Cost effectiveness analysis of operative versus nonoperative management of humeral shaft fractures in Denmark.

Context:Functional humeral bracing remains the gold standard for treatment of humeral shaft fractures. There is an increasing trend in the literature to perform operative fixation of these fractures.Evidence Acquisition:The aim of this systematic review was to compare the level one evidence for the outcome of non-operative with operative management of humeral shaft fractures in adults. A comprehensive electronic literature search of Medline and PubMed was performed with specific inclusion criteria to identify randomized controlled trials.Results:In total, seventeen different studies were identified from the search terms and combinations used. Only one study met the inclusion criteria; however, this was a published study protocol of an ongoing trial currently being conducted. One additional published protocol for an ongoing trial was also identified, but this was for a prospective comparative observational study. Although this latter study may not be level one evidence, it would offer great insight into the functional outcome of humeral shaft fractures and economic implications of operative management, which is currently not addressed in the literature. Two retrospective comparative studies were also identified, one of which demonstrated a significantly lower rate of nonunion and malunion in those patients undergoing operative management.Conclusions:This systematic review demonstrated a deficiency in the current literature of level one evidence available for the management of humeral shaft fractures. The current ongoing randomized control trail would offer a greater insight into the management of humeral shaft fractures and help confirm or refute the current literature. If this randomized control trial affirms the reduction in the rate of nonunion with operative fixation, a cost economic analysis is essential. As it would seem to offer operative management to all patients may be over treatment and not to offer this at all would undertreat.

Objective: To determine the non-surgical versus surgical outcomes in individuals who suffered from humeral shaft fractures. Methods: A randomized controlled trial was undertaken at the Department of Orthopedics Bolan Medical College Hospital Quetta, Pakistan between 09-March-2019 to 08-October-2019. A total number of 248 patients who presented with humeral shaft fractures having age 20-60 years were included in this study. Eligible patients were randomly grouped into two equal sets. Group I: were allotted to patients in whom non-operative management of humeral shaft fractures was done. In group II patients: operative management was done. Surgical outcomes were noted in terms of delayed union and radial nerve palsy. Study outcomes were noted after 1 month of principal procedure. Results: The mean age of individuals included in this study was 45.46±9.64 years. Mean body mass index (BMI) of patients was 25.44±4.63 kg/m2. Mean duration of fracture to surgery was 8.80±8.07 days. There were 169 (68.15%) male patients and 79 (31.85%) female patients. Delayed union was found in 27 (21.80%) patients in non-operative groups versus 19 (15.30%) in patients who underwent operative management (p-value of 0.191). On comparison of frequency of radial nerve palsy between the groups, radial nerve palsy was found in 12 (9.70%) patients in non operative group versus 16 (12.90%) in patients in operative group (0.422). Conclusion: The study revealed that the non-surgical management of humeral shaft fractures gives outcomes that are comparable to operative management. We did not find any evidence of significant difference in the frequency of delayed union and radial nerve palsy between the groups. Keywords: humeral shaft fractures, operative management, non-operative management.

Decision-making with regard to the treatment of humeral shaft fractures remains under debate. The cost-effectiveness of these treatment options has yet to be established. This study aims to compare the cost-effectiveness of operative treatment with that of nonoperative treatment of humeral shaft fractures. We developed a decision tree for treatment options. Surgical costs included the ambulatory surgical fee, physician fee, anesthesia fee, and, in the sensitivity analysis, lost wages during recovery. We used the Current Procedural Terminology codes from the American Board of Orthopaedic Surgery to determine physician fees via the U.S. Centers for Medicare & Medicaid Services database. The anesthesia fee was obtained from the national conversion factor and mean operative time for included procedures. We obtained data on mean wages from the U.S. Bureau of Labor and data on weeks missed from a similar study. We reported functional data via the Disabilities of the Arm, Shoulder and Hand (DASH) scores obtained from existing literature. We used rollback analysis and Monte Carlo simulation to determine the cost-effectiveness of each treatment option, presented in dollars per meaningful change in DASH score, utilizing a $50,000 willingness-to-pay (WTP) threshold. The cost per meaningful change in DASH score for operative treatment was $18,857.97 at the 6-month follow-up and $25,756.36 at the 1-year follow-up, by Monte Carlo simulation. Wage loss-inclusive models revealed values that fall even farther below the WTP threshold, making operative management the more cost-effective treatment option compared with nonoperative treatment in both settings. With an upward variation of the nonoperative union rate to 84.17% in the wage-exclusive model and 89.43% in the wage-inclusive model, nonoperative treatment instead became more cost-effective. Operative management was cost-effective at both 6 months and 1 year, compared with nonoperative treatment, in both models. Operative treatment was found to be even more cost-effective with loss of wages considered, suggesting that an earlier return to baseline function and, thus, return to work are important considerations in making operative treatment the more cost-effective option. Economic and Decision Analysis Level III . See Instructions for Authors for a complete description of levels of evidence.

<p class="abstract"><strong>Background:</strong> <span lang="EN-IN">Operative management of humeral shaft fractures is mostly accomplished by surface plating or intra-medullary nail osteosynthesis. Both the treatment options have been variably reported to give good rates of union and functional outcome. We compared both the options to know the better one in multitude of variables.</span></p><p class="abstract"><strong>Methods:</strong> <span lang="EN-IN">Thirty patients with fracture shaft of humerus were followed up for a period of 12 to18 months. 15 patients each underwent open reduction and internal fixation with dynamic compression plate and closed antegrade locked intra-medullary nailing. All patients were clinically and radiologically assessed till fracture union</span>.<strong></strong></p><p class="abstract"><strong>Results:</strong> <span lang="EN-IN">Diaphyseal humeral fractures in all the patients treated with nailing united and had a tendency to unite early compared to plating. Shoulder pain was initially complained by 2 patients from the nailing group and got subsided later on. The incidence of complications was more in the plate osteosynthesis group. </span></p><p class="abstract"><strong>Conclusions:</strong> <span lang="EN-IN">In our study Intra-medullary nailing turned out to be superior to plating for amenable diaphyseal fractures of humerus in terms of higher rate of union, early union and lesser complications.</span></p>

Objectives:Complete disruptions of the medial collateral ligament (MCL) are rare, but do occur with anterior cruciate ligament (ACL) tears. Complete ACL/MCL injuries may be managed with ACL reconstruction and either conservative or operative treatment of the MCL. MCL tear location has also been associated with outcome. We hypothesized that outcomes would be best with acute surgery and worse with proximal MCL tears.We also hypothesized that operative management of MCL injuries would not influence outcome.Methods:Patients enrolled in a multicenter prospective longitudinal cohort who underwent unilateral primary ACL reconstruction between 2002-2008 and who had 2-year follow-up were evaluated. Patients with concomitant grade III MCL injuries treated either operatively or non-operatively were identified. Concurrent injuries (to meniscus or articular cartilage) and subsequent surgeries were documented. Comparisons of surgical chronicity (before and after 30 days from injury) and MCL tear location (femoral or tibial) were performed. Patient reported outcomes (KOOS, IKDC and Marx activity scores) were measured at the time of ACL reconstruction and at 2-year follow-up.Results:Initially, 3028 patients were identified to have undergone primary ACL reconstruction in the cohort during the identified time frame, with 2586 patients completing 2-year follow-up (85%). Complete MCL tears were documented in 1.1% (27/2586) of the cohort: 16 operatively managed patients and 11 conservatively treated MCLs during ACL reconstruction. Concurrent articular pathology was similar between groups. Clinically important differences were seen in baseline KOOS (all subscales) and IKDC scores, with lower scores seen in patients who underwent operative MCL treatment. Reoperation for arthrofibrosis was higher after operative repair of the MCL (19%) versus nonoperative treatment (9%). At 2 years the non-operative MCL cohort maintained significantly better KOOS Sports Rec (88.2 versus 74.4), KOOS QOL (81.3 versus 68.4), and IKDC (87.6 versus 76.0) scores compared to the MCL surgery group. Marx activity scores were equal between groups at the time of study enrollment, however patients who underwent operative MCL management had lower activity scores at 2 years (6.5 versus 10.7). Tibial-sided MCL injuries were associated with worse baseline outcomes compared with femoral-sided MCL injuries in terms of KOOS ADL, Sports Rec, and QOL subscales, but these differences were resolved by 2 years. Surgical chronicity did not influence 2-year outcome.Conclusion:Complete and combined ACL/MCL injuries are rare. Both operative and nonoperative management of MCL tears in our cohort demonstrated clinical improvements between study enrollment and 2-year follow-up. MCL surgery during ACL reconstruction was associated with more frequent stiffness, worse patient-reported outcomes and lower activity at 2 years. There may be a subset of patients with severe combined ACL and medial knee injuries that may benefit from operative management, however, that patient population has yet to be defined.

Retrospective database analysis. To identify nationwide temporal trends in management of geriatric odontoid fractures and to compare comorbidities, inpatient complications, hospital characteristics, and cost between patients receiving operative versus nonoperative management. The treatment of geriatric odontoid fractures remains controversial with some studies demonstrating decreased mortality and improved functional outcomes associated with operative management and significant morbidity associated with halo devices during nonoperative management. Patients between ages 65 to 90 years with odontoid fractures who underwent operative or nonoperative management between the years 2003 and 2017 were identified in the National Inpatient Sample (NIS) database. Year of injury, demographic variables, comorbidities, inpatient complications, mortality, length of stay, inpatient cost, and hospital characteristics were compared between operative and nonoperative treatment groups. Thirty two thousand four hundred nineteen patients (average age 77 yr, 54% female) were included in the final analysis. Operative treatment occurred in 21,954 (67%) patients and nonoperative treatment occurred in 10,465 (32%). In 2003, operative treatment occurred in 46% of patients and nearly doubled to 86% in 2017, with an average increase of 3.7% per year (P < 0.001). Patients undergoing operative management had a lower prevalence of at least one major medical comorbidity (76% vs. 83%, P < 0.001). Patients undergoing operative treatment demonstrated higher odds of developing most complications, particularly pulmonary, gastrointestinal, and renal (P < 0.01). Inpatient mortality was 3.6% in patients receiving operative treatment and 5.9% in patients receiving nonoperative treatment (P < 0.001). Average cost per episode of care during the study period was $131,855 for operative treatment and $65,374 for nonoperative treatment (P < 0.001). This study demonstrates a clear national paradigm shift in the management of geriatric odontoid fractures, wherein operative management nearly doubled from 46% in 2003 to 86% in 2017.Level of Evidence: 3.

Purpose: Treatment of midshaft clavicle fractures in adolescents remains controversial. The adult literature suggests more favorable outcomes with open reduction internal fixation (ORIF), and it is unknown how this has influenced the management in the adolescent population over the past decade. The purpose of this study was to longitudinally evaluate the rates of operative management of midshaft clavicle fractures in adolescent patients. Methods: The Healthcare Cost and Utilization Project State Inpatient Database, State Ambulatory Surgery and Services Database, and State Emergency Department Database were evaluated for the years 2005–2015. Patients 10–18 years-old with a midshaft clavicle fracture, who underwent operative or nonoperative management, were identified using diagnosis and procedure codes. Data regarding age, sex, race, insurance type, and income percentile were also collected. The overall number of fractures managed operatively and nonoperatively were compared. Throughout the study period, factors associated with operative and non-operative management were analyzed. Descriptive statistics as well as univariate and multivariate analyses were performed. Results: There were 4,815 adolescent midshaft clavicle fractures identified between 2005 and 2015, and 375 (7.8%) of these fractures underwent operative management. There was a significant increase in the rate of operative management from 4.26% (n = 62) between 2005 and 2008 to 12.13% (n=141) between 2012 and 2015 (p<0.001). This increase was seen across all racial groups (p<0.05). Patients undergoing operative management were significantly older [16.0±1.7 vs. 14.1±2.3 years-old, p<0.001], were more likely to have Medicaid insurance (p<0.001), and were more likely to be in the bottom 75th percentile for income. Conclusion: The rate of adolescent midshaft clavicle fractures treated operatively has significantly increased over the past decade, and there are several demographic and socioeconomic differences between patients treated with and without surgery. Additional outcomes research is needed to justify this trend in adolescent patients with midshaft clavicle fractures in the bottom 75th percentile income brackets. Additional studies are needed to understand and validate the increased rates in operative management of midshaft clavicle fractures in adolescents.

Purpose: The treatment of intra-articular fractures of the calcaneum remains controversial. There is no consensus in the current literature regarding the optimal treatment of intra-articular fractures of the calcaneum. In the current study, we intend to compare the outcome of operative and conservative management for intra-articular calcaneum fractures based on the objective criteria, i.e., restoration of Bohler's angle, subtalar range of motion, and subjective criteria such as pain, return to work, return to physical activity, and change in shoe wear. Materials and Methods: This retrospective cum prospective study was conducted in a government hospital at Patna, Bihar, during the period extending from April 2016 to March 2019. Twenty-four patients with 25 intra-articular calcaneum fractures were included in the study. The outcome of conservative and operative management was compared using the Creighton-Nebraska Health Foundation Assessment Score (C-N scoring system). Pretreatment and posttreatment (at follow-up) Bohler's angle were also compared. Results: Restoration of the Bohler's angle was better with operative management as compared to conservative management. In our study, the results of type I fractures managed conservatively had a better outcome than those of displaced fractures and the difference was statistically significant. Furthermore, type II and type III fractures had a better outcome with operative management, but the difference was not statistically significant. In type IV fractures, operative management was significantly better than conservative management. A significant correlation was seen between the posttreatment Bohler's angle and C-N scores. Conclusions: Conservative management has better functional outcome for undisplaced fractures. For displaced and comminuted fractures, anatomical reduction and restoration of Bohler's angle is very important. Bohler's angle has a prognostic importance and correlates well with the functional outcome.

Cost-effectiveness of operative versus nonoperative treatment of lateral compression type 1 pelvic fractures.

Category: Ankle, Sports Introduction/Purpose: The management of acute Achilles tendon ruptures remains controversial. Proponents of operative treatment cite lower rates of re-rupture, the potential for better functional outcomes and earlier return to activity. However, operative management incurs the added risks of surgical complications and the considerable cost of the surgical procedure. The goal of this study was to evaluate the cost-effectiveness of operative versus nonoperative management of acute Achilles tendon ruptures using the best available evidence regarding the costs and benefits of these two strategies. Methods: A Markov cost-utility analysis was conducted from the societal perspective to evaluate the cost-effectiveness of operative versus nonoperative management of acute Achilles tendon ruptures over a two-year time-period. Hospital costs were derived from New York SPARCS data, physician and rehabilitation costs were derived from Medicare physician fee schedules, and indirect costs of missed work were calculated using the average U.S. hourly earnings from the Bureau of Labor Statistics. Rates of re-rupture, major and minor complications, and the costs of managing these complications were obtained from the literature. For the base-case model, operative and non-operative patients were assumed to have the same utilities (quality of life) following surgery. The robustness of the model to uncertainty in the input parameters was examined through sensitivity analyses varying inputs over plausible ranges from the literature. Results are presented as costs (2014 US$), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios with 95% confidence intervals. Results: In the base-case model, nonoperative management of acute Achilles tendon ruptures dominated operative management, resulting in both lower costs and greater benefits. The total cost of operative management was $13,936 versus $13,430 for nonoperative management. The initial surgical cost for Achilles tendon repair, $3,145 ($3,045-$3,244), was largely offset through reduced indirect costs from fewer missed days of work, 19 (4-34) days). In sensitivity analyses, if surgical costs dropped below $2,621 or the hourly wage rose above $29, then operative treatment became a cost-effective strategy at the willingness-to-pay threshold of $50,000/QALY. The model results were highly sensitive to the relative utilities for operative versus nonoperative treatment. If nonoperative utilities decreased relative to operative utilities by just 1.6%, then operative management became the dominant treatment strategy. Conclusion: Surgical costs and the economic impact associated with return to work are important determinants of cost- effectiveness for Achilles tendon ruptures. These results suggest that operative treatment of Achilles tendon injury may be cost- effective at low-cost centers and for high wage earning individuals. Furthermore, operative treatment is cost-effective if it produces incrementally better function and quality of life relative to nonoperative management. The available literature is inconclusive regarding differences in function and quality of life between operative and nonoperative treatment. Further research is needed to evaluate the quality of life benefits associated with operative and non-operative treatment of Achilles tendon injury.

The purpose of this study is to compare the outcomes and complications of operative vs non-operative management of mid-diaphyseal clavicle fractures in the skeletally immature population. Traditionally, skeletally immature clavicle fractures have been managed non-operatively. However, there has been an increasing trend towards operative management with a lack of evidence indicating its effectiveness. Two reviewers searched three online databases (MEDLINE, EMBASE and PubMed), independently and in duplicates, for literature comparing the outcomes and complications of operative versus non-operative management in skeletally-immature patients (defined as birth to 18 years of age) with a middiaphyseal clavicle fracture. Where possible, risk ratios (RR) and mean differences (MD) were combined using a random effects model. Seven studies, containing 522 skeletally immature patients (with 528 mid-diaphyseal clavicle fractures) with an age range of 8 to 18years, with 148 patients undergoing operative management and 380 patients undergoing non-operative management, were included. Across the 6 studies that reported gender (N = 444), there were 335 males and 109 females. Patients were followed up from 2weeks to 3.7years across five studies (N = 201 patients) that reported follow-up time. There was no significant difference in the time to achieve union (p = 0.1), the time to return to activity (p = 0.09), and the overall complication rate (p = 0.50) between the operative and the non-operative groups. There is no significant difference between operative and non-operative management of skeletally immature mid-diaphyseal clavicle fractures. Clinical equipoise exists to study this further by means of a prospective, randomized, blinded control trial. Level IV, systematic review and meta-analysis of level II, III, and IV.

Decision-making on management of proximal femoral fractures in frail patients with limited life expectancy is challenging, but surgical overtreatment needs to be prevented. Current literature provides limited insight into the true outcomes of nonoperative management and operative management in this patient population. To investigate the outcomes of nonoperative management vs operative management of proximal femoral fractures in institutionalized frail older patients with limited life expectancy. This multicenter cohort study was conducted between September 1, 2018, and April 25, 2020, with a 6-month follow-up period at 25 hospitals across the Netherlands. Eligible patients were aged 70 years or older, frail, and institutionalized and sustained a femoral neck or pertrochanteric fracture. The term frail implied at least 1 of the following characteristics was present: malnutrition (body mass index [calculated as weight in kilograms divided by height in meters squared] <18.5) or cachexia, severe comorbidities (American Society of Anesthesiologists physical status class of IV or V), or severe mobility issues (Functional Ambulation Category ≤2). Shared decision-making (SDM) followed by nonoperative or operative fracture management. The primary outcome was the EuroQol 5 Dimension 5 Level (EQ-5D) utility score by proxies and caregivers. Secondary outcome measures were QUALIDEM (a dementia-specific quality-of-life instrument for persons with dementia in residential settings) scores, pain level (assessed by the Pain Assessment Checklist for Seniors With Limited Ability to Communicate), adverse events (Clavien-Dindo classification), mortality, treatment satisfaction (numeric rating scale), and quality of dying (Quality of Dying and Death Questionnaire). Of the 172 enrolled patients with proximal femoral fractures (median [25th and 75th percentile] age, 88 [85-92] years; 135 women [78%]), 88 opted for nonoperative management and 84 opted for operative management. The EQ-5D utility scores by proxies and caregivers in the nonoperative management group remained within the set 0.15 noninferiority limit of the operative management group (week 1: 0.17 [95% CI, 0.13-0.29] vs 0.26 [95% CI, 0.11-0.23]; week 2: 0.19 [95% CI, 0.10-0.27] vs 0.28 [95% CI, 0.22-0.35]; and week 4: 0.24 [95% CI, 0.15-0.33] vs 0.34 [95% CI, 0.28-0.41]). Adverse events were less frequent in the nonoperative management group vs the operative management group (67 vs 167). The 30-day mortality rate was 83% (n = 73) in the nonoperative management group and 25% (n = 21) in the operative management group, with 26 proxies and caregivers (51%) in the nonoperative management group rating the quality of dying as good-almost perfect. Treatment satisfaction was high in both groups, with a median numeric rating scale score of 8. Results of this study indicated that nonoperative management of proximal femoral fractures (selected through an SDM process) was a viable option for frail institutionalized patients with limited life expectancy, suggesting that surgery should not be a foregone conclusion for this patient population.

BackgroundThe management of acute Achilles tendon ruptures is controversial, and most injuries are treated with surgery in the USA. The cost utility of operative versus non-operative treatment of acute Achilles tendon injury is unclear.Questions/PurposesThe purpose of this study was to compare the cost-effectiveness of operative versus functional non-operative treatment of acute Achilles tendon ruptures.MethodsA Markov cost-utility analysis was conducted from the societal perspective using a 2-year time horizon. Hospital costs were derived from New York State billing data, and physician and rehabilitation costs were derived from the Medicare physician fee schedule. Indirect costs of missed work were calculated using estimates from the US Bureau of Labor Statistics. Rates of re-rupture, major and minor complications, and the associated costs were obtained from the literature. Effectiveness was expressed in quality-adjusted life years (QALYs). For the base-case analysis, operative and non-operative patients were assumed to have the same utilities (quality of life) following surgery. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the robustness of model assumptions.ResultsIn the base-case model, non-operative management of acute Achilles tendon ruptures dominated operative management, resulting in both lower costs and greater QALY gains. The differences in costs and effectiveness were relatively small. The benefit of non-operative treatment was 1.69 QALYs, and the benefit of operative treatment was 1.67 QALYs. Similarly, the total cost of operative and non-operative management was $13,936 versus $13,413, respectively. In sensitivity analyses, surgical costs and days of missed work were important drivers of cost-effectiveness. If hospitalization costs dropped below $2621 (compared with $3145) or the hourly wage rose above $29 (compared with $24), then operative treatment became a cost-effective strategy at the willingness-to-pay threshold of $50,000/QALY. The model results were also highly sensitive to the relative utilities for operative versus non-operative treatment. If non-operative utilities decreased relative to operative utilities by just 2%, then operative management became the dominant treatment strategy.ConclusionFor acute Achilles tendon ruptures, non-operative treatment provided greater benefits and lower costs than operative management in the base case; however, surgical costs and the economic impact associated with return to work are important determinants of the preferred cost-effective strategy.

The purpose of the current review is to describe the management of displaced midshaft clavicle fractures in pediatric and adolescent patients. Midshaft clavicle fractures are relatively common in pediatric and adolescent patients. They most commonly occur from direct trauma and are often related to sports participation in adolescents. Recent literature in the management of adult midshaft clavicle fractures has supported operative management due to improved functional outcomes, decreased time to union, leading to early return to activity. A similar trend of increasing frequency in operative management has been seen in pediatric and adolescent patients with no consensus in the literature on optimal management. Nonoperative treatment consists of with a brief period of sling immobilization followed by range of motion. Operative management may be considered for open fractures, fractures with significant neurovascular compromise and soft tissue complications. Studies have shown comparable mid- to long-term functional and patient-reported outcomes after operative and nonoperative management of midshaft clavicle fractures in pediatric patients.

This article provides a summary of orthopaedic foot and ankle research from September 2021 to September 2022. The included studies were published in The Journal of Bone & Joint Surgery, Foot & Ankle International, Foot and Ankle Surgery, Clinical Orthopaedics and Related Research, the Journal of Orthopaedic Trauma, The American Journal of Sports Medicine, JAMA (Journal of the American Medical Association), The New England Journal of Medicine, The Bone & Joint Journal, and the Journal of the AAOS (American Academy of Orthopaedic Surgeons). Forefoot Minimally invasive techniques involving the lesser metatarsals continue to grow in popularity. Neunteufel et al.1 reported a case series of 30 patients (31 feet) who underwent minimally invasive distal metatarsal metaphyseal osteotomy for metatarsalgia of ≥1 lesser metarsals2–5. All clinical scores (American Orthopaedic Foot & Ankle Society [AOFAS] Forefoot Score, Foot Function Index, Foot and Ankle Outcome Score [FAOS], and visual analog scale [VAS] pain score) improved significantly at a mean follow-up of 15.5 months. Plantar peak pressure at the relevant area was also reduced significantly. The mean metatarsal shortening across all osteotomies was 6.6 mm. Del Vecchio et al.2 reported the results of a sliding distal metatarsal minimally invasive osteotomy for the correction of a bunionette deformity in 57 patients (74 feet). At a minimum follow-up of 30 months, all radiographic and clinical outcome measures improved, with 89.1% of patients rating the procedure as excellent. The overall complication rate was 6.75%. Syndactyly release remains surprisingly problematic. Langlais et al.3 retrospectively reviewed 38 pediatric patients with 68 syndactylies who underwent syndactyly release with a dorsal commissural flap and cutaneous resurfacing. The recurrence rate was 28.1% and the complication rate was 11.7% at a mean follow-up of 6.9 years. Age of >2 years at the time of the surgical procedure was a risk factor for recurrence. Of the patients with simple syndactylies, only one-half were satisfied. Hallux Valgus Further data continue to demonstrate short-term equivalency but not superiority for minimally invasive hallux valgus surgery compared with open techniques. Hernández-Castillejo et al.4 performed a longitudinal, prospective study on 72 patients (72 feet) who underwent open chevron, open scarf, or percutaneous Reverdin-Isham osteotomy for the correction of hallux valgus deformity. At a mean follow-up of 17.7 months, all patient-reported outcome measures, including the VAS pain score and Manchester Oxford Foot Questionnaire (MOXFQ), demonstrated significant improvement independent of the preoperative radiographic parameters and type of surgical procedure. Lewis et al.5 prospectively reported on 106 consecutive feet (78 patients) that underwent third-generation minimally invasive chevron and Akin (MICA) osteotomies for severe hallux valgus. In the 86 feet (81.1%) with a minimum 2-year follow-up, there was significant improvement in all MOXFQ domains. The mean intermetatarsal angle and hallux valgus angle also improved significantly. The authors reported an 18.8% overall complication rate. Mikhail et al.6 retrospectively reviewed 248 patients (274 feet) who underwent MICA osteotomies for hallux valgus correction. At a mean follow-up of 12.9 months, the intermetatarsal angle, hallux valgus angle, and Foot Function Index improved significantly. The overall satisfaction rate was 91.6%, the mean number of 5-mg oxycodone tablets consumed postoperatively was 2.2 tablets, and the complication rate was 8.4%. The Lapidus procedure continues to grow in popularity. A retrospective review comparing Lapidus bunionectomy (73 patients) with scarf bunionectomy (63 patients) found no difference in Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function scores between groups, although patients in the scarf group had a 25% lower chance of achieving a normal intermetatarsal angle, at a mean follow-up of 17.8 months7. Veracruz-Galvez et al.8 prospectively followed 82 patients who underwent scarf osteotomy for moderate to severe hallux valgus. Normal postoperative sesamoid position (48 patients) was associated with significantly less pain (VAS), higher Self-Reported Foot and Ankle Score, and higher patient satisfaction (Likert scale) than the group with outlier sesamoid positions (34 patients). In a retrospective study comparing patients with hallux valgus (34 feet) with normal controls (20 feet), Lalevée et al.9 found that the distal metatarsal articular angle was overestimated on conventional radiographs compared with weight-bearing computed tomographic (CT) scans by a mean of 14°. However, even after computerized correction of the first metatarsal rotation and plantar flexion, the valgus alignment of the first metatarsal distal articular surface was 8.6° higher in patients with hallux valgus than in the control patients on weight-bearing CT scans. Hallux Rigidus Cichero et al.10 retrospectively reviewed 280 first metatarsophalangeal arthrodeses. The overall nonunion rate was 7.9% (22 feet). The risk of nonunion was >3 times higher in patients who had a single-construct locking plate with an interfragmentary compression screw inserted through the plate compared with patients who had a locking plate and a lag screw inserted outside of the plate. Hindfoot Tarsal Tunnel Syndrome The results of tarsal tunnel release remain inconsistent. Bouysset et al.11 retrospectively reviewed 73 patients (84 feet) who underwent tarsal tunnel release with follow-up of at least 1 year. The effectiveness of the release, based on patient willingness to repeat the procedure under similar preoperative circumstances, was significantly lower in patients with marked hindfoot varus or valgus and in patients with plantar fasciitis. Patients in only 51% of cases (43 feet) said that they would undergo the procedure again. Plantar Fasciitis Bildik and Kaya12 performed a double-blinded, randomized controlled trial that compared platelet-rich plasma (30 patients) with autologous blood (30 patients) for the treatment of plantar fasciitis. At 6 months after the injection, both groups demonstrated significant and similar improvements in the VAS pain scores and the Foot and Ankle Disability Index health-related quality-of-life scores compared with baseline. Kaiser et al.13 performed a prospective randomized controlled trial comparing a 6-week formal physical therapy program (27 patients) with a 6-week home stretching program (30 patients) for the treatment of plantar fasciitis. At 6 months, both groups significantly and identically improved from baseline in terms of VAS pain scores, Foot and Ankle Ability Measure scores, and Short Form-36 (SF-36) scores, and results were maintained through the 1-year follow-up. Insertional Achilles Tendinitis Arunakul et al.14 compared conventional rehabilitation (18 patients) with accelerated rehabilitation (31 patients) after debridement and reattachment of the Achilles tendon. At 3 months, the mean scores for VAS pain, Foot and Ankle Ability Measure, and SF-36 were significantly better in the accelerated rehabilitation group, but by 6 and 12 months there were no differences. There also were no complications. In a retrospective series of 50 open Zadek osteotomies fixed with a 6-hole lateral plate for treatment of Haglund syndrome, Tourne et al.15 reported significant improvement in the AOFAS Hindfoot scores and the Victorian Institute of Sport Assessment–Achilles scores at a mean follow-up of 7 years. Of 50 patients, 46 (92%) returned to the same or higher level of sports activity. The authors recommended using the Zadek osteotomy for the treatment of Haglund syndrome in the setting of a long calcaneus or when the novel X/Y ratio proposed in the study is <2.5, where X is the length of the calcaneus and Y is the length of the tuberosity on a lateral weight-bearing radiograph. Pes Planus In an attempt to establish the diagnostic reliability of a new classification for progressive collapsing foot deformity, Li et al.16 distributed a survey to current trainees, graduates, and faculty of 13 foot and ankle fellowship programs. For the entire cohort, the diagnostic accuracy rates were 71.0% overall, 78.3% for class, and 81.7% for stage. The misdiagnosis rates for the entire cohort for were 3.3% for class A, 17.5% for class B, 11.1% for class C, 26.0% for class D, and 3.7% for class E. Importantly, this survey used example patients for whom the physical examination findings were provided to the raters. The reliability of the scheme would likely be even lower in a real-world practice situation. The classification scheme for progressive collapsing foot deformity was evaluated with actual patients by Lee et al.17. Three independent observers assessed 92 feet (84 patients). The authors reported very good intraobserver reliability (Cohen kappa, 0.851; p < 0.001) and much worse interobserver reliability (Fleiss kappa, 0.561; p < 0.001). The classification scheme should not be considered reliable until changes result in improved interobserver reliability. The Cotton osteotomy is a dorsally based opening-wedge osteotomy of the medial cuneiform that is utilized to correct the forefoot varus component of adult-acquired flatfoot deformity, but it may not provide lasting results. Abousayed et al.18 reported a mean 8.6-year follow-up for the Cotton osteotomy performed with either allograft wedges (17 feet) or metal wedges (2 feet). Although a significant improvement was noted in the lateral talus-first metatarsal angle from preoperatively to the first postoperative follow-up (p < 0.0001), approximately one-half of the patients lost >50% of that correction at the final follow-up. The lengthened angular shape of the medial cuneiform was maintained, indicating that collapse occurred through surrounding medial column joints. Sports Osteochondral Lesions of the Talus The management of large osteochondral lesions of the talus is challenging. Shi et al.19 retrospectively compared autologous osteoperiosteal transplantation from the iliac crest (23 patients) with autologous osteochondral transplantation from the ipsilateral knee (23 patients) for the treatment of large, cystic, medial osteochondral lesions of the talus. At a mean follow-up of 48 months, there was no difference between the groups in terms of VAS pain scores, AOFAS scores, or Tegner scores. There was significantly less donor site morbidity in the autologous osteoperiosteal transplantation group. Magnetic resonance observation of cartilage repair tissue (MOCART) scores and International Cartilage Regeneration & Joint Preservation Society (ICRS) scores from second-look arthroscopy showed no differences between groups. Fletcher et al.20 reported on a prospective series of 31 patients who underwent fresh structural allograft transplantation for osteochondral lesions of the talar shoulder. At a mean 56.2-month follow-up, significant improvement was found in VAS scores, SF-36 scores, and the Short Musculoskeletal Functional Assessment Bother Index and Function Index compared with the preoperative status. The overall graft survival was 96.8%. Fifteen patients (48.4%) underwent an additional surgical procedure, typically implant removal or arthroscopic debridement. Microfracture for osteochondral lesions of the talus that have previously undergone a surgical procedure (secondary lesions) may not be as beneficial as previously reported. Arshad et al.21 performed a systematic review of 12 studies to assess patient-reported outcomes and pain scores after arthroscopic bone marrow stimulation for secondary talar lesions. No perioperative complications were noted, but, in studies that reported a revision surgical procedure as an end point, 26 (34%) of 77 patients underwent a revision procedure. Overall, patient-reported outcomes such as AOFAS score and VAS pain score showed inconsistent improvements, and many positive changes were less than the minimal clinically important difference (MCID) for these scales. Enthusiasm for subchondroplasty in the talus has waned. Hanselman et al.22 retrospectively reviewed 7 cases of talar osteonecrosis after subchondroplasty for bone marrow lesions. The mean time to radiographic confirmation of osteonecrosis was 23 months. Three of 7 patients had osteonecrosis risk factors (alcoholism and/or chronic corticosteroid use). The authors urged caution with this procedure, especially in patients with osteonecrosis risk factors. Achilles Rupture and Tendinosis Research continues on the optimal management of acute Achilles tendon ruptures. Seow et al.23 performed a meta-analysis to determine complication rates after the treatment of acute Achilles tendon ruptures and included a best-case and worst-case scenario analysis for rerupture rates. The best-case scenario assumed a 0% rerupture rate in those lost to follow-up, and the worst-case scenario assumed a 100% rerupture rate. Surgical treatment significantly reduced the risk of rerupture compared with nonoperative management. The pooled rerupture rate was 3.6% (3.4% best-case scenario, 8.3% worst-case scenario) in the surgical treatment arm and 12.1% (11.7% best-case scenario, 15.0% worst-case scenario) in the nonoperative treatment arm. The rate of complications, excluding reruptures, was significantly lower with nonoperative treatment (pooled complication rate, 7.1%) compared with surgical treatment (pooled complication rate, 18.5%). Percutaneous Achilles repair may be better paired with less aggressive rehabilitation to avoid stretching the repair. Maffulli et al.24 compared a traditional rehabilitation protocol (31 patients) with a slowed-down rehabilitation protocol (29 patients) for patients undergoing percutaneous repair of an acute Achilles tendon rupture. At a 12-month follow-up, the Achilles tendon resting angle and Achilles Tendon Rupture Score were significantly better in the slowed-down rehabilitation protocol group. Additionally, calf circumference and isometric strength were more similar to those in the contralateral, uninjured leg in the slowed-down rehabilitation protocol group. Trauma The Major Extremity Trauma Research Consortium (METRC)25 published a randomized controlled trial comparing a high perioperative FiO2 (fraction of inspired oxygen) of 80% with a standard perioperative FiO2 of 30% and its effect on surgical site infections in patients undergoing a surgical procedure for tibial plateau, tibial pilon, or calcaneal fractures. At 6 months postoperatively, they found a significant difference in overall surgical site infections (superficial and deep) between the groups: 7.0% for the experimental group compared with 10.7% for the control group (relative risk [RR], 0.65; p = 0.03). The difference was driven by fewer superficial infections in the experimental group (1.7%) compared with the control group (4.3%), for which the RR was 0.41 (p = 0.02); there was no difference in the risk of deep infections (5.6% in the experimental group compared with 6.6% in the control group [RR, 0.86; p = 0.5]). Anterior impaction of the tibial plafond has been shown to portend a particularly poor prognosis. Jo et al.26 retrospectively reviewed 50 patients (52 fractures) who underwent open reduction and internal fixation (ORIF) of OTA/AO 43B and C pilon fractures. At a mean follow-up of 25 months, the group with anterior impaction (28 fractures) had significantly higher rates of implant removal for pain, significantly greater anterior subluxation, and significantly worse posttraumatic arthritis than the group without anterior impaction. Noori et al.27 found that the Lawrence and Botte classification of proximal fifth metatarsal fractures has a low level of interrater reliability (an observed agreement of 77% compared with a chance agreement of 33%). Classification at the interface between Zones 2 and 3 was much less reliable than that between Zones 1 and 2. The authors suggested that a new classification system for these fractures is required for both clinical and research purposes. Ankle Fractures Allen et al.28 studied the effect of acute, intermediate, and late-phase synovial fluid fracture hematoma on cartilage discs from fresh allograft human tali. Compared with controls, the cartilage discs cultured in synovial fluid fracture hematoma demonstrated a significantly greater production of inflammatory cytokines, metalloproteinases, and cartilage matrix fragments, suggesting that cartilage-damaging pathways had been activated. The addition of compounds that inhibit inflammation (interleukin 1 receptor antagonist or doxycycline) decreased the pro-inflammatory effect of synovial fluid fracture hematoma on the cartilage tissue. Clinical tests for fracture stability continue to be debated. In a retrospective Level-III study of supination-external rotation 2 (SER-2) ankle fractures, Ali et al.29 reported no difference (p = 0.595) between manual stress views and gravity stress views for determining fracture stability and the need for a surgical procedure. Despite their ability to limit complications in older patients, fibular nails appear to have drawbacks when used in younger patients. Kho et al.30 retrospectively compared young patients (mean age, 41.4 years) who underwent closed reduction and intramedullary fixation (CRIF) with a fibular nail (n = 94) compared with ORIF with a locking plate (n = 110). At a minimum follow-up of 3 years, complications were lower in the CRIF group (9.5% compared with 39%; p < 0.001). However, the CRIF group demonstrated significantly higher rates of posttraumatic arthritis (21.3% compared with 9.1%; p = 0.024) and fair or poor reduction (p < 0.001) on 3-D CT scans. The authors recommended that surgeons consider ORIF in active young patients, especially for more complex fracture patterns. Stupay et al.31 performed a retrospective cohort study to identify risk factors for aseptic revision of operatively treated ankle fractures. Using multivariable logistic regression modeling, the authors reported that falls in the early postoperative period, movement-altering disorders, a nonanatomic mortise (medial clear space was greater than superior clear space) on initial postoperative imaging, more severe initial fracture displacement, substance abuse, and polytrauma are independent risk factors for aseptic revision after ankle ORIF. Identifying these risk factors may help surgeons to counsel patients and improve safety and outcomes after ankle fracture surgery. Syndesmotic Injuries Bhimani et al.32 retrospectively reviewed preoperative bilateral weight-bearing CT scans in patients with unilateral Weber B fibular fractures and a symmetric medial clear space who did (n = 23) and did not (n = 18) have intraoperatively confirmed syndesmosis instability. The authors found that weight-bearing CT was able to distinguish a stable from an unstable syndesmosis even in the presence of a Weber B fibular fracture. Syndesmotic volume measured to a height of 5 cm proximal to the tibial plafond was the best measurement for diagnosing syndesmosis instability. Wong et al.33 utilized 4-D CT scans to characterize the of ankle of on The authors found significant medial and rotation of the ankle plantar but no in with in There was no difference in between in The authors that reduction in the setting of an ankle fracture be from the uninjured ankle the ankle position is The same used 4-D CT scans to at 12 months after syndesmosis fixation (n = and syndesmosis fixation (n = Although the patient were with initial fixation demonstrated significantly reduced syndesmosis of in of 5 measures (p < when compared with the uninjured No differences in syndesmosis of between and uninjured were observed in the group with Lee et retrospectively reviewed patients with a minimum follow-up after surgical fixation of the syndesmosis in the setting of an ankle fracture. patients had chronic syndesmosis as pain with a and >2 of syndesmosis compared with the ankle on bilateral CT scans at 5 years analysis a of (p = and the presence of a fracture (p = as risk factors for chronic syndesmosis instability. et performed a study the as the of the syndesmosis on a mortise of the The authors a 12 from the which that utilized to fractures are not in the syndesmosis and not the tendon. Ankle and outcomes of 3-D and for ankle and hindfoot have been reported. In a of ankle cases with and 25 cases with standard et found no difference between the techniques for component position or of the surgical procedure. All cases were performed by a In a study of cases that utilized 3-D for of the hindfoot and/or et found that of cases required secondary and of cases required removal of the implant for or aseptic outcomes are at least similar to or better than findings using allograft for these in the of was associated with the need for a secondary procedure ratio p = 0.03). and follow-up of ankle has been including of the first Using the et found of metal to be at 5 years and at years. age, and low volume for the procedure were independent of The first data for ankle were reported by et who reviewed the cases performed by the of the Of the for the were with the in at the follow-up or at the time of The authors proposed as a for and third-generation have compared the results of ankle with those of revision ankle an important the of when a et performed a cohort study of patients with ankle and 23 patients with revision ankle No were There was significantly greater improvement (p = 0.024) in the overall MOXFQ scores for ankle compared with revision deformity for ankle or is less than previously but In an et found at follow-up of 2 to 3 years, patients with deformity of who underwent either or from the procedure. No difference between the 2 be using the SF-36 and the Musculoskeletal Functional but the results as a were to those of a control cohort without deformity. ankle is an to the more anterior procedure. rates using this procedure have to be reported. et reported radiographic in of 86 cases at a mean follow-up of months. Using more CT imaging, et reported lesions in of cases at a mean follow-up of months. rates of are similar to those observed for The to the lateral are to by the same on the same cohort of patients found a rate of early complications and in The results of may be In a retrospective review of patients who underwent hindfoot with an intramedullary et reported an overall hindfoot rate at a mean follow-up of months. A greater nail ratio (p = and hindfoot compression (p = were associated with a higher rate. medial was nonunion (p = and hindfoot (p = and clinical factors including age, and did not rates. and retrospectively reviewed patients (23 feet) who underwent with internal fixation for and At a mean follow-up, the authors reported a 100% rate of with of 23 patients weight-bearing There were 6 The authors for a a and and the of in the Although is as a risk factor for is a of patients age, was associated with a of to and a of The risk was in patients with ratio p = followed by chronic and p < The study the need for improved early and for patients with Orthopaedics The of reviewed a large number of published studies to the system that a higher of In addition to in this relevant to foot and ankle surgery are to this review after the standard with a article to help in an in this Orthopaedics of corticosteroid to therapy for Achilles a randomized clinical JAMA In a randomized controlled trial on the treatment of Achilles et compared corticosteroid and physical therapy with and physical were and were in the tissue anterior to the of the tendon than in the tendon At 6 months, the corticosteroid group had significantly greater improvement in the Victorian Institute of Sport Assessment–Achilles score compared with the group. There was no of improvement at the 2-year follow-up. There were no infections and no ruptures in either group. Although traditional corticosteroid for the treatment of Achilles of corticosteroid the anterior tissue to be a and to physical therapy when Achilles or surgical treatment of acute tendon rupture. In this large randomized controlled et compared open and minimally invasive surgical treatment of acute Achilles tendon ruptures. This is by the study of the The authors reported no significant difference between groups in the mean in the Achilles Tendon Rupture Score from the baseline to and 12 months Although was not reported by the the study was for a of rerupture rates. The rate of rerupture was significantly higher in the nonoperative treatment group of patients) compared with the groups of patients in the open repair group and 1 of patients in the repair were reported in the group, and 5 were reported in the open repair group. Although this study suggested that there was no difference in patient-reported between and operatively treated acute Achilles tendon ruptures at 1 it is important to that the results may have been by the to Achilles Tendon Rupture of patients who a as in the protocol This the likely results from the nonoperative group. A study without data that patient-reported outcomes through the entire of of complications, be required to more the for a surgical procedure. Patients a surgical procedure to an Achilles should be that they similar results for nonoperative management and management as long as they not a but the risk of rerupture is higher with nonoperative management. A, of platelet-rich plasma on ankle and in patients with ankle a randomized clinical 2021 clinical improvement of ankle arthritis after platelet-rich plasma has been by and case et found no to platelet-rich plasma at 26 in a randomized Although the outcome was the AOFAS Hindfoot Score, which has a and is not an patient-reported secondary outcome also their Patients should be that there is no for platelet-rich plasma in ankle C, blood with treatment for chronic plantar a randomized controlled Foot Ankle This double-blinded, randomized controlled trial compared autologous blood patients) and patients) for the treatment of chronic plantar fasciitis. The mean pain scores both groups improved by at a final follow-up. There were no differences in patient-reported or pain scores at time plantar should patients that there is no clear to autologous blood to