A National Survey of Orthopaedic Residents Identifies Deficiencies in the Understanding of Medical Statistics.

BACKGROUND: Biomedical research is essential for optimizing patient care. Research has suggested inadequacies in nonorthopaedic trainees' understanding of study design and biostatistics. This study assesses orthopaedic residents' knowledge of common biostatistical and study design concepts, as well as their confidence in utilizing the medical literature. METHODS: A validated survey assessing knowledge and the application of study design concepts was administered to residents at 10 U.S. institutions. The survey tested knowledge as well as confidence and attitudes regarding common biostatistics principles. The association of demographic characteristics, work activities, and confidence and attitude ratings with test performance were examined using t tests and analysis of variance. RESULTS: The survey response rate was 64% (178 of 279). The largest group of participants were men (83%, 137 of 165), were between the ages of 26 and 30 years (59%, 105 of 177), and had graduated medical school within the past 4 to 10 years (43%, 76 of 175). Fifty-three percent (93 of 176) had prior biostatistics training, while 44% (77 of 176) had prior epidemiology training. Less than 5% of biostatistics or epidemiology training had taken place after medical school. Forty-seven percent (83 of 176) were unable to determine a study's design. Thirty-eight percent (67 of 178) could not apply the concept of specificity and sensitivity. Eighty-three percent (147 of 178) could not assess the strength of a relationship using odds ratios. Sixty-nine percent (123 of 178) understood the implications of p values. Previous biostatistics training, but not epidemiology or evidence-based medicine training; inclusion of reading research, attending conferences, and data analysis; as well as a self-reported finding of statistics as important for the analysis of one's own research data were significantly associated with better test performance (p < 0.05). CONCLUSIONS: Notable deficits exist in orthopaedic residents' biostatistical knowledge. Greater emphasis is needed to improve biostatistics and research design training. The impact of biostatistics knowledge and/or aptitude on clinical decision-making is an area of suggested research.

A systematic review and meta-analysis of complications in conversion arthroplasty methods for failed intertrochanteric fracture fixation.

BACKGROUND: Conversion arthroplasty for failed primary fixation of intertrochanteric fractures can be achieved using various methods, including cemented total hip arthroplasty, uncemented total hip arthroplasty, hybrid total hip arthroplasty, and hemiarthroplasty. Complication rates vary between each conversion method. The purpose of this paper is to examine the effect of conversion method on total conversion complication rates. METHODS: We performed a meta-analysis of five studies with sufficient data for analysis. We created a null hypothesis stating that the expected distribution of complications across conversion methods would reflect the distribution of conversion method used for failed primary fixation. Using a z test, we compared proportions of the expected distribution of complications to the observed distribution of complications. RESULTS: A total of 138 cases of conversion arthroplasty with 49 complications were available for analysis. The mean age was 73 (range, 32-96) years. 19 males and 48 females were included, with one study not including patient gender. The mean time from primary fixation failure to conversion was 11 months, and the mean duration of conversion surgery was 132 min. Expected and observed complication rate distributions were as follows: cemented total hip arthroplasty, 6.5% versus 4.1% (p = 0.79); uncemented total hip arthroplasty, 77.5% versus 81.6% (p = 0.69); hybrid total hip arthroplasty, 2.9% versus 2.0% (p = 1); and hemiarthroplasty, 13% versus 12.2% (p = 1). CONCLUSIONS: Our findings suggest that the method of conversion arthroplasty following failed primary intertrochanteric femur fracture fixation does not influence complication rate.

Prevalence and Safety of Left-Footed Driving Following Right Foot Surgery Patients Including a Driving Simulation.

BACKGROUND: For many patients, returning to driving after right foot and ankle surgery is a concern, and it is not uncommon for patients to ask if driving may be performed with their left foot. A paucity of literature exists to guide physician recommendations for return to driving. The purpose of this study was to describe the driving habits of patients after right-sided foot surgery and assess the safety of left-footed driving using a driving simulator. METHODS: Patients who underwent right foot or ankle operations between January 2015 and December 2015 were retrospectively identified. A survey assessing driving habits prior to surgery and during the recovery period was administered via a REDCap database through email or telephone. Additionally, simulated driving scenarios were conducted using a driving simulator in 20 volunteer subjects to compare characteristics of left- versus right-footed driving. RESULTS: Thirty-six of 96 (37%) patients who responded to the survey reported driving with the left foot postoperatively. No trends were found associating left-footed driving prevalence and socioeconomic status. In driving simulations, patients exceeded the speed limit significantly more (P < .001) and hit other vehicles more (P < .026) when driving with the right foot than the left. The time to fully brake and fully release the throttle in response to vehicular hazards was significantly prolonged in left-footed driving compared with right (P = .019 and P = .034, respectively). CONCLUSION: A significant proportion of right foot ankle surgery patients engaged in left-footed driving during postoperative recovery. Driving with both the right and left foot presents a risk of compromised safety. This study provides novel objective data regarding the potential risks of unipedal left-footed driving using a standard right-footed console, which indicates that driving with the left foot may prolong brake and throttle release times. Further studies are warranted for physicians to be able to appropriately advise patients about driving after foot and ankle surgery. LEVEL OF EVIDENCE: Level IV, case series.

Use of intramedullary carbon fiber nail in hindfoot fusion: A small cohort study.

BACKGROUND: Current literature on carbon fiber implant use in foot and ankle surgery is scant. The purpose of this paper is to report medium-term outcomes of hindfoot fusion using a carbon fiber intramedullary nail. METHODS: We retrospectively reviewed 30 cases of hindfoot fusion using carbon fiber intramedullary nail fixation between 2014 and 2017. We excluded revisions and cases with bulk allograft or ankle infection prior to surgery. We reviewed charts for length of followup, radiographic union, and complications. RESULTS: Eleven patients were included (6 females, 5 males; mean age=52±15years; mean BMI=29.0±6.4kg/m2). Mean followup was 20 (range, 1.5-107) months. Nine of eleven cases achieved radiographic union while one case developed a complication requiring surgery. The mean time to union was 3 (range, 1.5-6) months. CONCLUSIONS: Carbon fiber implants offer several theoretical advantages over traditional metallic implants. They can be used safely in foot and ankle surgery without concern for high failure or complication rate. Larger scale studies with longer followup are needed on this topic.

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.

Revisiting the Prevalence of Associated Copathologies in Chronic Lateral Ankle Instability: Are There Any Predictors of Outcome?

BACKGROUND: Multiple ankle pathologies have been found to coexist with chronic lateral ankle ligament instability, but their prevalence varies widely in the literature. The purpose of this study is to reexamine the prevalence of these associated pathologies and to determine their impact on reoperation rate. METHODS: We retrospectively reviewed 382 cases of lateral ankle ligament repair/reconstruction between June 2006 and November 2016. Patient charts and radiograph reports were examined for the presence of any associated foot and ankle pathologies as well as clinical course. The effect of copathologies on reoperation rate was examined using binary logistic regression and the χ2 test. RESULTS: We included a total of 99 cases. Copathologies included peroneal pathology (75/99, 75.8%), ankle impingement (40/99, 40.4%), and osteochondral lesion of the talus (17/99, 17.2%); 36.4% (36/99) had a low-lying muscle belly of peroneus brevis. The total reoperation rate was 12/92 (13.1%). It was lower in cases with peroneal pathology (8.7% vs 27.5%, P = .032). CONCLUSION: Peroneal pathology, ankle impingement, and osteochondral lesions were the most common associated copathologies in surgical patients with chronic lateral ankle ligament instability. The presence of peroneal pathology may lead to fewer reoperations, possibly as a result of a more comprehensive first-time surgical approach. Level of Evidence: Level III: Retrospective cohort.

Preoperative Assessment of the Peroneal Tendons in Lateral Ankle Instability: Examining Clinical Factors, Magnetic Resonance Imaging Sensitivity, and Their Relationship.

The purpose of our study was to examine the preoperative clinical factors and magnetic resonance imaging (MRI) findings associated with peroneal pathology in chronic lateral ankle instability patients, as well as the clinical factors associated with peroneal lesions being detected on MRI. Peroneal pathology was determined from intraoperative findings. Patients with/without peroneal pathology were compared regarding their preoperative clinical findings. MRI reports were examined to determine the sensitivity of detecting peroneal pathologies. Clinical factors were compared between patients (N = 238) with undetected and detected peroneal lesions on MRI. Conservative treatment, preoperative physical therapy, and lack of a traumatic inciting event were associated with peroneal pathology. MRI had a sensitivity of 61.11% for detecting peroneal pathology. No clinical factors were significantly different between "detected" and "undetected" cases. Certain historical factors were associated with peroneal pathology in patients with chronic lateral ankle instability, and MRI had a high false-negative rate. Surgeons should exercise caution when ruling out peroneal pathology based on preoperative physical examination or MRI.

Is retained bone debris in cannulated orthopedic instruments sterile after autoclaving?

AIMS: Cannulated surgical instruments may retain biologic debris after routine cleaning and sterilization. Residual debris after cleaning is assumed to be sterile; however, there is no experimental basis for this assumption. The purpose of this study was to determine the sterility of retained biodebris found within cannulated surgical instruments after autoclave sterilization. MATERIALS AND METHODS: Fifteen cannulated drill bits were used to drill pig scapulae to create a plug of bone that was exposed to a mixture of Bacillus cereus, Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus for 60, 120, or 180 minutes prior to sterilization. The drill bits were autoclave sterilized using standard settings. The "sterilized" bone cores were then incubated in solution and streak-plated on blood agar. RESULTS: All 3 positive controls were positive for the experimental bacteria. Two negative controls were positive for contaminant bacteria. A B. cereus strain was recovered from 1 of the experimental group drill bits in the 180-minute group. Pulsed-field gel electrophoresis confirmed that the recovered B. cereus strain was identical to the experimental inoculate. CONCLUSION: Retained biodebris in cannulated drills may not be sterile after standard autoclave sterilization. In addition, delay of surgical instrument reprocessing may increase the risk of resistant contamination.

Gastrocnemius recession for recalcitrant plantar fasciitis in overweight and obese patients.

BACKGROUND: Plantar fasciitis is a common foot pathology that is typically treated non-operatively. However, a minority of patients fail non-operative management, develop chronic symptoms, and request a surgical option. Gastrocnemius recession has recently been shown to be effective for the treatment of chronic plantar fasciitis. The purpose of this paper is to present evidence that gastrocnemius recession is safe and effective in the subset of chronic plantar fasciitis patients who are overweight and obese. METHODS: We retrospectively reviewed 18 cases (17 patients) of chronic plantar fasciitis in overweight or obese patients who underwent gastrocnemius recession (mean age=46years, mean body mass index=34.7kg/m2, mean follow-up=20months). Data was gathered regarding pre-operative and post-operative pain (visual analog scale, 0-10), Foot Function Index score, and complications. RESULTS: Mean Foot Function Index score improved from 66.4 (range, 32.3-97.7) preoperatively to 26.5 (range, 0-89.4) postoperatively (p<0.01). Mean pain score improved from 8.3 (range, 5-10) preoperatively to 2.4 (range, 0-7) at final follow-up (p<0.01). CONCLUSIONS: Gastrocnemius recession improved foot function and pain symptoms in overweight and obese patients with chronic plantar fasciitis.

ROLE OF BONE GRAFTS AND BONE GRAFT SUBSTITUTES IN ISOLATED SUBTALAR JOINT ARTHRODESIS.

OBJECTIVES: The purpose of this study was to compare union rates for isolated subtalar arthrodesis with and without the use of bone grafts or bone graft substitutes. METHODS: We retrospectively reviewed 135 subtalar fusions with a mean follow-up of 18 ± 14 months. The standard approach was used for all surgeries. Graft materials included b-tricalcium phosphate, demineralized bone matrix, iliac crest autograft and allograft, and allograft cancellous chips. Successful subtalar fusion was determined clinically and radiographically. RESULTS: There was an 88% (37/42) union rate without graft use and an 83% (78/93) union rate with bone graft use. Odds ratio of union for graft versus no graft was 0.703 (95% CI, 0.237-2.08). The average time to union in the graft group was 3 ± 0.73 months and 3 ± 0.86 in the non-graft group, with no statistically significant difference detected (p = 0.56). CONCLUSION: Graft use did not improve union rates for subtalar arthrodesis. Level of Evidence IV, Case Series.

OBJETIVOS: O propósito deste estudo foi comparar as taxas de união de artrodese subtalar isolada com e sem uso de enxertos ósseos ou seus substitutos. MÉTODOS: Revisamos retrospectivamente 135 fusões subtalares com seguimento médio de 18 ± 14 meses. A via de acesso padrão foi utilizada em todas as cirurgias. Os enxertos utilizados incluíram fosfato b-tricálcico, matriz óssea desmineralizada, autoenxerto e aloenxertos da crista ilíaca e aloenxerto de lascas de osso trabecular. A fusão subtalar bem-sucedida foi determinada clínica e radiograficamente. RESULTADOS: Verificou-se uma taxa de união de 88% (37/42) sem uso de enxerto e de 83% (78/93) com enxerto ósseo. A análise da razão de chances (odds ratio) de união óssea para enxerto e não enxerto foi 0,703 (IC 95%, 0,237-2,08). O tempo médio de união no grupo com enxerto foi de 3 ± 0,73 meses e 3 ± 0,86 no grupo sem enxerto, sem detecção de diferença estatisticamente significante (p = 0,56). CONCLUSÃO: O uso de enxerto não melhorou as taxas de união na artrodese subtalar. Nível de Evidência IV, Série de Casos.

Outcomes of Locking-Plate Fixation for Hindfoot Fusion Procedures in 15 Patients.

Tibiotalocalcaneal arthrodesis is a salvage procedure for various end-stage foot and ankle pathologic entities. Several factors are known to influence the union rate after these procedures, including construct rigidity. The data on locked plates as a fixation technique have been inconclusive, with variable union rates reported. One recent study suggested that locking plates can lead to high nonunion rates owing to excessive rigidity. The purpose of the present study was to retrospectively examine the outcomes of locking plate fixation. We retrospectively reviewed the cases of 15 patients (7 [46.7%] male, 8 [53.3%] female) who underwent tibiotalocalcaneal, tibiocalcaneal, or tibiotalar arthrodesis fixed with a locking plate from January 2013 to January 2014. The average age was 52.19 ± 5.8 years. The mean follow-up period was 17 ± 5.3 months. We examined the overall union rates and the effects of smoking, diabetes, and rheumatologic status on the union rate. Of the 15 cases, 11 (73.3%) did not achieve union. The mean time to failure was 10 ± 5.3 months. Age, gender, smoking, diabetes, use of augmentation screws outside the plate, and operating surgeon did not have an effect on the failure rate (p > .50). In addition, gender, smoking, and diabetes did not predict for nonunion. The high failure rate of rigid locking plate fixation reported might be attributable to the high incidence of smoking and diabetic comorbidities in our study. However, excessive construct rigidity might play an important role. Larger studies are needed to establish more reliable union rates with the use of locking plates in foot and ankle fusion.

Role of bone grafts and bone graft substitutes in isolated subtalar joint arthrodesis / Papel do enxerto ósseo e substitutos ósseos na artrodese isolada da articulação subtalar

ABSTRACT Objectives: The purpose of this study was to compare union rates for isolated subtalar arthrodesis with and without the use of bone grafts or bone graft substitutes. Methods: We retrospectively reviewed 135 subtalar fusions with a mean follow-up of 18 ± 14 months. The standard approach was used for all surgeries. Graft materials included b-tricalcium phosphate, demineralized bone matrix, iliac crest autograft and allograft, and allograft cancellous chips. Successful subtalar fusion was determined clinically and radiographically. Results: There was an 88% (37/42) union rate without graft use and an 83% (78/93) union rate with bone graft use. Odds ratio of union for graft versus no graft was 0.703 (95% CI, 0.237-2.08). The average time to union in the graft group was 3 ± 0.73 months and 3 ± 0.86 in the non-graft group, with no statistically significant difference detected (p = 0.56). Conclusion: Graft use did not improve union rates for subtalar arthrodesis. Level of Evidence IV, Case Series.

RESUMO Objetivos: O propósito deste estudo foi comparar as taxas de união de artrodese subtalar isolada com e sem uso de enxertos ósseos ou seus substitutos. Métodos: Revisamos retrospectivamente 135 fusões subtalares com seguimento médio de 18 ± 14 meses. A via de acesso padrão foi utilizada em todas as cirurgias. Os enxertos utilizados incluíram fosfato b-tricálcico, matriz óssea desmineralizada, autoenxerto e aloenxertos da crista ilíaca e aloenxerto de lascas de osso trabecular. A fusão subtalar bem-sucedida foi determinada clínica e radiograficamente. Resultados: Verificou-se uma taxa de união de 88% (37/42) sem uso de enxerto e de 83% (78/93) com enxerto ósseo. A análise da razão de chances (odds ratio) de união óssea para enxerto e não enxerto foi 0,703 (IC 95%, 0,237-2,08). O tempo médio de união no grupo com enxerto foi de 3 ± 0,73 meses e 3 ± 0,86 no grupo sem enxerto, sem detecção de diferença estatisticamente significante (p = 0,56). Conclusão: O uso de enxerto não melhorou as taxas de união na artrodese subtalar. Nível de Evidência IV, Série de Casos.

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.

Recurrent Extra- and Intra-articular Synovial Chondromatosis of the Ankle with Tarsal Tunnel Syndrome: A Rare Case Report.

INTRODUCTION: Synovial chondromatosis is a rare, benign monoarticular condition characterized by the metaplastic formation of cartilaginous nodules from the synovium of joints (intra-articular), tendons and bursae (extra-articular). These nodules have the potential to detach and form loose bodies within the joint space. The most common locations are the large joints such as the knees, hips, elbows, and shoulders, with less common locations being the foot and ankle joints. Synovial chondromatosis primarily occurs in men between the third and fifth decades of life, and it typically presents as chronic joint pain with swelling, decreased joint range of motion, and osteoarthritis. Treatment is usually centered on excision and retrieval of nodules and loose bodies. Prognosis is usually good with a low-moderate likelihood of recurrence. CASE REPORT: We report the very rare case of a 27-year-old male with recurrent intra- and extra-articular ankle synovial chondromatosis, who also reported symptoms consistent with tarsal tunnel syndrome. His initial presentation was left ankle pain which was managed by open surgical debridement. Two years after, he re-presented with continued pain and tingling along the plantar aspect of his foot. On his second presentation, a dual approach was taken with arthroscopic as well as open debridement. He reported resolution of his symptoms postoperatively as well as at 3 years of follow-up. CONCLUSION: Simultaneous extra- and intra-articular chondromatosis of the ankle is very rare and can be difficult to treat. It is important to recognize this disease as a rare but plausible cause of tarsal tunnel syndrome. Treatment may be complicated with early or late recurrence despite complete excision, highlighting the need for intentional follow-up of all cases.

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.