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Posterior malleolus fractures vary in morphology. A computed tomography scan is imperative to evaluate fragment size, comminution, articular impaction, and syndesmotic disruption. Despite an increasing body of literature regarding posterior malleolus fractures, many questions remain unanswered. Although, historically, fragment size guided surgical fixation, it is becoming evident that fragment size should not solely dictate treatment. Surgical treatment should focus on restoring ankle joint structural integrity, which includes restoring articular congruity, correcting posterior talar translation, addressing articular impaction, removing osteochondral debris, and establishing syndesmotic stability.

Ankle fractures are the third most common orthopaedic injury seen in the geriatric patient. Studies have identified mortality benefits with operative management, but treatment must be considered on a case-by-case basis. In the era of value-based analysis, a thorough of understanding of outcomes and costs of treatment is required. The purpose of this study was to analyze the inpatient and readmission costs associated with operative and nonoperative management of geriatric ankle fractures.Patients were identified using diagnosis codes for ankle fractures from all 2008 Part A Medicare claims. Patients younger than 65 years and those who sustained an ankle fracture during the previous year were excluded. Operative patients were then identified by ICD-9 procedure codes. Other variables collected included age, comorbidities, and the incidence of hospital readmissions. Inpatient costs were determined using Medicare reimbursement data.A total of 19 648 patients with ankle fractures were identified. Of these, 15 193 (77.3%) underwent operative intervention. The mean cost for initial fracture admission was $5097.20 for nonoperative management compared with $8798.10 for operative management ( P.05). The mean inpatient costs associated with readmission for nonoperative intervention was $5161.50 and for operative treatment, it was $5071.40 ( P.05). The reimbursement for hospital readmissions for both groups combined for approximately $29.7 million. The total cost of initial treatment plus readmission for both treatment groups combined was approximately $185 million.The total expenditure estimate of $185 million in this study has likely increased given the steady growth of the geriatric population. Expenditures associated with these readmissions was approximately $30 million-nearly a sixth of total costs. Future work must focus on determining which patients will benefit from operative intervention and optimizing care to decrease readmissions and their associated cost in this growing cohort of patients.Therapeutic, Level III: Retrospective study.

Background Total ankle arthroplasty (TAA) is becoming an increasingly utilized procedure for the management of end-stage ankle arthritis. Elderly patients are the fastest growing segment of the population in the western world, creating a unique challenge to the health economics of our era. Determining if elderly patients with end-stage ankle arthritis demonstrate the same improvements in clinical outcomes and functional measures of gait following TAA would be valuable. This can aid to evaluate the utilization of TAA in this enlarging cohort of our population. Methods Consecutive series of twenty-one patients over the age of 70, who underwent TAA for end-stage ankle arthritis, was prospectively compared to a series of twenty-one patients aged 50–60, who underwent the same procedure by single surgeon during same time period. Clinical outcomes were measured with outcome scores including VAS pain score, AOFAS Ankle and Hindfoot Score, and the SF-36. Three-dimensional gait analysis was performed preoperatively and at a minimum of one year postoperatively, to measure temporal-spatial, kinematic, and kinetic parameters of gait. Mixed model multivariate statistical analysis was used to evaluate and compare the independent contributions to outcomes of the surgical intervention over time; of patient age; and of time-plus-age interaction, as these influenced both the clinical outcomes and the functional gait outcomes. Results Statistically significant improvements in VAS pain scores, AOFAS ankle/hindfoot scores, and SF-36 scores were demonstrated in both age groups. Following surgery, there were improvements in all parameters of gait, including temporal-spatial parameters as step length and walking velocity; kinematic parameters, including, increase in total range of motion to a total of 17–19°; and kinetic parameters, including increase in ankle power and moment. The improvements both in clinical and gait outcomes were equivalent in the two age groups. Conclusions In this comparative study, it is shown that both elderly patients over the age of 70 and younger patients aged 50–60 demonstrated equivalent improvements clinical and gait outcomes following ankle arthroplasty. This may be important data both for clinical decision-making and the health economics for our ageing population.

Background: The Life Space Assessment (LSA) is a validated outcomes measure that aims to assess the level of mobility and physical functioning within one’s own environment following a medical event. We sought to study the recovery of geriatric ankle fracture patients utilizing the LSA. We hypothesized that the LSA would provide improved assessment of these patients and help identify key differences in operative and nonoperatively treated patients. Methods: Prospective observational study of geriatric patients age 65 years and older with an ankle fracture with 1-year follow-up. Operative versus nonoperative intervention was determined by the attending physician on a patient-specific basis. The LSA, Short Form–36 (SF-36), and visual analog pain scale (VAPS) were administered at predetermined intervals postinjury and scores were analyzed for significance. Results: 20 patients were enrolled in this study. 11 underwent surgery whereas 9 were treated nonoperatively. Regardless of treatment, the preinjury LSA score was 86.7. This significantly dropped to 20.6 at 6 weeks and recovered to 73.6 at 12 months. In the operative cohort, the LSA scores preinjury were 91.4 and improved to 87.6 after 1 year. The nonoperative group recorded 80.9 preinjury and only improved to 59.5 at 1 year ( P = 0.007). There was no statistically significant difference when comparing the results of the SF-36 and VAPS to the LSA. Conclusion: The LSA was effective in assessing recovery in geriatric ankle fracture patients. A severe deficit in mobility was seen for the first 6 months of recovery regardless of treatment. Operative patients ultimately returned to their baseline LSA at 1 year while nonoperative patients did not. Outcomes from the VAS and SF-36 mirrored the LSA but were not found to be statistically significant. Level of Evidence: Level II.

Category: Lesser Toes Introduction/Purpose: Hammertoe deformities are common, often painful deformities of the lesser foot and are known to severely affect daily activities. When patients seek surgical management, x-rays are utilized for diagnosis, evaluation for surgical candidacy, and selection of the operative technique. Postoperatively, radiographs are retaken to assess bone health, healing status, and alignment. Despite the frequent use of radiographs pre- and post-operatively, radiographic results are not necessarily indicative of clinical presentation or surgical outcomes. The aim of this study is to identify specific radiographic parameters that are predictive of improved pain and function after surgical correction of hammertoe deformity. Methods: Prospectively collected data was reviewed on 51 consecutive patients who underwent operative correction of hammertoe deformity. Patient demographics, comorbidities, and post-surgical complications were recorded from their electronic medical records. Clinical outcomes were assessed utilizing preoperative and postoperative Visual Analogue Scale (VAS) and Short Form Health Survey Physical Component (SF-36 PCS) scores with a minimum of six-month follow-up. Radiographs were scored by a foot & ankle fellowship-trained orthopaedic surgeon to assess preoperative severity, postoperative joint fusion, and both pre- and postoperative joint instability and arthritis. Data was examined using a multivariable analysis. Results: Preoperatively, 15.7% (8/51) of patients had a deformity classified radiographically as mild, 37.3% (19/51) as moderate, and 47.1% (24/51) as severe. Additionally, 60.8% (31/51) had joint instability, 17.7% (9/51) had joint dislocation, and 7.8% (4/51) had joint arthritis. Postoperatively, 74.5% had PIP joint fusion, 35.3% (18/51) had joint arthritis, and 9.8% (5/51) had joint instability. A significant association was found between PIP joint fusion and improved SF-36 PCS scores (p=.004). Preoperative anticoagulant therapy was associated with reduced rates of PIP joint fusion (p=0.02). There was no association found between the other demographic or radiographic parameters, and no parameters were associated with improvement in VAS scores. Conclusion: After undergoing surgical correction of hammertoe deformity, postoperative PIP joint fusion was the only variable determined to be indicative of improved physical function. However, pre- and postoperative metatarsophalangeal joint arthritis nor instability was predictive of outcomes. This work informs foot & ankle specialists that healing of the PIP joint is critical to successful hammertoe surgery.

Total ankle replacement demonstrates reliable improved clinical function and enhances gait parameters in patients with end-stage ankle arthritis. There are also a significant number of patients, however, who will require revision surgery and/or salvage arthrodesis for prosthetic failure and patient-related complications. Total ankle replacement is just beginning to have surgical series with midterm and long-term results, and there is currently a paucity of evidence about the role of component revision for total ankle replacement. Accordingly, future work is needed to define the appropriate role of revision total ankle replacement. There is need for enhanced instrumentation and dedicated revision prosthetic components to better deal with challenges of bone loss and malalignment that the revision setting presents. However, in select instances, INBONE and INBONE II Total Ankle Systems are important tools for foot and ankle specialists to consider when planning revision total ankle replacement.

Radiation therapy encompassing an active epiphysis can negatively impact the potential for bone growth by disrupting cell-cycle progression and accelerating apoptosis and terminal differentiation in physeal chondrocytes. Despite functional derangement following radiation exposure, the irradiated growth plate retains a capacity for regeneration and recovery of growth. The purpose of this study was to characterize the initial sequence of events leading to functional growth recovery in irradiated weanling rat growth plates. We hypothesized that growth in an irradiated epiphysis would be partially restored due to the expansion of chondrocytic clones. Stereological histomorphometry was used to compare chondrocytic cell and matrix turnover between the first and second week following irradiation, and to determine the relative contribution of each of the cellular and extracellular matrix (ECM) compartments to growth. We found that restoration of growth in the irradiated limb was strongly associated with the proliferative activity and production of ECM by these chondrocytic clones, as they expand in average volume, but not in numerical density. We conclude that chondrocytes forming expansive clones and exhibiting increased mitotic and matrix synthesis activity initiate the early restoration of function in the irradiated growth plate, and would be a logical target for strategies to restore full growth potential.

Background: The incidence of ankle fractures is increasing in the geriatric population, and several studies suggest them to be the third most common extremity fracture in this age group. Previous work has reflected relatively low complication rates during operative treatment. Little is known, however, about the association between these injuries and overall mortality, nor whether operative intervention has any effect on mortality. We hypothesized that geriatric ankle fractures would be correlated with an elevated mortality rate and that operative intervention would be associated with a reduced mortality when compared to nonoperative management. Methods: Following Institutional Review Board approval we retrospectively assessed all relevant 2008 part A inpatient claims from the Medicare database. We queried diagnosis codes for ankle fractures, and then excluded any patients whose age was less then 65 or had an admission related to an ankle fracture during the previous year. Operative patients were then identified by their ICD-9 procedure codes occurring within 30 days of their initial diagnosis code; all other patients were presumed to be treated without operative intervention, thereby creating 2 groups for comparison. We then analyzed this database for specific variables including overall mortality, length of stay, age distribution, and other demographical characteristics. Groups were compared with Elixhauser and Deyo–Charlson scores to determine the level of comorbidities in each group. Multivariate logistic regression analysis was used to determine if operative intervention had a protective effect. Results: In all, 19 648 patients with an ankle fracture were identified. Of those, 15 193 underwent operative intervention (77.3% ) and 4455 were treated nonoperatively (22.7% ). The mean ages for nonoperative and operative intervention were 80.9 and 76.5, respectively ( P < .0001). The average length of stay for nonoperative management was 4.5 days, while operative intervention resulted in a length of stay of 4.6 days ( P = .43). One-year mortality was 21.5% for the nonoperative group and 9.1% for the operative group ( P < .0001). The mean Elixhauser score for the nonoperative group was 2.5 and 2.2 for the operative group ( P < .0001). The mean Deyo–Charlson score was 1.3 and 1.0 for the nonoperative and operative groups, respectively ( P < .0001). Multivariate logistic regression analysis demonstrated an odds ratio of 0.534 of death within 1 year for patients undergoing operative intervention as compared to nonoperative intervention (95% CI 0.483-0.591, P < .0001). Conclusion: The incidence of geriatric ankle fractures continue to increase as our population continues to grow older. A significantly larger number of those patients were treated with operative intervention, at a ratio of approximately 3:1 versus nonoperative management. Despite a relatively low overall reported complication rate with treatment of these injuries, they are associated with substantially increased 1-year mortality in both patient groups. Compared to the operative group, the nonoperative cohort demonstrated a 2-fold elevated mortality rate, although this may be related to them being an arguably more frail population as suggested by both comorbidity indexes. In spite of the difference in comorbidities, logistic regression analysis demonstrated operative intervention to have a protective effect. Level of Evidence: Level III, comparative series.

Category: Hindfoot Introduction/Purpose: Stage 1 posterior tibial tendon dysfunction (PTTD) may be present without intra-substance tendon pathology. We hypothesize that in individuals with the clinical diagnosis of Stage 1 PTTD, with no MRI-detectable intra-substance tendon pathology, that sheath fluid amount is a confirmatory finding of PTTD. This purpose of this study was to quantify the amount of PTT sheath fluid in 1) individuals with the clinical diagnosis of Stage 1 PTTD and no MRI-detectable intra-substance tendon pathology and compare to controls with medial ankle pain (causes other) also without MRI-detectable intra-substance PTT pathology, and 2) test if there was a sheath fluid measurement predictive of the clinical diagnosis of PTTD. Methods: 326 individuals with medial ankle pain, no intra-substance PTT pathology, were studied, 48 with the clinical diagnosis of Stage 1 PTT dysfunction and 278 with medial ankle pain, causes other. Geometric methods defined MRI-based sheath fluid volume, maximum cross-sectional fluid area, and maximum fluid width. Fluid measurements were compared between groups and a predictive measurement calculated to identify individuals with PTTD. Measurement reliability was tested. Results: Individuals with PTT dysfunction had larger PTT sheath fluid volume, area, and width than controls (p’s < 0.001). An 9 mm threshold maximum fluid width was associated with PTTD (sensitivity 84%, specificity 85%). Measurements were reliable (p’s Conclusion: The amount of PTT sheath fluid, in individuals with medial ankle pain and no intra-substance PTT pathology, was associated with Stage 1 PTTD and a maximum PTT sheath fluid width of > 9 mm predicted PTTD. This is clinically significance as MRI-detected sheath fluid can now be used as a confirmatory finding in individuals with the clinical diagnosis of Stage 1 PTTD who do not have MRI-detectable intra-substance pathology

Category: Ankle, Ankle Arthritis, Hindfoot Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is a common procedure used in the management of foot and ankle pathologies. TTC fusions are frequently performed in patients with limited bone stock and poor vascular status. Adequate compression at the arthrodesis site is vital to successful fusion as even small amounts of bone resorption greatly increase nonunion risk. A recently designed hindfoot nail contains a built in nickel titanium alloy (nitinol) that has psuedoelastic properties which maintains compression across joint surfaces in the setting of bone resorption. The authors present a case series of patients who were managed with this nitinol containing intramedullary hindfoot nail system. Methods: Patients treated by one board certified orthopaedic foot and ankle surgeon who were managed with the nitinol containing hindfoot nailing system were retrospectively reviewed over a two year span. Electronic medical records were reviewed to collect demographic information and details regarding the patient’s procedure. Operative specifics collected included the data of the procedure and the preoperative diagnosis. Records were reviewed postoperatively as well to document the incidence of postoperative complications and functional outcomes. Proximal migration of the distal interlocking screw on lateral radiographs were measured in a standardized fashion at two, six, and twelve weeks to objectively assess additional compression obtained through the nitinol nailing system. Results: Eight patients were included in the case series with an average follow up time of 7 months postoperative (minimum of 4 months for one patient). The most common preoperative diagnosis was posttraumatic arthritis (n = 4). One patient suffered from wound dehiscence postoperatively that required operative intervention within the first three months – this patient’s wound healed by six months with no further complications. All patients were cleared for full weight bearing and activities as tolerated by six months, except only had four months of follow up available. The compression obtained through this nailing system increased at each follow up for all patients. The average compression obtained was 2.9 mm at two weeks, 3.8 mm at six weeks, and 4.4 mm at twelve weeks. Conclusion: Tibiotalocalcaneal arthrodesis can be an excellent procedure that provides significant pain relief and restores function. The patients in this case series all had excellent results with only one postoperative complication that ultimately did not result in any functional deficits. Furthermore, patients all demonstrated increased compression at each follow up radiographs which demonstrates the sustained compression obtained at the arthrodesis site through this hindfoot nail system. Further prospective work with a larger patient cohort is warranted to determine if this nailing system is superior to other TTC hindfoot nails.

Category: Hindfoot, Trauma Introduction/Purpose: Calcaneus fractures are common injuries of the foot and account for approximately sixty percent of all tarsal bone fractures. Anatomic reduction of the articular surface is associated with good long-term outcomes. Unfortunately, there is a high rate of complications following surgical fixation due to the fragile soft tissue envelope surrounding these injuries. External fixation of joint depression calcaneus fractures allows for restoration of morphology and preservation of soft tissues. The purpose of this work is to determine if acute external fixation in the management of joint depression calcaneus fractures leads to decreased postoperative complications and better outcomes. Methods: Patients were identified using the appropriate procedure codes over a ten year span at a level one trauma center. Those under the age of eighteen and underwent nonoperative treatment were excluded. Electronic medical records were reviewed to obtain, basic demographic data, comorbidities, and injury specifics. Calcaneus fractures were classified as open or closed and using the Essex-Lopresti classification system. Operative reports were reviewed to determine which patients initially underwent external fixation versus open reduction internal fixation (ORIF), furthermore any staged operative interventions were also noted. Electronic records were also reviewed to determine the length of follow up and incidence of postoperative complications. Bivariate analysis was used to identify an association between collected variables and postoperative complications (wound dehiscence, hardware failure, infection, nonunion). Multivariate logistic regression analysis was used to determine if patients treated with acute external fixation were associated with lower postoperative complication rates. Results: 152 calcaneus fractures were identified and included for analysis. The average age was thirty-eight and the majority of patients were male (111/152 = 73%). Average follow up was approximately five months. Seventeen percent (26/152) were open fractures. Twenty-six (17%) were treated initially with external fixation and eleven of these were a staged ORIF. The overall complication rate was 11% (17/152) with the most common complication being wound dehiscence. Only one complication occurred in the group initially managed with external fixation. Statistical analysis revealed that open fractures were associated with increased postoperative complication rates in a bivariate and multivariate model. Conclusion: External fixation of joint depression calcaneus fractures restores height and preserves the soft tissue envelope. Although there was only one complication in the external fixation group, the difference in complication rates was not statistically significant based on initial treatment. The low number of patients treated with external fixation initially and the short follow up are limitations of this study. Further work is needed with a larger patient cohort in a prospective setting. Acute external fixation may prove to be a useful tool to help prevent postoperative complications following joint depression calcaneus fractures.

Category: Trauma Introduction/Purpose: Ankle fractures are the third most common type of fracture seen in the elderly population and recent work has suggested that operative intervention may provide improved outcomes. Current outcome measures do not accurately assess true mobility in the geriatric population. In this study, we utilize the Life Space Assessment (LSA), a novel medical assessment survey which focuses specifically on how a patient functions within his/her environment following a medical event. This tool has not been previously utilized in orthopedic patients. We postulated that the LSA would provide improved assessment of these patients and help identify key differences in operative and non-operatively treated patients when compared to current outcome measures. Methods: This study was designed as a prospective observational study in which all geriatric patients age 65 and older with an ankle fracture were followed for one year from the time they presented for treatment. Treatment options of either non- operative or operative were determined by the attending physician on a patient specific basis. The patient was invited to participate in the study at the initial injury visit. The LSA was administered at the initial visit and 6 weeks, 3 months, 6 months and 12 months post injury/surgery. The SF-36 and Visual Analogue Pain Scale surveys were administered at 6 months and 12 months as a comparison. Survey scores were tallied and standard means were determined for each time point. Statistical analyses were performed to determine significance. Results: 26 patients met inclusion criteria and 20 were enrolled. 11 underwent surgery while 9 were treated non-operatively. The surgical LSA group scored 91.4 pre-injury and improved to 87.6 after 1 year which was near baseline (Graph #1). The non-op group recorded 80.88 pre-injury and only improved to 59.5 at 1 year. For the VAS, surgical patients reported pain of 2.2 and 1.75 at 6 and 12 months. Non-op patients recorded pain of 2.25 and 2.4 at 6 and 12 months. For SF-36 physical score, surgical patients recorded 57.6 and 75.8 at 6 and 12 months while non-op patients scored 53.3 and 59.43. SF-36 mental scores for the surgical group was 60.63 and 74.83 while non-op patients recorded 76.88 and 86.5 at 6 and 12 months. Conclusion: Operative patients returned to their baseline LSA while non-operative patients continued to have lower mobility at one year. All patients’ mobility was significantly limited for first three months. Surgical patients had less pain at 12 months compared to non-op. Surgical patients showed significant improvement in SF-36 physical scores from 6 months to 1 year while non-op patients had minimal improvement echoing our findings from LSA. The operative group had improved outcomes compared to non-op and this is reflected in both their LSA and SF- 36 scores. Further investigations are needed to determine optimal treatment paradigm for geriatric ankle fracture patients.

Category: Ankle, Trauma Introduction/Purpose: Frailty, a multifaceted syndrome resulting from a decrease in physiologic reserves, has been previously shown to play a significant role in elderly morbidity and mortality. The literature on frailty within orthopaedic surgery is limited currently. No study to date has assessed frailty as a predictor of postoperative outcomes in elderly patients with ankle fractures. We hypothesized that increasing frailty would be associated with increased 30-day reoperation rates and increased postoperative complications. Methods: The National Surgical Quality Improvement Project (NSQIP) was queried using the appropriate CPT codes to identify inpatients from 2005-2014 who were aged 50 years and older that sustained an ankle fracture and underwent operative fixation. Frailty was assessed using a modified frailty index (MFI), abbreviated with 11 variables from the Canadian Study of Health and Aging Frailty Index. The primary outcome was 30-day reoperation rate and secondary outcomes were postoperative surgical and medical complications, readmission rates, and length of stay. Bivariate and multivariate analysis was used to determine association between outcomes and MFI. Results: 6,749 patients were identified, and the mean age of these patients was 64.4 years. Patients with increased MFI scores had significantly higher rates of postoperative complications. In addition, increased MFI scores was also associated with increased 30 day readmissions and reoperations. Multivariate analysis also demonstrated that MFI was a stronger predictor of 30 day reoperation rates (odds ratio of 17.7, P < 0.001) than age, wound class, and ASA class. Conclusion: Frailty has the potential to be an important predictive variable of postoperative outcomes in patients aged 50 years and older who sustain ankle fractures. The modified frailty index can be a valuable preoperative risk assessment tool for the orthopaedic surgeon. Further study is necessary to examine the effect of the MFI in a larger prospective setting.

Background: Osteonecrosis of the talus is a well-recognized pathology, which can result in significant hindfoot collapse resulting in poor function and pain. Treatment with intramedullary tibiotalocalcaneal arthrodesis (IMTCA) using a retrograde intramedullary nail is widely utilized for severe concomitant tibiotalar and subtalar pathologies. This study reports the results of ankle and hindfoot arthrodesis in patients with arthritis and deformity caused specifically by talar osteonecrosis. Methods: Fourteen ankle and hindfoot arthrodeses with retrograde intramedullary nail were studied, with a mean follow-up of 26 months. Medical records were reviewed for operative technique, concomitant procedures, bone graft used, and postoperative complications including nonunion, infection, nerve injury, wound healing issues, and the need for additional surgeries. Clinical outcomes included Visual Analogue Scale for pain, the AOFAS Ankle/Hindfoot Score, and the SF-36 questionnaire. Results: Over 80% of cases had osteonecrosis involving the entire body of the talus. In 4 cases tibiocalcaneal arthrodesis was performed, with the remaining talar head-neck portion fused to anterior aspect of tibia. Union was achieved in all cases. The mean preoperative VAS score was 6.9 (range 5 to 9, SD ± 1.5) decreasing to 1.7 (range 0 to 6, SD ± 2.2) postoperatively ( P = .00008). The mean preoperative AOFAS score was 32.7 (range 20 to 46, SD ± 8.7), increasing to 72.1 (range 46 to 86, SD ± 10.1, P = .00003). The mean preoperative SF-36 physical component score was 30.5 (range 21 to 42, SD ± 6.9) increasing to 42.8 (range 20 to 60, SD ± 11.4) postoperatively ( P = .02). Complications included 1 stress fracture, 4 hardware removals, and 1 superficial infection. Conclusion: Ankle and hindfoot arthrosis due to extensive talar AVN can be successfully treated with IMTCA. Level of Evidence: Level IV, retrospective case series.

Future physician leaders must be able to critically assess health care policy and patient advocacy issues. Currently, no nationally accepted, standardized curriculum to provide advocacy education during orthopedic residency training exists. We therefore developed an "Advocacy" curriculum for our orthopedic residents designed to direct particular attention to patient advocacy, specialty advocacy, and healthcare policy.Residents were given pre- and post-curriculum questionnaires to gauge their perception of the importance, strengths, and weaknesses of this curriculum. A paired t-test was used to compare pre- and post-curriculum responses.Twenty-one of 24 orthopedic residents completed the pre-curriculum and post-curriculum questionnaire regarding the importance of advocacy education (87.5% response rate). Overall, 85.7% (18/21) of responders ranked the curriculum on orthopedic advocacy as good or excellent. Prior to the advocacy curriculum, 33.3% (7/21) of residents felt that learning about orthopedic advocacy was important to their education, while following the curriculum 100% (21/21) felt so (p0.05). The percentage of residents who considered health policy to be important increased from 71.4% (15/21) to 95.2% (20/21) following the curriculum(p0.05). Following the advocacy curriculum, 90.5% (19/21) of responders would be interested in getting involved in orthopedic advocacy.This curriculum significantly increased residents' belief in the importance of advocacy issues. Following the curriculum, 100% of responding residents considered orthopedic advocacy education as important. An advocacy curriculum may serve as an integral preparatory educational core component to residency training.

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

Background Total ankle replacement has increased in popularity in the management of severe tibiotalar arthritis. Most previous clinical reports focused on mobile-bearing designs. This study evaluates early radiographic and clinical results of the Salto fixed bearing design. Methods Twenty-three Salto fixed-bearing implants were prospectively studied. Records were reviewed for clinical outcome scores (VAS, AOFAS, SF36), subsequent surgeries, complications, radiographic data and implant survivorship. Average follow-up was 36 months. Results Statistically significant improvements in VAS, AOFAS ankle/hindfoot scores, and SF36 scores were shown at an average of 3 years postoperatively. At 3 years followup, survivorship of the implant was 82.6% with any reoperation as the endpoint and 95.6% for revision or removal of components. Seven patients had radiolucencies around the implant, one of which required revision to arthrodesis. Conclusion The fixed-bearing Salto ankle replacement has comparable early radiographic and clinical results to reports of the mobile-bearing Salto of comparable followup. Level of evidence: Level IV

Calcaneal osteotomy is a commonly used tool in cavovarus foot reconstructions. Understanding the indications and limitations of such an osteotomy is critical to success in reconstruction. We present a comprehensive review of surgical calcaneal osteotomy techniques and the currently available state of literature for their indications and limitations.

Multi-filament orthopaedic cerclage cables have been used in clinical practice for several decades, and are commonly utilized to provide greater trochanteric fixation following an osteotomy or fracture. We present the first known report of patients who experienced early catastrophic failure following use of the Dall-Miles Cable Grip System (DMCGS). A root cause analysis determined that the jaws of one crimper had an increased distance at closure, resulting in inadequate ultimate fixation strength. It was discovered that operating room staff had not been trained to perform regular calibration checks and the required calibration tool was not included in any of the institution’s DMCGS sets. Surgeons should be aware that these surgical instruments require regular maintenance and should be gauge tested prior to every use.

Subtrochanteric femur fractures present a challenge to orthopedic surgeons. Anatomic reduction and stabilization can be technically difficult. A variety of intramedullary and extramedullary devices have been used to stabilize these fractures. The authors describe a novel technique for easier proximal interlock fixation for reconstruction intramedullary nailing to ensure proper placement into the nail. This will likely save time in a patient population that may be either frail and elderly or young with high-energy polytrauma, and it may reduce radiation exposure for both patients and surgeons. [ Orthopedics. 2014; 37(2):107–110.]

Background Supination external rotation (SER) injuries are commonly fixed with a one third tubular neutralization plate. This study investigated if a combination locked plate with additional fixation options was biomechanically superior in osteoporotic bone and comminuted fracture models. Methods Using an osteoporotic and a comminuted Sawbones model, SER injuries were fixed with a lag screw for simple oblique fibula fractures, and either a one third tubular neutralization plate or a locking plate. Samples were tested in stiffness, peak torque, displacement at failure, and torsion fatigue. Results There was no statistically significant difference in biomechanical testing for fractures treated with a lag screw and plate. For comminuted fractures, locked plating demonstrated statistically significant stiffer fixation. Conclusion A combination locked plate is biomechanically superior to a standard one third tubular plate in comminuted SER ankle fractures. There was no biomechanical superiority between locked and one third tubular plates when the fracture was amenable to a lag screw.

While intracompartmental pressure monitoring is a widely used diagnostic tool to measure intracompartmental pressures in the setting of compartment syndrome, its invasive nature has prompted the development of noninvasive techniques, such as near-infrared spectrometry. We prospectively assessed the association between tissue oxygen saturation measured by near-infrared spectrometry and compartment pressure measured by intracompartmental pressure monitoring in a cohort of patients with compartment syndrome of the lower extremity. We hypothesized that tissue oxygen saturation measured by near-infrared spectrometry would negatively correlate with intracompartmental pressures. Tissue oxygen saturation was determined for all 4 compartments of the lower extremity in 7 patients using near-infrared spectrometry. All patients subsequently underwent lower-extremity fasciotomies. Mechanism of injury, compartment pressures, blood pressure, near-infrared spectrometry measurement of tissue oxygen saturation, and characteristics of the muscle at the time of fasciotomy were recorded. The strength of the correlations between tissue oxygen saturation and absolute and relative compartment pressures was estimated based on mixed linear (growth) models with repeated observations nested within patients. Our analyses demonstrated no significant relationship between tissue oxygen saturation measured by near-infrared spectrometry and the absolute or relative compartment pressures. This suggests that compartment tissue oxygen saturation measurements by near-infrared spectrometry do not correlate with the diagnosis of compartment syndrome, and that near-infrared spectrometry would not serve as a reliable diagnostic tool.

Systemic regulation of the cellular processes that produce endochondral elongation and endochondral mineralization during postnatal skeletal maturation are not completely understood. In particular, a mechanism coupling the decline of cellular activity in the bone microenvironment to the onset of sexual maturity remains elusive. The purpose of this study was to empirically integrate the dynamic progression of bone mineral accrual and endochondral elongation as a function of animal age in growing male and female Sprague-Dawley rats. We used serial dual-energy X-ray absorptiometry (DXA) and radiography to study the temporal progression of bone growth and mineral accrual from weaning to adulthood. We observed that skeletal maturation proceeds in a pattern adequately described by the Gompertz function. During this period of growth, we found that serum markers of osteoblastic bone formation declined with age, while osteoclastic bone resorption activity remained unchanged. We also report a slight lag in the age at inflection in the rate of bone mineral accrual relative to the rate of tibial elongation and that both endochondral processes eventually come to asymptotic equilibrium by approximately 20 weeks of age. In addition, we studied tibial growth plate histomorphometry at select time points through 1 year of age. We report that, despite the histologic persistence of physeal cartilage, very little proliferative or elongative activity was measured in this tissue beyond 20 weeks of age. Taken together, these data provide insight to the temporal coordination of postnatal endochondral growth processes.

Radiation therapy encompassing an active epiphysis can negatively impact the potential for bone growth by disrupting cell-cycle progression and accelerating apoptosis and terminal differentiation in physeal chondrocytes. Despite functional derangement following radiation exposure, the irradiated growth plate retains a capacity for regeneration and recovery of growth. The purpose of this study was to characterize the initial sequence of events leading to functional growth recovery in irradiated weanling rat growth plates. We hypothesized that growth in an irradiated epiphysis would be partially restored due to the expansion of chondrocytic clones. Stereological histomorphometry was used to compare chondrocytic cell and matrix turnover between the first and second week following irradiation, and to determine the relative contribution of each of the cellular and extracellular matrix (ECM) compartments to growth. We found that restoration of growth in the irradiated limb was strongly associated with the proliferative activity and production of ECM by these chondrocytic clones, as they expand in average volume, but not in numerical density. We conclude that chondrocytes forming expansive clones and exhibiting increased mitotic and matrix synthesis activity initiate the early restoration of function in the irradiated growth plate, and would be a logical target for strategies to restore full growth potential.

Little is known of the normal physiological processes that govern the cell surface residency of the human follitropin receptor (hFSHR), a G protein-coupled receptor expressed in the ovary and testis. In the hFSHR, the third intracellular (3i) loop is considered to be pivotal in attenuation of ligand activation, particularly internalization. To gain a better understanding of these processes, we used a yeast-based interaction trap to identify cytoplasmic proteins in a human ovarian cDNA library that interacted with the hFSHR 3i loop. Among the cDNA identified, four encoded isoforms of ubiquitin. Immunoprecipitated hFSHR probed with an antiubiquitin antibody revealed that the receptor is ubiquitinated, although not exclusively on the 3i loop. Cell-surface hFSHR levels increased when expressed at nonpermissive temperature in a temperature-sensitive, ubiquitination-defective cell line. Similarly, after treatment with proteasome inhibitors, HEK293 cells stably transfected with an hFSHR expression plasmid showed an increase in follitropin binding. Proteasome inhibitors did not affect the rate of FSH internalization when receptors were saturated before internalization was measured. In contrast, internalization decreased when binding experiments were performed under nonequilibrium conditions. A mutant hFSHR-K555R, which removes the only lysine in the 3i loop available for ubiquitination, was still ubiquitinated, illustrating that, although the third loop enables and interaction with ubiquitin, it is not the sole site of ubiquitination. These observations are consistent with a role for ubiquitination in the regulation of hFSHR cell surface residency. Additionally, it can be inferred that a sequence in the 3i loop is involved in regulating receptor ubiquitination and internalization.

Introduction Radiocarpal dislocations are complex injuries characterized by having a high-energy shear and rotational force to the wrist. While these injuries were previously managed using closed reduction and immobilization, recent reports have recognized the instability of these complex injuries, and have described treatment algorithms using open reduction and internal fixation. Current management of radiocarpal dislocations has been based on the following previously described principals: concentric reduction of the radiocarpal joint, identification and appropriate treatment of intercarpal ligament injuries, and stable repair of the osseous-ligamentous avulsions. Treatment with wrist arthroscopy has never been described. We report a case of ulnar radiocarpal wrist dislocation successfully treated with wrist arthroscopy and percutaneous pinning Methods A 23-year-old right-hand–dominant man presented after a motor vehicle accident with a right ulnar radiocarpal wrist dislocation, ulnar styloid fracture, and triquetrum avulsion fracture. The patient was taken to the operating room where a closed reduction was attempted. During stress exam under fluoroscopic imaging, it was apparent that a closed reduction was unobtainable, and we converted to wrist arthroscopy. From the 3-4 portal, a portion of the radioscaphocapitate ligament was seen interposed within the radiocarpal joint preventing concentric reduction of the carpus. The ligament was reflected back into position and the carpus subsequently concentrically reduced. From the 4-5 portal the dorsal radiocarpal ligament was found to be ruptured and was debrided. Two K-wires were placed across the wrist; one was placed proximal to the radial styloid through the scaphoid and capitate, and the second placed from proximal to the radial styloid through the radius, and across the lunate and triquetrum. The wrist was immobilized for 3 months, and the pins were then removed. Results At the 4-month follow-up appointment, the patient had grip strength of 86 lbs, compared to 145 lbs in his contralateral hand (59%), with 40 degrees of flexion and 60 degrees of extension. At 10 months, the patient had full pronation and supination, grip strength of 130 lbs compared to 155 lbs in the contralateral hand (84%), and lacked only 20 degrees of wrist flexion compared to the contralateral side. He returned to his pre-injury job as a manual laborer. Conclusion This is the first description of an ulnar radiocarpal dislocation successfully treated with wrist arthroscopy and percutaneous pinning. While the current applications for wrist arthroscopy are extensive, its use in fracture and dislocations of the carpus are limited. Advantages of wrist arthroscopy are that it allows for direct visualization and treatment of intercarpal and midcarpal injuries. More importantly, treatment of these injuries can be completed with minimal disruption of the soft tissues. While our treatment algorithm followed the majority of the previously described treatment principles for the treatment of radiocarpal dislocations, we did not address neurovascular structures and the extrinsic wrist ligaments, which would require open decompression. Our results show that a successful clinical outcome and stable radiocarpal wrist joint are obtainable by addressing intercarpal injuries arthroscopically, and stabilizing the radiocarpal joint.

Radiocarpal dislocations are complex injuries characterized by high-energy shear and rotational forces to the wrist, often combined with a fracture of the distal part of the radius or ulna1. They often present as open fractures and can be complicated by soft-tissue injuries such as intercarpal and radiocarpal ligament tears and nerve injuries1-3. Current management of radiocarpal dislocations is based on treatment principles described by Ilyas and Mudgal, which include concentric reduction of the radiocarpal joint, identification and appropriate treatment of intercarpal ligament injuries, and stable repair of the osseous-ligamentous avulsions1. While these injuries were previously managed with the use of closed reduction and immobilization4-7, authors of recent reports have recognized the instability of these complex injuries and have described treatment algorithms using open reduction and internal fixation1. We report a case of ulnar radiocarpal wrist dislocation treated with wrist arthroscopy and percutaneous pinning without repair of the extrinsic wrist ligaments. A twenty-three-year-old right-hand-dominant male presented with pain in the left wrist one week after a motorcycle accident. He had no neurological symptoms and no pain in other extremities. The patient's medical and surgical histories were noncontributory. The findings on the neurovascular examination of the left hand were normal, and the patient was able to actively flex and extend the wrist approximately 20° with extreme pain. There was diffuse swelling about the wrist and pain with passive wrist motion. There was diffuse tenderness about the radiocarpal and midcarpal joints, and the patient was unable to tolerate any instability examinations secondary to severe pain. He had painless motion of the ipsilateral elbow and shoulder. Radiographs of the wrist demonstrated an ulnar styloid fracture, triquetral avulsion fracture, and ulnar shift of the carpus that was approximately 3.3 mm more …