Ankle fracture surgery performed by orthopaedic residents without supervision has comparable outcomes to surgery performed by fellowship trained orthopaedic surgeons.

BACKGROUND: Unstable fractures often necessitate open reduction and internal fixation (ORIF), which generally yield favourable outcomes. However, the impact of surgical trainee autonomy on healthcare quality in these procedures remains uncertain. We hypothesized that surgery performed solely by residents, without supervision or participation of an attending surgeon, can provide similar outcomes to surgery performed by trauma or foot and ankle fellowship-trained orthopaedic surgeons. METHODS: A single-center cohort of an academic level-1 trauma center was retrospectively reviewed for all ankle ORIF between 2015 and 2019. Data were compared between surgery performed solely by post-graduate-year 4 to 6 residents, and surgery performed by trauma or foot and ankle fellowship-trained surgeons. Demographics, surgical parameters, preoperative and postoperative radiographs, and primary (mortality, complications, and revision surgery) and secondary outcome variables were collected and analyzed. Univariate analysis was performed to evaluate outcomes. RESULTS: A total of 460 ankle fractures were included in the study. Nonoperative cases and cases operated by senior orthopaedic surgeons who are not trauma or foot and ankle fellowship-trained orthopaedic surgeons were excluded. The average follow-up time was 58.4 months (SD ± 12.5). Univariate analysis of outcomes demonstrated no significant difference between residents and attendings in complications and reoperations rate (p = 0.690, p = 0.388). Sub-analysis by fracture pattern (Lauge-Hansen classification) and the number of malleoli involved and fixated demonstrated similar outcomes. surgery time was significantly longer in the resident group (p < 0.001). CONCLUSION: The current study demonstrates that ankle fracture surgery can be performed by trained orthopaedic surgery residents, with similar results and complication rates as surgery performed by fellowship-trained attendings. These findings provide valuable insights into surgical autonomy in residency and its role in modern clinical training and surgical education. LEVEL OF EVIDENCE: Level III - retrospective cohort study.

Lateral malleolus closed reduction and internal fixation with intramedullary fibular rod using minimal invasive approach for the treatment of ankle fractures.

BACKGROUND: Ankle fractures are extremely common and represent nearly one quarter of all lower-limb fractures. Techniques for fixation of displaced fractures of the lateral malleolus have remained essentially unchanged in recent decades. The current gold standard of treating unstable fractures is with open reduction and internal fixation (ORIF), using plates and screws construct. This study evaluates the use of fibula intramedullary nailing based on minimal invasive surgical approach. METHODS: Thirty-nine cases treated with fibula intramedullary nailing between the years 2014-2016 were retrospectively studied. A fibular nail was utilized for the treatment of various ankle fractures either as the sole method of fixation or combined with another method. Patient charts were reviewed for fracture patterns, comorbidities, quality of reduction, complications and additional surgeries. RESULTS: Out of 39 cases in the study cohort, 37 were closed fractures while 2 had an associated medial malleolus open injury. According to Weber classification of lateral malleolus fractures, 20 cases were type B, 18 cases type C, and one case of a pathologic fracture type B like fracture. Quality of reduction was based on previously published criteria. It was determined to be good in 32 cases, fair in 5 cases and poor in 2 cases that were revised intraoperatively to plate fixation. Overall no systemic complications occurred. Eight patients have undergone additional surgeries, namely hardware removals. In two cases, the nail was later revised to a different fixation method: one case to a plate, due to secondary displacement at 2 weeks, and one to an intramedullary tibiotalocalcaneal arthrodesis secondary to hardware failure and Charcot neuroarthropathy. CONCLUSION: Intramedullary fibular nail offers a satisfactory and safe procedure to establish good reduction and fixation of lateral malleoli fractures. It may be considered as treatment of choice for patients with soft tissue problems due to its minimal invasive approach. The current study shows that while good fracture reduction can be achieved, without major complications, more than fifth of patients, required secondary procedures, mainly hardware removals. LEVEL OF EVIDENCE: Level IV.

Foot Width Changes Following Hallux Valgus Surgery.

BACKGROUND: Hallux valgus (HV) adversely affects quality of life. Patients frequently express concerns regarding postoperative foot appearance, foot width and footwear anticipations. However, only scarce data are available regarding postoperative foot width. MATERIALS AND METHODS: Seventy-one cases with moderate to severe HV treated with scarf osteotomy were included. The average age was 55.7 years (range, 20-76), with average follow-up of 20.7 months (range, 6-96). Patients' medical records were reviewed for demographic, operative, and radiographic data. Foot width was assessed radiographically by measuring both bone (distance between the first and fifth metatarsal heads) and soft tissue width (maximal distance of the soft tissue outline). RESULTS: Preoperative HV deformity (mean hallux valgus angle [HVA] 35.8 degrees, intermetatarsal angle [IMA] 14.1 degrees, and distal metatarsal articular angle [DMAA] 15.2 degrees) was successfully corrected (postoperative mean HVA 13.7 degrees, IMA 6.9 degrees, and DMAA 7.7 degrees). Overall bony foot width was reduced by 5% and soft tissue foot width by 2%. Further analysis showed that 13 feet (18.3%) had increased (>5%) bone width, 26 feet (36.6%) with no change (±5%), and 32 feet (45.1%) for which the width decreased (>5%) postoperatively. Angular deformity (HVA, IMA, and DMAA) showed low correlation with postsurgery foot width. CONCLUSION: HV surgery effect on foot width was very limited, overall reducing foot width by 2%. Furthermore, in only about half of the patients, the postoperative foot width decreased, regardless of angular deformity magnitude. Patients with the widest feet had a decrease in foot width following surgery, whereas patients with the narrowest feet had an increase in foot width. LEVEL OF EVIDENCE: Level III, comparative series.

Joint salvage after neglected intra-articular physeal fracture of the hallux in high-level gymnasts.

UNLABELLED: Chronic sports-related injuries involving the hallux are well known in adult populations. However, they are less frequently described in adolescents. We present 2 cases of elite-level gymnasts with neglected Salter-Harris IV fractures involving the proximal phalanx of the great toe following a severe hyperextension injury to the metatarsophalangeal joint. Both were successfully treated with open reduction and internal fixation with return to pre-injury level of activity, improvement in outcome scores, and demonstration of no disability from injury 2 years after surgical intervention. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case Series.