Michael D. Johnson

Background: AO/OTA 43C pilon fractures are severe intra-articular distal tibia injuries associated with high complication rates. Although open reduction internal fixation (ORIF) remains the standard treatment, tibiotalocalcaneal (TTC) nailing has been used in select patients; this study compared characteristics and outcomes of patients treated with ORIF or TTC nailing. Methods: A retrospective cohort study was performed of adult patients (≥18 years) with AO/OTA 43C pilon fractures and ≥90 days of follow-up treated operatively at a single level 1 trauma center between 2020 and 2025. Patients treated with TTC nailing were matched 1:1 to patients treated with ORIF based on open vs closed fracture status, with open fractures further matched by Gustilo-Anderson classification. Primary outcomes included fracture-related infection (FRI), reoperation, fracture nonunion, amputation, and hospital length of stay (LOS). Results: In the unmatched cohort (n = 436), TTC patients had higher rates of open fractures (58.6% vs 38.8%, P = .002), higher Injury Severity Scores (ISSs) (15.8 vs 11.3, P = .001), and higher rates of polytrauma (42.9% vs 22.4%, P < .001). TTC nailing was associated with higher rates of FRI (25.7% vs 13.7%, P = .011), longer hospital LOS (13.0 vs 9.4 days, P = .004), and more frequent intensive care unit (ICU) admission (31.4% vs 20.2%, P = .038). After matching, the cohort included 70 TTC and 70 ORIF patients. TTC patients continued to have higher ISS (15.8 vs 11.4, P = .009), higher polytrauma rates (42.9% vs 20.0%, P = .004), more blood transfusions (48.6% vs 17.1%, P < .001), and more frequent ICU admission (31.4% vs 17.1%, P = .049). However, rates of FRI, reoperation, fracture nonunion, and amputation were similar between groups. Conclusion: With the numbers available, rates of postoperative complications showed no significant difference that could be detected between TTC nailing and ORIF after matching, supporting its use as a viable limb salvage strategy in patients with pilon fractures characterized by severe articular comminution, poor bone quality, or compromised soft tissues limiting conventional reconstruction. Level of Evidence: Level III, retrospective cohort study.

OBJECTIVE: To evaluate the association between resilience, as measured by the Brief Resilience Scale (BRS), and both clinical and patient-reported outcomes (PROs) following operative fixation of pilon fractures. METHODS: Design : Retrospective cohort study. Setting: Single Level I trauma center. Patient selection criteria: Adult patients (≥18 years) with AO/OTA 43 pilon fractures treated operatively between 2022 and 2026 were included. Patients without postoperative PROs or a 6-month BRS were excluded. Patients were stratified by median 6-month BRS into low (2 , respectively), sex (52.1% vs 42.1% male respectively), and race (60.4% vs 73.7% White, respectively), although patients in the low-resilience group demonstrated higher ISS (15.8 vs 9.8, p < 0.001). Compared with the low-resilience group, the high-resilience group demonstrated higher GMH at all timepoints (all p ≤ 0.021), while depression and anxiety scores were lower at 6 weeks, 3 months, and 6 months (all p ≤ 0.019). Compared with the low-resilience group, the high-resilience group also demonstrated higher GPH and PF scores and lower PI scores at 3 and 6 months (all p ≤ 0.045), as well as higher percent of normal function at 6 months (51.7% vs 40.5%, p = 0.040). CONCLUSION: Higher resilience was associated with improved PROs following operative fixation of pilon fractures, with differences observed early and persisting over time. Resilience represents an important patient-specific factor associated with recovery and may provide additional context when interpreting postoperative outcomes. LEVEL OF EVIDENCE: III

Introduction: Pilon fractures are high-energy injuries with substantial soft-tissue compromise and risk of impaired healing, sometimes necessitating revision surgery to promote bone healing (RPBH). The aim of this study was to identify factors associated with RPBH after surgical fixation of pilon fractures. Methods: A retrospective cohort study was conducted at a single Level I trauma center (2014 to 2019). Adult patients who underwent surgical fixation of pilon fractures (AO/OTA 43) were included; those with less than 6 months of follow-up or amputation before definitive fixation were excluded. Demographic, injury, surgical, and postoperative characteristics were compared between patients with and without RPBH. Statistical significance was defined as P < 0.05. Results: Of 349 patients included, 48 (13.8%) required RPBH. The mean age was 46.0 years, and 54.4% were male. Patients requiring RPBH more frequently sustained open fractures (50.0% vs. 24.6%, P = 0.001) and had higher BMI (32.2 vs. 28.5 kg/m ² , P = 0.005). Bone grafting (25.0% vs. 4.7%), skin grafting (14.6% vs. 4.7%), and flap coverage (12.5% vs. 2.3%) were more common among patients with RPBH (all P < 0.001). Plate fixation overlapping external fixator pin sites occurred more frequently in the RPBH group (35.4% vs. 18.3%, P < 0.001), whereas medial column fixation was less common (43.8% vs. 69.1%, P < 0.001). Fracture-related infection (FRI) was the strongest independent predictor of RPBH (OR = 11.17, 95% CI 4.33 to 28.81, P < 0.001), while medial column fixation was associated with reduced odds (OR = 0.41, 95% CI 0.19 to 0.89, P = 0.024). Conclusion: One in seven patients required revision surgery to promote bone healing after pilon fracture fixation. FRI emerged as the strongest independent predictor of RPBH, while medial column fixation as part of the overall fixation construct was associated with reduced odds of RPBH. Although plate-pin site overlap was more common among patients with RPBH, it was not independently associated after controlling for FRI. Strategies to optimize medial stability and minimize infection risk may improve healing outcomes.

Background: First tarsometatarsal (TMT) arthrodesis is a surgical option for moderate to severe hallux valgus, particularly in the setting of first-ray instability. The use of a supplemental intermetatarsal screw (IMS) has emerged as a technique intended to enhance transverse plane stability and may help maintain correction; however, limited clinical data exist regarding its radiographic and complication profile. This study compared radiographic correction, maintenance of alignment, and postoperative complications following TMT arthrodesis with vs without IMS fixation. Methods: A retrospective review was performed of adult patients who underwent first TMT arthrodesis for hallux valgus from 2013 to 2023 at a tertiary academic center. Patients undergoing additional midfoot fusion or with .05). Conclusion: Supplemental IMS fixation in first tarsometatarsal arthrodesis for hallux valgus was associated with greater maintenance of radiographic correction without observed differences in complication rates. These findings support IMS augmentation as a potential adjunct in appropriately selected patients. Level of Evidence: Level III, retrospective review.

Background: Achilles tendon rupture (ATR) is among the most common foot and ankle injuries, with a rising incidence of up to 50 per 100 000 persons. We sought to investigate the medicolegal characteristics associated with ATR. Methods: Westlaw Precision, an online, legal database from across the United States, was queried for all jury verdicts and settlements pertaining to “malpractice” and “Achilles” tendon rupture from 1980 to 2024. Data extracted included date and state of claim filing, patient and defendant demographics, jury verdict, monetary payments, basis of litigation, and listed patient complications. Results: A total of 50 of 236 claims were included in this analysis. A defendant verdict was reached in 82% of claims. The average indemnity payment was $431 405. Orthopaedic surgeons were named in 44% of claims. Nearly one-half of claims were levied due to a delayed or missed diagnosis (24%) or insufficient informed consent (18%). Subsequent surgery was the most frequent complication of the alleged negligence (18%); however, patient death occurred in 14% of claims as well. Patient disagreement with the treatment strategy was seen in 18% of claims. Conclusion: Achilles tendon rupture is an infrequent source of medicolegal burden within foot and ankle treatment. Such legal action most commonly arises from diagnostic delays, insufficient informed consent, and patient disagreement with the treatment strategy. Early recognition, comprehensive counseling on management options and risks, and shared decision making are essential strategies to reduce litigation risk and improve patient outcomes. Level of Evidence: Level IV, case series / retrospective database review without comparison group.

Introduction: Orthopaedic applicants have increased the average number of publications on their residency application to compete with the growing competitiveness of the field. The purpose of this study was to assess whether research productivity before orthopaedic residency and caliber of one's institution is correlated with academic productivity during residency. Methods: Scopus was used to extract publication metrics. Quantity and quality (how often the publications were cited) were analyzed at 2 different time periods: before and during residency. All subjects in the study had graduated an ACGME-accredited orthopaedic surgery residency in 2021. Military residents, international medical graduates, and residents not listed on their department's website were excluded. Residents were categorized as both high (≥2 publications) or low (<2 publications) publishers according to their pre-residency publications. They were also categorized based on their program's Jones et al. research productivity ranking. Results: For the 758 residents, the median number of publications was 0 (Interquartile Range [IQR]: 0-2) and 3 (IQR: 1-6) before and during residency, respectively. High publishing medical students had more publications during training than low publishers (6 [IQR: 3-14] and 2 [IQR: 1-4], p < 0.001). Residents at higher ranked programs also had more publications (4 [IQR: 2-9] and 2 [IQR: 0-4], p < 0.001). High publishing students now training at lower ranked institutions had more publications during residency than low publishers who trained at more productive institutions (4 [IQR: 1-9] and 3 [IQR: 1-6], p < 0.001). Conclusion: Having 2 or more publications before residency is correlated with an increased number of publications during residency. While attending a higher academically productive program is associated with increased resident publications, a high publishing medical student would be expected to have more publications during residency than a low publishing student, regardless of program rank. Notably, most matched applicants continue to have zero publications before matriculation.

Background: There is limited literature comparing the publications on ankle arthrodesis (AA) and total ankle arthroplasty (TAA) in the setting of hemophilic arthropathy. Our objective is to systematically review the existing literature and to assess ankle arthroplasty as an alternative to ankle arthrodesis in this patient population. Methods: This systematic review was conducted and presented according to the PRISMA statement standards. A search was conducted on March 7-10, 2023, using MEDLINE (via PubMed), Embase, Scopus, ClinicalTrials.gov, CINAHL Plus with Full Text, and the Cochrane Central Register of Controlled Studies. This search was restricted to full-text human studies published in English, and articles were screened by 2 masked reviewers. Systematic reviews, case reports with less than 3 subjects, letters to the editor, and conference abstracts were excluded. Two independent reviewers rated study quality using the MINORS tool. Results: Twenty-one of 1226 studies were included in this review. Thirteen articles reviewed the outcomes associated with AA in hemophilic arthropathy whereas 10 reviewed the outcomes associated with TAA. Two of our studies were comparative and reviewed the outcomes of both AA and TAA. Additionally, 3 included studies were prospective. Studies showed that the degree of improvement in American Orthopaedic Foot & Ankle Society hindfoot-ankle score, visual analog scale pain scores, and the mental and physical component summary scores of the 36-Item Short Form Health Survey were similar for both surgeries. Complication rates were also similar between the 2 surgeries. Additionally, studies showed a significant improvement in ROM after TAA. Conclusion: Although the level of evidence in this review varies and results should be interpreted with caution, the current literature suggests similar clinical outcomes and complication rates between TAA and AA in this patient population.

Background: The sinus tarsi (ST) approach for calcaneus fractures has gained popularity in recent years with an increased interest in shifting to less invasive approaches for calcaneal fracture fixation allowing for adequate fixation if complications do not arise. Although the ST approach has gained acceptance as standard for calcaneus fracture fixation, the literature surrounding early complications rates based on age differences for this specific approach and pathology is lacking. The objective of this study was to determine if rates of complications based on age varied for patients undergoing open reduction and internal fixation (ORIF) of closed calcaneus fractures using the ST approach. Methods: A retrospective review of patients undergoing ORIF for closed calcaneus fractures from 2012 to 2020 was performed. Inclusion criteria were based on an age greater than 18 years, surgical management of a closed calcaneus fracture using a ST approach, requirement of a preoperative computed tomographic scan, and a minimum of 180 days’ follow-up. Patients were divided into 2 groups: those aged 50 years. Results: A total of 196 fractures were included with 114 fractures in the 50-year age group. Mean age was 34.2 and 59.7 years in the younger and older groups, respectively. The older group had similar rates of wound dehiscence (1.2% vs 4.4%, P = .204), superficial surgical site infection (1.2% vs 2.6%, P = .490), deep infection (9.8% vs 7.9%, P = .648), and nonunion (4.9% vs 3.5%, P = .633) compared with the younger group. Rates of 30-day readmission, unplanned reoperation, and symptomatic hardware were not significantly different. Postoperative Bohler and Gissane angles were not significantly different between both groups. Conclusion: Older patients with intraarticular calcaneus fractures treated via the ST approach maintain complication rates similar to those in younger individuals. Level of Evidence: Level III, retrospective study.