Financial Literacy in Orthopaedic Surgery Residents: A COERG Survey.

INTRODUCTION: Financial literacy is the individual ability and skill to make informed decisions in the management of resources within the financial marketplace to yield a lifetime of financial well-being. Residents across several subspecialties have demonstrated low levels of financial literacy, and it is thought that more financial education is needed during residency training. The purpose of this study is to perform a comprehensive evaluation on financial literacy and financial attitudes of orthopaedic surgery residents. The authors hypothesize that orthopaedic residents will have low levels of financial literacy and financial satisfaction. METHODS: A 46-question anonymous survey was administered through COERG (Collaborative Orthopaedic Educational Research Group) to 1028 orthopaedic surgery residents of all postgraduate year at 43 programs with broad national distribution. Resident demographics and survey responses regarding knowledge of finance and investment topics, application of financial principles, and personal financial status were compared. RESULTS: The survey response rate was 48% (494/1028). The average financial literacy score of all orthopaedic resident participants was 60.9% (±16.5%). A total of 35.5% of orthopaedic residents were satisfied with their current financial situation. Saving for retirement and lower loan burdens correlated with greater financial satisfaction in financial situation. Scores were higher in orthopaedic residents with greater childhood annual household income, no credit card debt, higher levels of parent education, and active retirement savings plans. CONCLUSIONS: Orthopaedic residents show significant deficits in overall financial and investment knowledge combined with a dissatisfaction with financial situations while in residency. Orthopaedic residency programs have the opportunity to implement program-sponsored training and financial resources to enhance the resident education experience.

Suture Anchor-Enhanced Medial Capsulorrhaphy of the Great Toe.

The suture anchor-enhanced medial capsulorrhaphy of the great toe is utilized as an adjuvant procedure to proximal and distal osteotomies for the treatment of hallux valgus. In traditional open techniques, hallux valgus repair requires both osseous correction along with shortening of the capsule on the medial side of the metatarsophalangeal joint. Osseous correction typically corrects the intermetatarsal angle, whereas capsular correction maintains the hallux valgus angle1. Description: A standard medial approach to the 1st metatarsophalangeal joint is performed. A medial midline horizontal capsulotomy is performed starting just proximal to the medial eminence and extending distally to the base of the proximal phalanx. Once the concomitant osseous and soft-tissue procedures are completed, a vertical capsulotomy is made in the inferior capsular flap at the level of the metatarsophalangeal joint in a manner perpendicular to the first ray in order to form an L shape. A 3 to 4-mm wedge of capsule is formed near the base of the vertical limb, running obliquely to the horizontal limb, and is excised. Optionally, the free limbs of the inferior capsule are imbricated. A unicortical hole is then drilled in the first metatarsal head, and a 2.7-mm outer diameter by 7-mm deep suture anchor with 2-0 FiberWire (Arthrex) is placed. The free ends of the suture are then utilized to close the horizontal capsulotomy in a running-locking interrupted fashion. Fluoroscopic imaging is performed throughout the procedure to prevent overcorrection and varus malignment. Alternatives: Alternative treatments include L-shaped capsulorrhaphy without suture anchor augmentation, dorsolinear capsulorrhaphy, Y-shaped capsulorrhaphy, and proximal hallux osteotomy or distal hallux osteotomy without capsulorrhaphy. Rationale: Anchor-enhanced capsulorrhaphy has been proven to assist in early maintenance of hallux valgus angle correction when combined with relevant distal osteotomy techniques. The anchor-enhanced capsulorrhaphy has an advantage over traditional capsulorrhaphy methods because it allows enhanced tightening of the capsule to the bone and, therefore, the potential for enhanced short-term maintenance. Additionally, the use of a running-locking interrupted suture technique reduces the number of suture knots required for capsular closure, potentially reducing the chance of complications such as suture granuloma formation. This technique is useful in all patients with hallux valgus deformity because it helps to provide durable deformity correction through additional modification of the soft tissues surrounding the 1st metatarsophalangeal joint. Expected Outcomes: Medial capsulorrhaphy has been shown to help with short-term reduction of the hallux valgus angle, both with and without the use of suture anchors1-3. Gould et al. demonstrated the superiority of adding suture anchors to the L-shaped medial capsulorrhaphy in order to aid in prevention of early postoperative relapse of the valgus deformity in patients undergoing chevron or modified McBride osteotomy1. We have utilized this suture anchor-enhanced capsulorrhaphy technique as an adjuvant procedure in most patients receiving osteotomies or Lapidus procedures for hallux valgus correction with consistent, reproducible results. In our experience, the suture anchor-enhanced medial capsulorrhaphy is an effective and time-efficient adjunctive soft-tissue corrective procedure in hallux valgus patients. Important Tips: Always excise a small capsular wedge to start with.Throughout the capsular tightening process, utilize clinical judgment and fluoroscopy to avoid pulling the hallux into varus malalignment.If varus is noted during plication of the plantar capsule, simply undo the tightening stitch.Because the majority of capsular tightening occurs at the first distal knot during the running horizontal capsular closure, if varus is noted, untie the knot and proceed with less correction.The extra cost of the suture anchor is a drawback but should be weighed against the enhanced durability of capsular correction compared with a traditional capsulorrhaphy.Always check the position of the suture anchor under fluoroscopy before proceeding with capsular closure in order to ensure proper deployment and adequate osseous purchase.Suture anchor failure can cause misleading radiographic presentation or joint impingement. Acronyms and Abbreviations: VAS = Visual analog scaleAOFAS = American Orthopaedic Foot & Ankle SocietyHV = Hallux valgusHVA = Hallux valgus angleMTP = Metatarsophalangeal jointDVT = Deep venous thrombosis.

Civilian Ballistic Tibia Shaft Fractures Compared With Blunt Tibia Shaft Fractures: Open or Closed?

OBJECTIVES: To identify a group of ballistic tibia fractures, report the outcomes of these fractures, and compare them with both closed and open tibia fractures sustained by blunt mechanisms. We hypothesized that ballistic tibia fractures and blunt open fractures would have similar outcomes. DESIGN: Retrospective cohort study. SETTING: A single Level-1 trauma center. PATIENTS/PARTICIPANTS: Adult patients presenting with ballistic (44), blunt closed (179), or blunt open (179) tibia fractures. INTERVENTION: Intramedullary stabilization of tibia fracture. MAIN OUTCOMES: Unplanned reoperation, soft tissue reconstruction, nonunion, compartment syndrome, and fracture-related infection. RESULTS: Compared with the blunt closed group, the ballistic fracture group required more operations (P < 0.01), had a higher occurrence of soft tissue reconstruction (P < 0.01), and higher incidence of compartment syndrome (P = 0.02). Ballistic and blunt closed groups did not significantly differ in rates of unplanned reoperation (P = 0.67), nonunion (11.4% vs. 4.5%, P = 0.08), or deep infection (9.1% vs. 5.6%, P = 0.49). In comparison to the blunt open group, the ballistic group required a similar number of operations (P = 0.12), had similar rates of unplanned reoperation (P = 0.10), soft tissue reconstruction (P = 0.56), nonunion (11.4% vs. 17.9%, P = 0.49), and fracture-related infection (9.1% vs. 10.1%, P = 1.0) but a higher incidence of compartment syndrome (15.9% vs. 5.0%, P = 0.02). CONCLUSIONS: Ballistic tibia fractures require more surgeries and have higher rates of soft tissue reconstruction than blunt closed fractures and seem to have outcomes similar to lower severity open fractures. We found a significantly higher rate of compartment syndrome in ballistic tibia fractures than both open and closed blunt fractures. When treating ballistic tibia fractures, surgeons should maintain a high level of suspicion for the development of compartment syndrome and counsel patients that ballistic tibia fractures seem to behave like an intermediate category between closed and open fractures sustained through blunt mechanisms. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Distal clavicle autograft for anterior-inferior glenoid augmentation: A comparative cadaveric anatomic study.

INTRODUCTION: The aim of this study was to anatomically compare distal clavicle and coracoid autografts and their potential to augment anterior-inferior glenoid bone loss. METHODS: Ten millimeters of distal clavicle and 20 mm of coracoid were harvested bilaterally from 32 cadavers. Length, weight, and height were measured and surface area and density were calculated. For each graft, ipsilateral measurements were compared and the ability to restore corresponding glenoid bone loss was calculated. RESULTS: Distal clavicle grafts were larger than coracoid grafts with respect to length (22.3 mm versus 17.7 mm; p < 0.001), height (12.49 mm versus 9.65 mm; p < 0.001), mass (2.72 g versus 2.45 g; p = 0.0437), and volume (2.36 cm3 versus 1.96 cm3; p = 0.002). Coracoid grafts had larger widths (14.56 mm versus 10.52 mm; p < 0.001) and greater density (1.24 g/cm3 versus 1.18 g/cm3; p < 0.001). Distal clavicle surface area was greater on both the articular (2.93 cm2 versus 1.5 cm2; p < 0.001) and superior surfaces (2.76 cm2 versus 1.5 cm2; p < 0.001) when compared to lateral coracoid surface area. DISCUSSION: Distal clavicle grafts were larger and restored larger bony defects but had greater variability and lower density than coracoid grafts. Clinical studies are needed to compare these graft options.

A Novel Technique in Treatment of Calcaneocuboid Dislocation with Bifurcate Ligament Reconstruction Using a Semitendinosus Allograft: A Case Report.

CASE: A 19-year-old woman sustained a plantar flexion-inversion injury to her right ankle after a low-speed motor vehicle collision. Clinical examination demonstrated supinated, adducted deformity of the foot, and prominent calcaneus laterally. Radiographs revealed dislocation of the calcaneocuboid joint, a rare injury, which was successfully stabilized by a novel technique using a hamstring allograft. The presentations and clinical and surgical management of this rare condition are discussed. CONCLUSION: We present a technique that has shown good long-term results in a young patient with recurrent calcaneocuboid joint dislocations. Our novel ligament reconstruction technique using a semitendinosus allograft seems to be a promising treatment option in young patients with unstable calcaneocuboid joints.

A comparison of union rates and complications between single screw and double screw fixation of sliding calcaneal osteotomy.

BACKGROUND: The number of screws used for sliding calcaneal osteotomy fixation has not been examined in the literature. The purpose of this paper is to examine this topic. METHODS: Retrospective chart review was performed on 190 patients who met selection criteria. We compared complication risk for single versus double screw, headed versus headless screw, and short versus longitudinal incision cases. RESULTS: The mean age was 48.4 (18-83) years and average follow up was 28 (12-150) weeks. All cases achieved radiographic union. Overall complication rate was 19.5% (37/190). Risk of complication did not differ significantly between single and double screw (RR: 1.170; 95% CI: 0.66-2.09; p=0.594) or short and extended incision groups (RR: 0.868; 95% CI: 0.42-1.80; p=0.704). Risk of complication differed significantly between headed and headless screw fixation (RR: 5.558; 95% CI: 2.69-11.50; p<0.0001). CONCLUSIONS: Single screw fixation of sliding calcaneal osteotomy achieves similar outcomes as double screw fixation. Headless screws are advantageous for minimizing hardware pain and subsequent hardware removal.

The success rate of first metatarsophalangeal joint lateral soft tissue release through a medial transarticular approach: A cadaveric study.

BACKGROUND: The objective of this study was to evaluate the success rate of first metatarsophalangeal joint (MTPJ) lateral soft tissue release through a medial transarticular approach. METHODS: Ten cadaveric specimens were used (6 females/4 males, mean age, 73.4years). Lateral release was performed through a 4cm medial approach using a number 15 blade. Surgical aim was to release four specific structures: lateral capsule, lateral collateral ligament (LCL), adductor hallucis tendon (AHT) and lateral metatarsosesamoid suspensory ligament (LMSL). Once completed, a dissection of the first intermetatarsal space was performed. Success rate was graded in accordance to the number of structures successfully released: 0% (no structures), 25% (1/4), 50% (2/4), 75% (3/4) and 100% (4/4). Inadvertent injuries to other soft tissue structures were recorded. RESULTS: The success rate for lateral soft tissue release was 100% in 7 cadaveric specimens, and respectively 75%, 50% and 25% in the other 3 specimens. The LCL was successfully released in all specimens. The lateral joint capsule, AHT and LMSL were released in 80% of the specimens. Chondral damage to the first metatarsal head, unintended release of the conjoined tendon and lateral head of the flexor hallucis brevis (FHB) occurred respectively in 40%, 50% and 20% of the specimens. CONCLUSIONS: Our cadaveric study demonstrated high success rate in the release of specific lateral soft tissue structures of the first MTPJ through a medial transarticular approach. Inadvertent release of the lateral head of the FHB, conjoined tendon and iatrogenic chondral damage of the first metatarsal head are complications to be considered. LEVEL OF EVIDENCE: Cadaveric study - Level V.

Mini-open Repair of Achilles Tendon Rupture With the Patient in the Supine Position.

Surgical repair of the Achilles tendon is a common procedure for acute Achilles tendon ruptures. Variations in surgical technique and patient positioning exist, with the ultimate goal of achieving a durable repair while minimizing complications. Recently the use of a mini-open approach has been demonstrated to provide a durable repair that is comparable to using a larger traditional open approach. In this paper we describe a mini-open approach for surgical repair of the Achilles tendon while the patient is in the supine position.

First Metatarsophalangeal Joint Arthrodesis: Does the Addition of a Lag Screw to a Dorsal Locking Plate Influence Union Rate and/or Final Alignment after Fusion.

First metatarsophalangeal (MTP-1) joint fusion is a reliable method for the correction of various deformities, including hallux valgus and hallux rigidus. Ideal constructs provide high rates of fusion in the desired alignment. The present study examined the union rates and the change in dorsiflexion angle during the follow-up period in patients who had undergone MTP-1 fusion with a dorsal locking plate and a lag screw compared with patients who had undergone fusion with a dorsal locking plate alone. We performed a retrospective review of 99 feet undergoing MTP-1 fusion. The joints were fused using either a dorsal locking plate alone or a lag screw plus a dorsal locking plate. Union was determined radiographically during the follow-up period. Suspected nonunions were confirmed by computed tomography. The dorsiflexion angles were radiographically measured at the first postoperative visit and at the final follow-up visit. Of the 99 feet, 36 (36.4%) were in the lag screw plus dorsal plate group and 63 (63.6%) in the dorsal plate group. The mean follow-up period was 12.9 (range 12 to 33.5) months. The dorsal plate plus lag screw group had a significantly lower change in the mean dorsiflexion angle (0.57° ± 5.01°) during the postoperative period compared with the dorsal plate group (6.73° ± 7.07°). The addition of a lag screw to a dorsal locking plate for MTP-1 arthrodesis might offer improved stability of the joint in the sagittal plane over time compared with a dorsal plate alone.

Radiographic evaluation of first MTP joint arthrodesis for severe hallux valgus: Does the introduction of a lag screw improve union rates and correction of the intermetatarsal angle?

BACKGROUND: First metatarsophalangeal (MTP-1) joint fusion is a reliable method for the correction of various deformities including hallux valgus and hallux rigidus. Ideal constructs provide high rates of fusion in desired alignment. The present study examines the union rates, as well as the change in dorsiflexion angle during the follow up period in patients who underwent MTP-1 fusion with a dorsal locking plate and a lag screw, versus patients fused with a dorsal locking plate alone. METHODS: This is a retrospective review of 99 feet undergoing MTP-1 fusion. Joints were fused using either a dorsal locking plate alone or a lag screw plus a dorsal locking plate. Union was determined radiographically during the follow up period. Suspected nonunions were confirmed with CT. Dorsiflexion angles were radiographically measured at first post-operative visit and at final follow up. RESULTS: There were 36 patients in the lag screw plus dorsal plate group, and 63 in the dorsal plate group. Mean follow up was 12.9 months (Range: 12-33.5 months). The dorsal plate plus lag screw group had a significantly lower change in mean dorsiflexion angle (0.57°±5.01°) during the post-operative period compared to the dorsal plate group at final follow up versus the dorsal plate group (6.73°±7.07°). CONCLUSION: The addition of a lag screw to a dorsal locking plate for MTP-1 arthrodesis may offer improved stability of the joint in the sagittal plane over time compared to a dorsal plate alone. LEVEL OF EVIDENCE: Retrospective level III evidence.

Results of lateral ankle ligament repair surgery in one hundred and nineteen patients: do surgical method and arthroscopy timing matter?

PURPOSE: Ankle sprains are the most common athletic injury. One of five chronic lateral ankle instability patients will require surgery, making operative outcomes crucial. The purpose of this study is to determine if operative method influences failure and complication rates in chronic lateral ankle ligament repair surgery. METHODS: We retrospectively reviewed 119 cases (118 patients) of lateral ankle ligament surgery between 2006 and 2016. Patient charts and operative reports were examined for demographics, use and timing of ankle arthroscopy, ligament fixation method, type of surgical incision, presence of calcaneofibular ligament repair, and operative technique. Impact of operative methods on failure (one-year minimum follow-up) and complication outcomes was explored using Chi-square test of independence (or Fisher's exact test). Statistical significance was set at p less than .05. RESULTS: Mean age at surgery was 40 (range, 18-73) years. Mean follow-up was 51 (range, 12-260) weeks. Failure rate was 8.4% (10/89 cases) while complication rate was 17.6% (21/119). Failure rate did not differ significantly between any data subgroups (p > .05). Single stage arthroscopy was associated with a significantly lower complication rate (11%, 4/37) than double-stage arthroscopy (47%, 9/19) (p < .01) as was suture anchor ligament fixation (9%, 6/67) compared to direct suture ligament fixation (29%, 15/52) (p < .01). CONCLUSION: Failure rate was not impacted by any of the studied variables. Use of suture anchors and concurrent ankle arthroscopy may be favourable options to achieve fewer complications in chronic lateral ankle instability repair surgery.

Neurovascular Structures at Risk With Curved Retrograde TTC Fusion Nails.

BACKGROUND: The purpose of this study was to assess the risk of iatrogenic injury to plantar neurovascular structures of the foot during insertion of a curved retrograde tibiotalocalcaneal (TTC) fusion nail. MATERIAL AND METHODS: Ten below-knee thawed fresh-frozen cadaveric specimens underwent curved retrograde nailing of the ankle. The shortest distance between the nail and the main plantar neurovascular branches and injured structures were recorded during dissection. We also evaluated the relative position of these structures along 2 lines (AB, connecting the calcaneus to the first metatarsal, and BC, connecting the first and fifth metatarsal). RESULTS: The lateral plantar artery was found to be in direct contact with the nail 70% of the time, with a macroscopic laceration 30% of the time. The Baxter nerve was injured 20% of the time, as was the lateral plantar nerve. The medial plantar artery and nerve were never injured. The most proximal structure to cross line AB was the Baxter nerve followed by the lateral plantar artery, the nail, the lateral plantar nerve, and the medial plantar nerve. CONCLUSION: Our cadaveric anatomic study found that the most common structures at risk for iatrogenic injury by lateral curved retrograde TTC fusion nails were the lateral plantar artery and nerve, and the Baxter nerve. CLINICAL RELEVANCE: Determination of a true neurovascular safe zone is challenging and therefore warrants careful operative dissection to minimize neurovascular injuries.

Epstein-Barr virus associated smooth muscle tumors in post transplant pediatric patients two cases of rare locations, and review of the literature.

Epstein-Barr virus (EBV) may present few or no symptoms in immunocompetent individuals; however, in immunocompromised patients as in the case of AIDS and post-transplant patients, the virus occasionally stimulates neoplastic transformations. Epstein-Barr virus may play a role in the development of smooth muscle tumors (SMT). In the case of Epstein-Barr associated smooth muscle tumors (EBV+SMT), the virus is thought to be the leading factor to the tumorigenic pathway. We report two pediatric patients (6 and 13 years old) who underwent liver transplantation and developed EBV+SMT in the colon and orbit. These two cases represent rare locations for this kind of lesion.

Pharyngeal hairy polyps: five new cases and review of the literature.

Pharyngeal hairy polyps are rare lesions that present as a pedunculated mass that may arise from the oropharyngeal or nasopharyngeal regions of the pharynx. The mass has the potential to partially or completely obstruct pathways towards the trachea and/or esophagus resulting in respiratory distress and/or feeding difficulties respectively. They have a predilection for female infants of 6:1 with the vast majority of the cases occurring in the infantile period. We report 5 cases of the hairy polyp in female infants, one of which showed unusual presentation since it was diagnosed at ten months of age.