten (nine males and one female) patients underwent triple arthrodesis. The mean age for double and triple arthrodesis was 20.15 ± 5.63 and 25.10 ± 8.36 years, respectively, and the mean follow-up lengths were 12.46 and 12.9 months, respectively. There were no statistically significant differences between both groups in age, gender, laterality, or duration of follow-up. There were no statistically significant differences between both groups in AOFAS hindfoot scores or radiographic parameters. All patients were available for the final follow-up evaluation. All patients in both groups achieved union by four months post-operatively. The mean time to union in the double and triple arthrodesis groups was 3.39 ± 0.65 vs. 3.31 ± 0.6 months, respectively, with no statistically significant differences (p = 0.77). The mean operative time was significantly shorter in the double arthrodesis group than the triple arthrodesis group, 55.77 ± 15.18 vs. 91.6 ± 24.14 min (p < 0.001), respectively. Both double and triple arthrodesis groups had a statistically significant improvement of the mean AOFAS hindfoot score post-operatively (71.46 ± 7.77 vs. 88.38 ± 3.66, p < 0.001) and (66.9 ± 7.69 vs. 85 ± 5.83, p < 0.001), respectively. In the double arthrodesis group, the mean calcaneal pitch angle increased from 11.46° pre-operatively to 19.34° (MD = 8.45°, p < 0.001). The mean Meary's angle improved from - 4.19 to 2.9° (MD = 7.32°, p < 0.001). Hibbs angle had a mean reduction of 6.45° post-operatively (p = 0.069). In the triple arthrodesis group, the mean calcaneal pitch angle improved from 10.06° pre-operatively to 17.49° post-operatively (MD = 7.12°, p < 0.001). The mean Meary's angle improved from - 4.72 to 2.29° (MD = 7.09°, p < 0.001). The mean Hibbs angle decreased from 153.07 to 142.32° (MD = 10.54°, p < 0.001). The double vs. triple arthrodesis groups had no statistically significant differences in AOFAS hindfoot score improvement (16.92 vs. 19.1, p = 0.44), respectively. The two groups had no statistically significant differences in the magnitude of correction of all the radiographic parameters. CONCLUSION: Double arthrodesis is an equally reliable surgical option for AAFD stage III for achieving union, improving the functional outcomes, and deformity correction as triple arthrodesis with a significantly shorter operative time in the former. The authors recommend double arthrodesis if the calcaneocuboid joint is unaffected.

Peroneal tendon dislocation in talus fracture and diagnostic value of fleck sign.

INTRODUCTION: Talus fractures are not uncommon and one of the serious fractures in the foot and ankle. Peroneal tendon dislocation is one of the commonly missed soft tissue injuries which may have significant impact on the outcomes including persistent pain and swelling. They have been reported to be associated with calcaneum as well as talus fractures. AIM: To report the incidence of peroneal tendon dislocation in talus fracture and the significance of fleck sign in the diagnosis of peroneal tendon dislocation. METHODS: We retrospectively reviewed 93 consecutive talus fractures in the period between 1/1/2011 to 1/11/2018. Inclusion criteria were: The patient underwent open reduction and internal fixation, had pre-operative CT scan that is available for review and three view ankle plain radiographs. Two independent authors review the radiographs for peroneal tendon dislocation, fleck sign and fracture classification, if any. Any dispute was resolved by the senior author.Patient records were reviewed for laterality, age, sex,mode of injury, associated injuries and operative interventions. 50 ankles met the inclusion criteria. 49 were males, mean age was 32.5 year and the predominant mode of injury was a fall from height. RESULTS: Peroneal tendon dislocation was found in ten patients out of 50 (20%). Risk of dislocation increased with severity of the fracture and neck fractures. Most of the dislocations were missed by surgeons and radiologist, and no additional procedures were done to address such an injury. The Fleck sign had a statistically significant correlation with peroneal tendons dislocations (p=.005) CONCLUSION: Peroneal tendons dislocation is associated with as high as 20% of talus fractures. The authors recommend carefully reviewing CT scans by surgeons and radiologists alike to avoid missing such injury and allow for appropriate surgical approach utilization. The Fleck sign is a highly specific radiographic sign that has a statistically significant correlation with PT dislocation and hence we recommend intra-operative assessment of peroneal tendons in patients with the fleck sign.

Arthroscopic Bankart repair for the acute anterior shoulder dislocation: systematic review and meta-analysis.

BACKGROUND: The ideal treatment of acute anterior shoulder dislocation remains one of the topics that spark debate over the value of primary repair for the first-time anterior shoulder dislocation. The high rate of complications especially in young adults, such as recurrent instability, residual pain, and inability to return to sports, has led to the quest for an ideal management of such injuries. OBJECTIVE: In this meta-analysis, we compare between the immediate arthroscopic repair and conservative treatment of primary anterior shoulder dislocation as well as arthroscopic reconstruction of recurrent anterior shoulder dislocation. Outcome measures were failure rate (dislocation, subluxation, and instability) and revision rates. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched several database including PubMed, MEDLINE, EMBASE, Web of Science, Cochrane Library, and ClinicalTrials.gov through August 2017 to identify observational and experimental randomized controlled trials comparing the outcomes of immediate arthroscopic repair and conservative treatment of primary shoulder dislocations as well as arthroscopic reconstruction of recurrent dislocation. The primary outcome was failure rate, whereas, secondary outcomes were revision rate and functional outcomes. RESULTS: Out of the 710 studies identified, 12 were eligible for meta-analysis. The estimated pooled failure rate was 13.7% (7.7%-19.6%), whereas, the pooled revision rate was 7.1% (3.8%-10.4%) in immediate arthroscopic repair of primary shoulder dislocation. The odd ratio (OR) of failure and revision rates were significantly lower in arthroscopic repair of primary shoulder dislocation compared to conservative treatment (OR 0.103, 95% CI [0.052, 0.201]), (OR 0.217, 95% CI [0.078, 0.607]), respectively. The odd ratio (OD) of failure and revision rates were lower in arthroscopic repair of primary shoulder dislocation compared to arthroscopic reconstruction of the recurrent shoulder dislocation; however, the difference was statistically insignificant (OR 0.423, 95% CI [0.117, 1.522]) and (OR 0.358, 95% CI [0.044, 2.920]) respectively. CONCLUSION: The outcome of immediate arthroscopic repair of primary anterior shoulder dislocation is superior and encouraging with significant reduction in failure and revision rates compared to conservative treatment. Nevertheless, the failure and revision rates are statistically insignificant compared to arthroscopic reconstruction of recurrent dislocation. Hence, there is evidence to support immediate arthroscopic repair option for primary anterior shoulder dislocations over conservative treatment in young active patients, in order to reduce the risk of failure and revision rates. However, the evidence is inconclusive compared to arthroscopic reconstruction of recurrent dislocation.

Is Subtle Cavovarus a Problem for Athletes?

Cavovarus or high-arched foot is a common foot deformity that occurs due to the disruption of the foot-driven equilibrium between the first metatarsal, fifth metatarsal, and the heel. This imbalance leads to an increase in the foot's normal plantar concavity. Cavovarus deformity ranges from a mild and flexible malalignment to a fixed, complex, and severe deformation. Subtle cavovarus foot, the mild form of the cavus foot, was first described by Manoli and colleagues.

Outcomes and Complications of Open Versus Minimally Invasive Repair of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: An acute Achilles tendon rupture is one of the most common sports injuries, affecting 18 per 100,000 persons, and its operative repair has been evolving and increasing in frequency since the mid-1900s. Traditionally, open surgical repair has provided improved functional outcomes, reduced rerupture rates, and a quicker recovery and return to activities at the expense of increased wound complications such as infections and skin necrosis compared with nonoperative management. In 1977, Ma and Griffith introduced the percutaneous approach, and over the following decades, multiple improved techniques, and modifications thereof, have been described with comparable outcomes with open repair. PURPOSE: The current study aimed to provide updated level 1 evidence comparing open repair with minimally invasive surgery (MIS) through a comprehensive search of the literature published in English, Arabic, Spanish, Portuguese, and German while avoiding limitations of previous studies such as heterogeneous study designs and a small number of included trials. STUDY DESIGN: Meta-analysis; Level of evidence, 1. METHODS: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases to identify randomized controlled trials (RCTs) comparing open repair and MIS of Achilles tendon ruptures. The primary outcomes were (1) functional outcomes, (2) reruptures, (3) sural nerve injuries, and (4) infections (deep/superficial), whereas the secondary outcomes were (1) skin complications, (2) adhesions, (3) other complications, (4) ankle range of motion, and (5) surgical time. RESULTS: There were 10 RCTs that qualified for the meta-analysis with a total of 522 patients. Overall, 260 (49.8%) patients underwent open repair, while 262 (50.2%) underwent MIS. The mean postoperative AOFAS score was 94.8 and 95.7 for open repair and MIS, respectively, with a nonsignificant difference (mean difference [MD], -0.73 [95% CI, -1.70 to 0.25]; P = .14; I2 = 0%). The pooled mean total complication rate was 15.5% (0%-36.4%) for open repair and 10.4% (0%-45.5%) for MIS, with a nonsignificant statistical difference (odds ratio [OR], 1.50 [95% CI, 0.87-2.57]; P = .14; I2 = 40%). The mean rerupture rate was 2.5% (0%-6.8%) for open repair versus 1.5% (0%-4.6%) for MIS, with a nonsignificant statistical difference (OR, 1.56 [95% CI, 0.42-5.70]; P = .50; I2 = 0%). No cases of sural nerve injuries were reported in the open repair group. The mean sural nerve injury rate was 3.4% (0%-7.3%) in the MIS group, which was statistically significant (OR, 0.16 [95% CI, 0.03-0.46]; P = .02; I2 = 0%). The mean overall superficial infection rate was 6.0% (0%-18.2%) and 0.4% (0%-4.5%) for open repair and MIS, respectively, with a statistically significant difference (OR, 5.70 [95% CI, 1.80-18.02]; P < .001; I2 = 0%). The mean overall deep infection rate reported in the open repair group was 1.4% (0%-5.0%), while no deep infection was reported in the MIS group, with no statistically significant difference (OR, 3.14 [95% CI, 0.48-20.54]; P = .23; I2 = 0%). There were no significant differences between the open repair and MIS groups in the skin necrosis and dehiscence rate, adhesion rate, or keloid scar rate. The mean surgical time was 51.0 and 29.7 minutes for open repair and MIS, respectively, with a statistically significant difference (MD, 21.13 [95% CI, 15.50-26.75]; P < .001; I2 = 15%). CONCLUSION: Open Achilles tendon repair was associated with a longer surgical time, higher risk of superficial infections, and higher risk of ankle stiffness, while MIS was associated with a greater risk of temporary sural nerve palsy. The rerupture rate and functional outcomes were mostly equivalent. We found MIS to be a safe and reliable technique. However, high-quality standardized RCTs are still needed before recommending MIS as the gold standard for managing Achilles tendon ruptures.

Surgical Management of Jones Fractures in Athletes: Orthobiologic Augmentation: A Systematic Review and Meta-analysis of 718 Fractures.

BACKGROUND: The use of orthobiologics is expanding. However, the use of orthobiologic augmentation in primary fracture fixation surgery remains limited. Primary fracture fixation of the fifth metatarsal (Jones) in athletes is one of the rare situations where primary orthobiologic augmentation has been advocated. PURPOSE: To determine the effect of orthobiologic augmentation on the outcome of surgically managed Jones fractures in athletes. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through March 2021 to identify studies reporting on surgically managed Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the return to play (RTP) rate and time to RTP, whereas the secondary outcomes were time to union, union rate, and refractures. Data were presented by type of treatment (biologically augmented fixation or fixation alone). RESULTS: In the biologically augmented fixation group, successful RTP was reported in 195 (98.98%) of 197 fractures (odds ratio [OR], 97.5%; 95% CI, 95.8%-100%; I2 = 0), with a mean time to RTP of 10.3 weeks (95% CI, 9.5-11.1 weeks; I2 = 99%). In the group that received fixation without biological augmentation, successful RTP was reported in 516 (99.04%) of 521 fractures (OR, 98.7%; 95% CI, 97.8%-99.7%; I2 = 0], with a mean time to RTP of 9.7 weeks (95% CI, 7.84-11.53 weeks; I2 = 98.64%]. In the biologically augmented fixation group, fracture union was achieved in 194 (98.48%) of 197 fractures (OR, 97.6%; 95% CI, 95.5%-99.7%; I2 = 0%), with a mean time to fracture union of 9.28 weeks (95% CI, 7.23-11.34 weeks; I2 = 98.18%). In the group that received fixation without biological augmentation, fracture union was achieved in 407 (93.78%) of 434 fractures (OR, 97.4%; 95% CI, 96%-98.9%; I2 = 0%), with a mean time to fracture union of 8.57 weeks (95% CI, 6.82-10.32 weeks; I2 = 98.81%). CONCLUSION: Orthobiologically augmented surgical fixation of Jones fractures in athletes is becoming increasingly common, despite the lack of comparative studies to support this practice. Biologically augmented fixation of Jones fractures results in higher fracture union rates than fixation alone but similar rates of RTP and time to RTP. Although the current evidence recommends primary surgical fixation for the management of Jones fractures in athletes, further high quality comparative studies are required to establish the indication for orthobiologic augmentation.

First Metatarsophalangeal Arthrodesis for the Failed Hallux.

Hallux metatarsophalangeal joint (MTPJ) arthrodesis was first described in 1894 by Clutton, who recommended ankylosing the MTPJ to treat painful hallux valgus (HV). He used ivory pegs to stabilize the MTP joint. Surgeons over the last century have modified the procedure and added indications, including hallux rigidus, rheumatoid arthritis, and revision of failed surgeries. This article addresses many common yet challenging clinical scenarios, and a few hot topics, related to hallux MTPJ arthrodesis, including matarsus primus elevatus, severe hallux valgus, avascular necrosis, and infections. The article provides a condensed evidence-based discussion on how to manage these challenges using MTPJ arthrodesis.

Tranexamic Acid Utilization in Foot and Ankle Surgery: A Meta-analysis.

BACKGROUND: Tranexamic acid (TXA) has been widely used in various orthopaedic subspecialities to decrease blood loss, transfusions, and wound complications. However, the role of TXA in foot and ankle surgery is not clearly delineated. This meta-analysis aims to report the efficacy and safety of TXA in relation to foot and ankle surgical procedures. METHODS: Database searches were conducted for eligible studies from data inception through January 2022. Clinical studies on the use of TXA in foot and ankle procedures reporting the desired outcomes were included. Outcomes were estimated blood loss, change in hemoglobin, and overall complications. Risk of bias was assessed using the Newcastle-Ottawa quality assessment scale and the Joanna Briggs Institute (JBI) critical appraisal tool. RESULTS: Nine studies met the inclusion criteria. A total of 752 foot and ankle procedures were included, in which 511 (67.95%) procedures received TXA whereas 241 (32.05%) served as controls and did not receive TXA. The pooled data of change in hemoglobin and overall complications showed no difference between the TXA and control group. Estimated blood loss was significantly lower in the patients who received TXA. CONCLUSION: In conclusion, TXA use was associated with lower estimated blood loss in foot and ankle surgeries without increased risk of thromboembolic events, wound complications, or changes in hemoglobin. LEVEL OF EVIDENCE: Level IV, meta-analysis.

Middle East Authors' Contribution to the Journal of Arthroplasty's Publications in the Past 20 years (2000-2020).

BACKGROUND: This study aimed to evaluate the Middle East (ME) countries' contribution to the Journal of Arthroplasty (JOA)'s publications in the past 20 years. METHODS: All articles published in JOA from 2000 to 2020 were evaluated for the contribution prevalence of ME countries' authors, which were divided into category I, if all the authors were affiliated to ME institutions, and category II, if at least one coauthor affiliated to ME institutions was listed in the articles with other international authors. RESULTS: A total of 7837 original articles were evaluated. Authors affiliated with ME institutions contributed to 144 (1.8%) articles (148 individual country contributions) from ten (62.5%) out of a total of 16 ME countries. Sixty-eight articles (47.2%) were classified as category I; cooperation between different ME institutes (The authors were from two different ME countries.) was reported in two (1.4%) articles. The top five contributing countries were Egypt, Iran, Israel, Saudi Arabia, and Turkey, contributing 89.2% of the total articles published by ME institutions. Out of the 144 articles, 80 (55.6%) articles were published between 2016 and 2020, 37 (25.7%) articles between 2011 and 2015, and 29 (20.1%) articles between 2000 and 2010. There was a 15.7% mean annual growth in the percentage of ME articles. CONCLUSION: Although there was an increasing trend in the contributions of ME countries' authors to JOA publications over the past 20 years, the overall contribution is still low; moreover, the cooperation between ME institutions is minimal.

Projections and Epidemiology of Total Ankle and Revision Total Ankle Arthroplasty in the United States to 2030.

Background: Total ankle arthroplasty (TAA) utilization is increasing in the United States. As the incidence of this procedure grows, it is important for providers to understand the future projections for ankle arthroplasty and more importantly revision total ankle arthroplasty (rTAA). Methods: The National Inpatient Sample (USA) was queried from 2005 to 2017 for all TAA and rTAA. Poisson and linear regression analysis was performed to project annual incidence of TAA and rTAA to 2030, with subgroup analyses on septic rTAA. Results: There were 5315 TAAs performed in 2017, a 564% (P < .001) increase when compared with the TAAs performed in 2005. From 2017 to 2030, the incidence of TAAs is projected to increase from 110% to 796% (P < .001). There were 1170 rTAAs performed in 2017, a 155% (P < .001) increase when compared with rTAAs performed in 2005. There was a 256% increase in the incidence of septic rTAAs from 2005 to 2017 with a projected increase between 22% and 120% by 2030. Conclusions: The incidence of both TAAs and rTAAs is projected to significantly increase over the next decade. Given the known risk factors of TAA and rTAA, these findings reinforce the need for thoughtful consideration when selecting patients for TAA.

Return to Play After Low-Energy Lisfranc Injuries in High-Demand Individuals: A Systematic Review and Meta-Analysis of Athletes and Active Military Personnel.

BACKGROUND: Although studies are available on high-energy Lisfranc injuries, the evidence for increasingly reported low-energy Lisfranc injuries in active individuals, including athletes and military personnel, remains scarce and mostly retrospective. PURPOSE: This meta-analysis aimed to review the return-to-play (RTP) and return-to-duty (RTD) rates with regard to the anatomic type and the management of low-energy Lisfranc injuries in a high-demand, active population. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the MEDLINE (PubMed), EMBASE, Google Scholar, and Cochrane databases through June 2019 to identify studies on low-energy Lisfranc injuries in athletes and military personnel. The primary outcomes were RTP/RTD rates and time to RTP/RTD, and the secondary outcomes were time missed from practice, games missed, time to full recovery, midfoot arthritis rate, and reoperation rate. RESULTS: Overall, 15 studies (N = 441 patients) were included in the meta-analysis. Of these, 6 studies were of level 3 evidence, 8 studies were level 4 (case series), and 1 study was level 5. Of the 441 subjects, 380 (86.17%) were able to RTP and RTD. There was no statistically significant difference in RTP rates for operative versus nonoperative treatment, ORIF versus PA, or bony versus ligamentous injuries. The mean time missed from practice/duty for operative versus nonoperative treatment was 58.02 days (95% CI, 13.6-102.4 days; I 2 = 98.03%) and 116.4 days (95% CI, 62.4-170.4 days; I 2 = 99.45%), respectively. The mean time missed from practice/duty for bony versus ligamentous injury was 98.9 days (95% CI, 6.1-191.7 days; I 2 = 99.82%) and 76.5 days (95% CI, 37.9-115.02 days; I 2 = 99.83%), respectively, with no statistically significant differences (standardized mean difference = 3.62 days [95% CI: -5.7 to 13 days]; I 2 = 83.17%). CONCLUSION: This review indicated an overall excellent RTP/RTD rate for low-energy Lisfranc injuries in high-demand individuals. The time missed from athletic participation/military duty was not affected by injury treatment type, the bony versus ligamentous nature of the injury, or athlete player position. However, the low evidence levels and significant heterogeneity of the included studies precludes making conclusions regarding length of time missed or optimal management. Higher-quality studies on low-energy Lisfranc injuries are needed.

Return to Play and Fracture Union After the Surgical Management of Jones Fractures in Athletes: A Systematic Review and Meta-analysis.

BACKGROUND: Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. The management of this injury can be challenging because of delayed union and refractures. Intramedullary (IM) screw fixation rather than nonoperative management has been recommended in the athletic population. PURPOSE: To provide an updated summary of the return-to-play (RTP) rate and time to RTP after Jones fractures in athletes with regard to their management, whether operative or nonoperative, and to explore the union rate and time to union as well as the rate of complications such as refractures. STUDY DESIGN: Meta-analysis. METHODS: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through November 2019 to identify studies reporting on Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the RTP rate and time to RTP, whereas the secondary outcomes were the number of games missed, time to union, and union rate as well as the rates of nonunion, delayed union, and refractures. RESULTS: Of 168 studies identified, 22 studies were eligible for meta-analysis with a total of 646 Jones fractures. The overall RTP rate was 98.4% (95% CI, 97.3%-99.4%) in 626 of 646 Jones fractures. The RTP rate with IM screw fixation only was 98.8% (95% CI, 97.8%-99.7%), with other surgical fixation methods (plate, Minifix) was 98.4% (95% CI, 95.8%-100.0%), and with nonoperative management was 71.6% (95% CI, 45.6%-97.6%). There were 3 studies directly comparing RTP rates with surgical versus nonoperative management, which showed significant superiority in favor of surgery (odds ratio, 0.033 [95% CI, 0.005-0.215]; P < .001). The RTP rate according to type of sport was 99.0% (95% CI, 97.5%-100.0%) in football, 91.1% (95% CI, 82.2%-99.4%) in basketball, and 96.6% (95% CI, 92.6%-100.0%) in soccer. The overall time to RTP was 9.6 weeks (95% CI, 8.5-10.7 weeks). The time to RTP in the surgical group (IM screw fixation) was 9.6 weeks (95% CI, 8.3-10.9 weeks), which was significantly less than that in the nonoperative group of 13.1 weeks (95% CI, 8.2-18.0 weeks). The pooled union rate in the operative group (excluding refractures) was 97.3% (95% CI, 95.1%-99.4%), whereas the pooled union rate in the nonoperative group was 71.4% (95% CI, 49.1%-93.7%). The overall time to union was 9.1 weeks (95% CI, 7.7-10.4 weeks). The time to union with IM screw fixation (8.2 weeks [95% CI, 7.5-9.0 weeks]) was shorter than that with nonoperative treatment (13.7 weeks [95% CI, 12.7-14.6 weeks]). The rate of delayed union was 2.5% (95% CI, 1.2%-3.7%), and the overall refracture rate was 10.2% (95% CI, 5.9%-14.5%). CONCLUSION: The RTP rate and time to RTP after the surgical management of Jones fractures in athletes were excellent, regardless of the implant used and type of sport. IM screw fixation was superior to nonoperative management, as it led to a higher rate of RTP, shorter time to RTP, higher rate of union, shorter time to union, and improved functional outcomes. We recommend surgical fixation for all Jones fractures in athletes.

Outcomes of Open Versus Arthroscopic Broström Surgery for Chronic Lateral Ankle Instability: A Systematic Review and Meta-analysis of Comparative Studies.

BACKGROUND: Nearly 20% of acute ankle sprains progress to chronic lateral ankle instability that requires surgical intervention. In recent years, there has been a growing interest in arthroscopic Broström techniques as an alternative to open surgery. PURPOSE: To review the most up-to-date evidence comparing the outcomes of open and arthroscopic Broström procedures for chronic lateral ankle instability. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: This review was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Relevant comparative studies in English up to May 2020 were identified. The primary outcomes were (1) functional scores (Karlsson Ankle Function Score and American Orthopaedic Foot & Ankle Society [AOFAS] score) and (2) the 10-point visual analog scale (VAS) score for pain. The secondary outcomes were differences in (1) postoperative anterior drawer and talar tilt, (2) surgical time and complication rate, and (3) time to return to sports and weightbearing. RESULTS: A total of 408 patients in 8 studies met the inclusion criteria. Of these, 193 (47.3%) patients underwent open surgery, while 215 (52.7%) patients underwent arthroscopic surgery. There were significant differences between the open and arthroscopic repair groups in mean 6-month AOFAS scores (82.4 vs 92.25, respectively; mean difference [MD], 11.36; 95% CI, 0.14-2.56; I 2 = 90%; P = .03), 1-year AOFAS scores (80.05 vs 88.6; MD, -11.96; 95% CI, -21.26 to -2.76; I 2 = 82%; P = .01), 6-month VAS scores (1.7 vs 1.4; MD, -0.38; 95% CI, -0.54 to -0.21; I 2 = 78%; P < .001), and 1-year VAS scores (2.05 vs 1.45; MD, 0.31; 95% CI, 0.09-0.54; I 2 = 0%; P < .001). The mean time to weightbearing was 14.25 and 9.0 weeks in the open and arthroscopic repair groups, respectively (MD, 1.89; 95% CI, 1.24-2.54; I 2 = 99%; P < .001). There were no statistically significant differences in the remaining outcomes evaluated. CONCLUSION: While technically more demanding, arthroscopic Broström was superior to open Broström-Gould surgery in postoperative AOFAS scores, VAS pain scores, and time to return to weightbearing. The operative time, complication rate, talar tilt, and anterior drawer tests were excellent and statistically comparable. Long-term clinical trials are required before recommending arthroscopic Broström as the new gold standard.

Conservative Management of Neglected Post-Traumatic Chronic Patellar Dislocation: A Case Report and Literature Review.

CASE: We present a case of a 44-year-old gentleman with a left post-traumatic chronic patellar dislocation that has been neglected and remained irreducible for 20 years. Our patient has maintained his full knee range of motion and has minimal symptoms and hence was treated nonoperatively. We also present a review of the rather scarce literature of similar cases and the decision-making process performed in our case to decide for nonoperative management. CONCLUSION: Early surgical management of this condition may not be warranted if the patient is able to perform high-demand physical activities. However, a later surgery may be indicated when/if his symptoms and/or function deteriorates.

Failure Rates of 5-Strand and 6-Strand vs Quadrupled Hamstring Autograft ACL Reconstruction: A Comparative Study of 413 Patients With a Minimum 2-Year Follow-up.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) with hamstring autograft has gained popularity. However, an unpredictably small graft diameter has been a drawback of this technique. Smaller graft diameter has been associated with increased risk of revision, and increasing the number of strands has been reported as a successful technique to increase the graft diameter. PURPOSE: To compare failure rates of 5-strand (5HS) and 6-strand (6HS) hamstring autograft compared with conventional 4-strand (4HS) hamstring autograft. We describe the technique in detail, supplemented by photographs and illustrations, to provide a reproducible technique to avoid the variable and often insufficient 4HS graft diameter reported in the literature. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We retrospectively reviewed prospectively collected data of all primary hamstring autograft ACLRs performed at our institution with a minimum 2-year follow-up and 8.0-mm graft diameter. A total of 413 consecutive knees met the study inclusion and exclusion criteria. The study population was divided into 5HS and 6HS groups as well as a 4HS control group. The primary outcome was failure of ACLR, defined as persistent or recurrent instability and/or revision ACLR. RESULTS: The analysis included 224, 156, and 33 knees in the 5HS, 6HS, and 4HS groups, respectively. The overall ACLR failure rate in this study was 11 cases (8%): 5 cases for 5HS, 3 cases for 6HS, and 3 cases for 4HS. No statistically significant differences were found among groups (P = .06). The mean graft diameter was 9 mm, and the mean follow-up was 44.27 months. CONCLUSION: The 5HS and 6HS constructs have similar failure rates to the conventional 4HS construct of 8.0-mm diameter and are therefore safe and reliable to increase the diameter of relatively smaller hamstring autografts. We strongly recommend using this technique when the length of the tendons permits to avoid failures reportedly associated with inadequate graft size.

Delayed Soft Tissue Necrosis in an Atypical Closed Calcaneal Fracture: A Case Report.

INTRODUCTION: Calcaneal fracture is the most common foot fracture. It occurs due to an axial load and is associated with high morbidity, especially when the articular surface is involved. There are two types of calcaneal fractures: Joint depression type and tongue type. The latter has a high risk of skin necrosis and should be operated on promptly. CASE REPORT: This is a 37-year-old Bangladeshi man who sustained a comminuted calcaneal fracture and a Lisfranc fracture of the left foot. Initial radiograph showed a joint depression-type fracture, excluding a surgical emergency. Nevertheless, the patient developed skin necrosis over the posterior aspect of the heal that improved after open reduction and internal fixation of the calcaneus. Pre-operative computed tomography (CT) scan demonstrated a bony fragment that was displaced posteriorly causing the skin necrosis. CONCLUSION: X-ray imaging is not sufficient to exclude surgical emergencies with calcaneal fractures. Highly comminuted fractures should be assessed more thoroughly with urgent CT scan.