Characteristics and Trends of Highly Cited Articles in Calcaneus Fracture Research.

Background: Despite significant effort expended toward exploring fracture patterns, surgical timing, surgical approaches, and possible implants within the calcaneus fracture literature, treatment is still fraught with complications and controversy. This study aims to conduct a citation analysis of the most cited articles related to calcaneus fractures to highlight the most historically influential articles, as well as the more recent breakthrough articles that are leading change within the field. Methods: A literature search was performed via Scopus on September 20, 2021 using the terms "(calcaneus OR calcaneal OR hindfoot) AND (fracture OR injury)" to search "article title, abstract, and keywords" of all primary and review articles. Search results were rigorously reviewed to ensure appropriateness for this study. The 50 highest total cited included articles were analyzed. Title, authors, journal, country of origin, institution, year of publication, citation variables (total citation count, total citation density, citation count from the last 5 years, and 5-year citation density), and level of evidence were collected for each article. One-way analysis of variance with post hoc testing was used to identify differences in citation variables and level of evidence. Pearson correlation was used to directly compare different citation variables. Results: The total citation count average was 178±33, with a total citation density average of 9±2. The year of publication for the 50 articles ranged from 1948 to 2014, with a median year of 1999. Roy W. Sanders was the most productive author in the field, authoring 6 articles and lead authoring 3. The most frequent level of evidence was IV with 19 articles. There was a strong correlation between total citation density and 5-year citation density. The article level of evidence showed no impact on the included measures of an article's influence. Conclusion: This study successfully analyzes and presents the characteristics among the highest cited articles related to calcaneus fractures. The provided characterization of influential works and authors highlights trends, impactful findings, and future areas of focus within calcaneus fracture literature.Level of Evidence: Review Article.

Biologic Augmentation of Tibiotalocalcaneal Arthrodesis With Allogeneic Bone Block Is Associated With High Rates of Fusion.

BACKGROUND: The orthopaedic conditions and systemic comorbidities that occur in patients who require bone block tibiotalocalcaneal (TTC) arthrodesis have made this procedure associated with a higher-than-normal risk of nonunion, graft collapse, hardware failure, and amputation. Here, we present a novel approach to bone block TTC arthrodesis using adjunctive osteoinductive agents and a prolonged course of protected weightbearing to assess if we could improve on historical outcomes. We also evaluated the efficacy of a vascularized medial femoral condyle (MFC) free flap to augment TTC arthrodesis. METHODS: Fourteen adult patients underwent bone block TTC arthrodesis biologically augmented with fresh-frozen femoral head allograft, bone marrow aspirate concentrate, and demineralized bone matrix cortical fibers. Three patients with soft tissue defects underwent vascularized reconstruction with an MFC free flap. Radiographic union, the Foot Function Index (FFI), and PROMIS pain interference (PI), and physical function (PF) scores were assessed at follow-up. RESULTS: TTC fusion was documented on plain radiograph in 13 of 14 patients (92.9%) and CT in 10 of 11 patients (90.9%). Mean time to fusion was 183.2 ± 83.2 days. One patient (7.1%) experienced nonunion and persistent infection requiring amputation. Patients who underwent vascularized bone grafting had significantly shorter time to fusion (112.3 ± 31.7 days vs 204.4 ± 82.7 days, P = .05). Patient-reported outcomes revealed mild to moderate pain and dysfunction after 1 year (mean FFI = 41.0% ± 23.1%, PROMIS PI = 58.3 ± 1.8, PROMIS PF = 39.0 ± 2.2). CONCLUSION: In this relatively small series, the biologic augmentation of bone block TTC arthrodesis with osteoinductive agents and protective weightbearing resulted in excellent rates of fusion, modest pain, and preserved function of the lower extremity in almost all those treated. Osseous healing appears to be enhanced and accelerated with application of an MFC flap. We believe that this approach offers a viable salvage option for these challenging clinical problems. LEVEL OF EVIDENCE: Level IV, case series.

Interleukin-6 gene polymorphism in Saudi population with recurrent aphthous stomatitis.

INTRODUCTION: Recurrent aphthous ulcers are common but poorly understood mucosal disorder. Local and systemic conditions, genetic, immunological, and microbial factors may play a role in the pathogenesis of recurrent aphthous ulceration (RAS). Different aetiologies and mechanisms might be involved in the aetiopathogenesis of aphthous ulceration. Cytokines are thought to play an important role and high levels of interleukin (IL)-6, a pro-inflammatory cytokine, have been detected in the circulation of ulcer tissue. The purpose of the present study was to investigate if polymorphisms of IL-6 gene are associated with RAS in a cohort of specific population. METHODOLOGY: A total of 37 RAS patients and 18 healthy controls were included in the study. The genotypes of IL-6 gene -174G\C polymorphisms were determined using polymerase chain reaction and sequencing. RESULTS: Four SNPs were analyzed, one known mutation which been evaluated as a risk factor for RAS, and three new mutations were investigated. The genotype frequencies of -174G\C polymorphism showed no statistically significant differences between RAS patients and controls (p\ 0.629). Polymorphisms of Rs1800795 heterozygous genotype were found in 21.62% of cases, and 33.33% of controls. Homozygous mutant genotype was found in 5.41% of cases and no homozygous mutant genotype was found in control group. The normal alleles were found in 72.97% of cases and 66.67% of control. CONCLUSION: Thus, according to our study, IL-6 gene polymorphism is not involved in RAS pathogenesis. Further studies should be done on large sample size to detect any association with pathogenesis. However, an alternative reasoning could point out to a complex interactive effect on IL-6 expression that might exist between any of the detected polymorphisms.

Trends in Leadership Within Orthopedic Foot and Ankle Fellowships.

BACKGROUND: No study in the orthopedic literature has analyzed the demographic characteristics or surgical training of foot and ankle fellowship directors (FDs). Our group sought to illustrate demographic trends among foot and ankle fellowship leaders. METHODS: The American Orthopaedic Foot & Ankle Society (AOFAS) Fellowship Directory for the 2021 to 2022 program year was queried in order to identify all foot and ankle fellowship leaders at programs currently offering positions in the United States and Canada. Data points gathered included age, sex, race/ethnicity, location of surgical training, time since training completion until FD appointment, length in FD role, and individual research H-index. RESULTS: We identified 68 fellowship leaders, which consisted of 48 FDs and 19 co-FDs. Sixty-five individuals (95.6%) were male, and 3 (4.4%) were female. As regards race/ethnicity, 88.2% of the leadership was Caucasian (n = 60), 7.4% was Asian American (n = 5), 1.5% was Hispanic/Latino (n = 1), and 1.5% was African American (n = 1). The average age was 51.5 years, and the calculated mean Scopus H-index was 15.28. The mean duration from fellowship training to fellowship leader position was 11.23 years. CONCLUSION: Leaders within foot and ankle orthopedic surgery are characterized by research prowess and experience, but demographic diversity is lacking. LEVEL OF EVIDENCE: Level III.

Evaluating Prospective Patient-Reported Pain and Function Outcomes After Ankle and Hindfoot Arthrodesis.

BACKGROUND: Hindfoot and ankle fusions are mechanically limiting procedures for patients. However, patient-reported outcomes of these procedures have not been well studied. This study assessed outcomes of hindfoot and ankle fusions by using Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) Computer Adaptive Tests (CATs). METHODS: Between 2014 and 2018, 102 patients were prospectively enrolled after presenting to a tertiary care facility for ankle and hindfoot fusions, including tibiotalar, tibiotalocalcaneal, subtalar, and triple arthrodeses. Study participants completed preoperative and 12-month postoperative PF and PI CATs. The differences between mean 12-month postoperative and preoperative PROMIS PF and PI T scores were analyzed with paired t tests. The relationship between the 12-month PF and PI differences for the overall sample and patient factors was examined using multiple regression modeling. RESULTS: The sample had mean age of 57.69 years; 48% were male, and 55% were obese. Patients who underwent ankle and hindfoot arthrodesis had statistically significant improvements from preoperative to 12 months postoperative in mean PF (36.26±7.85 vs 39.38±6.46, P = .03) and PI (61.07±7.75 vs 56.62±9.81, P = .02). Triple arthrodesis saw the greatest increases in physical function (▵PF = 7.22±7.31, P = .01) and reductions in pain (▵PI = -9.17±8.31, P = .01), achieving minimal clinically important difference (MCID). Patients who underwent tibiotalar fusion had significant improvement in physical function (▵PF = 4.18±5.68, P = .04) and pain reduction that approached statistical significance (▵PI = -6.24±8.50, P = .09), achieving MCID. Older age (≥60 years ) was associated with greater improvements in PF (ß = 0.20, P = .07) and PI (ß = -0.29, P = .04). Preoperative PF and PI T scores were significantly associated with the 12-month change in PF and PI T scores, respectively (ß = -0.74, P < .01; ß = -0.61, P < .01). CONCLUSION: Hindfoot and ankle fusions are procedures with favorable patient outcomes leading to increased physical function and decreased pain at 12 months postoperation relative to preoperation. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Low-Energy Lisfranc Injuries: When to Fix and When to Fuse.

Lisfranc injuries can be devastating to the athlete and nonathlete. In the athletic population, minor loss of midfoot stability compromises the high level of function demanded of the lower extremity. The most critical aspect of treatment is identifying the injury and severity of the ligamentous/articular damage. Not all athletes are able to return to their previous level of function. With appropriate treatment, a Lisfranc injury does not mandate the cessation of an athletic career. We focus on the diagnosis and an algorithmic approach to treatment in the athlete discussion the controversy of open reduction and internal fixation versus arthrodesis.

Turf Toe, Traumatic Hallux Valgus, and Hallux Rigidus -What Can I Do After an Metatarsophalangeal Fusion?

Turf toe injuries should be recognized and treated early to prevent long-term disability. The accurate clinical assessment and radiological evaluation of appropriate cases is important. Both conservative and surgical treatments play a major role in getting athletes back to their preinjury level. There are more recent reported case series and systemic reviews that encourage operative treatment as early as possible for grade III turf toe injury. If the patient presents late from a traumatic hallux injury with subsequent degenerative changes or has hallux rigidus from other etiologies, a first metatarsophalangeal arthrodesis should be considered to minimize pain and improve function.

Current Trends in Sex, Race, and Ethnic Diversity in Orthopaedic Surgery Residency.

BACKGROUND: The representation of minorities among medical students has increased over the past two decades, but diversity among orthopaedic residents lags behind. This phenomenon has occurred despite a recent focus by the American Academy of Orthopaedic Surgeons on the recruitment of minorities and women. OBJECTIVE: To analyze the impact of recent efforts on diversity in orthopaedic residents in comparison with other surgical specialties from 2006 to 2015. METHODS: Data from the American Association of Medical Colleges on residents in surgical specialty programs in the years 2006 to 2015 were analyzed. Linear regression models were used to estimate trends in diversity among orthopaedic residents and residents in other surgical specialties. A mixed model analysis of variance was used to compare rates of diversification among different specialties over time. RESULTS: Female representation in orthopaedic programs increased from 10.9% to 14.4% between 2006 and 2015. However, the rate of increase was significantly lower compared with other specialties (all P < 0.05) studied, except for urology (P = 0.64). Minority representation in orthopaedics averaged 25.6% over the 10-year period. Residents of Hispanic origin in orthopaedic programs increased (P = 0.0003) but decreased for Native Hawaiian/Pacific Islander (P < 0.0001). During the same period, white representation increased (P = 0.004). No significant changes were found in African Americans or Asian American representation. Diversity decreased among orthopaedic residents over the period studied (P = 0.004). CONCLUSIONS: Recruitment efforts have not reversed the sex, racial, and ethnic disparities in orthopaedic residents. Orthopaedics has the lowest representation of women and minorities among residencies studied. The rate of increase in women lags behind all surgical subspecialties, except for urology.