Talar Osteolytic Lesion as the Initial Presentation of Terminal Primary Metastatic Adenocarcinoma: A Case Report.

The purpose of this case report is to present an osseous foot lesion as the initial presentation of advanced metastatic adenocarcinoma. A 65-year-old female presented with 5 months of atraumatic left ankle pain. Initial radiographs and computed tomography scan showed a lytic lesion in the talar dome and calcaneus. Further workup and evaluation revealed diffuse metastatic disease in the lung, abdomen, and brain. A biopsy of the talar lesion demonstrated metastatic adenocarcinoma, and the patient elected to transition to hospice care less than 2 months after initial diagnosis. Although exceedingly rare, metastatic disease should be included in the differential for any lesion in the distal extremities including the foot and ankle. Unfortunately, these patients may have widespread metastases and poor prognosis at the time of initial presentation. This case report describes an acrometastasis of a primary adenocarcinoma and highlights the importance of considering metastatic disease in the differential of foot and ankle lesions. Delay in recognition and diagnosis of metastatic disease may have devastating consequences, and physicians could benefit from a high index of suspicion when treating these patients.

Depression, Suicidal Thoughts, and Burnout Among Physicians During the COVID-19 Pandemic: a Survey-Based Cross-Sectional Study.

OBJECTIVES: Frontline workers have been a bulwark in the fight against COVID-19, while being subject to major unexpected stressors. These include conflicting news, evolving guidelines, perceived inadequate personal protective equipment, overflow of patients with rising death counts, absence of disaster training, and limitations in the implementation of social distancing. This study investigates the incidence and associated factors of depression, suicidal thoughts, and burnout among physicians during the COVID-19 pandemic. METHODS: In a cross-sectional survey-based study of resident, fellow, and attending physicians from a tertiary university hospital during the height of the COVID-19 pandemic in New York from April 24 to May 15, 2020, demographics and practice specialty, attending vs. resident/fellow status, call frequency, emotional exhaustion, depersonalization, and depression severity were examined. RESULTS: Two hundred twenty-five subjects completed the survey (response rate of 16.3%), with rates of 6.2% depression, 6.6% suicidal ideation, and 19.6% burnout. Depression, suicidal ideation, and burnout were all associated with history of prior depression/anxiety and frequency of on call. Suicidal ideation and burnout were also associated with younger age. There was no difference in rates of depression, suicidal ideation, or burnout between attending and resident physicians. Female physicians reported less work-life balance and more burnout. CONCLUSIONS: These findings highlight the importance of considering physician mental health during times of peak stress, such as natural or man-made disasters. The prominence of premorbid depression/anxiety as a relevant factor underscores the need to further understand physician mental health and provide early screening and treatment.

In vivo evaluation of human patellar tendon microstructure and microcirculation with diffusion MRI.

BACKGROUND: Patellar tendon (PT) microstructure integrity and microcirculation status play a crucial role in the progression of tendinopathy and tendon repair. PURPOSE: To assess the feasibility and robustness of stimulated-echo based diffusion-weighted MRI with readout-segmented echo-planar imaging (ste-RS-EPI) for noninvasive assessment of microstructure and microcirculation of human PT. STUDY TYPE: Prospective. SUBJECTS: Fifteen healthy volunteers. FIELD STRENGTH/SEQUENCE: PT diffusion tensor imaging (DTI) and intravoxel incoherent motion (IVIM) were acquired with an ste-RS-EPI protocol on a 3T MRI scanner. ASSESSMENT: Subjects were positioned with their PT at the magic angle. DTI-derived parameters including axial diffusivity (AD), radial diffusivity (RD), mean diffusivity (MD), and fractional anisotropy (FA) were estimated with b-values of 0 and 800 s/mm2 and 12 diffusion directions. IVIM-derived parameters, f p , D* × f p , V b , and D* × V b were assessed in the central-third and the outer-two thirds of the PT with b-values of 0, 20, 30, 60, 80, 120, 200, 400, and 600 s/mm2 in three orthogonal directions. STATISTICAL TESTS: Paired t-tests were used to evaluate differences in IVIM parameters between the central-third and outer-two thirds regions of the patellar tendon. Paired t-tests and within-subject coefficient of variation were used to assess the intra- and intersession reproducibility of PT DTI and IVIM parameters. RESULTS: DTI parameters for healthy PT were 1.54 ± 0.09 × 10-3 mm2 /s, 1.01 ± 0.05 × 10-3 mm2 /s, 1.18 ± 0.06 × 10-3 mm2 /s, and 0.30 ± 0.04 for AD, RD, MD, and FA, respectively. Significantly higher (P < 0.05) IVIM parameters f p and D* × f p were observed in the outer-two thirds (6.1% ± 2.4% and 95.2 ± 49.6, respectively) compared with the central-third (3.8% ± 2.3% and 48.6 ± 35.2, respectively) of the PT. DATA CONCLUSION: Diffusion MRI of PT with an ste-RS-EPI protocol is clinically feasible. Both DTI- and IVIM-derived parameters of the PT demonstrated good test-retest reproducibility and interrater reliability. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2020;51:780-790.

Abbreviated quantitative UTE imaging in anterior cruciate ligament reconstruction.

BACKGROUND: Existing ultrashort echo time magnetic resonance imaging (UTE MRI) methods require prohibitively long acquisition times (~ 20-40 min) to quantitatively assess the clinically relevant fast decay T2* component in ligaments and tendons. The purpose of this study was to evaluate the feasibility and clinical translatability of a novel abbreviated quantitative UTE MRI paradigm for monitoring graft remodeling after anterior cruciate ligament (ACL) reconstruction. METHODS: Eight patients who had Graftlink™ hamstring autograft reconstruction were recruited for this prospective study. A 3D double-echo UTE sequence at 3.0 Tesla was performed at 3- and 6-months post-surgery. An abbreviated UTE MRI paradigm was established based on numerical simulations and in vivo validation from healthy knees. This proposed approach was used to assess the T2* for fast decay component ([Formula: see text]) and bound water signal fraction (fbw) of ACL graft in regions of interest drawn by a radiologist. RESULTS: Compared to the conventional bi-exponential model, the abbreviated UTE MRI paradigm achieved low relative estimation bias for [Formula: see text] and fbw over a range of clinically relevant values for ACL grafts. A decrease in [Formula: see text] of the intra-articular graft was observed in 7 of the 8 ACL reconstruction patients from 3- to 6-months (- 0.11 ± 0.16 ms, P = 0.10). Increases in [Formula: see text] and fbw from 3- to 6-months were observed in the tibial intra-bone graft ([Formula: see text]: 0.19 ± 0.18 ms, P < 0.05; Δfbw: 4% ± 4%, P < 0.05). Lower [Formula: see text] (- 0.09 ± 0.11 ms, P < 0.05) was observed at 3-months when comparing the intra-bone graft to the graft/bone interface in the femoral tunnel. The same comparisons at the 6-months also yielded relatively lower [Formula: see text] (- 0.09 ± 0.12 ms, P < 0.05). CONCLUSION: The proposed abbreviated 3D UTE MRI paradigm is capable of assessing the ACL graft remodeling process in a clinically translatable acquisition time. Longitudinal changes in [Formula: see text] and fbw of the ACL graft were observed.

Conjoined Tendon Transfer for Traumatic Anterior Glenohumeral Instability in Patients With Large Bony Defects and Anterior Capsulolabral Deficiency.

PURPOSE: To report outcomes of a conjoined tendon transfer procedure in a small case series of young active patients of various activity levels with recurrent traumatic anterior shoulder instability. METHODS: A retrospective chart review identified 10 consecutive patients who underwent conjoined tendon transfer (8 open and 2 arthroscopic) for anterior glenohumeral instability from January 2009 through December 2012. The indications were traumatic anterior shoulder instability with 25% or greater anterior glenoid bone loss, engaging Hill-Sachs lesion, or absent anterior-inferior labral tissue with anterior capsular tissue that did not readily hold sutures or a combination of these deficiencies. Patients did not undergo the procedure if they had healthy capsulolabral tissue and small bony defects or if they competed in high-level collision sports or were overhead throwers. The American Shoulder and Elbow Surgeons (ASES) questionnaire and a physical examination were completed preoperatively. Postoperatively, patients answered questions about shoulder stability and completed ASES and Western Ontario Shoulder Index questionnaires. A physical examination was performed postoperatively to assess range of motion. RESULTS: Of 10 patients, 9 were available for follow-up. The mean age was 33.0 years (range, 18-51 years) at the time of surgery. Eight of nine patients underwent a physical examination at 31.3 ± 10.5 months (range, 24-58 months) postoperatively. There were no revisions or complications except for recurrent instability in 1 patient who underwent the arthroscopic procedure and reported gross deviation from the postoperative protocol. The ASES score improved significantly (62.8 ± 21.2 at baseline vs 89.2 ± 11.5 at final follow-up, P = .01). The postoperative Western Ontario Shoulder Index score was 74.5 ± 19.7. No significant change was found in external rotation in 90° of abduction (80.6° ± 12.9° at baseline vs 88.4° ± 6.1° at final follow-up, P = .11) or in flexion (145.6° ± 14.9° at baseline vs 153.1° ± 16.4° at final follow-up, P = .19). All patients returned to their previous activity level. CONCLUSIONS: Stability was restored and no significant range-of-motion loss was observed in noncollision athletes who underwent conjoined tendon transfer. Recurrent instability occurred in 1 patient who underwent the arthroscopic procedure. There were no other complications. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Increased Complications in Obese Patients Undergoing Direct Anterior Total Hip Arthroplasty.

The direct anterior (DA) approach for total hip arthroplasty (THA) has demonstrated successful short term outcomes in several studies. However, there is no consensus about which patients are appropriate candidates for DA total hip arthroplasty. It is also unclear if short term outcomes in obese patients undergoing THA through a DA approach are elevated in comparison to non-obese patients. The purpose of this study was to evaluate complication rates and short term outcomes of obese, pre-obese, and normal body mass index (BMI) patients undergoing THA with a DA approach in a consecutive group of patients. This study was a retrospective review of 210 consecutive patients who underwent unilateral THA through a DA approach for osteoarthritis or avascular necrosis during the early peri-operative period. The study included 61 patients with normal BMI, 70 pre-obese patients, and 79 obese patients according to World Health Organization (WHO) classification (49 class I obese, 22 class II obese, and 8 class III obese patients). Patient charts were reviewed to determine differences in surgical time, length of stay, disposition, major complications, wound complications, and short term outcome measures. When comparing normal and pre-obese patients (BMI <30) to a combined group of WHO class I, II, and III obese patients (BMI >30), the obese group demonstrated increased surgical times by 12.7 minutes (P<0.0001), as well as increased length of stay (P=0.0303), narcotic use (P=0.0037), and assistive device use at two weeks (P<0.0030). In addition, major complications and wound complications were both significantly increased in the obese group (odds ratio [OR], 8.8; P=0.0493 and OR, 3.6; P=0.0431, respectively). There was also a trend toward increased use of rehabilitation facilities in the obese group at disposition, 15.4% vs 7.6% (P=0.0774). This study demonstrates that obese patients undergoing a DA approach have a 8.8 and 3.6 times increase in major and wound complications, respectively, compared to patients with a BMI <30. Obese patients also demonstrated significant increases in operative time, use of narcotics, use of assistive devices, and length of stay. There was a trend toward higher use of rehabilitation placement. While significant, these findings are similar to complication rates in the literature for other THA operative approaches. This study further defines the risks associated with performing THA on obese patients regardless of approach.

Early outcome comparison between the direct anterior approach and the mini-incision posterior approach for primary total hip arthroplasty: 150 consecutive cases.

This study evaluated early postoperative results of 150 consecutive primary total hip arthroplasties performed by a single surgeon; 50 from mini-incision posterior approach, 50 during the learning curve for the direct anterior approach, and 50 subsequent cases when the approach was routine. The anterior approach groups had significantly reduced hospital length of stays (2.9 and 2.7 days versus 3.9 days for the posterior group; P < 0.0001) and discharge to home versus rehab was more likely (80% and 84% in anterior groups, 56% in posterior group; P = 0.0028). In the anterior groups, there was significantly less use of assistive devices and narcotics at 6 weeks, and pain was significantly lower. Primary total hip arthroplasty using the anterior approach allows for superior recovery in a matched cohort of patients.

Tarsal Tunnel Syndrome Associated With a Bipartite Talus.

BACKGROUND: Talus bipartitus is a rare skeletal anomaly that may be mistaken for an os trigonum, a relatively common accessory ossicle found posterior to the talus. Both are believed to be formed similarly with the failed fusion of the talus with a second ossification center. Os trigonum is often diagnosed incidentally or found on radiographs obtained in symptomatic patients with signs of os trigonum syndrome, which presents with posterolateral ankle pain. A bipartite talus may also present with similar symptoms but may be differentiated through its articular involvement. CASE: In this article, we describe the rare presentation of tarsal tunnel syndrome in a patient caused by a bipartite talus. The patient underwent surgical decompression with the removal of the posterior fragment. CONCLUSION: A bipartite talus is a rare entity that may be mistaken for an os trigonum, a common accessory ossicle. In this article, we describe an outcome of a bipartite talus fragment removal due to tarsal tunnel syndrome and illustrate a rare pathological consequence of a bipartite talus. We further highlight the importance of early surgical management in patients presenting with an identifiable structure contributing to tibial nerve compression.

Demographic and Diagnostic Factors in Physical Therapy Attendance.

Introduction Physical therapy (PT) is an effective nonoperative treatment for various orthopedic diagnoses. However, patients may have many reasons to dismiss PT, including favoring another intervention for their injury, time constraints, transportation, and cost. This dismissal of PT may contribute to inadequate patient compliance. This study aimed to elucidate patient compliance with a basic PT prescription and whether PT led to subjective injury improvement. Methods This is a retrospective study of patients observed in Stony Brook Orthopedic clinics from 08/01/2022 to 12/23/2022. Patients prescribed PT received a phone call six weeks after the PT prescription. The primary outcome was patient attendance at PT. Secondary outcomes were subjective; symptomatic improvement was listed as better, worse, or the same. Chi-square testing was used to compare outcomes. Results A total of 100 patients were enrolled in the study. Patients prescribed PT following surgery were more likely to attend compared to patients prescribed PT as a primary treatment (P value=0.027). The association between attendance at PT and a change in subjective symptoms (better, worse, same) was not significant. Patients' age, sex, and chronicity of injury were not significant factors in PT attendance. Of the 40 patients who did not attend PT, 14 cited time constraints, 11 utilized self-directed treatment, three cited insurance, two cited transportation, and 10 cited other reasons. Conclusions Overall, postoperative patients were more likely to attend PT compared to patients prescribed PT as a primary treatment. Factors such as age, sex, and chronicity of injury did not affect whether a patient attended PT. Of the patients enrolled, 71% stated subjective improvement in symptoms, but there was no association between symptoms and PT attendance. This study highlights the characteristics of those patient factors that may influence PT compliance and underscores the importance of further research into the population most likely to attend and benefit from PT.

Chronic Steroid Use Does Not Increase the Risk of Superficial Surgical Site Infection or Wound Dehiscence Following Total Ankle Arthroplasty.

Introduction Total ankle arthroplasty (TAA) is an effective treatment for end-stage ankle arthritis. Recent surgical and technological advances have led to a significant increase in the surgical volume of TAA. While a majority of ankle arthritis is post-traumatic in nature, other causes include autoimmune or inflammatory conditions. Medical management of these conditions frequently requires chronic corticosteroid administration, which is a well-established risk factor for complications following surgery. The purpose of this study was to investigate the association between chronic preoperative steroid use and postoperative complications following TAA. Methods The American College of Surgeons National Surgical Quality Improvement (NSQIP) database was analyzed to identify all patients who underwent TAA between 2015 and 2020. Patient characteristics including demographics, comorbidities, surgical characteristics, and 30-day postoperative complication data were collected. The data was analyzed using bivariate and multivariate logistic regression to identify all postoperative complications associated with chronic preoperative steroid use. Results A total of 1,606 patients were included in this study: 1,533 (95.5%) were included in the non-steroid cohort, and 73 (4.5%) were included in the chronic steroid cohort. Chronic steroid use was significantly associated with female sex (p < 0.001) and American Society of Anesthesiologists (ASA) ≥3 (p < 0.001). Chronic steroid use was not associated with superficial surgical site infection (SSI) (p = 0.634) or wound dehiscence (p = 0.999). The postoperative complication that was significantly associated with chronic steroid use was sepsis (p = 0.031). After adjusting for female sex and the ASA grade, chronic steroid use was found to be independently associated with sepsis (p = 0.013). Conclusion Preoperative chronic steroid use is not associated with superficial SSI or wound dehiscence within 30 days following TAA. As TAA becomes a more attractive alternative to ankle arthrodesis, a better understanding of preoperative risk factors can aid in widening indications and knowing what patients are at risk for complications.

Closed Reduction and Percutaneous Pinning in Isolated Cuboid Dislocation Management: A Case Report.

Cuboid dislocations are a rare type of injury with few cases reported. A 41-year-old female came in for an assessment of her left foot, seeking evaluation 13 days post-injury. On inspection of the left lower extremity, we found swelling and ecchymosis throughout the midfoot. There was dimpling along the fourth/fifth tarsometatarsal (TMT) joint with palpable dorsal subluxation. A closed cuboid reduction with percutaneous pinning was performed 20 days after the initial injury. The cuboid was reduced with a combination of traction and direct pressure. One 1.6 mm Kirschner wire was passed from the fifth metatarsal across the TMT joint into the cuboid. At the 10-week follow-up appointment, she was ambulating with her boot and had successfully returned to work as a teacher. Radiographs demonstrated a maintained reduction of the dislocation and interval healing of the navicular and fourth metatarsal base fractures. Dislocations of the cuboid have only a handful of cases reported. They can occur in isolation or with other injuries of the midfoot. This patient was successfully treated with closed reduction and percutaneous pinning. Further studies are required to obtain a consensus on optimal treatment for these types of injuries.

Biomechanical Comparison of Krackow Repair and Percutaneous Achilles Repair System for Achilles Tendon Rupture Fixation: A Cadaveric and Finite Element Analysis Study.

Background: Open and percutaneous repair surgeries are widely used for the Achilles tendon rupture. However, prior biomechanic studies of these 2 approaches have mixed conclusions; therefore, we designed a cadaver and finite element (FE) model biomechanical study to compare the mechanical differences between the percutaneous Achilles repair system (PARS) and Krackow open repair under tensile load and rotation. Methods: Sixteen Achilles tendons were extracted from fresh-frozen cadaver ankles and the calcaneums were fixed in mortar. A force control dynamic tensile mechanical test was performed at 1 Hz with 30- and 100-N cyclic loads. Initial intact baseline testing was followed by an incision on all Achilles tendons, 4 cm from the calcaneus insertion, which were then repaired using the PARS (n = 8) or Krackow (n = 8) method. Recorded force-displacement values were used to calculate mechanical parameters, and statistical significance of differences was determined by unpaired (between repair techniques) and paired (intact vs repaired) t tests. Material properties of the Achilles tendon in the FE model were modified and a 10-Nm flexion was simulated for intact and surgical groups. Results: No differences were found between intact tendons assigned to PARS or Krackow repairs in Young's modulus (P = .582) and stiffness (P = .323). Pre- and postoperative Young's modulus was significantly decreased for both groups (Intact 230.60±100.76 MPa vs PARS 142.44±37.37 MPa, P < .012; Intact 207.46±81.12 MPa vs Krackow109.43±27.63 MPa, P < .002). Stiffness decreased significantly after surgery for both groups (Intact 25.33±10.89 N/mm vs PARS 6.51±1.68 N/mm, P < .003; Intact 20.30±8.65 N/mm vs Krackow 5.97±1.30 N/mm, P < .003). PARS ultimate tensile strength was significantly higher than the Krackow (PARS 280.29±47.32 N vs Krackow 196.97±54.28 N, P < .003) but not significantly different in the ultimate tensile strain. PARS had a significantly lower postoperative gap compared to Krackow (PARS 9.75±5.87 mm vs Krackow 25.19±7.72 mm, P < .001). FE analysis predicted an increased talocalcaneal contact pressure, maximum principal stress, and rotation in the Krackow vs PARS models, respectively. Conclusion: Biomechanical parameters observed in this study through mechanical testing and FE analysis favor the selection of PARS over the Krackow repair based on better strength, higher failure force, and lower gap generation.Clinical Relevance: The study has analyzed two Achilles tendon repair methods using cadaver and numerical estimation and may help clinicians gain insight into selection of tendon repair approaches to generate better clinical outcomes.

Full-thickness supraspinatus tears are associated with more synovial inflammation and tissue degeneration than partial-thickness tears.

BACKGROUND: The objective of this study was to determine whether the tear size of a supraspinatus tendon correlated with synovial inflammation and tendon degeneration in patients who underwent shoulder arthroscopy for rotator cuff repair. We hypothesized that increased synovial inflammation would correlate with greater tear size of the supraspinatus tendon at the time of surgery. MATERIALS AND METHODS: Tissue from the synovium, bursa, torn supraspinatus tendon, and subscapularis tendon was obtained from patients during shoulder arthroscopy to evaluate the messenger RNA expression of proinflammatory cytokines, tissue remodeling, and angiogenesis factors in the tendon, bursa, and synovium. Additional tissue was fixed to determine histologic changes including inflammation, vascular ingrowth, and collagen organization. RESULTS: Increased expression of interleukin 1ß, interleukin 6, cyclooxygenase 2, matrix metalloproteinase (MMP) 9, and vascular endothelial growth factor was found in the synovium of patients with full-thickness tears versus partial-thickness tears (P < .05). In the supraspinatus tendon, increased expression of MMP-1, MMP-9, MMP-13, and vascular endothelial growth factor was found in the full-thickness group. The upregulation of these genes in the full-thickness group was consistent with enhanced synovial inflammation, greater vascular ingrowth, and the loss of collagen organization in both supraspinatus and subscapularis tendons as determined by histology. CONCLUSION: Increased synovial inflammation and tissue degeneration correlate with the tear size of the supraspinatus tendon. A better understanding of the relationship between synovial inflammation and the progression of tendon degeneration can help in the design of novel and effective treatments to limit the advancement of rotator cuff disease and to improve their clinical outcomes.

Orthopaedic Surgeon Mental Health During the COVID-19 Pandemic.

Introduction: This study compares rates of depression, suicidal ideation, and burnout among resident/fellow and attending physicians in orthopaedic surgery to other specialties during height/end of the first wave of the coronavirus disease 2019 (COVID-19) pandemic at our institution. Main outcomes and measures included suicidal ideation, Patient Health Questionnaire for Depression (PHQ-9) scores for depression, and 2 single-item measures for emotional exhaustion and depersonalization. This study provides valuable information regarding orthopaedic surgeon mental health during world crises. Methods: This is a cross-sectional survey-based study of resident, fellow, and attending physicians from 26 specialties during and after the first wave of the COVID-19 pandemic at our institution from April 24, 2020 to May 15, 2020. The survey contained 22 items. This includes consent, demographics and general data, 2 single-item questions of emotional exhaustion and depersonalization, and the PHQ-9. Subjects were eligible if they were a resident/fellow or attending physician at our institution. Results: The response rate for the study was 16.31%. Across all specialties rates were 6.2% depression, 19.6% burnout, and 6.6% suicidal ideation. The results for orthopaedic surgeons are as follows: 0% tentative diagnosis of depression, 3.8% suicidal ideation, and 4% burnout. Anesthesiology had the highest rate of depression (14.3%). Internal medicine and other non-surgical specialties had the highest rate of suicidal ideation (10.2%). Orthopaedic surgeons were significantly more likely to achieve work-life balance and experience less burnout than anesthesiologists and pediatricians. Discussion: Depression, suicidal ideation, and burnout continue to affect physicians across all specialties. These issues are amplified in light of crisis. Job satisfaction and rigorous training may be protective factors that allow orthopaedic surgeons to adapt to novel clinical settings under stress when compared to anesthesiologists and pediatricians. Resilience training and stress management strategies should continue to be investigated to better prepare physicians for world crises.

Avulsion Fractures of the Calcaneal Tuberosity: A Single-Center Review of Outcomes and Complications.

OBJECTIVES: The goal of this investigation was to determine the incidence of complications and revision surgery after calcaneal tuberosity avulsion fractures, to describe experience with different fixation constructs, and to compare revision surgery rates between tuberosity and tongue-type fractures of the calcaneus. DESIGN: This was a retrospective study at a single level 1 trauma center between 2001 and 2019, including patients with calcaneal tuberosity avulsion fractures compared with patients with calcaneal tongue-type fractures. RESULTS: Twenty-nine tuberosity fractures (23 surgical and six nonsurgical) and 37 tongue-type fractures (29 surgical and eight nonsurgical) were treated during the study period. Revision surgery was more common in the tuberosity group (26% versus 7%, P = 0.013). In the tuberosity group, 35% experienced some degree of implant failure, with 13% catastrophic loss of reduction and 22% loss of initial reduction with eventual union. Fragment size and initial displacement were not associated with revision surgery. No patients with implant failure noted in the tongue-type group. DISCUSSION: Calcaneal tuberosity fractures showed significantly higher rate of revision surgery and failure of fixation compared with tongue-type fractures.

Open Achilles Tendon Rerupture: A Case Report and Review of the Literature.

In this report, we describe a rare case of open rerupture of an Achilles tendon following primary surgical repair. The rerupture occurred 12 weeks postoperatively and was associated with a transverse open wound perpendicular to the original surgical incision. This complication was successfully managed utilizing the preexisting transverse wound and a minimally invasive repair technique, minimizing further risk to the soft tissues overlying the tendon. This rare complication has only been described a few times in the literature and is likely associated with adhesions between the tendon repair and the subcutaneous tissues.

Variability in orthopedic surgeon treatment preferences for nondisplaced scaphoid fractures: A cross-sectional survey.

PURPOSE: The absence of a best practice treatment standard contributes to clinical variation in medicine. Often in the absence of evidence, a standard of care is developed and treatment protocols are implemented. The purpose of this study was to examine whether the standard of care for the treatment of nondisplaced scaphoid fractures is uniform among orthopedic surgeons. METHODS: A survey of orthopedic surgeons actively practicing in the US or abroad was conducted to elicit preferred treatment strategies for nondisplaced scaphoid fractures. The surgeons were recruited at orthopedic conferences, clinical visits, and via email. The survey included demographic questions along with a short clinical vignette. The option for fracture management included surgical versus nonsurgical treatment. For those who chose nonsurgical treatment, type/duration of immobilization was recorded. Cost analysis was performed to estimate direct and indirect costs of various treatment options. RESULTS: A total of 494 orthopedic surgeons completed the survey. The preference for surgical treatment was preferred in 13% of respondents. Hand/upper extremity specialists were significantly more likely to operate compared with generalists (p = 0.0002). Surgeons younger than forty-five were nearly twice as likely to choose surgery (p = 0.01). There was no clear consensus on duration of immobilization as 30% of surgeons chose 6 weeks, 33% selected 8 weeks, and 27% opted for 12 weeks. Total cost of surgery was 49% greater than that of nonoperative treatment. With each additional week of immobilization for nonoperative treatment, the total costs of surgical treatment near that of nonoperative treatment. CONCLUSION: There exist clear trends in how specific demographic groups choose to treat the nondisplaced scaphoid fracture. Whether these trends are the result of generational gaps or additional subspecialty training remains difficult to determine, but there is need to pursue a more consistent approach that benefits the patients and the health care system as a whole.

Lack of Agreement on Distal Radius Fracture Treatment.

INTRODUCTION: Variation in clinical practice resulting from the absence of evidence-based treatment protocols has negative implications on both the cost and the quality of medical care. The objective of this study was to assess whether a standard of care for the treatment of extra-articular nondisplaced distal radius fracture has developed despite the lack of a conclusive recommendation from the American Academy of Orthopaedic Surgeons. METHODS: A case-vignette survey was conducted. Treatment type and duration of casting selections were analyzed. The cost implications of responses were assessed. Participants were practicing orthopedists primarily in the mid-Atlantic region of the United States. Orthopedists (n = 494) were recruited via E-mail and at the American Academy of Orthopaedic Surgeons Annual Meeting held in Chicago in March 2013. Inclusion criteria required that participants be graduates of an accredited medical school and be practicing orthopedists at the time of survey distribution. The main outcome measure was surgical or nonsurgical intervention. RESULTS: Nonsurgical treatment was selected by 60% of respondents, with surgery preferred by 37%. Duration of casting responses varied from 2 to 12 weeks. Among nonsurgical responses, 69% indicated 6 weeks as their preferred duration of casting (95% confidence interval, 64.9-73.1%). Surgery imposes a 76% greater total cost to society than nonsurgical treatments. CONCLUSIONS: Our findings suggest the absence of a consensus strategy for the treatment of extra-articular nondisplaced distal radius fractures. Implications of variance in treatment on cost and quality support the need for established, evidence-based guidelines or further clinical trials to assist in the management of this common fracture.

Cost and value of spinal deformity surgery.

STUDY DESIGN: Literature review. OBJECTIVE: To assess (1) quality of life in patients with adult scoliosis who underwent nonoperative and/or surgical treatment, and (2) cost-effectiveness of different scoliosis treatment modalities. SUMMARY OF BACKGROUND DATA: Recently, there has been an interest in examining quality of life of patients undergoing treatment for adult scoliosis, comparing the value of nonoperative versus operative management. This article reviews the current literature on treatment of adult scoliosis, in the hopes of drawing conclusions for the best approach to these patients. METHODS: MEDLINE and PubMed databases were searched to identify articles. Health-related quality of life measures included Oswestry Disability Index scores, Scoliosis Research Society (SRS) instrument scores, 12-Item Short Form Health Survey, and numerical rating scale for leg and/or back pain. Studies included were those involving patients with adult scoliosis who underwent primary surgery or nonoperative management. The studies that focused on the change in validated outcome scores from the onset of the study to final follow-up were found to be valuable. Studies on predominantly adolescent scoliosis and those that only measured postoperative outcomes scores were excluded. RESULTS: The SRS-22, Oswestry Disability Index, 12-Item Short Form Health Survey, and numerical rating scale were found to be validated for measuring quality of life in patients with scoliosis. Thirteen studies were included, which evaluated changes in health-related quality of life outcomes from baseline in surgical and nonsurgical treatment of adult scoliosis. There was a trend toward improved quality of life measures in patients undergoing surgical treatment for adult scoliosis. CONCLUSION: Adults with painful and disabling scoliosis may benefit from surgical treatment compared with nonsurgical treatment, given the proper indications. Nonsurgical treatment does not seem to be cost-effective and has not shown to have a positive impact on quality of life, although there is a possibility that patients' health may have deteriorated if they did not receive the nonsurgical treatment. Future prospective studies focusing on the cost-effectiveness of adult scoliosis treatment and improvement of quality of life are needed to confirm the assertion of the current retrospective literature that surgery provides better quality of life than nonoperative treatment. LEVEL OF EVIDENCE: N/A.

Irreducible longitudinal distraction-dislocation of the hallux interphalangeal joint.

Although volar and dorsal dislocations have been described in the literature, dislocation of the hallux interphalangeal joint is a disorder rarely encountered by orthopedic and foot surgeons. In this article, we report a case of a distinct irreducible longitudinal distraction-dislocation that originally presented to the emergency department but required open reduction in the operating room. We also describe the presentation, anatomy, and treatment of this unique disorder.