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Maisonneuve fractures are rare ankle injuries, accounting for up to 7% of all ankle fractures. They consist of a proximal third fibula fracture, syndesmotic disruption, and medial ankle injury (either a deltoid ligament disruption or a medial malleolus fracture), and are often successfully managed with nonoperative treatment of the proximal fibula fracture and open reduction and internal fixation (ORIF) of the medial ankle injury and syndesmotic disruption. The hyperplantarflexion variant ankle fracture comprises approximately 7% of all ankle fractures and features dual posterior tibial lip fractures featuring a posterolateral fragment and a posteromedial fragment. Good functional results have been reported in the literature after ORIF of both the posterolateral and posteromedial fragments of this variant fracture that is not described by the Lauge-Hansen classification. In this report, the authors present the unique case of an isolated ankle fracture demonstrating characteristics of both a Maisonneuve fracture and a hyperplantarflexion variant ankle fracture. They also highlight the diagnostic imaging characteristics, including magnetic resonance imaging (MRI) and preoperative radiograph findings, surgical treatment, and postoperative clinical outcome for this patient with a Maisonneuve-hyperplantarflexion variant ankle fracture. To the authors’ knowledge, this unique fracture pattern has not been reported previously in the literature. The authors conclude that although good results were seen postoperatively in this case, the importance of ORIF of both the posteromedial and posterolateral fragments of variant fractures cannot be overstated. They also found MRI to be a particularly helpful adjunct in formulating the correct diagnosis and treatment plan.

Despite educational focus regarding orthopedic oncology during residency, assessment of resident orthopedic oncology caseload has not been performed. The purpose of this study was to evaluate orthopedic oncology caseload trends and variation among residents. The Accreditation Council for Graduate Medical Education case log reports for orthopedic surgery residents were reviewed for graduating years 2007 to 2013. Trends in orthopedic oncology cases and variation in the median number of cases performed by residents in the 90th, 50th, and 10th percentiles of caseload were evaluated. The proportion of orthopedic oncology caseload among all cases performed by residents increased significantly (P = 0.005) from 2007 to 2013. Likewise, the mean number of adult (P = 0.002), pediatric (P = 0.003), and total orthopedic oncology cases increased significantly (P = 0.002). On average, residents in the 90th, 50th, and 10th percentiles performed 83, 28, and 3 cases, respectively. The current study demonstrates a significant increase in adult, pediatric, and total orthopedic oncology caseload. There is also evidence of substantial caseload variation among residents. Caseload variation may influence the education and technical proficiency of orthopedic residents.

Introduction Piriformis fossa entry antegrade femoral nailing is a common method for stabilizing diaphyseal femur fractures. However, clinically significant complications such as chronic hip pain, hip abductor weakness, heterotopic ossification and femoral head osteonecrosis have been reported. A recent cadaveric study found that piriformis entry nailing damaged either the deep branch of the medial femoral circumflex artery (MFCA) or its distal superior retinacular artery branches in 100 % of specimens and therefore recommended against its use. However, no study has quantitatively assessed the effect of different femoral entry points on femoral head perfusion. Materials and methods Twelve fresh-frozen cadaveric lower extremity specimens were randomly allocated to either piriformis fossa or trochanteric entry nailing using a 13-mm reamer. The contralateral hip served as an internal matched control. All specimens subsequently underwent gadolinium-enhanced fat-suppressed gradient-echo sequence MRI to assess femoral head perfusion. Gross dissection was also performed to assess MFCA integrity and distance to the opening reamer path. Results MRI quantification analysis revealed near full femoral head perfusion with no significant difference between the piriformis and trochanteric starting points (95 vs. 97 %, p  = 0.94). There was no observed damage to the deep MFCA in either group. The mean distance from the reamer path to the deep MFCA was 3.2 mm in the piriformis group compared to 18.5 mm in the trochanteric group ( p  = 0.001). Additionally, there was a significantly greater number of mean terminal superior retinacular vessels damaged by the opening reamer in the piriformis cohort (1 vs. 0; p  = 0.007). Conclusions No statistically significant difference in femoral head perfusion was found between the two groups. Therefore, we cannot recommend against the use of piriformis entry femoral nails. However, we caution against multiple errant starting point attempts and recommend meticulous soft tissue protection during the procedure.

The objectives of this investigation were to report temporal trends in resident performed upper extremity fracture procedures and analyze case volume variability. Orthopaedic resident case logs from the Accreditation Council for Graduate Medical Education were reviewed for graduating years 2007 to 2014. The mean number of wrist, forearm, elbow, humerus, and shoulder fracture-dislocation procedures performed by residents was analyzed. The median number of procedures reported by the top 30% and bottom 30% of residents (by case volume) was also recorded. Linear regression modeling was used to assess temporal trends. The mean number of wrist and forearm fracture cases performed per resident fell from 55.3 in 2007 to 46.7 in 2014 (p = 0.325) while the number of elbow and humerus fracture procedures remained relatively constant (45.6 to 45.4; p = 0.224). The mean number of shoulder fracture cases increased significantly (14.7 to 22.5; p < 0.001). Over the 8-year period, residents in the 70th percentile of caseload performed significantly more wrist and forearm (62.6 versus 39.5; p < 0.001), elbow and humerus (55 versus 34.9; p < 0.001), and shoulder (23 versus 12.9; p < 0.001) fracture procedures than residents in the 30th percentile. Resident case volume for wrist, forearm, elbow, and humerus fractures is constant or falling. However, shoulder fracture caseloads are increasing. Regardless, there is substantial disparity in upper extremity fracture case volume among residents. Further investigation is needed to assess possible educational effects of resident caseload disparity.

Background: Distal radius fractures (DRFs) are common geriatric fractures with the overall incidence expected to increase as the population continues to age. The purpose of this investigation was to compare the short-term complication rates in geriatric versus nongeriatric cohorts following osteosynthesis of DRFs. Methods: The American Board of Orthopaedic Surgery (ABOS) part II database was queried for adult DRF cases performed from 2007 to 2013. Current Procedural Terminology codes were used to identify cases treated via osteosynthesis. Patient demographic information and reported complication data were analyzed. Comparisons between geriatric (age ≥65 years) and nongeriatric (age <65 years) patients were performed. Results: From 2007 to 2013, a total of 9867 adult DRFs were treated via osteosynthesis by ABOS part II candidates. Geriatric patients comprised 28% of the study cohort. Mean age of the geriatric and nongeriatric cohorts was 74 ± 7 and 46 ± 13 years, respectively. There was a greater proportion of female patients (P < .001) in the geriatric cohort as compared with the nongeriatric cohort. The geriatric cohort demonstrated higher rates of anesthetic complications (P = .021), iatrogenic bone fracture (P = .021), implant failure (P = .031), loss of reduction (P = .001), unspecified medical complications (P = .007), and death (P = .017) than the nongeriatric cohort. The geriatric cohort also showed lower rates of nerve palsy (P = .028) when compared with the nongeriatric cohort, though no differences in rates of secondary surgery were noted between the two cohorts. Conclusion: Increased rates of complications related to poor bone quality and poor health status may be expected among geriatric patients following osteosynthesis of DRFs. However, geriatric and nongeriatric patients have similarly low rates of secondary surgery. Future studies are needed to delineate the economic, functional, and societal impact of geriatric DRFs treated via osteosynthesis.

Background: Trochanteric osteotomy still has an important role in hip arthroplasty in cases of (1) preexisting developmental hip dysplasia with superior subluxation, (2) revision arthroplasty, specifically with acetabular component revision in the face of well-fixed femoral component, and (3) recurrent dislocation without component loosening or malalignment, in treatment of complicated trochanteric fixation in osteoporotic bone and nonunions may be difficult. This study reports the clinical outcomes of trochanteric fixation following total hip arthroplasty (THA) utilizing a hook plate construct in a cohort of ten patients. Materials and Methods: The Arbeitsgemeinschaft für Osteosynthesefragen (AO) articulated hook plate was used in nine cases of established approach related nonunion following THA and in one case of osteopenic bone during primary THA. All ten patients returned for interviews and clinical examination. The average time for clinical followup was 35 months (range 5–48 months). The mean age of the study cohort was 65 years (range 56–74 years). Time to union and incidence of postoperative complications were assessed. Results: Union occurred in all ten cases at an average of 3.3 months postoperatively. One patient developed symptomatic trochanteric bursitis and required plate removal. Another patient developed a superficial infection which was successfully treated with local wound debridement and antibiotics. A third patient developed a symptomatic neuroma at the site of the iliac crest bone harvest and was successfully treated with excision of the neuroma. No catastrophic implant failures occurred. Conclusions: The articulated design of the plate allows for ease in application and functional construct stability. The articulated hook plate is an option for fixation of osteopenic bone fragments and established nonunions of the greater trochanter.

Background: Distal radius fractures (DRFs) are common geriatric fractures with the overall incidence expected to increase as the population continues to age. The purpose of this investigation was to compare the short-term complication rates in geriatric versus nongeriatric cohorts following osteosynthesis of DRFs. Methods: The American Board of Orthopaedic Surgery (ABOS) part II database was queried for adult DRF cases performed from 2007 to 2013. Current Procedural Terminology codes were used to identify cases treated via osteosynthesis. Patient demographic information and reported complication data were analyzed. Comparisons between geriatric (age ≥65 years) and nongeriatric (age <65 years) patients were performed. Results: From 2007 to 2013, a total of 9867 adult DRFs were treated via osteosynthesis by ABOS part II candidates. Geriatric patients comprised 28% of the study cohort. Mean age of the geriatric and nongeriatric cohorts was 74 ± 7 and 46 ± 13 years, respectively. There was a greater proportion of female patients (P < .001) in the geriatric cohort as compared with the nongeriatric cohort. The geriatric cohort demonstrated higher rates of anesthetic complications (P = .021), iatrogenic bone fracture (P = .021), implant failure (P = .031), loss of reduction (P = .001), unspecified medical complications (P = .007), and death (P = .017) than the nongeriatric cohort. The geriatric cohort also showed lower rates of nerve palsy (P = .028) when compared with the nongeriatric cohort, though no differences in rates of secondary surgery were noted between the two cohorts. Conclusion: Increased rates of complications related to poor bone quality and poor health status may be expected among geriatric patients following osteosynthesis of DRFs. However, geriatric and nongeriatric patients have similarly low rates of secondary surgery. Future studies are needed to delineate the economic, functional, and societal impact of geriatric DRFs treated via osteosynthesis.

Category: Other Introduction/Purpose: The Internet has been reported to be the first informational resource for many fellowship applicants. Despite being a popular resource, no accessibility or quality standards exist for fellowship websites. The objective of this study was to assess the accessibility of orthopaedic foot and ankle fellowship websites and to evaluate the quality of information provided via program websites. Methods: The American Orthopaedic Foot and Ankle Society (AOFAS) and the Fellowship and Residency Electronic Interactive Database (FREIDA) fellowship databases were accessed to generate a comprehensive list of orthopaedic foot and ankle fellowship programs. The databases were reviewed for links to fellowship program websites and compared with program websites accessed from a Google search. Accessible fellowship websites were then analyzed for the quality of recruitment and educational content pertinent to fellowship applicants. Results: Forty-seven orthopaedic foot and ankle fellowship programs were identified. The AOFAS database featured direct links to 7 (15%) fellowship websites with the independent Google search yielding direct links to 29 (62%) websites. No direct website links were provided in the FREIDA database. Thirty-six accessible websites were analyzed for content. Program websites featured a mean 44% (range, 5-75%) of the total assessed content. The most commonly presented recruitment content was a program description featured on 94% of fellowship websites. The most commonly presented educational content was a description of fellow operative experience featured on 83% of websites. Conclusion: There is substantial variability in the accessibility and quality of orthopaedic foot and ankle fellowship websites. Comparison of the results of our study with those of similar investigations indicates a paucity of fellowship websites presenting comprehensive program information to applicants. Recognition of deficits in accessibility and content quality may assist foot and ankle fellowships in improving program information online.

Category: Other Introduction/Purpose: The Internet has been reported to be the first informational resource for many fellowship applicants. Despite being a popular resource, no accessibility or quality standards exist for fellowship websites. The objective of this study was to assess the accessibility of orthopaedic foot and ankle fellowship websites and to evaluate the quality of information provided via program websites. Methods: The American Orthopaedic Foot and Ankle Society (AOFAS) and the Fellowship and Residency Electronic Interactive Database (FREIDA) fellowship databases were accessed to generate a comprehensive list of orthopaedic foot and ankle fellowship programs. The databases were reviewed for links to fellowship program websites and compared with program websites accessed from a Google search. Accessible fellowship websites were then analyzed for the quality of recruitment and educational content pertinent to fellowship applicants. Results: Forty-seven orthopaedic foot and ankle fellowship programs were identified. The AOFAS database featured direct links to 7 (15%) fellowship websites with the independent Google search yielding direct links to 29 (62%) websites. No direct website links were provided in the FREIDA database. Thirty-six accessible websites were analyzed for content. Program websites featured a mean 44% (range, 5-75%) of the total assessed content. The most commonly presented recruitment content was a program description featured on 94% of fellowship websites. The most commonly presented educational content was a description of fellow operative experience featured on 83% of websites. Conclusion: There is substantial variability in the accessibility and quality of orthopaedic foot and ankle fellowship websites. Comparison of the results of our study with those of similar investigations indicates a paucity of fellowship websites presenting comprehensive program information to applicants. Recognition of deficits in accessibility and content quality may assist foot and ankle fellowships in improving program information online.

Pertrochanteric fractures represent an important health issue. The goal of treatment is to restore function and pre-injury level of independence. This chapter discusses indications, surgical technique and postoperative outcome of intramedullary fixation. Fracture stability is the clinical most important determinant. Whereas stable fractures will withstand medial compressive forces after fixation, unstable fractures will collapse and/or displace under medial compressive forces despite axial reduction. Intramedullary devices have the theoretical advantage of more efficient load transfer due to its proximity to the medial calcar compared to extramedullary implants as well as less implant strain because of its closer positioning to the mechanical axis of the femur resulting in a shorter lever arm. A precise intramedullary nail starting point and skillful operative technique reduces this risk of iatrogenic neurovascular or musculotendinous injury. The reduction of the pertrochanteric fracture is recommended prior to placement of the intramedullary nail. Correct placement of the nail prevents postoperative complications and assures uneventful healing. Outcome is depending on the preoperative condition of the patient and the quality of reduction and fixation.