Effect of Postoperative Immobilization Time on PROMIS Scores and Clinical outcomes in Ankle Fracture Patients.

Background: Ankle fractures are among the most common injuries treated by orthopaedic surgeons, yet little guidance exists in postoperative protocols for ankle fractures concerning time of immobilization. Here, we aim to investigate the association between early mobilization and patient-reported outcomes. Our null hypothesis was that no difference in Patient-Reported Outcomes Measurement Information System (PROMIS) scores would be identified in patients when comparing the effect of time of immobilization. Methods: A retrospective review identified ankle fractures that underwent surgical fixation between 2015 and 2020 at a level 1 trauma center and its associated facilities. One hundred nineteen patients from 9 providers met inclusion criteria for our final analysis. Forty-seven patients were immobilized for <6 weeks (early) and 68 patients were immobilized for ≥6 weeks (late). Our primary outcome measures included the PROMIS questionnaire, time of immobilization, and time to full weightbearing. Our secondary outcome measures included time to return to work, wound complications (infection, delayed healing), and complications associated with fracture fixation (loss of reduction, delayed union, reoperation, hardware failure). Repeated measures analysis of variance as well as linear mixed outcome regression were used to predict each of the PROMIS outcomes of anxiety, depression, physical function, and pain interference. Each model included the predictors of age, sex, race, body mass index (BMI), diabetes, rheumatoid arthritis, smoking status, payor, provider, time to radiographic union, time to return to work, time to full weightbearing, and early vs late immobilized groups. Results: We found no differences in PROMIS scores between mobilization groups even when controlling for possible confounders such as age, BMI, rheumatoid arthritis, smoking status, and diabetes mellitus (P > .05). Furthermore, we found no differences in complications associated with fracture fixation (P > .05). Across our cohort, lower physical function scores were associated with higher BMI, increasing age, and longer time to return to work/play (P < .05). Our analysis further showed that depression, anxiety, pain interference, and physical function levels improve as a function of time (P < .05). Higher BMI was also noted to have a significant impact on PROMIS depression and anxiety when controlling for other variables. African Americans had greater pain interference scores (P < .05). Conclusion: Our study suggests that early mobilization in a walker boot after operative treatment of ankle fractures is a safe alternative to casting in non-neuropathic patients. When considering operative treatment of ankle fractures, factors such as increasing age and BMI are likely to negatively affect postoperative anxiety, physical function, and depression PROMIS scores regardless of immobilization time. Level of Evidence: Level III, retrospective cohort study.

Does the Canadian Orthopaedic Foot and Ankle Society Postoperative COFAS End-Stage Ankle Arthritis Classification System Correlate With Pre- and Postoperative PROMIS Scores for Total Ankle Arthroplasty?

Background: Recently, the Canadian Orthopaedic Foot and Ankle Society (COFAS) proposed a classification system addressing adjunct procedures in the treatment for end-stage ankle arthritis. We reviewed Patient-Reported Outcome Measures Information System (PROMIS) data to determine if outcomes of total ankle arthroplasty (TAA) correlated with postoperative COFAS classification. We hypothesize that as COFAS classification increases, patients will demonstrate greater improvement in the change between pre- and postoperative PROMIS scores. Methods: From June 2015 to December 2018, a total of 127 patients underwent 132 TAA. Demographic factors and preoperative and most recent postoperative PROMIS scores were collected. Univariate, multivariate and post hoc analyses with a significance threshold of P <.05 were performed. Results: Eighty-seven patients with a mean follow-up of 13.6±7.3 months and complete PROMIS scores were classified into COFAS types 1-4. Significant differences were identified in the PROMIS Pain Interference domain comparing COFAS types 2 and 4 and COFAS types 3 and 4. These results demonstrate that more complex ankles with a higher COFAS score had worse interval improvement in PROMIS scores. Additionally, multivariate linear regression showed that age and BMI were associated with worse physical function and depression, whereas diabetes and a history of prior surgeries were associated with improved postoperative function. Conclusion: The COFAS postoperative classification system is useful for categorizing end-stage ankle arthritis. Further research into the ideal timing of surgery and higher-level studies to better determine TAA efficacy with different classification systems is warranted. This information can be helpful with preoperative counseling about treatment outcomes.Level of Evidence: Level IV, retrospective analysis of prospectively collected data.

Outcomes Following Repeat Ankle Arthroscopy and Microfracture for Osteochondral Lesions of the Talus.

BACKGROUND: The management of symptomatic osteochondral lesions of the talus (OLTs) previously treated with arthroscopy is controversial. Minimal data exist on the role for repeat arthroscopy. Here, we describe our experience with repeat arthroscopy and microfracture for symptomatic OLTs. METHODS: Our database was queried over an 8-year period to identify patients undergoing repeat arthroscopy and microfracture as treatment for symptomatic OLTs. Phone surveys were conducted to assess residual pain, patient satisfaction, and need for subsequent surgery. We compared patient outcomes based on the size of their OLT (small lesions ≤150 mm2, large >150 mm2) and the presence or absence of subchondral cysts. RESULTS: We identified 14 patients who underwent repeat arthroscopy and microfracture for symptomatic OLTs. Patients reported reasonable satisfaction (7.6 ± 3.5 out of 10) but moderate residual pain (4.7 ± 3.4 out of 10) at midterm follow-up (5.1 ± 2.9 years). In total, 21% (3/14) of patients had undergone subsequent surgery. Patients with small (n = 5) and large OLTs (n = 9) had similar postoperative pain scores (4.2 ± 4.1 vs 4.9 ± 3.2) and postoperative satisfaction levels (6.4 ± 4.9 vs 8.3 ± 2.5). CONCLUSION: At midterm follow-up, repeat arthroscopy for symptomatic OLTs demonstrated reasonable satisfaction but moderate residual pain. Lesion size or presence of subchondral cysts did not affect outcome, but our sample size was likely too small to detect statistically significant differences. These data show that repeat ankle arthroscopy can be performed safely with modest outcomes, and we hope that this report aids in managing patient expectations.Level of Evidence: Level IV Case Series.

Does the Preferred Study Source Impact Orthopedic In-Training Examination Performance?

OBJECTIVE: This study examines the role of electronic learning platforms for medical knowledge acquisition in orthopedic surgery residency training. This study hypothesizes that all methods of medical knowledge acquisition will achieve similar levels of improvement in medical knowledge as measured by change in orthopedic in-training examination (OITE) percentile scores. Our secondary hypothesis is that residents will equally value all study resources for usefulness in acquisition of medical knowledge, preparation for the OITE, and preparation for surgical practice. DESIGN: 9 ACGME accredited orthopedic surgery programs participated with 95% survey completion rate. Survey ranked sources of medical knowledge acquisition and study habits for OITE preparation. Survey results were compared to OITE percentile rank scores. PARTICIPANTS: 386 orthopedic surgery residents SETTING: 9 ACGME accredited orthopaedic surgery residency programs RESULTS: 82% of participants were utilizing online learning resources (Orthobullets, ResStudy, or JBJS Clinical Classroom) as primary sources of learning. All primary resources showed a primary positive change in OITE score from 2018 to 2019. No specific primary source improved performance more than any other sources. JBJS clinical classroom rated highest for improved medical knowledge and becoming a better surgeon while journal reading was rated highest for OITE preparation. Orthopedic surgery residents' expectation for OITE performance on the 2019 examination was a statistically significant predictor of their change (decrease, stay the same, improve) in OITE percentile scores (p<0.001). CONCLUSIONS: Our results showed that no specific preferred study source outperformed other sources. Significantly 82% of residents listed an online learning platform as their primary source which is a significant shift over the last decade. Further investigation into effectiveness of methodologies for electronic learning platforms in medical knowledge acquisition and in improving surgical competency is warranted.

When (Almost) Everyone is Above Average: A Critical Analysis of American Orthopaedic Association Committee of Residency Directors Standardized Letters of Recommendation.

The American Orthopaedic Association introduced standardized letters of recommendations (SLORs) to improve on traditional letters of recommendations by "providing a global prospective on an applicant." However, no study has defined the utilization of SLORs, the distribution of applicant ratings in SLORs, or the impact of sex, race, or degree of involvement between the letter writer and applicant on SLOR domain ratings. METHODS: One-hundred seventy-nine applications were randomly selected from all applicants submitted to a single, academic orthopaedic residency program. A single reviewer extracted both applicant characteristics and SLOR characteristics from applications. Descriptive statistics, chi-square tests, and nonparametric one-way analysis of variance analysis were conducted. RESULTS: Six hundred twenty-eight letters of recommendation from 179 applicants were analyzed. Four hundred ninety-seven of 628 (79.1%) letters contained a SLOR. Mean percentile ratings were calculated for all the following domains: patient care (mean ± SD = 86.7 ± 8.7), medical knowledge (87.2 ± 8.6), interpersonal and communication (87.7 ± 9.3), procedural (86.6 ± 8.9), research (88.9 ± 9.0), ability to work within a team (89.6 ± 8.4), professionalism (90.8 ± 7.3), initiative and drive (90.6 ± 7.6), and commitment to orthopaedic surgery (91.1 ± 6.7). Forty-eight percent of applicants were indicated as "ranked to guarantee match." When compared with male applicants, female applicants demonstrated higher percentile ratings in patient care (88.6 ± 8.2 vs. 86.3 ± 8.7, p = 0.010), interpersonal and communication skills (90.6 ± 7.3 vs. 86.9 ± 9.6, p < 0.001), and ability to work within a team (91.3 ± 6.3 vs. 89.2 ± 8.8, p = 0.045). Higher United States Medical Licensing Examination step 1 (r = 0.08, p = 0.05) and step 2 scores (r = 0.10, p = 0.02) correlated with higher medical knowledge ratings. The number of publications (r = 0.3, p < 0.001) and presentations (r = 0.25, p < 0.001) correlated with research ratings. CONCLUSION: SLORs demonstrated a profound ceiling effect, potentially limiting the utility of the instrument for the comparison of applicants. Future modifications to this instrument may include measures to better delineate between applicants.

Outcome of Lesser Metatarsophalangeal Joint Interpositional Arthroplasty With Tendon Allograft.

BACKGROUND: Lesser toe metatarsal head degeneration and collapse can cause significant pain and disability. In the setting of global metatarsal head collapse, there are limited operative options. The purpose of our study was to evaluate clinical and radiographic outcomes after lesser toe metatarsophalangeal (MTP) joint interpositional arthroplasty with a tendon allograft and to describe the operative technique. METHODS: We retrospectively reviewed a consecutive series of patients treated by 3 fellowship-trained foot and ankle surgeons at one institution. We created a phone survey to evaluate satisfaction, pain, and likelihood to repeat the surgery. Foot and Ankle Ability Measure (FAAM) scores were reviewed before and after surgery. Preoperative and postoperative radiographs were evaluated for preservation of metatarsal length. The procedure was performed through a dorsal midline approach. The metatarsal head was reamed to a concave shape. A tendon allograft was fashioned into a ball and secured to the metatarsal with an anchor. Fifteen feet in 14 patients underwent lesser MTP joint interposition arthroplasty, with the average age of 49 years (range, 24-69), and an average follow-up of 4.2 years. RESULTS: Eighty percent (12/15) reported they would have the procedure again. Visual analog scale pain scores showed a decrease in pain from 7 to 1. FAAM sports subscale improved from 56% to 85%. Radiographically, the ratio of the affected metatarsal length to the adjacent metatarsal remained constant before and after surgery, suggesting preservation of the metatarsal cascade. CONCLUSION: Interpositional arthroplasty of the lesser MTP joints with a rolled tendon allograft provided a unique solution, as it allows the surgeon to fill a large void without harvesting an autograft. This study showed improved patient-reported outcomes, high patient satisfaction, and good radiographic outcomes. Lesser metatarsophalangeal joint allograft interposition arthroplasty was a viable solution as a salvage procedure in the setting of global metatarsal head collapse. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Skeletal Muscle Regeneration in Advanced Diabetic Peripheral Neuropathy.

BACKGROUND: Decreased lean muscle mass in the lower extremity in diabetic peripheral neuropathy (DPN) is thought to contribute to altered joint loading, immobility, and disability. However, the mechanism behind this loss is unknown and could derive from a reduction in size of myofibers (atrophy), destruction of myofibers (degeneration), or both. Degenerative changes require participation of muscle stem (satellite) cells to regenerate lost myofibers and restore lean mass. Determining the degenerative state and residual regenerative capacity of DPN muscle will inform the utility of regeneration-targeted therapeutic strategies. METHODS: Biopsies were acquired from 2 muscles in 12 individuals with and without diabetic neuropathy undergoing below-knee amputation surgery. Biopsies were subdivided for histological analysis, transcriptional profiling, and satellite cell isolation and culture. RESULTS: Histological analysis revealed evidence of ongoing degeneration and regeneration in DPN muscles. Transcriptional profiling supports these findings, indicating significant upregulation of regeneration-related pathways. However, regeneration appeared to be limited in samples exhibiting the most severe structural pathology as only extremely small, immature regenerated myofibers were found. Immunostaining for satellite cells revealed a significant decrease in their relative frequency only in the subset with severe pathology. Similarly, a reduction in fusion in cultured satellite cells in this group suggests impairment in regenerative capacity in severe DPN pathology. CONCLUSION: DPN muscle exhibited features of degeneration with attempted regeneration. In the most severely pathological muscle samples, regeneration appeared to be stymied and our data suggest that this may be partly due to intrinsic dysfunction of the satellite cell pool in addition to extrinsic structural pathology (eg, nerve damage). CLINICAL RELEVANCE: Restoration of DPN muscle function for improved mobility and physical activity is a goal of surgical and rehabilitation clinicians. Identifying myofiber degeneration and compromised regeneration as contributors to dysfunction suggests that adjuvant cell-based therapies may improve clinical outcomes.

Late Effects of Clubfoot Deformity in Adolescent and Young Adult Patients Whose Initial Treatment Was an Extensive Soft-tissue Release: Topic Review and Clinical Case Series.

Children with congenital clubfoot often have residual deformity, pain, and limited function in adolescence and young adulthood. These patients represent a heterogeneous group that often requires an individualized management strategy. This article reviews the available literature on this topic while proposing a descriptive classification system based on a review of patients at our institution who underwent surgery for problems related to previous clubfoot deformity during the period between January 1999 and January 2012. Seventy-two patients (93 feet) underwent surgical treatment for the late effects of clubfoot deformity at an average age of 13 years (range 9 to 19 years). All patients had been treated at a young age with serial casting, and most had at least one previous surgery on the affected foot or feet. Five common patterns of pathology identified were as follows: undercorrection, overcorrection, dorsal bunion, anterior ankle impingement, and lateral hindfoot impingement. Management pathways for each group of the presenting problems is described. To our knowledge, this topic review represents the largest report of adolescent and young adult patients with residual clubfoot deformity in the literature.

Preoperative Anxiety Effect on Patient-Reported Outcomes Following Foot and Ankle Surgery.

BACKGROUND: Preoperative emotional distress has been shown to negatively influence joint arthroplasty and spine surgery, but limited data exist for foot and ankle outcomes. Emotional distress can be captured through modern tools like the Patient-Reported Outcomes Instrument Measurement System (PROMIS) anxiety domain. We hypothesized that patients with greater preoperative PROMIS anxiety scores would report greater pain and less function after foot and ankle surgery than patients with lower preoperative anxiety levels. METHODS: Elective foot and ankle surgeries from May 2016 to December 2017 were retrospectively identified. PROMIS anxiety, pain interference (PI), and physical function (PF) scores were collected before and after surgery. Patients were grouped based on preoperative PROMIS scores greater or less than 59.4. A cutoff of PROMIS anxiety above 59.4 was selected as the threshold that corresponds to traditional measures of anxiety. RESULTS: Compared to patients with less preoperative anxiety (average: 47.2, n=146), patients with higher preoperative anxiety (average: 63.9, n=59) had greater preoperative pain (PROMIS PI: 63.5 vs 59.1, P < .001) and lower physical function (PROMIS PF: 37.9 vs 42.0, P = .001). Postoperatively, patients with higher preoperative anxiety had more residual pain and greater functional disability as compared to patients with less preoperative emotional distress (PROMIS PI: 58.6 vs 52.9, P < .001; PROMIS PF: 39.8 vs 44.4, P < .001; respectively). CONCLUSION: Our evidence showed that preoperative emotional anxiety predicted worse pain and function at early operative follow-up. Measures of preoperative anxiety could be useful in identifying patients at risk for poorer operative outcomes, but continued study is necessary. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Patient-Reported Allergies Do Not Predict Poorer PROMIS Function, Pain, and Depression Scores Following Foot and Ankle Surgery.

BACKGROUND: Identifying preoperative risk factors that may portend poorer operative outcomes remains a topic of current interest. In hip and knee arthroplasty patients, the presence of patient-reported allergies (PRAs) has been associated with worse pain and function after joint replacement. However, these results have not been replicated across studies, including in shoulder arthroplasty cases. The impact of PRAs on foot and ankle outcomes has yet to be studied. The purpose of our study was to evaluate whether PRAs influence patient-reported outcome in foot and ankle surgery. METHODS: To determine if PRAs are linked to poorer operative outcomes, we retrospectively identified 159 patients who underwent elective foot and ankle surgery. PRA data were obtained via chart review, and patient-reported outcomes were assessed preoperatively and postoperatively via multiple domains, including Patient Reported Outcome Measurement Information System (PROMIS) physical function, pain interference, and depression measures. Consistent with prior methodology, we compared outcome measures (preoperative, postoperative, and the change in outcome scores) between patients without self-reported allergies to patients with at least 1 PRA. RESULTS: There were 159 patients studied; 79 patients had no allergies listed, and 80 patients had at least 1 PRA. Of the 80 patients with at least 1 PRA, there were a total of 170 possible allergies. There were no differences in preoperative, postoperative, or the change in outcome scores for all PROMIS measures (physical function, pain interference, and depression; P > .05) between patients with at least 1 PRA and those patients without any listed PRAs. CONCLUSIONS: We were unable to prove our hypothesis that PRAs were linked to poorer patient-reported outcomes following foot and ankle surgery. Closer review of the published reports linking PRAs to worse total joint arthroplasty outcomes revealed data that, while statistically significant, are likely not clinically relevant. Our negative findings, then, may in fact parallel prior studies on hip, knee, and shoulder arthroplasty patients. The presence of PRAs does not appear to be a risk factor for suboptimal outcomes in foot and ankle surgery. LEVEL OF EVIDENCE: Level III, comparative series.

Rheumatoid Forefoot Reconstruction in the Nonrheumatoid Patient.

BACKGROUND: Recurrent pain and deformity following forefoot surgery can cause significant patient disability. In patients with rheumatoid arthritis, first metatarsophalangeal (MTP) joint arthrodesis with lesser metatarsal head resections-termed the rheumatoid forefoot reconstruction-has been shown to be a reliable operation for pain relief and deformity correction. Limited data, however, have been published on outcomes of the same forefoot reconstruction operation in the nonrheumatoid patient. Here, we describe our experience with this procedure in patients without rheumatoid disease, hypothesizing improved clinical and radiographic outcomes following surgery. METHODS: Following chart review and reviewing billing codes, we retrospectively identified patients without a diagnosis of rheumatoid arthritis who underwent first MTP arthrodesis with lesser metatarsal head resections. Phone surveys were conducted to assess clinical outcomes including pain and patient satisfaction. Preoperative and postoperative radiographs were reviewed for 1, 2 intermetatarsal angle (IMA), hallux valgus angle (HVA), second MTP angle (MTP-2), and lesser MTP alignment (in both sagittal and axial planes). Postoperative radiographs were assessed for radiographic union. We identified 14 nonrheumatoid patients (16 feet) who underwent forefoot reconstruction. Of those, 13 patients (15 feet) were successfully contacted via follow-up phone survey at an average of 44.3 months postoperatively (range: 20-76 months). RESULTS: Mean postoperative satisfaction scores were 9.0 (out of 10). No patients required reoperation at final phone follow-up. Pain scores significantly decreased from 6.2 preoperatively to 1.9 postoperatively ( P <.001). Radiographic parameters (1,2 IMA, HVA, MTP-2, and lesser MTP alignment in the sagittal plane) improved with surgery ( P <.05), and all 16 feet achieved union of the first MTP arthrodesis. CONCLUSION: With decreased pain, high satisfaction rates, and improved radiographic parameters, first MTP arthrodesis coupled with lesser metatarsal head resection was a viable option for nonrheumatoid patients who failed prior attempts at forefoot reconstruction or have chronic forefoot pain with deformity. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Clinical and Operative Factors Related to Successful Revision Arthrodesis in the Foot and Ankle.

BACKGROUND: Arthrodesis is a common operative procedure used to manage arthritis and deformity in the foot and ankle. Nonunion is a possible and undesirable outcome in any arthrodesis surgery. Rates of nonunion in the foot and ankle literature range from 0% to 47% depending on the patient population and joint involved. Multiple factors can contribute to developing a nonunion including location, fixation method, tobacco use, diabetes, infection, and others. METHODS: The case logs of 3 foot and ankle surgeons were reviewed from January 2007 to September 2014 to identify nonunion arthrodesis revision cases. The patient factors reviewed included diabetes, inflammatory arthropathy, tobacco use, history of infection, nonunion elsewhere, neuropathy, Charcot arthropathy, posttraumatic arthritis, and prior attempt at revision arthrodesis at the same site. Operative records were reviewed to identify location of the nonunion, instrumention, use of allograft or autograft bone, use of iliac crest bone marrow aspirate (ICBMA) and use of orthobiologics such as bone morphogenetic protein (BMP) during the revision arthrodesis. Successful revision was defined as radiographic union on the final radiograph during follow-up. Eighty-two cases of revision arthrodesis were identified with an average follow-up of 16 months. RESULTS: The overall nonunion rate was 23%. Neuropathy and prior attempts at revision were identified as significant risks (P <.05) for persistent nonunion. Odds ratio calculated based on previous attempts at revision arthrodesis found a 2.8-fold increase in the risk of failure for each attempt at revision. CONCLUSION: Revision arthrodesis for nonunion in the foot and ankle was successful (77%) under a variety of patient and operative conditions. Neuropathy was a significant patient risk factor for persistent nonunions, and we believe it is important to identify even in the nondiabetic patient. As the number of attempts at revisions increases, there is a subsequent 3-fold increase in the risk of persistent nonunion. LEVEL OF EVIDENCE: Level IV, case series.

Arterial Anatomy of the Posterior Tibial Nerve in the Tarsal Tunnel.

BACKGROUND: Both vascular and compression etiologies have been proposed as the source of neurologic symptoms in tarsal tunnel syndrome. Advancing the understanding of the arterial anatomy supplying the posterior tibial nerve (PTN) and its branches may provide insight into the cause of tarsal tunnel symptoms. The purpose of this study was to describe the arterial anatomy of the PTN and its branches. METHODS: Sixty adult cadaveric lower extremities (thirty previously frozen and thirty fresh specimens) were amputated distal to the knee. The vascular supply to the PTN and its branches was identified, measured, and described macroscopically (the thirty previously frozen specimens, prepared using a formerly described debridement technique) and microscopically (the thirty fresh specimens, processed using the Spälteholz technique). RESULTS: On both macroscopic and microscopic evaluation, the PTN and the medial and lateral plantar nerves were observed to have multiple entering vessels within the tarsal tunnel. On microscopic evaluation, a vessel was observed to enter the nerve at the bifurcation of the PTN into the medial and lateral plantar nerves in twenty-two (73%) of the thirty specimens. There was a significant difference (p < 0.05) in vascular density between the PTN and each of its branches. CONCLUSIONS: The abundant blood supply to the PTN and its branches identified in this study is consistent with observations of other peripheral nerves. This rich vascular network may render the PTN and its branches susceptible to nerve compression related to vascular congestion. The combination of vascular and structural compression may also elicit neurologic symptoms. CLINICAL RELEVANCE: Advancing the understanding of the arterial anatomy supplying the PTN and its branches may provide insight into the cause and treatment of tarsal tunnel syndrome.

Correlation of Clinical, Operative, and Histopathologic Diagnosis of Interdigital Neuroma and the Cost of Routine Diagnosis.

BACKGROUND: Diagnosis of an interdigital neuroma (IDN) is clinically based on patient symptoms. During operative excision, it is common to send the excised specimen for routine histopathologic examination. The purpose of this study was to evaluate the accuracy of the clinical and intraoperative diagnosis of IDN and correlate these with the histopathologic results of IDN. METHODS: Case logs of 3 fellowship-trained foot and ankle surgeons were reviewed to identify all neuroma excisions completed between 1997 and 2014. Charts were reviewed to identify the preoperative clinical diagnosis and intraoperative diagnosis as well as concern for pathology besides a neuroma. All results were compared to final histopathology to identify instances of discordance between diagnoses. A total of 123 patients with 133 neuromas were identified. RESULTS: Of the total 133 neuromas, 5 cases included a clinical or intraoperative concern for a diagnosis other than neuroma. In these 5 instances surgeons accurately identified cysts and rheumatoid nodules. 132 of 133 histopathology reports indicated the presence of nerve tissue in their report. There were no reports of malignancy or abnormal nerve tissue. There were no changes to the postoperative protocol based on histopathology. CONCLUSION: The clinical, intraoperative, and histopathologic diagnosis of neuroma was in concordance 100% of the time. With a high level of clinical and intraoperative acumen in identifying a neuroma, we believe it is reasonable not to submit the specimen for histopathologic evaluation. In addition, limiting the amount of routine histopathologic evaluation could have saved approximately $480 per case. LEVEL OF EVIDENCE: Level IV, case series.

Outcomes of the Bridle Procedure for the Treatment of Foot Drop.

BACKGROUND: The purpose of this study was to determine the clinical outcomes and objective measures of function that can be expected for patients following the Bridle procedure (modification of the posterior tibial tendon transfer) for the treatment of foot drop. METHODS: Nineteen patients treated with a Bridle procedure and 10 matched controls were evaluated. The Bridle group had preoperative and 2-year postoperative radiographic foot alignment measurements and completion of the Foot and Ankle Ability Measure. At follow-up, both groups were tested for standing balance (star excursion test) and for ankle plantarflexion and dorsiflexion isokinetic strength, and the American Orthopaedic Foot & Ankle Society and Stanmore outcome measures were collected only on the Bridle patients. RESULTS: There was no change in radiographic foot alignment from pre- to postoperative measurement. Foot and Ankle Ability Measure subscales of activities of daily living and sport, American Orthopaedic Foot & Ankle Society, and Stanmore scores were all reduced in Bridle patients as compared with controls. Single-limb standing-balance reaching distance in the anterolateral and posterolateral directions were reduced in Bridle participants as compared with controls (P < .03). Isokinetic ankle dorsiflexion and plantarflexion strength was lower in Bridle participants (2 ± 4 ft·lb, 44 ± 16 ft·lb) as compared with controls (18 ± 13 ft·lb, 65 ± 27 ft·lb, P < .02, respectively). All Bridle participants reported excellent to good outcomes and would repeat the operation. No patient wore an ankle-foot orthosis for everyday activities. CONCLUSION: The Bridle procedure was a successful surgery that did not restore normal strength and balance to the foot and ankle but allowed individuals with foot drop and a functional tibialis posterior muscle to have significantly improved outcomes and discontinue the use of an ankle-foot orthosis. In addition, there was no indication that loss of the normal function of the tibialis posterior muscle resulted in change in foot alignment 2 years after surgery. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Relative mortality in U.S. Medicare beneficiaries with Parkinson disease and hip and pelvic fractures.

BACKGROUND: Parkinson disease is a neurodegenerative disease that affects gait and postural stability, resulting in an increased risk of falling. The purpose of this study was to estimate mortality associated with demographic factors after hip or pelvic (hip/pelvic) fracture in people with Parkinson disease. A secondary goal was to compare the mortality associated with Parkinson disease to that associated with other common medical conditions in patients with hip/pelvic fracture. METHODS: This was a retrospective observational cohort study of 1,980,401 elderly Medicare beneficiaries diagnosed with hip/pelvic fracture from 2000 to 2005 who were identified with use of the Beneficiary Annual Summary File. The race/ethnicity distribution of the sample was white (93.2%), black (3.8%), Hispanic (1.2%), and Asian (0.6%). Individuals with Parkinson disease (131,215) were identified with use of outpatient and carrier claims. Cox proportional hazards models were used to estimate the risk of death associated with demographic and clinical variables and to compare mortality after hip/pelvic fracture between patients with Parkinson disease and those with other medical conditions associated with high mortality after hip/pelvic fracture, after adjustment for race/ethnicity, sex, age, and modified Charlson comorbidity score. RESULTS: Among those with Parkinson disease, women had lower mortality after hip/pelvic fracture than men (adjusted hazard ratio [HR] = 0.63, 95% confidence interval [CI]) = 0.62 to 0.64), after adjustment for covariates. Compared with whites, blacks had a higher (HR = 1.12, 95% CI = 1.09 to 1.16) and Hispanics had a lower (HR = 0.87, 95% CI = 0.81 to 0.95) mortality, after adjustment for covariates. Overall, the adjusted mortality rate after hip/pelvic fracture in individuals with Parkinson disease (HR = 2.41, 95% CI = 2.37 to 2.46) was substantially elevated compared with those without the disease, a finding similar to the increased mortality associated with a diagnosis of dementia (HR = 2.73, 95% CI = 2.68 to 2.79), kidney disease (HR = 2.66, 95% CI = 2.60 to 2.72), and chronic obstructive pulmonary disease (HR = 2.48, 95% CI = 2.43 to 2.53). CONCLUSIONS: Mortality after hip/pelvic fracture in Parkinson disease varies according to demographic factors. Mortality after hip/pelvic fracture is substantially increased among those with Parkinson disease.

Variables associated with return to sport following anterior cruciate ligament reconstruction: a systematic review.

BACKGROUND: As one of the purposes of anterior cruciate ligament reconstruction (ACLR) is to return athletes to their preinjury activity level, it is critical to understand variables influencing return to sport. Associations between return to sport and variables representing knee impairment, function and psychological status have not been well studied in athletes following ACLR. PURPOSE: The purpose of this review was to summarise the literature reporting on variables proposed to be associated with return to sport following ACLR. STUDY DESIGN: Systematic review. METHODS: Medline, EMBASE, CINAHL and Cochrane databases were searched for articles published before November 2012. Articles included in this review met these criteria: (1) included patients with primary ACLR, (2) reported at least one knee impairment, function or psychological measure, (3) reported a return to sport measure and (4) analysed the relationship between the measure and return to sport. RESULTS: Weak evidence existed in 16 articles suggesting variables associated with return to sport included higher quadriceps strength, less effusion, less pain, greater tibial rotation, higher Marx Activity score, higher athletic confidence, higher preoperative knee self-efficacy, lower kinesiophobia and higher preoperative self-motivation. CONCLUSIONS: Weak evidence supports an association between knee impairment, functional and psychological variables and return to sport. Current return to sport guidelines should be updated to reflect all variables associated with return to sport. Utilising evidence-based return to sport guidelines following ACLR may ensure that athletes are physically and psychologically capable of sports participation, which may reduce reinjury rates and the need for subsequent surgery.

Short-term radiographic analysis of operative correction of adult acquired flatfoot deformity.

BACKGROUND: Multiple procedures have been described to treat stage II (flexible) deformities driven by the clinical presence of "mild" versus "severe" deformity. The purpose of this study was to identify the radiographic correction after bony realignment procedures and to compare preoperative measures with postoperative measures to better understand the clinical application of these procedures. METHODS: Seventy-two feet in 68 patients treated for stage II deformity between January 1999 and December 2010 were available for retrospective chart review. The average age of the patients was 55 years, and final radiographs were evaluated at an average of 9 months postoperatively. All patients had a flexor digitorum longus transfer to the navicular and bony realignment. Radiographic parameters measured included lateral talus-first metatarsal angle, medial cuneiform-floor distance, calcaneal pitch, anteroposterior talus-second metatarsal angle, and talonavicular coverage angle. Differences in pre- and postoperative measurements and between group comparisons were analyzed. RESULTS: Three patient groups were identified: medial displacement calcaneal osteotomy (group 1), lateral column lengthening (group 2), and both medial displacement calcaneal osteotomy and lateral column lengthening (group 3). The lateral talus-first metatarsal angle mean difference was 5.1 degrees in group 1, 16.2 degrees in group 2, and 16.5 degrees in group 3. The talonavicular coverage angle mean difference was 5.7 degrees in group 1, 24.2 degrees in group 2, and 19.4 degrees in group 3. Changes in pre- to postoperative measures were statistically significant for all groups for the parameters measured. The pairwise group comparison revealed a statistically significant difference in the correction obtained in group 3 compared with that of group 1. CONCLUSION: Clinical and radiographic parameters are a consideration when choosing bony realignment procedures to reconstruct a flexible flatfoot deformity. In the treatment of more severe deformities, lateral column lengthening resulted in a greater radiographic improvement in alignment. A medial displacement osteotomy alone is also a valuable tool to correct these deformities although it provided a different level of correction compared with the lateral column lengthening. LEVEL OF EVIDENCE: Level III, comparative case series.

Vascular anatomy of the tibiofibular syndesmosis.

BACKGROUND: Injuries to the tibiofibular syndesmosis commonly cause prolonged ankle pain and disability. Syndesmotic injuries are associated with slower healing rates compared with rates for other ankle ligament injuries and typically result in longer time away from sports. To our knowledge, the vascular supply to the syndesmosis and its clinical implication have not previously been studied. The purpose of this study was to describe the vascular supply to the tibiofibular syndesmosis with use of a method of chemical debridement of cadaveric specimens. METHODS: Twenty-five matched pairs of adult cadaver legs, fifty legs total, were amputated below the knee. India ink, followed by Ward Blue Latex, was injected into the anterior tibial, peroneal, and posterior tibial arteries under constant manual pressure to elucidate the vascular supply of the ankle syndesmotic ligaments. Chemical debridement was performed with 6.0% sodium hypochlorite to remove soft tissue, leaving bones, ligaments, and casts of the vascular anatomy intact. The vascular supply to the syndesmosis was evaluated and recorded. RESULTS: The anterior vascularity of the syndesmosis was clearly visualized in forty-three of fifty specimens. The peroneal artery supplied an anterior branch (the perforating branch) that perforated the interosseous membrane, an average of 3 cm proximal to the ankle joint. This branch provided the primary vascular supply to the anterior ligaments in twenty-seven specimens (63%). The anterior tibial artery provided additional contribution to the anterior ligaments in the remaining sixteen specimens (37%). CONCLUSIONS: The location of the perforating branch of the peroneal artery places it at risk when injury to the syndesmosis extends to the interosseous membrane 3 cm proximal to the ankle joint. In the majority of specimens, injury to this vessel would result in loss of the primary blood supply to the anterior ligaments.

Lower extremity-specific measures of disability and outcomes in orthopaedic surgery.

Outcome measures may be simple questions or complex measures that assess multiple interrelated domains affecting treatment outcomes. Outcome measures should be relevant to patients, easy to use, reliable, valid, and responsive to clinical changes. Joint and disease-specific outcome measures have been developed for the hip, knee, and foot and ankle. Many of these measures would benefit from further research into their validity, reliability, and optimal applicability. General health measures and activity level scores should be included in outcome assessments after treatment for orthopaedic conditions.