C ervical myelopathy is the most common cause of spinal cord dysfunction in adults. 1 Given the unforgiving nature of the spinal cord, efficient treatment is necessary to avoid the risk of progression and permanent disability. Traditionally, anterior cervical discectomy and fusion (ACDF) has successfully achieved these goals. However, more recently, cervical disk arthroplasty (CDA) has been an appealing alternative to fusion given its ability to preserve motion at the surgical level(s) and theoretical reduction of adjacent segment degeneration (ASD). 2 However, preservation of motion has been highlighted as a potential concern in cases of myelopathy, as it theoretically allows continued microtrauma to the spinal cord after surgery. A randomized, multicenter control trial comparing CDA to ACDF for single-level cervical myelopathy revealed equivalent patient-reported and neurological outcomes at 2 years. 2 Recently, longterm outcomes showed patients who underwent arthroplasty not only experienced improved patient-reported pain scores, but they also demonstrated preserved cervical motion during radiographic analysis at 8 years of follow-up. In addition, postarthroplasty motion was even increased when compared with preoperative motion in many patients. 3 Another concern is that arthroplasty does not fully address all the potential sources of the pathology in myelopathy, to include compression often associated with isolated cervical radiculopathy. 1 A 2014 study showed

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Background Combat-related pelvic ring injuries frequently lead to placement of a temporizing external fixation device for early resuscitation and transport. These injuries are commonly complicated by concomitant polytrauma and extensive soft-tissue injuries, which may preclude early internal fixation and lead to prolonged use of external fixation. To date, few studies have reported on the outcomes of definitive external fixation for combat-related pelvic ring injuries. Questions/purposes (1) In patients treated with definitive external fixation after combat-related pelvic ring injuries, how often is the quality of reduction within radiographically acceptable parameters at the end of treatment? (2) What proportion of patients demonstrate local heterotopic ossification after these injuries? (3) What patient- and treatment-related factors are associated with increased complications and pain? Methods We retrospectively studied all patients with pelvic ring injuries treated at a tertiary military referral center from January 2003 to December 2012. In total, 114 patients were identified, 55 of whom maintained an external fixation frame throughout their treatment. During that time, the general indications for definitive external fixation were an open, contaminated pelvic ring injury with a high risk of infection or open urologic injury; confluent abdominal, perineal, and thigh wounds; or comminution of the pubic ramus that would necessitate plate fixation extending up the anterior column in patients with open abdomen or exposure-compromising abdominal wounds. Posterior fixation, either sacroiliac or lumbopelvic, was applied in patients with sacroiliac instability. Of the 55 patients with pelvic ring injuries treated with definitive external fixation (27 open and 28 closed), four underwent hemipelvectomy and construct removal for massive ascending infections and four were lost to follow-up, leaving 47 patients (85%) who were available at a minimum follow-up of 12 months (median 29 months, interquartile range 17-43 months). All 47 patients underwent serial imaging to assess their injury and reduction during treatment. External fixators were typically removed after 12 weeks, except in patients in whom pin-site irritation or infection prompted earlier removal, and all were confirmed to be grossly stable during an examination under anesthesia. Clinical union was defined as the absence of radiographically present fracture lines and stable examination findings under anesthesia when the external fixator was removed. Data on demographics, injury pattern, associated injuries, revision procedures, complications, and final functional outcomes including ambulation status, sexual function, and pain were collected. Pelvic radiographs were reviewed for the initial injury pattern, type of pelvic fixation construct, residual displacement after removal of the frame, and evidence of formation of heterotopic ossification in the pelvis or bilateral hips. Pelvic displacement and diastasis were determined by digital caliper measurement on plain images; malunion was defined as anterior diastasis of the pelvis or vertical incongruity of the hemipelvis greater than 10 mm. Results Radiographic malunion after construct removal occurred in eight of 24 patients with open injuries and in five of 23 patients with closed injuries. Heterotopic ossification developed in the pelvis or hips of all 24 patients with open injuries and in two of the 23 patients with closed injuries. In patients with open pelvic ring injuries, concomitant acetabular fractures were associated with pelvic pain at the final follow-up examination (risk ratio 1.9; 95% confidence interval, 1.0-3.5; p = 0.017). No treatment factor resulted in superior functional outcomes. In the closed-injury group, concomitant lower-extremity amputation was associated with improved radiographic final reduction (RR 0.4; 95% CI, 0.2-0.7; p = 0.02). There was no association between radiographic malunion and increased pain (RR 1.9; 95% CI, 0.5-7.0; p = 0.54 for the open group; RR 0.8; 95% CI, 0.7-1.0; p = 0.86 for the closed group). Conclusion In this series of patients with severe combat-related pelvic ring injuries who were treated anteriorly with definitive external fixation because of a severe soft-tissue injury, high infection risk, or unacceptable physiologic cost of internal fixation, malunion and chronic pelvic pain were less common than previously observed. Prior studies primarily differ in their lack of sacroiliac or lumbopelvic stabilization for posteriorly unstable fracture patterns, likely accounting for much of these differences. There may have been important between-study differences such as extremely severe injuries, concomitant injuries, and study population. Our study also differs because we specifically analyzed a large cohort of patients who sustained open pelvic ring injuries. Future studies should prospectively investigate the ideal construct type and pin material, optimize the length of treatment and assessment of healing, and improve radiographic measures to predict long-term functional outcomes. Level of Evidence Level IV, therapeutic study.

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Background:The purpose of this study was to evaluate the extent to which orthopaedic training programs utilize social media for education, recruitment, and engagement. Methods:A cross-sectional study of Instagram utilization by orthopaedic surgery residency programs that were accredited by the Accreditation Council for Graduate Medical Education was performed from September 27, 2020 to October 7, 2020. If an account existed, engagement metrics including account type, number of posts, post types, number of followers, and number of accounts being followed were identified. Programs were also evaluated for US News and World Report rank, Doximity rank, program size, board pass rates, gender diversity, and years since accreditation. Accounts were analyzed using Student ttest, Spearman correlation, and regression analysis. Results:Of 201 accredited programs, 11 were either military or unaffiliated with the Association of American Medical Colleges. From the 190 remaining eligible programs, 91 (47.9%) had an active Instagram account. The number of programs with an account exhibited exponential growth over the past year (R 2 = 0.93). The median number of posts was 22 (range 1 to 272), the median number of followers was 773 (range 99 to 2882), and the median number of following was 158 (range 6 to 740). Fifteen of 89 program accounts (16.9%) had a live story posted within 24 hr of review. Conclusions:The use of Instagram as a social media channel for orthopaedic residency programs has demonstrated exponential growth over the past year. These accounts offer unique and convenient ways to showcase a residency program. The development of a national or academy guidelines for use and content is recommended.

Background: The pattern of glenoid bone loss (GBL) in anterior glenohumeral instability is well described. It was recognized recently that posterior GBL after instability has a posteroinferior pattern. Purpose/Hypothesis: The purpose of this study was to compare GBL patterns in a matched cohort of patients with anterior versus posterior glenohumeral instability. The hypothesis was that the GBL pattern in posterior instability would be more inferior than the GBL pattern in anterior instability. Study Design: Cohort study; Level of evidence, 3. Methods: In this multicenter retrospective study, 28 patients with posterior instability were matched with 28 patients with anterior instability by age, sex and number of instability events. GBL location was defined using a clockface model. Obliquity was defined as the angle between the long axis of the glenoid and a line tangent to the GBL. Superior and inferior GBL were measured as areas and defined relative to the equator. The primary outcome was the 2-dimensional characterization of posterior versus anterior GBL. The secondary outcome was a comparison of the posterior GBL patterns in traumatic and atraumatic instability mechanisms in an expanded cohort of 42 patients. Results: The mean age of the matched cohorts (n = 56) was 25.2 ± 9.87 years. The median obliquity of GBL was 27.53° (interquartile range [IQR], 18.83°-47.38°) in the posterior cohort and 9.28° (IQR, 6.68°-15.75°) in the anterior cohort ( P < .001). The mean superior-to-inferior bone loss ratio was 0.48 ± 0.51 in the posterior cohort and 0.80 ± 0.55 ( P = .032) in the anterior cohort. In the expanded posterior instability cohort (n = 42), patients with traumatic injury mechanism (n = 22), had a similar GBL obliquity compared to patients with an atraumatic injury mechanism (n = 20) (mean, 27.73° [95% CI, 20.26°-35.20°] vs 32.20° [95% CI, 21.27°-43.14°], respectively) ( P = .49). Conclusion: Posterior GBL occurred more inferiorly and at an increased obliquity compared with anterior GBL. This pattern is consistent for traumatic and atraumatic posterior GBL. Bone loss along the equator may not be the most reliable predictor of posterior instability, and critical bone loss may be reached more rapidly than a model of loss along the equator may predict.

Category: Sports; Trauma; Other Introduction/Purpose: Achilles tendon ruptures are common injuries in the active duty US military population. Timely rehabilitation has critical importance in force readiness. There remains debate about optimal treatment of Achilles tendon ruptures. Recent studies have found decreased risk of rerupture but increased complication rates with operative management, with similar times to full recovery. The development of a minimally invasive, percutaneous Achilles tendon technique has shown lower rates of wound complications than open management, with similar re-rupture rates. However, there exists no comparative studies between the percutaneous, minimally invasive Achilles tendon surgery and nonoperative management. This was a retrospective cohort study comparing the results of the Percutaneous Achilles Repair System (PARS) and nonoperative management in the active duty military population. Methods: All Achilles tendon injuries in active duty patients were identified using the MHS system M2 from January 1, 2016 to December 31, 2020. Inclusion and exclusion criteria were applied and charts were reviewed. Demographic and treatment information were recorded. Time to return to duty, rerupture, complications, and deep vein thrombosis (DVT) were recorded and compared between each cohort. 47 patients met inclusion criteria with an average age of 38.7 years. There were 23 patients in the percutaneous operative group and 24 patients in the nonoperative group. Patients in the nonoperative group underwent regular functional rehabilitation supervised by a licensed physical therapist under the tri-service rehabilitation guidelines, based on the Willits protocol for nonoperative management (2010). 2 patients failed nonoperative management and underwent open Achilles reconstruction. They were excluded from the time to return to duty analysis. Demographics were described. There were no significant differences in group demographics. Results: There was no difference in time to return to duty in the nonoperative and percutaneous Achilles tendon repair (160.5 days, 5.35 months vs 161.7 days, 5.39 months) cohorts (p=0.47). No patient failed to return to duty due to treatment of an Achilles rupture. There were no DVTs in either group. There was 1 wound complication (infection) (4.3%) and 3 instances of postoperative paresthesias (2 sural, 1 peroneal) 13% in the operative cohort. 2 patients failed nonoperative management (reruptured Achilles tendon) and underwent open reconstruction with flexor halluces longus augmentation (8%). The operative cohort had a higher rate of complications (17.3% vs 8.3%, p=0.42, OR=2.11, CI= (0.34, 12.86)), although this was not statistically significant. There were no reruptures in the operative cohort. Conclusion: There was no difference in time to return to duty in the nonoperative and percutaneous Achilles tendon repairs. There was a higher rate of reruptures in the nonoperative group. Percutaneous operative treatment had a higher risk of complications. There were no failures in the operative cohort. The final decision on management of acute Achilles tendon ruptures should be based on specific patient factors and shared decision to return military members back to duty as quickly as possible. Prospective or well designed randomized controlled trials are necessary in the future to better delineate outcomes between nonoperative and percutaneous Achilles rupture management.

(1) Background: This systematic review summarizes the available studies investigating when it is safe for most patients to return to driving and when to modify for individual patients following elective foot and ankle procedures. (2) Methods: A systematic review of the literature was performed using three different electronic databases to identify English-language studies from 1999 to present that investigate the return to driving after right-sided elective foot and ankle procedures. (3) Results: A total of eight studies met inclusion criteria. All the studies investigated brake reaction time (BRT) as measured by a driving simulator as their primary outcome. Patients undergoing right ankle or subtalar arthroscopy should wait 2 weeks to drive, after total ankle arthroplasty or corrective hallux valgus surgery patients should wait 6 weeks, and the appropriate time to return to driving after ankle arthrodesis is still uncertain. Additionally, various clinical factors can be used to predict who may still be unfit to drive past the usual length of time. (4) Conclusions: The recommendations from these reviewed studies can guide physicians when counseling their patients on when they can expect to safely return to driving after a specific elective foot and ankle procedure. However, these recommendations should be tailored to the patient specifically based upon how they are doing clinically.