Medical Malpractice Litigation Following Hindfoot Arthrodesis.

Given high patient expectations in the setting of complex surgeries, orthopedic surgeons are at risk of being subject to malpractice claims which can impose significant economic and psychological burden. This study investigates malpractice claims against orthopedic surgeons and podiatrists performing hindfoot arthrodesis and determine factors associated with plaintiff verdicts and settlements using the Westlaw legal database. The database was queried for all cases involving hindfoot arthrodesis using the terms "malpractice" and either "ankle fusion," "arthrodesis," "subtalar fusion," "tibiotalar fusion," "tibiotalocalcaneal fusion," "TTC fusion," or "tibiofibular fusion" from 1987 to 2023. Data regarding patient demographics, causes cited for litigation, case outcomes, and indemnity settlements were collected. Cases were excluded if the defendant was not an orthopedic surgeon or a podiatrist, the procedure involved was not a hindfoot arthrodesis, or if the patient was a minor. Forty-five cases of hindfoot arthrodesis met the inclusion criteria. The mean plaintiff age was 51.5 ± 13.8 years with 51.1% male. Thirty-three cases (73%) were in favor of the defendant, with an average inflation-adjusted payout of $853,863 (± 456,179). The most alleged category of negligence was procedural/intraoperative error (75%) followed by post-surgical error (38%) and failure to inform (31%). The most common specific damages included functional/ROM limitation (49%), need for additional surgery (47%), continuing/worsened pain (27%), and nonunion/malunion (29%). Given the frequency of hindfoot arthrodesis performed, this study highlights the importance of effective communication with patients concerning potential postoperative complications, prognosis of their injury, and risks and benefits associated with each treatment modality. Level of Evidence: Level III, Retrospective Cohort Study; Epidemiology Study.

Clinical outcomes of posterior tibial tendon sheath ultrasound-guided corticosteroid injections.

Objectives: The purpose of this study was to assess the safety of ultrasound-guided corticosteroid injections into the posterior tibial tendon sheath for posterior tibialis tendinopathy. Secondary outcomes include duration of pain relief, amount of pain relief, need for repeat injections and progression to surgery. Methods: We retrospectively reviewed all patients in our electronic medical record who underwent a posterior tibial tendon sheath (PTTS) steroid injection between 2015 and 2020 for the diagnosis of posterior tibial tendon dysfunction and/or posterior tibialis tendon insufficiency, and/or ankle pain. Demographic information was obtained from the patient record in addition to MRI data, clinical response to injection based on follow-up visits, number of total injections and progression to surgery. Thirty-eight posterior tibial tendon sheath ultrasound-guided injections were administered in 33 patients who met inclusion criteria during the 5-year study period. Results: Thirty-three patients were included in the study with a total of 38 injections performed. Eighteen of 38 (47%) injections yielded good or better pain relief. Seven of 33 patients (21%) progressed to surgery. There were no reported complications with the 38 performed injections. Conclusion: Ultrasound-guided corticosteroid injection into the posterior tibial tendon sheath is a safe nonoperative treatment modality for progressive collapsing foot deformity. The efficacy of the injection appears highly variable with 47% of injections yielding 'good' or better clinical results. When evaluating body mass index (BMI), obese patients (BMI ≥30.0) were found to have a more sustained response to injection (P = 0.029) and more pain relief (P = 0.049) than non-obese patients.

The impact of e-scooter injuries : a systematic review of 34 studies.

AIMS: Due to the recent rapid expansion of scooter sharing companies, there has been a dramatic increase in the number of electric scooter (e-scooter) injuries. Our purpose was to conduct a systematic review to characterize the demographic characteristics, most common injuries, and management of patients injured from electric scooters. METHODS: We searched PubMed, EMBASE, Scopus, and Web of Science databases using variations of the term "electric scooter". We excluded studies conducted prior to 2015, studies with a population of less than 50, case reports, and studies not focused on electric scooters. Data were analyzed using t-tests and p-values < 0.05 were considered significant. RESULTS: We studied 5,705 patients from 34 studies. The mean age was 33.3 years (SD 3.5), and 58.3% (n = 3,325) were male. The leading mechanism of injury was falling (n = 3,595, 74.4%). Injured patients were more likely to not wear a helmet (n = 2,114; 68.1%; p < 0.001). The most common type of injury incurred was bony injuries (n = 2,761, 39.2%), of which upper limb fractures dominated (n = 1,236, 44.8%). Head and neck injuries composed 22.2% (n = 1,565) of the reported injuries, including traumatic brain injuries (n = 455; 2.5%), lacerations/abrasions/contusions (n = 500; 7.1%), intracerebral brain haemorrhages (n = 131; 1.9%), and concussions (n = 255; 3.2%). Standard radiographs comprised most images (n = 2,153; 57.7%). Most patients were treated and released without admission (n = 2,895; 54.5%), and 17.2% (n = 911) of injured patients required surgery. Qualitative analyses of the cost of injury revealed that any intoxication was associated with higher billing costs. CONCLUSION: The leading injuries from e-scooters are upper limb fractures. Falling was the leading mechanism of injury, and most patients did not wear a helmet. Future research should focus on injury characterization, treatment, and cost.Cite this article: Bone Jt Open 2022;3(9):674-683.

Assessment of Basic Ankle Arthroscopy Skills in Orthopedic Trainees.

BACKGROUND: There is increasing emphasis on assessing resident competency, but little has been published on how to best evaluate trainee competency for ankle arthroscopy. The purpose of this study was to validate an objective model for assessing basic ankle arthroscopy knowledge and operative skills on a cadaveric ankle. METHODS: The Diagnostic Ankle Arthroscopy Skills Scoring System was adapted from previously validated assessment tools for knee arthroscopy. The scoring system included (1) an oral questionnaire (0-23 points), (2) an operative task-specific checklist (0-19 points), and (3) a global operative skills rating (12-60 points). Thirty-three trainees consisting of orthopedic residents and medical students performed a diagnostic ankle arthroscopy on a cadaveric ankle and were assessed by a single observer, while a subset were tested by 2 evaluators to determine interobserver reliability. RESULTS: There was strong correlation between educational level and scores on the global operative skills rating scale (r = 0.967, P < .0001), task-specific checklist (r = 0.815, P < .815), and oral questionnaire (r = 0.896, P < .0001). The global operative skills scores significantly improved with training level, and the largest difference was between medical students and senior residents. The most notable year-to-year increases in skill were between postgraduate year (PGY) 1 and 2 (P < .01) and between PGY2 and PGY3 (P < .05). Oral questionnaire and task-specific checklists were significantly lower for medical students than PGY1 residents (P < .001). There was also significant improvement in the oral questionnaire between senior and junior residents (P < .05). There was a moderate correlation between number of self-reported ankle arthroscopy cases and scores on the global operative skills score (r = 0.7019, P < .0001). Interobserver reliability was high for the global operative skills scores (interclass correlation coefficient = 0.89). CONCLUSION: The study revealed a valid measure to objectively assess trainees' ankle arthroscopy clinical knowledge and operative skills in a bioskills laboratory. CLINICAL RELEVANCE: This tool should enable residency programs to evaluate competency and track individual trainee progress over time.

Flexor Hallucis Longus Transfer Improves Achilles Tendon Load to Failure in Surgery for Non-Insertional Tendinopathy: A Biomechanical Study.

BACKGROUND: Non-insertional Achilles tendinopathy is a common disorder that may be treated with surgical debridement. A flexor hallucis longus (FHL) transfer is recommended if debridement of ≥50% is performed; however, there are no biomechanical data to support this. The purpose of this study was to assess the added biomechanical strength provided by an FHL transfer with incrementally sized non-insertional Achilles tendon defects. METHODS: Thirty matched-pair below-the-knee cadaveric specimens (n = 60) (mean age at the time of donor death, 67 years; range, 36 to 74 years) were obtained and randomly divided into 3 groups according to whether the defect was 25%, 50%, or 75% of the tendon width. One specimen of each pair was then randomly selected to undergo FHL transfer using interference screw fixation. All specimens then underwent cyclic loading of 100 N, and elongation of the medial and lateral limbs of the tendon defect was recorded. The constructs were then loaded to failure to measure stiffness, ultimate strength, and peak elongation before failure. RESULTS: The specimens with a 75% defect had significantly less elongation of the medial and lateral tendon-defect limbs when an FHL transfer had been done (p < 0.05). Ultimate load to failure was significantly increased in all groups (by 242 to 270 N depending on the defect size) following FHL transfer. Failures usually occurred through the tendon defect in the 75% and 50% defect groups, whereas all failures occurred at the Achilles tendon insertion when a 25% defect had been created. No significant differences were found in peak elongation with the addition of an FHL transfer. FHL augmentation resulted in significantly greater stiffness in the 25% and 75% defect groups (p < 0.05). CONCLUSIONS: This study showed that an FHL transfer significantly increased load to failure of Achilles tendons with a non-insertional defect involving 25%, 50%, and 75% of the tendon width. The mechanism of failure was usually through the defect in the specimens with a 50% or 75% defect, supporting the use of FHL augmentation with debridement of ≥50%. CLINICAL RELEVANCE: The present study supports the mechanical concept that FHL transfer is indicated when debridement of the Achilles tendon is ≥50%.

Radiographic results after hallux metatarsophalangeal joint arthrodesis for hallux varus.

BACKGROUND: Hallux metatarsophalangeal (MP) joint arthrodesis for hallux varus is generally reserved for severe deformity, failed surgery or the development of osteoarthritis. The purpose of this study was to determine the radiologic results of arthrodesis of the hallux MP joint following treatment for hallux varus. Our hypothesis was that in the process of correcting the hallux valgus angle, the 1-2 intermetatarsal angle (1-2 IMA) and hallux valgus angle (HVA) will be improved due to correction of the deforming forces. METHODS: A retrospective review was performed on 26 patients with 29 feet that had symptomatic hallux varus deformities treated with arthrodesis of the hallux MP joint between September 1, 2002, and December 31, 2012. The 1-2 IMA and HVA were measured on the preoperative and most recent postoperative films and compared. Twenty-nine patients were followed with postoperative weight-bearing radiographs. Two were men and 24 were women. Twelve were performed on the right foot, 17 on the left, including 3 bilateral cases. Fourteen patients had concomitant procedures on the ipsilateral forefoot. RESULTS: The average 1-2 IMA changed from 4.8 degrees to 8.4 degrees, a difference of 3.6 degrees (P < .05), and the average HVA changed from -20.7 degrees to 8.1 degrees (P < .05). CONCLUSION: Our study showed that a hallux MP joint arthrodesis in patients with hallux varus resulted in a predictable increase in the 1-2 IMA. LEVEL OF EVIDENCE: Level IV, case series.

Graft fixation is highest with anatomic tunnel positioning in acromioclavicular reconstruction.

PURPOSE: The purposes were to determine the bone density at specific bone tunnel locations in the clavicle and to determine ultimate load to failure of a graft fixed with an interference screw at specific areas. METHODS: Bone mass densitometry was tested at 5-mm intervals from the lateral to the medial end of 11 clavicles (mean age, 70.0 ± 17.7 years). Tunnels were drilled in 10-mm increments from the lateral edge, and tenodesis screws were used to fix semitendinosus grafts in the tunnel. Grafts were cyclically loaded, followed by load to failure. RESULTS: The bone mineral density (BMD) of the cadaveric clavicles increased from lateral (0.304 ± 0.078 g/cm(2) at 10 mm) to medial (0.760 ± 0.103 g/cm(2) at 50 mm). Load to failure increased from lateral to medial, and most specimens failed by tendon pullout. The load was 125.3 ± 42.5 N at the most lateral tunnel and 349.3 ± 120.3 N at the most medial tunnel. The Pearson correlation coefficient was 0.653 between tunnel position and load to failure, 0.659 between bone density and load to failure, and 0.803 between tunnel position and bone density. These all showed strong correlation. CONCLUSIONS: BMD shows that optimal bone density is found in the anatomic insertion area of the coracoclavicular ligaments between 20 mm and 50 mm from the lateral end of the clavicle. Low BMD correlated with decreased load to failure. CLINICAL RELEVANCE: Failure at the lateral bone tunnel in coracoclavicular ligament reconstruction may be a result of poor bone quality. When one is drilling bone tunnels for this surgery, consideration should be given to both anatomic position and bone quality.

Outcomes and practical information for patients choosing nonoperative treatment for distal biceps ruptures.

The goal of this study was to evaluate the outcomes of patients selecting nonoperative treatment for distal biceps tendon ruptures to provide information to patients and caregivers to consider in decision making. Five men conservatively treated for distal biceps tendon rupture between November 2002 and December 2006 were compared to 5 age-matched controls treated operatively. Outcomes at 4.5 years included supination strength, range of motion, and American Shoulder and Elbow Surgeons (ASES) score. Two groups of 9 normal volunteers--1 young group averaging 30.7 years and 1 older group averaging 48.8 years--served as controls. In nonoperative patients, elbow supination strength in the injured arm was 4.14 Nm (SD 0.94) and in the uninjured arm was 4.91 Nm (SD 0.65). In operative patients, supination strength was 4.25+/-1.08 Nm in the operatively repaired arm and 5.74+/-1.27 Nm in the uninjured arm. Age-matched normal patients had supination strength of 5.78+/-1.46 Nm in the dominant arm and 5.59+/-1.32 Nm in the nondominant arm. The ASES score averaged 89.57, with 3 patients reporting pain, compared to a score of 87.5 in the operative patients. Patients choosing conservative treatment for distal biceps ruptures have residual pain and weakness approximately double that seen between normal dominant and non-dominant extremities.

Management of the failed AC joint reconstruction: causation and treatment.

With recent studies showing improved biomechanical behavior of anatomic acromioclavicular joint reconstructions, these techniques are more frequently being performed. With both the more historic methods of fixation such as coracoacromial ligament transfer along with the newer anatomic reconstruction, potential for failure exists. However, there is a paucity of literature addressing these failures and possible treatment options. The purpose of this review is to report cases of failed reconstructions, describe failure mechanisms, and propose treatment options.

Strain pattern comparison of double- and single-bundle anterior cruciate ligament reconstruction techniques with the native anterior cruciate ligament.

PURPOSE: The purpose of this study was to dynamically assess the native strain patterns of the anteromedial bundle (AMB) and posterolateral bundle (PLB) of the anterior cruciate ligament (ACL) and compare these findings with graft bundle strain patterns after double-bundle (DB) ACL reconstruction with tibial fixation under 40 N of tension at 75 degrees knee flexion (AMB) and under 20 N of tension at 20 degrees knee flexion (PLB) and after single-bundle (SB) reconstruction with tibial fixation under 40 N of tension at 20 degrees knee flexion. METHODS: The mean strain pattern of the AMB and PLB of the native ACL of 4 cadaveric knees was measured via differential variable reluctance transducers and 2-dimensional kinematic analysis during passive manual knee flexion-extension under a constant axial compression load. Measurements were repeated after DB and SB ACL reconstruction. Celeration line assessments with a split-middle technique were performed to quantify percent strain/knee flexion-extension angle change at reciprocating bundle function transition points. RESULTS: The DB ACL reconstruction technique displayed reciprocating AMB and PLB strain patterns that more closely replicated those of the native ACL. The SB ACL reconstruction technique tended to replicate AMB strain patterns, suggesting poor bundle function differentiation. CONCLUSIONS: The DB ACL reconstruction with differential AMB and PLB tensioning more closely replicated native ACL strain patterns than the SB ACL reconstruction. The SB ACL reconstruction that we used closely simulated native ACL AMB strain patterns; however, PLB function was not restored. CLINICAL RELEVANCE: The DB ACL reconstruction more closely replicated the AMB and PLB strain patterns of the native ACL.