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Hip fractures are common in elderly patients, and which surgical modality to pursue is often debated. Malnutrition, which cannot be corrected preoperatively in this population, is often not considered. Therefore, the authors sought to investigate the association between hypoalbuminemia and postoperative outcomes based on surgical intervention. Patients undergoing arthroplasty (hemiarthroplasty or total hip arthroplasty), open reduction and internal fixation, and intramedullary nailing placement for treatment of hip fractures were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by preoperative albumin level, with less than 3.5 g/dL indicating hypoalbuminemia. Albumin's association with postoperative complications was evaluated with multivariate logistic regression controlling for patient age, body mass index, American Society of Anesthesiologists score, and functional independence. A total of 20,278 patients with hip fractures and available albumin levels were included. Multivariate analysis revealed hypoalbuminemia was predictive of readmission, reintubation, mortality, and length of stay for all surgeries performed. When analyzing across surgical modalities, unique complications were identified for patients with hypoalbuminemia undergoing open reduction and internal fixation/prosthetic replacement (reoperation, P <.001) and arthroplasty (any infection, P =.028) compared with other treatment options. Hypoalbuminemia can predict postoperative complications for patients with hip fractures and should be considered preoperatively to guide surgical decision making in equivocal cases where multiple modalities may be used based on fracture pattern. This study supports that, compared with other interventions, intramedullary nailing is associated with fewer postoperative complications in patients with hypoalbuminemia. [ Orthopedics . 2018; 41(6):e789–e796.]

NIH/NIGMS-funded IDeA-Clinical and Translational Research (CTR) networks seek to expand translational research infrastructure to support research that has at its endpoints measurable clinical, public health, technological, or economic benefits. This retrospective case study followed 14 projects that received Pilot funding from the Great Plains IDeA-CTR (GP IDeA-CTR) at the University of Nebraska Medical Center. It focuses on the impact of pilot funding and GP IDeA-CTR resources on subsequent clinical and translational research. Metrics include extramural awards, lessons learned that relate to clinical and translational research infrastructure, and demonstrated and potential benefits using the Translational Science Benefits Model (TSBM).

Background: Considerable variability exists in return-to-play rates after anterior cruciate ligament (ACL) injury and reconstruction (ACLR) among National Football League (NFL) players of different positions. Purpose/Hypothesis: The purpose of this study was to compare return-to-play and performance levels by position in NFL players after ACLR. It was hypothesized that (1) ACL injuries have significant effects on the careers of NFL players, including return to play and performance, and (2) players of certain positions that involve relatively less pivoting and cutting perform better after ACLR. Study Design: Descriptive epidemiology study. Methods: All NFL players who underwent ACLR between 2013 and 2018 were identified using the FantasyData injury database. Player characteristics, snap count, games played, games started, and performance metrics were collected for 3 years before and after injury using the Pro Football Reference database. Performance was measured using an approximate value (AV) algorithm to compare performance across positions and over time. Nonparametric tests were used to compare the pre- and postinjury data and the percentage change in performance between different positions. Results: Overall, 312 NFL players were included in this study, and 174 (55.8%) returned to play. Of the eligible players, only 28.5% (n = 59/207) remained in the league 3 years postinjury. Within the first 3 years postinjury, players played in fewer games (8.7 vs 13.7; P < .0001), started in fewer games (3.0 vs 8.3; P < .0001), had lower AVs (1.5 vs 4.3; P < .0001), and had decreased snap counts (259.0 vs 619.0; P < .0001) compared with preinjury. Quarterbacks were most likely to return to play (92.9% vs 53.7%; P = .0040) and to return to performance (2% vs 50% decrease in AV; P = .0165) compared with the other positions. Running backs had the largest decrease in AV (90.5%), followed by defensive linemen (76.2%) and linebackers (62.5%). Conclusion: The study findings indicated that NFL players are severely affected by ACL injury, with only 28.5% still active in the league 3 years after the injury. Running backs, defensive linemen, and linebackers performed the worst after injury. Quarterbacks were most likely to return to play and had superior postinjury performance compared with the other positions.

Category: Ankle Arthritis; Ankle Introduction/Purpose: The current fourth generation of total ankle arthroplasty (TAA) continues to build upon previous advances in implant design. In contrast to these implants, which utilize a traditional anterior approach for implantation, the Zimmer Trabecular Metal Total Ankle (Zimmer-Biomet, Warsaw, IN) is unique in that it utilizes a transfibular approach to the ankle. This allows for a shallow resection depth, and the insertion of a curved prosthesis design, mimicking the native tibiotalar joint. While previous case-series have reported on implant survivorship, a comprehensive midterm study of the clinical and radiographic outcomes of this system is limited. Here we present the largest midterm study to date by a single-surgeon, and analyze the survivorship, clinical, and radiographic outcomes of the transfibular TAA at a minimum of 5-years follow-up. Methods: Retrospective review was performed on prospectively followed patients who underwent primary transfibular TAA by a single surgeon from October 2012 to December 2018. Inclusion criteria included: minimum 5-years of follow-up. patient-reported outcomes measures (PROM), and radiographic follow-up. Patient demographics and perioperative data were collected. PROMs included: 12-item Short Form Health Survey (SF-12) physical (PCS) and mental (MCS) component scores, Ankle Osteoarthritis Scale (OAS), and Visual Analog Scale (VAS). Functional outcomes included range of motion (ROM) measured on weightbearing ROM radiographs. Radiographic outcomes included coronal and sagittal alignment, and evaluation of periprosthetic lucency utilizing a 12-zone system. Adverse events and reoperations were reported using the Canadian Orthopedic Foot and Ankle Society (COFAS) Reoperation Coding System (CROCS). A total of 130 ankles (122 patients) with average follow-up of 5.9 years (range, 5.0-10.1) were included in the study. The average age was 60.8 years-old, with 50.8% being females. Results: Postoperative PROMs included SF-12 PCS: 41.5; SF-12 MCS: 54.9; VAS: 2.3; AOS Pain: 19.1; AOS Disability: 28.5. Postoperative tibiopedal ROM was 17.7° dorsiflexion and 21.8° plantarflexion. Postoperative tibiotalar ROM was 7.4° dorsiflexion and 17.3° plantarflexion. A total of 26 (20%) ankles had a single zone of lucency, while 7 (5.4%) ankles had 6 or more; none had more than 7 zones. There were no cases of cysts, subsidence, septic/aseptic loosening, or fibular non-union. Reoperation rate was 36.2% (n=47) at average 26.7 months, most commonly removal of fibula hardware (n=28, 21.5%), medial gutter debridement (n=18, 13.8%). There were 5 (3.8%) cases of acute infection treated with I&D and metal component retention. Overall implant survival, defined by retention of the metal components, was 100%. Conclusion: Transfibular TAA is an effective durable treatment option for end-stage ankle arthritis with excellent implant survivorship, providing sustained improvements in clinical and radiographic outcomes at the midterm. Reoperations were mostly elective removal of fibular hardware or medial impingement. There was 100% retention of the metal components. Deformity correction was achieved and maintained. The majority of ankles had no radiographic lucencies and only 20% had a single zone out of 12 zones which did not correlate with clinical outcomes. There were no cysts, subsidence, or fibular non-unions.

Category: Ankle Arthritis; Ankle Introduction/Purpose: Total ankle arthroplasty (TAA) has surpassed arthrodesis as the gold standard for treatment of end-stage ankle arthritis. The Zimmer Trabecular Metal Total Ankle Implant (Zimmer-Biomet, Warsaw, IN) differs from other newer- generation implants in the transfibular approach, non-mobile-bearing prosthesis, high-molecular-weight polyethylene, curved surface at every interface in the sagittal plane, and shallow resection depth. There is limited mid-term follow-up for this system. Therefore, we sought to report mid-term clinical, functional, and radiographic results we well as complications and survival for patients treated with the transfibular TAA at a minimum of 5-years follow-up. Methods: A retrospective review was performed on patients who underwent primary transfibular TAA by a single surgeon from October 2012 to January 2018. Inclusion criteria was a minimum of 5-years of follow-up with a completed consent for participation in the study and patient-reported outcome measures (PROM). Patient demographics and perioperative data were collected. PROMS included: 12-item Short Form Health Survey (SF-12) physical (PCS) and mental (MCS) component scores; Ankle Osteoarthritis Scale (OAS); and Visual Analog Scale (VAS). Functional outcomes included range of motion (ROM) measured on weightbearing ROM radiographs. Radiographic outcomes included coronal and sagittal alignment. Adverse events and reoperations were reported using the Canadian Orthopedic Foot and Ankle Society (COFAS) Reoperation Coding System (CROCS). Of the consecutive 151 TAAs, 83 (55.0%) ankles are included in this study, evaluated at a mean of 5.8 years clinical and 6.3 years radiographic follow-up. Results: The average age was 60.6 years-old. Preoperative tibiotalar coronal deformity included 27 valgus (10°, range 2-20°) and 25 varus ankles (-9°, range -2--25°), successfully corrected to neutral postoperatively. The postoperative PROMs were: SF-12 PCS: 40.4, SF-12 MCS: 56.0, VAS: 2.3, AOS Pain: 17.0, and AOS Disability: 24.9. Radiographic postoperative tibiopedal ROM was 17.8° dorsiflexion and 21.8° degrees plantarflexion. The overall reoperation rate was 38.6%(n=32) at an average of 28.7 months postoperative. Most common were removal of the fibula hardware (n=21,25.3%) and medial gutter debridement (n=15, 18.1%). There were 3 (3.6%) cases of acute postoperative infection (< 3 months) treated with operative irrigation and debridement but retention of the metal components. There were no cases of septic or aseptic loosening or subsidence. The overall implant survival, defined by retention of the metal components, was 100%. Conclusion: Transfibular TAA is a safe and effective treatment for end-stage ankle arthritis at 5-year mid-term follow-up. This study confirms excellent clinical results including PROMs and ROM as well as radiographic alignment correction and maintenance. The survival rate was 100% for retention of the trabecular metal components. The survival rate to reoperation was 60.7% with patients commonly requiring removal of the fibula hardware or medial gutter debridement. Patients should be counseled on the risk of reoperation preoperatively for postoperative expectation management.

Background Hallux rigidus (HR) is the most common arthritic condition of the foot. Although first metatarsophalangeal joint (MTPJ) arthrodesis has been the historical gold-standard treatment, polyvinyl alcohol (PVA) hydrogel implants have gained popularity as a joint-sparing technique. However, recent studies have shown variable failure rates of PVA hydrogel implants. The purpose of this study was to report the five-year experience with PVA hydrogel implants performed by a single surgeon. Methodology Health records were queried from August 2016 to 2021 for patients who underwent primary PVA hydrogel implant hemiarthroplasty for symptomatic late-stage HR. Patient demographics and postoperative outcomes variables were evaluated. Kaplan-Meier analysis was used to evaluate implant survival. A total of 146 PVA hydrogel implant procedures were performed with a minimum six-month follow-up. Results The majority of patients were female (n = 103, 70.5%), with a mean age of 58.1 (±10.1) years, body mass index of 27.3 (±5.2) kg/m , and American Society of Anesthesiologists score <3 (n = 131, 89.7%). The majority had stage II or III disease (n = 115, 78.8%). Patients experienced significant improvement in visual analog scale score (p < 0.0001) and hallux dorsiflexion (p = 0.0005). There were 22 (15.1%) complications, including implant subsidence (n = 15, 10.3%), deep infection (n = 6, 4.1%), and hypertrophic ossification (n = 1, 0.7%). Revision surgeries were required in 12.3% (n = 18) of patients at an average of 9.4 (±9.2) months postoperatively. This included nine (6.2%) revision PVA hydrogel implant procedures and nine (6.2%) first MTJP arthrodesis. The one- and two-year survival rates for MTPJ arthrodesis (n = 9) were 95.9% and 86.3%, respectively. Conclusions In the largest single-surgeon series reported, first MTPJ hemiarthroplasty with a PVA hydrogel implant significantly improved pain and hallux dorsiflexion at an average of 14.5 months postoperatively. There was a high two-year survivorship of 86.3% until failure which required first MTPJ arthrodesis. Future studies should be performed to refine the indications for PVA hydrogel implants and identify risk factors.

Category: Ankle; Ankle Arthritis Introduction/ Purpose: With the increased utilization of total ankle arthroplasty (TAA) for the treatment of end-stage ankle arthritis, the effect of joint line level on patient outcomes remains unclear. It has previously been demonstrated that patients with end-stage ankle arthritis have an elevated joint line level compared with nonarthritic ankles, and the joint line post-TAA remains elevated compared with nonarthritic ankles. The objectives of this study were to (1) Propose a reliable radiographic method to measure the ankle joint line level that can be applied both pre- and postoperatively following TAA and (2) Determine the effect of joint line level alterations in relation to tibiotalar range of motion (ROM) following TAA. Methods: A retrospective review was performed on patients who underwent a TAA at a single institution between January 2018 to April 2021. Inclusion criteria required patients to have a minimum of one-year postoperative follow-up with preoperative weight-bearing anteroposterior (AP) radiographs and postoperative weight-bearing AP and lateral flexion-extension ROM radiographs. Patients with concomitant procedures affecting ROM were excluded. Radiographic joint line and ROM measurements were performed by two observers. The proposed joint line measuring technique computes four joint line measurements for each AP radiograph- high, low, center of the talus, and center of the axis (Figure 1). Paired T-tests, Student T-tests, Chi-Square tests, univariable and multivariable regression models, and Spearman Correlation Coefficients were computed. The ankles were divided into two cohorts for subanalyses- lowered versus elevated joint line. Intra-class correlation coefficients (ICC) were calculated to assess inter-observer reliability. A probability of 0.05 or less was considered significant for all analyses. Results: A total of 33 patients were included with 17(51.5%) valgus-aligned ankles and 16(48.5%) varus ankles. The average postoperative tibiotalar ROM was 6.7°(±7.1°) dorsiflexion to 21.7°(±8.3°) plantarflexion. 22 patients had a lowered joint line compared to 11 patients with an elevated joint line (2.2±1.25mm lowered versus 1.9±1.2mm elevated; p< 0.0001). Of the four joint line measurements, three(high, center, axis) demonstrated a significant positive correlation between lowering the joint line and improved tibiotalar dorsiflexion and total ROM (all p< 0.05). Plantarflexion was not significantly affected by joint line alterations. Compared to patients with an elevated joint, patients with a lowered joint line had improved tibiotalar dorsiflexion (8.8° versus 2.5°; p=0.0015) and total ROM (31.0° versus 22.9°; p=0.0191), respectively. The inter-rater reliability was nearly perfect, ranging from ICC=0.96-0.99. Conclusion: Lowering the tibiotalar joint line level may more closely reestablish the native tibiotalar joint line and results in improved tibiotalar dorsiflexion and total ROM following TAA. This evidence may refute the concern that “overstuffing” the joint decreases postoperative ROM.

Background During the COVID-19 pandemic, Americans transitioned away from their normal routines, drove in motor vehicles less, and reduced their physical activity, ultimately influencing the incidence and nature of orthopedic injuries that were operatively managed. The purpose of this study was to evaluate the effect of the COVID-19 pandemic lockdown and subsequent deconditioning on the mechanism of injury and severity of Lisfranc injury. Methods This retrospective study included patients with a traumatic Lisfranc injury who were surgically treated by a foot and ankle fellowship-trained orthopedic surgeon between 2015 and 2021. Electronic health records were queried for patient demographics, mechanism of injury, physical exam findings, and pain scores. Preoperative radiographs were reviewed to grade Lisfranc injuries using the previously described Nunley-Vertullo classification system. Descriptive and univariate statistics were performed to compare 15 patients in the pre-COVID-19 cohort and 15 patients in the post-COVID-19 cohort. Results In the pre-COVID-19 cohort, 80% (n=12/15) of the patients were female, the mean age was 46±15 years, the mean BMI was 29.7±7 kg/m , and the mean follow-up period was 18.1±12 months. In the post-COVID-19 cohort, 53% (n=8/15) of the patients were female, the mean age was 48.5±17 years, the mean BMI was 31.4±7 kg/m , and the mean follow-up period was 9.5±4 months. Significantly higher proportions of plantar ecchymosis (n=8/15, 53%), neuropathic pain (n=7/15, 47%), and swelling (n=12/15, 80%) were present in the post-COVID-19 cohort. A low-energy mechanism of injury was sustained by 73% (n=11/15) of the pre-COVID-19 cohort and 80% (n=12/15) of the post-COVID-19 cohort. Lisfranc injuries for the pre-COVID-19 cohort and the post-COVID-19 cohort demonstrated the following classifications: Grade 1 (33%, n=5/15 vs. 40%, n=6/15), Grade 2 (60%, n=9/15 vs. 53%, n=8/15), and Grade 3 (7%, n=1/15 vs. 7%, n=1/15). Conclusion Although a higher proportion of plantar ecchymosis, neuropathic pain, and swelling was observed, there was no association between a low mechanism of injury and a higher grade of Lisfranc injury following the COVID-19 pandemic.

Institutional Development Awards for Clinical and Translational Research (IDeA-CTR) networks, funded by NIH/NIGMS, aim to advance CTR infrastructure to address historically unmet state and regional health needs. Success depends on the response to actionable feedback to IDeA-CTR leadership from network partners and governance groups through annual surveys, interviews, and governance body recommendations. The Great Plains IDeA-CTR applied internal formative meta-evaluation to evaluate dispositions of 172 governance recommendations from 2017 to 2021. Results provided insights to improve the classification and quality of recommendations, credibility of evaluation processes, responsiveness to recommendations, and communications and governance in a complex CTR network comprising multiple coalitions.

Category: Ankle; Hindfoot; Trauma Introduction/Purpose: Prosthetic substitution of the talus presents a unique challenge to the foot and ankle surgeon. The shear and compressive forces on the talus and its tenuous blood supply lead to high rates of avascular necrosis with possible talar collapse. The purpose of this systematic review is to evaluate whether total talus replacements (TTR) lead to improved clinical outcomes with appropriate safety metrics in patients with a history of avascular necrosis or significant trauma. Methods: Concepts of talus and arthroplasty were searched in MEDLINE (PubMed), Embase (Elsevier), CINAHL Complete (EBSCOhost), and Scopus (Elsevier) from the database's inception through November 4, 2021. Inclusion Criteria were 1) previous trauma to the talus, 2) post-traumatic or degenerative arthritis to the tibiotalar joint, 3) avascular necrosis of talus, 4) multiple failed prior interventions, 5) degenerative osteoarthritis to the tibiotalar joint, and 56) inflammatory arthropathy to tibiotalar joint. Manuscripts in non-English languages or those with concomitant total ankle arthroplasty or revision arthroplasty were excluded. All study designs were eligible according to the Journal of Bone and Joint Surgery criteria level I-IV. The modified Coleman Methodology Score was used to evaluate study quality and the Methodological Index for Non-Randomized Studies criteria was used to assess risk of bias. Results: Twenty-two studies of 191 patients (196 tali) at an average age of 50 (14-80) years were included (Figure 1a). Nineteen studies utilized third generation implants, two studies used first generation (n=9), and one study used second generation implants (n = 14) made of ceramic (n=82), cobalt chrome (n=49), or titanium (n=23) (Figure 1b). Radiographic and patient-reported outcomes are outlined in Figure 1c. The most common adverse outcome was osteosclerosis of the tibia (n=24), calcaneus (n=19), and navicular (n=5). Additionally, hindfoot varus (n=3), ankle discomfort (n = 3), decreased subtalar motion (n=7), periprosthetic fracture (n=1), calcaneal fracture (n=1), delayed wound healing (n=3), hindfoot valgus (n=1), prosthetic stem sunken into the talar neck (n=1), superficial peroneal nerve neuroma (n=1), loosening (n=2) were reported. Eight revisions were reported. Conclusion: TTR is an appealing option to maintain range of motion through the tibiotalar joint and allow for maintenance of more normal foot and ankle biomechanics. Given promising early- and mid-term outcomes, TTR is becoming more widely used in the setting of talar collapse. Still, high complication rates, especially adjacent joint osteoarthritis, may remain under-reported in the literature given inadequate long-term follow-up. Future research should aim to expand upon the indications of TTR, elucidate survivorship and complication rates, and directly compare TTR to existing forms of salvage options for advanced talar avascular necrosis.