Background:The standard of care for plating displaced midshaft clavicle fractures has been 6 cortices of purchase on each side of the fracture. The use of locking plates and screws may afford equivalent biomechanical strength with fewer cortices of purchase on each side of the fracture.Purpose:To compare the biomechanical and clinical performance of 3- versus 2-screw constructs for plating displaced midshaft clavicle fractures.Study Design:Controlled laboratory study/cohort study; Level of evidence, 3.Methods:Lateral fragments of simulated midshaft fractures in 10 pairs of cadaveric clavicles were randomly assigned to plate fixation with either 3 nonlocking screws or 2 locking screws. Cyclic tensile loads were applied along the long axis of the clavicle. The constructs were then loaded to failure with pullout forces applied parallel to the long axis of the screws. Additionally, clinical outcomes of patients who had midshaft clavicle fractures that were surgically repaired were retrospectively identified and compared; 21 patients were treated with 3-screw constructs and 20 with 2-screw constructs.Results:Biomechanically, there were no significant differences for cyclic displacement, stiffness, yield load, or ultimate load between groups. Forces required for screw pullout were considerably higher than physiologic forces experienced by a healing clavicle in vivo. Clinically, there were no significant differences in American Shoulder and Elbow Surgeons, Constant, visual analog scale, and Single Assessment Numeric Evaluation scores; complications; or mean time to union. Additionally, we found that the plates used in the 2-screw group were consistently shorter.Conclusion:Plate fixation of displaced midshaft clavicle fractures with 4 cortices of purchase with 2 locking screws demonstrated no significant differences biomechanically when compared with fixation with 6 cortices of purchase and 3 nonlocking screws. Clinically, there were no significant differences in outcomes or complications seen in patients receiving 2- or 3-screw constructs.Clinical Relevance:Clinical benefits of using the 3-screw construct for plate fixation include decreased surgical exposure, morbidity, and cost, and the use of shorter and noncontoured straight plates eliminates the extra time and technical difficulty associated with matching longer contoured plates to the complex morphology of the clavicle.

Background: The most common method to determine a traumatic knee arthrotomy is the saline load challenge. Recent literature has suggested high false-negative and false-positive rates using this method and also has shown that CT was effective in detecting these arthrotomies. The purpose of this study was to evaluate another method of diagnosing these injuries. We hypothesized that plain radiographs of the knee could be an effective alternative study in diagnosing a traumatic arthrotomy. Methods: After institutional review board approval, this retrospective cohort review identified 32 patients diagnosed with a traumatic arthrotomy by direct visualization in the operating room and another 32 patients with no evidence of traumatic arthopathy, according to the surgeon. The preoperative anteroposterior and lateral radiographs from both cohorts were blinded and randomized and then submitted to a radiologist to review for the presence of air in the joint space. Sensitivity and specificity were calculated based on radiographic review compared with the gold standard of direct visualization. Results: Plain film anteroposterior and lateral knee radiographs had a sensitivity of 78.1% and a specificity of 90.6% with a positive predictive value of 89.3% for diagnosis of traumatic arthrotomy in our cohort. Conclusions: Our study suggests that radiographs, which are obtained as standard of care during work-up of knee injuries, have a relatively high sensitivity and specificity and can be used as an adjunct to help diagnose a traumatic arthrotomy of the knee joint. Level of Evidence: Level III.

The purpose of this study was to compare the efficacy of a single-sugar-tong splint (SSTS) to a long-arm cast (LAC) in maintaining reduction of pediatric forearm fractures, while avoiding secondary intervention. One hundred patients age 3–15 with a forearm fracture requiring a reduction and immobilization were evaluated (50 LAC and 50 SSTS). Medical records and radiographs were reviewed at injury, postreduction, and at 1, 2, and 4 weeks postinjury. Sagittal and coronal angular deformities were recorded. Any secondary intervention due to loss of reduction was documented. The groups were matched by age (P = 0.19), sex (P = 0.26), mechanism of injury (P = 0.66), average injury sagittal deformity (LAC 27.4°, SSTS 25.4°; P = 0.50), and average injury coronal deformity (LAC 15.5°, SSTS 16°; P = 0.80) At 4 weeks postinjury follow-up, there were no statistically significant differences between use of an SSTS or LAC when comparing postimmobilization sagittal alignment (LAC 10.3 ± 7.2, SSTS 8.4 ± 5.1°; P = 0.46), coronal alignment (LAC 6.9 ± 4.6, SSTS 7.6 ± 9.3°; P = 0.46), or need for repeat manipulation or surgery (LAC 4/50, SSTS 3/50; P = 0.70).

Displaced pediatric forearm fractures often are treated with closed reduction and immobilization. Recent literature demonstrates no difference in maintaining alignment or needing repeat intervention in patients immobilized with either a single sugar-tong splint or a long-arm cast, but most series include patients with distal fractures. This study included patients 3 to 15 years old who underwent closed reduction and immobilization for displaced midshaft or proximal forearm fractures. Radiographs from the time of injury, after reduction, and at 4-week follow-up were reviewed for coronal and sagittal plane angular alignment. Secondary interventions also were recorded. A total of 121 patients (70 long-arm cast, 51 simple sugar-tong splint) met inclusion criteria. Groups were matched in terms of age ( P =.95), sex ( P =.41), body mass index ( P =.12), and angular deformity prior to reduction in the sagittal ( P =.78) and coronal ( P =.83) planes. Following closed reduction, sagittal ( P =.003) and coronal ( P =.002) alignment improved significantly in all patients. At 4-week follow-up, there were no significant differences in sagittal ( P =.15) or coronal ( P =.68) alignment between the 2 groups. Nine patients underwent a secondary intervention after the index reduction (long-arm cast, n=7; simple sugar-tong splint, n=2), with no statistically significant difference between groups ( P =.30). There were no statistically significant differences between patients managed with long-arm cast or simple sugar-tong splint regarding residual sagittal or coronal plane deformity at 4-week follow-up or incidence of secondary intervention. These findings indicate simple sugar-tong splint and long-arm cast appear to be acceptable and equivalent methods of immobilization for these injuries. [ Orthopedics . 2021;44(2):e178–e182.]

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Category: Ankle; Other Introduction/Purpose: Scientific publication and original articles remain the primary method of sharing scientific findings and thus advancing the knowledge base of that subject. These articles have the potential to reinforce or change current practice. Despite the value of these publications, little research has gone into surveying what topics are being published. Our goal was to identify and characterize the most common topics of publication in current foot and ankle literature. Methods: To determine the rate of publications in the literature, we reviewed all published articles in a 3.5-year period (January 2016 - June 2019) in three foot and ankle specific journals: Foot and Ankle International, Foot and Ankle Orthopaedics, and Foot and Ankle Surgery. We then sorted these articles into the topic of the article to identify the four most common domains of publication. These domains were further characterized by level of evidence as well as citations/year. Results: A total of 845 articles were published in the 3.5-year study period. During this time, the four most published topics in foot and ankle literature were hallux valgus (10%), arthroplasty (9%), ankle fracture (7.5%), and achilles pathology (6.4%). These four subjects accounted for 280/845 articles (33%). The average level of evidence for articles on hallux valgus, arthroplasty, ankle fracture, and Achilles pathology were 3.3 (3.1, 3.4, 3.4, and 3.4 respectively), and the average number of citations/year for these articles was 2.6 (2.3, 3.0, 2.3, and 3.1 respectively). Based on our study there is no correlation between level of evidence and number of citations. Conclusion: Despite the wide variety of cases (176 unique CPT codes) performed by an orthopedically trained foot and ankle surgeons, a small subset of publications represent a significant portion of scientific publication within the field.

Category: Ankle Arthritis; Ankle; Hindfoot Introduction/Purpose: Ankle and hindfoot arthrodesis are common interventions for degenerative and inflammatory foot and ankle conditions. These include, but are not limited to osteoarthritis, inflammatory arthritis, deformity, and instability. While we know the addition of bone graft is critical for successful union, we do not fully understand how graft selection affects union rates. Demineralized bone matrix (DBM) is commonly chosen due to its ease of availability and osteoconductive and osteoinductive properties. In our study, we aim to determine if adding BMAc, and thus osteogenic properties, to a DBM allograft improves union rates following ankle and hindfoot arthrodesis. Methods: After receiving IRB approval from our institution, we collected the records of patients who underwent arthrodesis of the hindfoot (subtalar, calcaneocuboid, talonavicular) or ankle during a 10-year time period. Patients were then divided into two groups: arthrodesis performed with the use of DBM and arthrodesis performed with DMB-BMAc. Cases using other graft options such as bulk allograft, autograft, or bone morphogenic protein (BMP) were excluded. Fusion was determined by standard radiographic and clinical criteria and CT scans were utilized in cases which fusion could not be determined. Patients were followed for a minimum of 6 months. If fusion was not complete at that time clinical and radiographic exams were performed at the 9- and 12-month period. Patients were analyzed for sucussesful arthrodesis. Complications and revisions were recorded and analyzed. Results: A total of 124 patients who met the inclusion criteria were identified. In 49 patients only DBM was utilized, and 75 patients BMC was added to the DBM. At 12 months post operatively the group utilizing only DBM had a union rate of 90% while the union rate of the BMAc/DBM had a union rate of 88% (p=0.985) There was no difference in the rate of complications between the two groups and the groups were matched in terms of age, smoking status, DM, sex and BMI. Additionally, in our cohort there was a trend toward increased non-union and complication rate in smokers, although this did not reach statistical significance. Conclusion: Ankle and hindfoot arthrodesis are a reliable treatment option for patients with specific foot and ankle pathology. Our study reports a fusion rate in line with previous studies. The addition of BMAc from the pelvis, attempting to improve the biology of the fusion site, to DBM does not seem to affect fusion rates.

Hallux valgus is one of the more common complaints for patients presenting to a foot and ankle clinic. The open distal chevron osteotomy has been a successful and widely used treatment option for symptomatic patients with a mild to moderate deformity. In this paper we will review the evidence with a focus on recent publications, our indications and contraindications, technique, results, and potential complications of the procedure.