Category: Ethics Introduction/Purpose: The objective of our study was to analyze COI nondisclosure for US based research articles that were published to three prevalent orthopaedic journals from the beginning of 2014 to the end of 2016. Methods: All US-based research articles published to FAI, JBJS, and JOA from the beginning of 2014 to the end of 2016 were reviewed. COI disclosure sections were analyzed to determine if a disclosure was made for first and/or last authors. Authors disclosing any financial relationship involving employment, royalties/licensing, speaking, and consulting fees were recorded as having disclosed a potential COI. First and last authors were then searched for using CMS Open Payments search tool to determine if they had received any of the aforementioned payment types. To determine if a COI nondisclosure (disclosure discrepancy) was present, an author’s disclosure statement for a published article was compared to CMS Open Payments data from the year prior to publication of the article. We used CMS data from the year prior to a publication to account for the time it takes to construct a paper and have it published. Results: Across all journals and years, we obtained disclosure accuracy data for 3,465 total first and last authors publishing 1,770 research articles. Within this sample, 7.1% (245/3,465) of the authors had a recorded undisclosed conflict-of-interest and 13.2% (233/1,770) of articles had a first and/or last author with an undisclosed potential conflict-of-interest. When looking at each journal individually over the three-year period, FAI contained the highest percentage of authors with undisclosed COI’s (42.3%), JBJS contained the lowest percent of authors with an undisclosed COI (4.6%), and JOA had an intermediate amount of authors with an undisclosed COI (7.0%). Conclusion: Discrepancies between payment disclosures made by authors and those published in the CMS database were present in all three journals reviewed in this study. The percentage of articles containing an author with a disclosure discrepancy varies widely between these journals. However, when analyzing the percentage of disclosure discrepancies by year, no trend was found.

Background: The Centers for Medicare & Medicaid Services (CMS) Open Payments public database, resulting from the Physician Payments Sunshine Act of 2010, was designed to increase transparency of physicians’ financial relationships with pharmaceutical manufacturers. We compared physician-reported conflict-of-interest (COI) disclosures in journal articles with this database to determine any discrepancies in physician-reported disclosures. Methods: COIs reported by authors from 2014 through 2016 were analyzed in 3 journals: Foot & Ankle International (FAI), The Journal of Bone & Joint Surgery (JBJS), and The Journal of Arthroplasty (JOA). Payment information in the CMS Open Payments database was cross-referenced with each author’s disclosure statement to determine if a disclosure discrepancy was present. Results: We reviewed 3,465 authorship positions (1,932 unique authors) in 1,770 articles. Within this sample, 7.1% of authorships had a recorded undisclosed COI (disclosure discrepancy), and 13.2% of articles had first and/or last authors with a disclosure discrepancy. Additionally, we saw a great variation in the percentage of authorships with disclosure discrepancies among the journals (JBJS, 2.3%; JOA, 3.6%; and FAI, 23.7%). Conclusions: Discrepancies exist between payment disclosures made by authors and those published in the CMS Open Payments database. Although the percentage of articles with these discrepancies varies widely among the journals that were analyzed in this study, no trend was found when analyzing the number of discrepancies over the 3-year period. Clinical Relevance: COI disclosures are important for the interpretation of study results and need to be accurately reported. However, COI disclosure criteria vary among orthopaedic journals, causing uncertainty regarding which conflicts should be disclosed.

Category: Diabetes; Other Introduction/Purpose: Charcot neuroarthropathy (CN) is a disabling condition of the foot and ankle with a prevalence of up to 13% of patients with Diabetes Mellitus (DM). In the acute phase, CN presents as a hot, swollen foot, with mild destruction of bone and joint structure. If left untreated it can progress to a chronic stage, with bone and joint destruction, presenting with a classic rocker bottom foot deformity. CN is often misdiagnosed in its acute phase; as a result the diagnosis is usually made once CN has progressed to the chronic phase. This delay causes prolonged treatment regimens and poorer outcomes. This systematic review examines the misdiagnosis of CN and the timeline preceding a correct diagnosis. Methods: A review of the literature was performed by searching Ovid Medline, CINAHL, and Scopus for articles published within the last five years that contained the terms Charcot and misdiagnosed, antibiotics, deep vein thrombosis, or osteomyelitis. The database search produced 110 articles, once duplicates were removed. 49 articles were screened out by title and 18 were screened by abstract; leaving 43 eligible articles. During the review of the 43 articles an additional 41 articles were added from references because they provided relevant information. Time of symptom onset to diagnosis was calculated in days, with 30 days counting as one month. Results: In total, 230 patients were included in analysis; of these, 27 (12%) presented with bilateral CN for a total of 257 affected extremities. Type 1 DM was present in 112/210 (53%) of patients, Type 2 DM in 98/210 (47%) of patients, and an unreported DM status in 20/230 (9%) patients. The average time from symptom onset to final diagnosis of CN was 84.8 days, with a range of 25 days to 203 days. Nearly half (110/230; 48%) of the patients experienced CN misdiagnosis. Of these, 99 specific misdiagnoses were reported, with the most common including cellulitis (22/99; 22%), fracture/sprain (18/99; 18%), deep vein thrombosis (13/99; 13%), osteomyelitis (11/99; 11%), and erysipelas and gout (10/99; 10%) each. A total of 42/146 (29%) of patients could recall an incidence of trauma prior to the onset of CN. Conclusion: A diagnosis of CN should be considered in patients with DM who present with peripheral neuropathy coupled with foot swelling, deformity, ulceration, or difficulty ambulating. This literature review has identified that nearly half of patients with CN are misdiagnosed, and many continue to ambulate and do not receive necessary total contact casting until they are correctly diagnosed later on. Subsequently, awareness of CN and the frequency of misdiagnoses associated with it is critical to preventing treatment delay. Further research is necessary to better clarify why CN is so frequently misdiagnosed and the amount of harm that can result from misdiagnoses.

Ankle fractures are common injuries treated by orthopedists. Indications for operative repair of deltoid ligament (DL) injuries in ankle fracture patients are debated. The purpose of this review is to determine the indications for operative DL repair.Ovid MEDLINE, CINAHL, and Scopus were searched up to December 2019. Web of Science was searched up to August 2018. Search terms included "Deltoid" and "Ligament" or "Ligaments." Comparative studies assessing conservative vs operative DL repair were searched for. Articles meeting inclusion criteria were screened in two stages to determine eligibility.Out of 1,542 articles, nine were included in our qualitative synthesis. These nine studies included 449 patients, of which 233 were treated with open reduction internal fixation (ORIF) with or without transsyndesmotic (TS) screw fixation, and 205 of which were treated with ORIF with DL repair. The remaining 21 patients were managed nonoperatively, had no evidence of DL injury, or were lost to follow-up.There is a lower rate of malreduction associated with DL repair compared to TS screw fixation. Moreover, DL repair may be useful in treating patients with Weber Type C fractures, concomitant DL-syndesmotic disruption, or residual valgus instability following ORIF in isolated lateral malleolar fractures.

We present a unique case of chronic peroneal tendon dislocation in a 47-year-old active duty military member with a 2-mo history of acute onset lateral ankle pain due to sports injury. Magnetic resonance imaging revealed superficial peroneal retinaculum (SPR) disruption, a flattened retrofibular groove, dislocation of the peroneus longus tendon, and a tear of the peroneus brevis tendon. The patient was managed operatively with fibular groove deepening, SPR reconstruction, peroneus brevis debridement, and peroneus longus tubulurization. No complications were observed during the intra- or perioperative periods. At their 3-mo follow-up, the patient reported near complete resolution of pain and the ability to ambulate without any brace or support. He returned to running and was able to deploy fit for full duty 4.5 mo from injury.

Background: Female representation varies geographically among orthopaedic residency programs, with the southern region of the United States reported as having relatively lower rates of female orthopaedic surgeons. Purpose: To determine the gender and geographic distributions of US-based orthopaedic sports medicine surgeons and analyze geographic patterns between their training locations and present-day practices. Study Design: Cross-sectional study. Methods: American Orthopedic Society of Sports Medicine (AOSSM) fellowship completion data from the 2016-2021 academic years were analyzed with regard to gender and fellowship location. Medical school, residency, and current practice locations were obtained via internet searches for all individuals identified within the databases. Locations were categorized into regions based on the US Census Bureau definitions. Descriptive statistical analysis was performed on the data. Results: A total of 1268 sports orthopaedic surgeons who graduated fellowship from 2016 to 2021 were analyzed: 141 (11%) were female and 1127 (89%) were male. The percentage of female sports medicine surgeons in fellowship remained constant (11%-12%) from 2016 to 2021. On average, the annual percentage of female orthopaedic sports medicine fellows was 7.2% in the South, 10.4% in the West, 14.2% in the Midwest, and 14.7% in the Northeast. Based on the orthopaedic sports medicine fellowship graduates from 2016 to 2021, the mean percentage of current female orthopaedic sports medicine surgeons in practice was 7.4% in the South, 11.7% in the Northeast, 12.8% in the Midwest, and 14.4% in the West. Conclusion: Approximately 11% of our sample was female; however, this percentage varied heavily by region, with the southern region having significantly lower rates of gender diversity.

Background: The Centers for Medicare & Medicaid Services (CMS) Open Payments public database provides a means for increased transparency of physicians’ financial relationships with industry. Total ankle arthroplasty is a procedure with long-term clinical implications and variable outcomes. We compared physician-reported conflict-of-interest (COI) disclosures in the journal Foot & Ankle International ( FAI) to CMS database information to evaluate for discrepancies. Methods: Articles published in FAI reporting clinical outcomes of total ankle arthroplasty from 2015 and 2019 were reviewed. Payment information in the CMS database was cross-referenced with disclosure statements and International Committee of Medical Journal Editors (ICMJE) forms associated with the manuscript. Statistical analysis was performed to determine if industry payments were appropriately disclosed or influenced outcomes. Results: We reviewed 173 articles pertaining to ankle arthroplasty, with 27 meeting inclusion criteria. Of 120 total authors with 98 unique authors, 114 (95%) disclosed appropriately in disclosure statements. Twenty-two studies (82%) had appropriate declarations for the entire manuscript. For the 27 senior authors, only 2 discrepancies between manuscript disclosure and the Open Payments public database were noted, showing 13 total disclosures in the Open Payments public database vs 11 disclosed in the manuscript. There was no relationship between industry payments and the outcome of the manuscript ( P = .725). Conclusion: The majority of author disclosure statements accurately reflected the Open Payments public data. Additionally, payments were not significantly associated with positive outcomes reported for the specific implant. Overall, authors publishing on ankle arthroplasty in FAI are disclosing appropriately. Level of Evidence: Level IV, systematic review; survey study; literature review.

Introduction: Women have historically been underrepresented in orthopaedics. This study analyzes the geographic distribution of female orthopaedic foot and ankle (OFA) surgeons, as well as geographic patterns between their training locations and current practices. Methods: American Orthopaedic Foot and Ankle Society (AOFAS) data regarding fellowship completion from 1988 to 2021 were analyzed. Internet searches were then performed to identify medical school, residency, and current practice locations of individual surgeons. States were categorized into regions and divisions based on US Census Bureau guidelines. Results: Of the 1088 OFA surgeons analyzed, 166 (15.26%) were women and 922 (84.74%) were men. The South has a higher number of female OFA surgeons; however, this region and the Midwest have the lowest percentages of female representation. The West and Northeast had significantly higher percentages of female representation and higher retention rates for women. There was high variability in the number and percentage of female OFA surgeons in divisions both within and between regions. Conclusion: Although the number of female OFA surgeons has increased, their representation remains low. Geographically, the East South Central division of the United States consistently had the least number of OFA surgeons, whereas the South Atlantic division had the highest. Level of Evidence: Not applicable.