Safe driving recommendations following lower extremity orthopedic surgery: a systematic review.

PURPOSE: We analyzed the published literature on return-to-driving (RTD) recommendations following lower extremity orthopedic surgery, including knee and hip arthroplasty and ankle and foot surgery. METHODS: We conducted a PubMed MEDLINE database search for the relevant literature spanning from 1988 to 2022. Data were extracted from the selected articles independently by six investigators, and the mean, standard deviation, and range of RTD recommendations for each surgical region and procedure were calculated. RESULTS: The 34 studies included in our review evaluated brake response time, reaction time, movement time, braking force, and other parameters. Average RTD recommendations in weeks were: hip surgeries, 4.1 (± 2.7); foot surgeries, 6.67 (± 0.94); Achilles surgeries, 6.67 (± 0.25); ankle surgeries, 4 (± 2); knee surgeries, 5.42 (± 0.77); and multiple lower extremity surgeries, 3.85 (± 0.15). CONCLUSION: Our findings can assist physicians in providing informed recommendations to patients, promoting safe driving practices, and optimizing postoperative recovery. LEVEL OF EVIDENCE: Therapeutic, Level III: Retrospective comparative study.

Differences in cancer amputee survival based on marital status: an analysis of the Surveillance, Epidemiology, and End Results (SEER) database.

PURPOSE: Limb amputation is a life-altering procedure used to treat certain cancer patients. The influence of psychosocial factors (such as marital status) on outcomes is poorly understood, hindering the development of targeted resources for the specific needs of these patients. This study was conducted to characterize the influence of marital status on survival after cancer-related amputation. DESIGN/RESEARCH APPROACH: Retrospective cohort study. SAMPLE: 1,516 patients with cancer-related amputation were studied from the Surveillance, Epidemiology and End Results database. METHODS: Patients were grouped by marital status as single, married or divorced/separated/widowed and survival was compared using multivariate cox regression adjusted for demographic, tumor and treatment factors. FINDINGS: Adjusted analysis showed that single (HR, 1.213; p = .044) patients had a significantly higher overall mortality-risk, while divorced/separated/widowed patients had both a significantly higher overall (HR, 1.397; p < .001) and cause-specific mortality-risk (HR, 1.381; p = .003) compared to married patients. CONCLUSION: We posit that the increased psychosocial support available to married cancer patients may play a key role in improving survival. IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS: These findings provide new insight about the psychosocial needs of cancer amputees and the prognostic implications for those lacking social support of a spouse.

Techniques and complications of popliteal nerve blocks.

BACKGROUND: Use of popliteal nerve blocks (PNBs) as an alternative or adjunctive therapy to traditional methods of pain control (e.g., systemic or spinal anesthesia and opioids) is increasingly popular in foot and ankle surgery. METHODS: We reviewed online databases for literature on PNBs in foot and ankle surgery to analyze the various techniques and positioning used, the influence of drugs on their efficacy, and possible complications associated with their use. Thirty articles were identified with a predefined search criteria, followed by a review process for relevance. RESULTS: Patient demographics, procedure specifics, and block techniques, such as anesthetic used, can impact the duration and success of a PNB. Administration with ultrasound guidance proved superior to nerve stimulation, and preoperative administration was superior to postoperative administration. CONCLUSIONS: PNBs are an effective method to control postoperative pain with minimal complications, leading to decreased analgesic use, earlier discharge, and higher patient satisfaction. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Radiographic Assessment of Fibular Length Variance: The Case for "Fibula Minus".

Given the high prevalence of ankle fractures and morbidity of malalignment after fixation, an appropriate anatomic relationship between the distal fibula and adjacent tibia and talus is important. The tip of the lateral malleolus of the fibula has often been described to be at the level of the lateral talar process. However, no studies to date have examined the relationship of the distal fibular tip to the lateral process of the talus. We assessed 66 weightbearing mortise radiographs for variability of the distal fibular tip in relation to the lateral process of the talus. The subjects were all skeletally mature, with a mean age of 45.3 ± 14.6 years. We used a paired t test with a null hypothesis that the true mean difference in the distance from the distal fibula to the lateral process was equal to 0. The mean distance of the distal tip of the fibula was 0.257 ± 0.127 cm proximal to the tip of the lateral process of the talus. The 95% confidence interval was 0.226 to 0.288. Of the 66 subjects, 65 had the distal tip of the fibula proximal to the lateral process of the talus, corresponding to a negative fibular variance. In the remaining subject, the distal tip of the fibula was at the same level of the tip as the lateral process of the talus. The distal tip of the fibula is most commonly not at the level of the talus lateral process, as often described in published reports. Instead, it has a variance analogous to the relationship between the lengths of the ulna compared with the radius. The distal tip of the fibula in our study was more often proximal to the tip of the lateral process of the talus and can be described as a negative fibular variance, or "fibula minus."

Biomechanical comparison of first metatarsophalangeal joint arthrodeses using triple-threaded headless screws versus partially threaded lag screws.

BACKGROUND: Triple-threaded, cannulated headless screws of varying thread diameters and pitch are designed to maintain thread length across the arthrodesis plane, provide joint compression, and reduce countersinking. This study tested the biomechanical fixation strength of conventional partially threaded lag screws compared to triple-threaded headless screws in first metatarsophalangeal joint arthrodesis. METHODS: First metatarsophalangeal joint arthrodesis using a crossed screw technique was performed on 11 paired, preserved cadaver first rays with two 4.0-mm triple-threaded, cannulated headless screws or two 4.0-mm partially threaded, cannulated lag screws. The constructs were tested to failure through dorsally directed cantilever bending. RESULTS: The triple-threaded, cannulated headless screws displayed significantly greater bending stiffness (p=0.017) and failure load (p=0.040) during load-to-failure testing compared to the partially threaded, cannulated lag screws. CONCLUSIONS: Triple-threaded, cannulated headless screws may be a viable alternative to partially threaded lag screws in first metatarsophalangeal arthrodesis.

Nicotine Dependence and Rates of Postoperative Complications in Achilles Tendon Repair.

BACKGROUND: Nicotine is a modifiable risk factor that is well demonstrated to cause deleterious effects on tendon healing and overall health. Individuals that have a dependence on nicotine may be at an elevated risk for numerous postoperative complications when compared to nondependent patients. The purpose of this study is to evaluate the complications postoperatively between nicotine- and non-nicotine-dependent Achilles tendon repairs. METHODS: The global health network database, TriNetX, was used to access and analyze deidentified patient information. Two cohorts were identified for the purposes of this study. Cohort A was defined as patients who had an Achilles tendon repair (Current Procedural Terminology [CPT]: 27650 or CPT: 27654) and had a dependence to nicotine (International Classification of Diseases, Tenth Revision, code: F17). Cohort B was defined as patients who had an Achilles tendon repair but did not have a dependence to nicotine. Data were gathered from health care organizations from August 21, 2000, to August 21, 2023. All postoperative complications were analyzed between 1 and 90 days after the Achilles tendon repair. RESULTS: A total of 2117 nicotine-dependent patients were matched with 18 102 non-nicotine-dependent patients. After propensity matching for age at event, ethnicity, race, sex, and type 2 diabetes mellitus, nicotine-dependent patients who underwent Achilles tendon repair experienced higher associated risk for numerous postoperative complications. When compared to nondependent patients, nicotine-dependent patients had increased risk for wound disruption (risk ratio [RR] 1.55, 95% CI 1.11-2.16) and infection following a procedure (RR 1.64, 95% CI 1.09-2.47) within 90 days post Achilles tendon repair. CONCLUSION: In this database study using propensity matching, nicotine-dependent patients who underwent Achilles tendon repair were correlated with an increased associated risk for wound disruption and infection after a procedure than their non-nicotine-dependent counterpart. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Radiographic Anatomy of the Lateral Ankle Ligament Complex: A Cadaveric Study.

BACKGROUND: When lateral ankle sprains progress into chronic lateral ankle instability (CLAI), restoring precise anatomic relationships of the lateral ankle ligament complex (LALC) surgically is complex. This study quantifies the radiographic relationships between the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and prominent osseous landmarks visible under fluoroscopy to assist in perioperative practices for minimally invasive surgery for CLAI. METHODS: Ten fresh frozen ankle specimens were dissected to expose the LALC and prepared by threading a radiopaque filament through the ligamentous footprints of the ATFL and CFL. Fluoroscopic images were digitally analyzed to define dimensional characteristics of the ATFL and CFL. Directional measurements of the ligamentous footprints relative to the lateral process of the talus and the apex of the posterior facet of the calcaneus were calculated. RESULTS: Dimensional measurements of the ATFL were a mean length of 9.3 mm, fibular footprint of 9.4 mm, and talar footprint of 9.1 mm. Dimensional measurements of the CFL were a mean length of 19.4 mm, fibular footprint of 8.2 mm, and calcaneal footprint of 7.3 mm. From the radiographic apparent tip of the lateral process of the talus, the fibular attachment of the ATFL was found 13.3 mm superior and 4.4 mm posterior, whereas the talar attachment was found 11.5 mm superior and 4.8 mm anterior. From the radiographic apparent posterior apex of the posterior facet of the calcaneus, the fibular attachment of the CFL was found 0.2 mm inferior and 6.8 mm anterior, whereas the calcaneal attachment was found 14.3 mm inferior and 5.9 mm posterior. CONCLUSION: The ATFL and CFL were radiographically analyzed using radiopaque filaments to outline the ligamentous footprints in their native locations. These ligaments were also localized with reference to 2 prominent osseous landmarks. These findings may assist in perioperative practices for keyhole incision placement and arthroscopic guidance. Perfect lateral ankle joint imaging with talar domes superimposed is required to be able to do this. CLINICAL RELEVANCE: Radiographic evaluation of the ATFL and CFL with reference to prominent osseous landmarks identified under fluoroscopy may assist in perioperative practices for minimally invasive surgery to address CLAI for keyhole incision placement and arthroscopic guidance.

Return to Play Rates Following Operative Ankle Fractures Differ Between High- and Low-Performing National Football League Athletes.

This study investigated predictive factors for return to play among National Football League athletes after operative treatment of ankle fractures and the impacts of these injuries on career longevity and player performance. Athletes who underwent surgery to repair ankle fractures from the 2013 to 2017 seasons were identified from injury reserve lists and press releases. Demographics and season metrics were collected before and after the injury. Statistical analysis assessed for differences in recorded variables between injured and uninjured players. Thirty-one players met study inclusion criteria. Twenty-two (71%) athletes successfully returned to play. Players who did not return showed no significant differences (P>.05) in position, age, body mass index, number of games or seasons played preinjury, or snaps per game the season prior to injury and had a significantly lower (42.6%, P=.013) preinjury season approximate value (SAV) compared with returning players. Returning athletes showed no significant differences (P>.05) in SAV or snaps per game compared with their preinjury season or with uninjured controls. A high preinjury SAV is associated with successful return to play. No difference in game time or performance metrics was detectable between returning players and uninjured controls, or between preinjury and postinjury seasons. [Orthopedics. 2024;47(1):22-27.].

Preventing Iatrogenic Fibula Fractures Using the Push-Pull Technique: A Biomechanical Comparison of Unicortical Versus Bicortical Post Screws.

BACKGROUND: Displaced diaphyseal fractures can be reduced using the push-pull technique, wherein a plate is affixed to the distal fragment of the fracture, a post screw is placed proximal to the plate, and a lamina spreader creates distraction. This study evaluated the load to failure and mechanism of failure of bicortical and unicortical post screws during reduction. MATERIALS AND METHODS: Four matched pairs of cadaver legs were subjected to a 2-cm oblique osteotomy simulating a displaced, oblique diaphyseal fracture. A 6-hole compression plate was affixed to the distal fragment with 2 unicortical locking screws, and a 12-mm uni-cortical or 20-mm bicortical screw was inserted as a post screw proximal to the plate. A lamina bone spreader was used to exert a distraction force between the plate and the post screw. A mechanical actuator simulated the distraction procedure until failure. Maximum applied load, displacement, and absorbed energy were recorded and compared across unicortical and bicortical groups by paired t tests. RESULTS: At maximum load, we found statistically significant differences in displacement (P=.003) and energy absorbed (P=.022) between the two groups. All unicortical screws failed through screw toggle and bone cut-out. Bicortical screws failed through bending, with no visible damage to the bone at the screw site. CONCLUSION: When diaphyseal fractures are significantly shortened and require a greater distraction force to achieve reduction, bicortical screws demonstrate a higher mechanical load to failure and increased bone loss from the screw-removal site. A unicortical post screw may be used if minimal distraction is needed. [Orthopedics. 202x;4x(x):xx-xx.].

Three-dimensional, digital, and gross anatomy of the Lisfranc ligament.

BACKGROUND: There are inconsistencies in the descriptive anatomy of the Lisfranc ligament. No information is available on orientation of fibers or presence of bundles, nor are there 3-dimensional anatomic data on the ligaments or their attachments. This study assessed the 3-dimensional anatomy of the Lisfranc ligament and its attachment sites. METHODS: A total of 37 cadaver feet were dissected to expose the ligament attachments at the Lisfranc joint. The Lisfranc ligament and plantar ligament attachments were outlined separately and then removed with the attachment outlines preserved. A 3-dimensional digitizer was used to digitize bony and articular surfaces, as well as ligament attachment sites, at approximately 1 mm intervals; the positional accuracy was 0.23 mm. The surface areas of the entire bone, articular regions, and Lisfranc and plantar ligament attachment regions were determined and anatomic details were noted. RESULTS: The Lisfranc ligament had a single bundle in 73% of the specimens and 2 bundles in 27%. Both variations had a single attachment to the second metatarsal (M2; mean attachment surface area, 135 mm(2)). The single-bundle variation attached to the medial cuneiform (C1; mean attachment surface area, 140 mm(2)). The plantar ligament, C1-M2-M3, attached to the anterior plantar surface of the lateral aspect of C1 (mean attachment surface, 64 mm(2)) and had attachment sites at the bases of M2 and M3. Its fibers ran anteriorly and inferiorly, with attachments to the proximal inferomedial aspect of M2 (mean attachment surface, 63 mm(2)) and fibers extending to a smaller attachment at the plantar aspect of M3 (mean attachment surface area, 26 mm(2)). CONCLUSION: The Lisfranc ligament is variable in anatomy and can have a single- or double-bundle arrangement. Its area of attachment is larger than that of the plantar ligament. CLINICAL RELEVANCE: Anatomic descriptions of location, dimensions, and variability in the position and surface area of the ligament attachment sites and of orientation of the bundles provide information for future attempts at repair or reconstruction of the Lisfranc ligament.

Accuracy of citation and quotation in foot and ankle surgery journals.

BACKGROUND: A recent review of technical editing of research suggests that over one third of references cited in articles in medical journals have some inaccuracies and one fifth of quotations to references in these articles are not accurate. METHODS: Two hundred and forty-nine citation references and 408 quotes from 25 articles published in 5 orthopaedic journals were randomly selected to determine referencing accuracy. The presence of citation errors was examined by 1 of the authors while the presence of quotation errors was determined by 2 of the authors. Full copies of articles as well as the references were obtained to compare the accuracies. RESULTS: The total citation error rate was 41% (103 out of 249 references), and the total quotation error rate was 20% (80 out of 408 quotes) for the 5 orthopaedic journals. CONCLUSION: Citation and quotation errors were still relatively common in orthopaedic journals. While we did not identify any factors associated with citation and quotation errors, the use of technical editing may reduce the amount of citation errors. CLINICAL RELEVANCE: Readers and authors should be aware that many citations of studies are inaccurate and one should review the original source if it is to be used in another publication or to guide clinical treatment.

Fixation strength of anteriorly inserted headless screws for talar neck fractures.

BACKGROUND: For noncomminuted talar neck fractures, traditional fixation is with small fragment screws or cannulated screws. Newer screw systems on the market allow placement of cannulated headless screws, which provide compression by virtue of a variable-pitch thread. The headless construct has an inherent advantage, particularly for the talus, when the screws must be countersunk to prevent wear of the joint articular surfaces. This study tested the biomechanical fixation strength of cannulated headless variable-pitch screws compared with conventional cannulated screws, both placed in an anterior to posterior direction. METHODS: A reproducible talar neck fracture was created in nine paired, preserved, cadaver talar necks using a materials testing machine. Talar head fixation was then performed with two cannulated headless variable-pitch 4/5 screws or two 4.0-mm conventional cannulated screws. The specimens were tested to failure and the fixations were normalized to their intact pairs and compared. RESULTS: The headless variable-pitch screw fixation had significantly lower failure displacement than the conventional screw fixation. No significant differences were found between the two fixations for failure stiffness, load at failure or energy absorbed. CONCLUSIONS: Cannulated headless variable-pitch screws significantly improved failure displacement when compared to conventional cannulated screws in a cadaveric model, and may be a viable option for talus fracture fixation. CLINICAL RELEVANCE: Headless, fully threaded, variable-pitch screws have inherent advantages over conventional screws in that they may be less damaging to the articular surface and can compress the fracture for improved reduction. This study demonstrates these screws are also biomechanically similar to conventional screws.

Current concepts in ankle fractures.

Ankle fractures are among the most common orthopaedic injuries. Operative management is performed in unstable ankle fracture patterns to restore the stability and native kinematics of the ankle mortise and minimize the risk of post-traumatic degenerative changes. In this study, we review current concepts in ankle fracture management, including posterior malleolus fixation, syndesmosis fixation, deltoid ligament repair, fibular nailing, and early weightbearing, from both a biomechanical and clinical perspective.

Quality and Readability of Information Regarding Total Ankle Arthroplasty Available to Patients on the Internet.

This study sought to evaluate the reliability, comprehensiveness, and readability of ankle arthroplasty information available on the Internet. We evaluated websites based on category, Journal of the American Medical Association (JAMA) criteria, Health on the Net (HON) code, DISCERN score, an author-created Ankle Replacement Index (ARI), and readability metrics. Based on the ARI, 80 (62.5%) websites provided poor information. The mean reading level was 8.96 ± 2.66, which is above the recommended sixth-grade reading level for patient information. Academic websites had the highest mean DISCERN, ARI, and JAMA scores, and a midrange reading level. The government category had high DISCERN and JAMA scores, a fair ARI score, and the lowest reading level. We found significant correlation between website class and DISCERN score, as well as HON code and DISCERN score. Our results suggest that academic and government websites provide more reliable, complete information than other categories and that websites with an HON code contain more reliable information than those without. We recommend that physicians create handouts to point patients to reliable resources and encourage them to critically evaluate information they read online. We also encourage physicians to take part in evaluating and updating information on their practice websites.Level of Clinical Evidence: N/A.

Squamous Cell Carcinoma of the Foot Occurring in a Wart.

Verrucous carcinoma is a rare form squamous cell carcinoma which appears similar to a wart. When it occurs in the feet, it can be easily misdiagnosed. It rarely metastasizes or recurs posttreatment. We report a case of a septuagenarian with recurrence of verrucous carcinoma diagnosed within 6 months at the site of previous treatment. Unique features in our patient's clinical presentation include his advanced age, being nondiabetic, and the rapid recurrence of carcinoma.Level of Evidence: Level IV: Case report.

Republication of "Peroneus Brevis Tenodesis: Side-to-Side or Weave?"

Background: Inversion ankle injuries are extremely common, sometimes causing injury to the peroneus brevis tendon. If more than 50% of the tendon is injured, it oftentimes requires tenodesis to the adjacent peroneus longus tendon. Both Pulvertaft (PT) and side-to-side (SS) techniques have been used for joining the 2 tendons. The purpose of this study was to compare the strength and stiffness of these 2 techniques. Methods: Five matched pairs of cadaver ankle specimens were randomized to receive either an SS or PT tenodesis of the peroneus brevis to longus tendons. Following the tenodesis, the specimens were tested for failure load, displacement, energy absorbed at failure, and peak load. Stiffness was also calculated. Paired t tests were performed to detect differences between the 2 conditions. Results: There were no statistically significant differences between the SS and PT tenodesis for any of the metrics measured. For stiffness, the techniques were very similar (SS = 10.14 [4.35], PT = 12.85 [1.72]). Conclusion: There is no difference in failure load, displacement, energy absorbed at failure, peak load or stiffness between the PT and SS techniques for peroneal tenodesis. Level of Evidence: Level V, cadaver study.

Five-Factor Modified Frailty Index as a Predictor of Complications Following Total Ankle Arthroplasty.

INTRODUCTION: Ankle arthritis adversely affects patients' function and quality of life. Treatment options for end-stage ankle arthritis include total ankle arthroplasty (TAA). A 5-item modified frailty index (mFI-5) has predicted adverse outcomes following multiple orthopaedic procedures; this study evaluated its suitability as a risk-stratification tool in patients undergoing TAA. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed for patients undergoing TAA between 2011 and 2017. Bivariate and multivariate statistical analyses were performed to investigate frailty as a possible predictor of postoperative complications. RESULTS: In total, 1035 patients were identified. When comparing patients with an mFI-5 score of 0 versus ≥2, overall complication rates significantly increased from 5.24% to 19.38%, 30-day readmission rate increased from 0.24% to 3.1%, adverse discharge rate increased from 3.81% to 15.5%, and wound complications increased from 0.24% to 1.55%. After multivariate analysis, mFI-5 score remained significantly associated with patients' risk of developing any complication (P = .03) and 30-day readmission rate (P = .005). CONCLUSIONS: Frailty is associated with adverse outcomes following TAA. The mFI-5 can help identify patients who are at an elevated risk of sustaining a complication, allowing for improved decision-making and perioperative care when considering TAA. LEVELS OF EVIDENCE: III, Prognostic.

Patient Perceptions of Surgeon Reimbursement in Total Ankle Arthroplasty.

INTRODUCTION: The incidence of total ankle arthroplasty (TAA) for ankle osteoarthritis has increased in the Medicare population by approximately 16.37% each year. This study examines the patient perception of orthopedic surgeon reimbursement for TAA by Medicare. METHODS: A total of 78 patients were surveyed anonymously at 2 foot and ankle clinics within an academic health care setting. The surveys were given anonymously before the patients were seen by an orthopedic surgeon. Surveys were returned to office staff who placed them in a collection box to ensure confidentiality. RESULTS: The average estimate of how much orthopedic surgeons should be reimbursed for TAA was $19 506 and the average estimate of how much orthopedic surgeons were actually reimbursed was $20 772. Fifty patients believed that orthopedic surgeons were under reimbursed, 9 believed that they were reimbursed appropriately, and 19 were unsure. Demographic variables such as age, sex, education level, income, and insurance status had no significant effect on the results. CONCLUSIONS: Most patients believed orthopedic surgeons are under reimbursed for TAA and that there is a lack of health care transparency regarding orthopedic reimbursement for TAA by Medicare.Levels of Evidence: Level V: Expert opinion.

The Effects of COVID-19 on Orthopaedic Surgery Training Programs in the United States.

INTRODUCTION: This study investigates the effects of the COVID-19 pandemic on medical education, research opportunities, and mental health in orthopaedic surgical training programs. METHODS: A survey was sent to the 177 Electronic Residency Application Service-participating orthopaedic surgery training programs. The survey contained 26 questions covering demographics, examinations, research, academic activities, work settings, mental health, and educational communication. Participants were asked to assess their difficulty in performing activities relative to COVID-19. RESULTS: One hundred twenty-two responses were used for data analysis. Difficulties were experienced in collaborating with others (49%), learning through online web platforms (49%), maintaining the attention span of others through online web platforms (75%), and in gaining knowledge as a presenter or participating through online web platforms (56%). Eighty percent reported that managing time to study was the same or easier. There was no reported change in difficulty for performing activities in the clinic, emergency department, or operating room. Most respondents reported greater difficulty in socializing with others (74%), participating in social activities with coresidents (82%), and seeing their family (66%). Coronavirus disease 2019 has had a significant effect on the socialization of orthopaedic surgery trainees. DISCUSSION: Clinical exposure and engagement were marginally affected for most respondents, whereas academic and research activities were more greatly affected by the transition from in-person to online web platforms. These conclusions merit investigation of support systems for trainees and evaluating best practices moving forward.

Accuracy of intraoperative fluoroscopy with and without laser guidance in foot and ankle surgery.

BACKGROUND: The use of intraoperative fluoroscopy in orthopedic surgery involves frequent exposure to ionizing radiation in the operating room. Although a number of studies have found radiation exposure to orthopedic surgeons to be well below recommended doses, the long-term effects of low-dose radiation are not well known. Thus, all effective practical methods should be undertaken to reduce the exposure to radiation. Our purpose was to determine whether the use of a laser-aiming device improves the accuracy of intraoperative fluoroscopy to reduce, by implication, radiation exposure in the operating room. METHODS: From March to October 2004, there were 92 consecutive cases requiring use of fluoroscopy in the orthopedic foot and ankle service of the authors' institution. The number of accurate and inaccurate images with or without the presence of a radiology technician and a laser-aiming device were compared. RESULTS: The accuracy of imaging with the laser-aiming device was higher than the imaging without the device (p < 0.001). The accuracy of the images obtained by the surgeon was higher than the technicians' images when laser guidance was used (p= 0.027). There was no significant difference between the images obtained by the surgeon or the technicians when the aiming device was not used (p = 0.09). CONCLUSION: The use of a laser-aiming device to help position during fluoroscopy is recommended in an effort to reduce radiation exposure in foot and ankle surgery.