Background: Intra-articular fractures of the calcaneus are a common injury to the hindfoot following high-energy trauma to the lower extremity. Treatment of these fractures has evolved. Due to the concern of wound complications associated with extensile open treatment, smaller incision techniques, such as the sinus tarsi approach, are increasing in popularity. A number of fixation strategies are utilized with this approach, and it is unknown which most accurately restores radiographic alignment. The purpose of this study was to compare the postoperative radiographic outcomes of a plate and screw construct versus a cannulated screw construct when using the sinus tarsi approach for open reduction and internal fixation (ORIF) of calcaneus fractures. Methods: After institutional review board approval, records for all patients treated surgically at our institution for calcaneus fractures from 2012 to 2017 were reviewed. Inclusion criteria were intra-articular calcaneus fractures, patients aged 18 years or older, and use of the sinus tarsi approach. Exclusion criteria were open fractures and fractures with less than 6 weeks of postoperative weightbearing, which were excluded for radiographic outcomes. A total of 51 fractures underwent ORIF using cannulated screws alone (group 1), and 23 fractures underwent ORIF using a sinus tarsi plate (group 2). Sixty-one fractures (41 vs 20, respectively) met criteria for radiographic comparison. The primary outcomes of interest included pre- and postoperative Bohler and Gissane angles, wound complications, unplanned return to the operating room (OR), and cost comparison. Results: There was no statistically significant difference between preoperative Bohler angles for group 1 (14.4 degrees) versus group 2 (12.2 degrees) ( P = .44), nor was there a significant difference between postoperative Bohler angles for group 1 (30.1 degrees) versus group 2 (27.1 degrees) ( P = .14). Similarly, preoperative Gissane angles for group 1 (130.5 degrees) and group 2 (133.4 degrees) ( P = .54) and postoperative Gissane angles for group 1 (118.2 degrees) and group 2 (119.8 degrees) ( P = .44) showed no statistically significant difference. There were a total of 3 wound complications in group 1 versus 2 wound complications in group 2 ( P = .66). There was no statistically significant difference in operative duration ( P = .97) or the number of unplanned returns to the OR between the 2 groups ( P = .68). Based on the implants used at this institution, and depending on the number of screws used, the estimated cost range of a plate construct was $1070 to $1235, while the estimated cost range of a cannulated screw construct was $717 to $1264. Conclusion: When comparing the cannulated screw and plate and screw fixation techniques, there was no difference in restoration of the Bohler and Gissane angles. Furthermore, the amount of angular correction achieved by initial reduction showed no statistically significant difference between groups, and the amount of reduction lost between initial and final postoperative radiographs showed no statistically significant difference between groups. With regard to the 2 techniques, there was no statistically significant difference in rates of postoperative complications and return to the OR. Our data suggest that fixation using cannulated screws alone versus sinus tarsi plate provides similar radiographic outcomes and risk of complications. The 2 techniques were also similar in terms of implant costs. Our results indicate that either technique effectively improved radiographic parameters. Level of Evidence: Level III, retrospective comparative study.

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Background: The Sunshine Act aims to increase the transparency of physicians receiving compensation from pharmaceutical and medical device companies. Nine states have supplementary legislation in addition to the Federal Sunshine Act. The purpose of this study is to assess the characteristics of financial compensation to orthopaedic residents on the Centers for Medicare and Medicaid Services (CMS) Open Payments Database in states with more restrictive regulations compared with those without additional restrictions. Methods: A complete list of accredited orthopaedic residency programs in the United States was compiled using the Accreditation Council for Graduate Medical Education and American Osteopathic Academy of Orthopedics websites. The website of each orthopaedic residency program was searched to compile a list of residents who attended their program from 2014 to 2016. The CMS Open Payments Database was used to search the residents identified for the corresponding years. All data available on the CMS Open Payments Database were recorded. Results: Over the 3-year period, 3,622 residents were identified from 151 programs. A total of 41% of the residents were reported as receiving compensation from the industry. The percent of residents reported from programs in less restrictive states was 45% versus 28% in more restrictive states (P < 0.001). Residents had a mean of 5.3 transactions per year in less restrictive states and 2.4 transactions per year in more restrictive states (P < 0.001). The mean compensation per resident reported was $2,730 for less restrictive sates versus $1,937 for more restrictive states (P < 0.001). Discussion: Overall, 41% of orthopaedic residents were reported on the CMS Open Payments Database with fewer transactions and less compensation going to residents in states with more restrictive legislature. Potential implications on resident education remain unknown.

Background:The prosperous financial relationship between physicians and industry remains a highly scrutinized topic. Recently, a publicly available website was developed in conjunction with the U.S. Affordable Care Act to shed light on payments from industry to physicians with the goal of increasing transparency. The purpose of this study was to assess possible relationships between industry payments and orthopaedic surgeon gender, subspecialty training, and practice settings.Methods:A retrospective analysis was performed using publicly available information from the Centers for Medicare & Medicaid Services (CMS) to identify the 25 orthopaedic surgeons with the highest compensation from each of the 10 largest orthopaedic companies from 2013 to 2017. Statistical analyses were conducted to investigate the factors that contributed to payment differences.Results:Among the 347 highest-compensated orthopaedic surgeons, only 1 woman (0.29%) was identified. Orthopaedic surgeons in the subspecialties of spine (32.9%), adult reconstruction (27.9%), and sports medicine (14.5%) made up a majority of the 25 highest earners. A larger proportion of the physicians in this study worked in private practice (57.6%) compared with an academic setting (42.4%). Orthopaedic surgeons who subspecialize in sports medicine had significantly higher total mean payment amounts when compared with all other specialties. The primary method of compensation was found to be through licensing or royalty payments.Conclusions:The large majority of orthopaedic surgeons who are highly compensated from industry are men. Among these, the greatest number specialize in the spine, while sports medicine surgeons receive significantly higher total mean payment amounts. Additional studies are warranted to evaluate the disparities between men and women and encourage policies to promote gender equality.

Aims The purpose of this study was to compare outcomes of combined total joint arthroplasty (TJA) (total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed during the same admission) versus bilateral THA, bilateral TKA, single THA, and single TKA. Combined TJAs performed on the same day were compared with those staged within the same admission episode. Patients and Methods Data from the National (Nationwide) Inpatient Sample recorded between 2005 and 2014 were used for this retrospective cohort study. Postoperative in-hospital complications, total costs, and discharge destination were reviewed. Logistic and linear regression were used to perform the statistical analyses. p-values less than 0.05 were considered statistically significant. Results Combined TJA was associated with increased risk of deep vein thrombosis, prosthetic joint infection, irrigation and debridement procedures, revision arthroplasty, length of stay (LOS), and in-hospital costs compared with bilateral THA, bilateral TKA, single THA, and single TKA. Combined TJA performed on separate days of the same admission showed no statistically significant differences when compared with same-day combined TJA, but trended towards decreased total costs and total complications despite increased LOS. Conclusion Combined TJA is associated with increased in-hospital complications, LOS, and costs. We do not recommend performing combined TJA during the same hospital stay. Cite this article: Bone Joint J 2019;101-B:573–581.

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Category: Hindfoot, Trauma Introduction/Purpose: Intra-articular fractures of the calcaneus are a common injury to the hindfoot following high energy trauma to the lower extremity. Treatment of these fractures has evolved. Due to the concern of wound complications associated with extensile open treatments, smaller incision techniques, such as the sinus tarsi approach, are increasing in popularity. A number of fixation strategies are utilized with this approach, and it is unknown which most accurately restores radiographic alignment. The purpose of this study is to compare the postoperative radiographic outcomes of a plate and screw construct versus a cannulated screw construct when using the sinus tarsi approach for open reduction and internal fixation (ORIF) of calcaneus fractures. Methods: After IRB approval, records for all patients treated surgically at our institution for calcaneus fractures from 2012 to 2017 were reviewed. Inclusion criteria were intra-articular calcaneus fractures, patients aged 18 years or older, and use of the sinus tarsi approach. Exclusion criteria were open fractures and clinical follow up less than 6 weeks. A total of 51 fractures underwent ORIF using cannulated screws alone (Group 1), and 23 fractures underwent ORIF using a sinus tarsi plate (Group 2). The primary outcomes of interest included pre- and postoperative Bohler and Gissane angles, wound complications, and unplanned return to OR. Results: There was no statistically significant difference between preoperative Bohler angles for Group 1 (14.5 degrees) versus Group 2 (12.3 degrees) (p=0.35), nor was there a significant difference between postoperative Bohler angles between Group 1 (30.1 degrees) and Group 2 (27.0 degrees) (p=0.09). Similarly, preoperative Gissane angles for Group 1 (128.4 degrees) and Group 2 (134.5 degrees) (p=0.17) and postoperative Gissane angles for Group 1 (116.7 degrees) and Group 2 (118.8 degrees) (p=0.44) showed no statistically significant difference. There were a total of 3 wound complications in Group 1 versus 2 wound complications in Group 2 (p=0.76). There was no statistically significant difference in operative duration (p=0.97) or the number of unplanned returns to the OR between the two groups (p=0.77). Conclusion: When comparing the cannulated screw and plate and screw fixation techniques, there was no difference in restoration of the Bohler and Gissane angles. Both techniques had similar rates of postoperative complications and return to the OR. Our data suggests that fixation using cannulated screws alone versus sinus tarsi plate provide similar radiographic outcomes and risk of complications. The two techniques are also similar in terms of implant costs. Our results indicate that either technique effectively improves radiographic parameters.