J. Alex Albright

Background: The gold standard for low bone mineral density (BMD) screening is dual-energy X-ray absorptiometry (DXA) scanning, which has declined in use in recent years for a variety of reasons. This decline warrants alternative screening mechanisms. This study aimed to determine if opportunistic foot radiographs can serve as a screening tool for predicting low BMD as measured by DXA scan. Methods: The fifth metatarsal index (5MI), a novel measurement made using the oblique foot radiograph to evaluate cortical thickness, was calculated for patients 50 years and older who underwent a DXA scan and a foot radiograph within 1 year. T scores and BMD were documented for each patient. Receiver operating characteristic curves were generated, and areas under the curves were calculated to determine which 5MI had optimized sensitivity and specificity for identifying osteoporosis. Results: A total of 89 patients were included in the study cohort. The average 5MI in patients with normal BMD, osteopenia, and osteoporosis was 52.6%, 44.6%, and 35.2%, respectively. The optimal 5MI for identifying osteoporosis based on the DXA-derived T scores was 46.8%, which correlated with an area under the curve of 0.977. This optimal cutoff for identifying osteoporosis had a sensitivity of 93.3% (95% CI, 70.2%-99.7%) and a specificity of 95.0% (95% CI, 76.4%-99.7%) ( P < .001). Conclusion: This study describes a potential screening method using low-cost foot radiographs to identify patients with low BMD, which may support earlier detection and referral for bone health evaluation. Level of Evidence: Level III, retrospective case series.

Background: Clear cell sarcoma (CCS) is a rare soft tissue sarcoma that primarily affects individuals ages 20-40. It typically presents as a slow-growing, often painless, mass in the extremities. Wide resection is the mainstay of treatment, though local recurrence and metastatic disease are common despite surgery. This case series highlights our experience treating CCS within the military population. Materials and Methods: This is a retrospective case series of 3 patients treated at our institution between 2016 and 2026 with biopsy-confirmed CCS. Median survival, local recurrence, and incidence of metastatic disease are reported. Results: Three male patients aged 17, 21, and 24 years were diagnosed with genetically confirmed CCS of the thigh. One patient was local to our institution’s area, and the remaining 2 were stationed across the country and therefore underwent initial workup at other hospitals. Tumor size ranged from 5.7 to 14.6 cm, and all lesions demonstrated an EWSR1-ATF1 translocation. Two patients presented with regional nodal metastases at diagnosis, while 1 developed nodal metastasis 6 months after treatment. All patients underwent multimodal therapy consisting of radiation therapy and surgical resection, with 2 receiving prophylactic carbon fiber intramedullary nail fixation. Postoperative complications included wound dehiscence in 2 patients and vascular graft occlusion in 1 patient. Despite additional systemic therapy, all patients developed progressive metastatic disease, including lymph node, pulmonary, and spinal metastases. Overall survival following diagnosis was 12, 12, and 21 months, respectively, with all patients ultimately succumbing to disease. Conclusions: CCS is an aggressive tumor with a high rate of local recurrence and metastatic disease. Overall survival is poor, and prompt treatment and early referral to an orthopedic oncologist are paramount to improve patient outcomes. Military providers should be aware of this rare entity, as it primarily affects military-age men and women.

Case: We present a case of a 30-year-old man with severe ulnar nerve neuropraxia and first dorsal interosseous muscle wasting. Intraoperatively, a large venous plexus compressing the terminal division of the deep motor branch of the ulnar nerve was identified as a contributing factor. Conclusion: This is the first documented instance of compression of the terminal branch of the ulnar nerve caused by a venous plexus, resulting in neurapraxia. This rare anatomical variant caused progressive functional impairment and was successfully treated with ligation of vessels distally along with proximal and distal nerve decompression.

Background: Calcaneal fractures are among the most challenging foot injuries managed by orthopaedic surgeons. Given their high technical demand and inherent complication profile, calcaneal fractures are often, but not always, referred to subspecialists with fellowship training in either Foot and Ankle (FA) or Trauma surgery. The primary purpose of this study was to evaluate practice trends and to determine whether calcaneal fracture ORIF volume and early complication rates differ among early-career American orthopaedic surgeons (typically within their first 1-2 years of practice) by fellowship training type. Methods: The American Board of Orthopaedic Surgery (ABOS) Part II database was used to identify all calcaneal fracture open reduction internal fixation (ORIF) cases performed from 2003 to 2019. Candidates were grouped by fellowship training. The percentage of surgeons performing calcaneal fracture surgery and the average number of cases performed per surgeon were analyzed using linear regression; odds of early complications were estimated using multivariable logistic regression. Results: A total of 3809 calcaneal fractures were surgically managed by 1624 early-career orthopaedic surgeons from 2003 to 2019. FA surgeons comprised the largest proportion (35.0%) and performed the greatest number of these cases (42.5%). They were closely followed by Trauma (29.6%), who performed 35.6% of the reported calcaneal fracture ORIF cases. Of all early-career FA and Trauma fellowship-trained surgeons, 72.4% and 55.1% performed calcaneus surgery, respectively. The number of cases performed significantly decreased by 0.05 cases per year over the 17-year study period. The number of cases performed on patients aged ≥50 years increased by 0.024 cases per year per surgeon. Fellowship-trained FA or Trauma surgeons had 37% higher odds of reporting an early complication compared with generalists (OR = 1.37; 95% CI, 1.04-1.80; P = .027). Conclusion: This study identified trends in the surgical management of calcaneal fractures over the last 2 decades. These findings may inform fellowship selection and training curriculum. Level of Evidence: Level III, retrospective case review.

Background: Public insurance has recently been associated with a decreased likelihood of receiving surgery to address glenohumeral instability in several state-specific analyses. The purpose of this study is to expand this literature and analyze this association in a nationwide sample. Methods: A national insurance claims database was used to identify shoulder dislocations between 2011 through 2019. Patients were stratified by insurance status (Medicaid or commercial) and age (5–24, 25–44, and 45–64 years). Billing codes were used to identify surgical stabilization and recurrent dislocations. Multivariable logistic regression was performed to compare the likelihood of surgical stabilization and recurrent instability. Results: Of 292 672 patients, those with Medicaid were 48% less likely to receive surgery within 30 days, 32% less likely within 1 year, and 31% less likely within 2 years of their dislocation. When compared to those with commercial insurance, patients aged 45–64 years with Medicaid were the least likely to undergo surgery to address their shoulder instability (OR = 0.51, 95% CI, 0.40–0.65, p < 0.001). Conclusion: Patients with Medicaid insurance are less likely to have their glenohumeral dislocation managed surgically, highlighting the limited healthcare access of patients with Medicaid insurance.

Objectives This study aims to characterize the association between the timing of MRI ordering and completion for pediatric knee injuries and Social Deprivation Index (SDI), which is a comprehensive, validated, county-level, measure of socioeconomic variation in health outcomes based upon combining geography, income, education, employment, housing, household characteristics, and access to transportation. Methods A retrospective chart review was completed of patients 21 years old and younger from our institution with a history of knee sports injury (ligamentous/soft tissue injury, structural abnormality, instability, inflammation) evaluated with MRI between 5/26/2017 and 12/28/2020. Patients were from three states and attended to by physicians associated with an urban academic institution. Patients were assigned SDI scores based on their ZIP code. Excluded from the study were patients with a non-knee related diagnosis (hip, foot, or ankle), patients from ZIP codes with unknown SDI, and non-sports medicine diagnoses (tumor, infection, fracture). Results In a multivariate regression analysis of 355 patients, increased SDI was independently associated with increased time from clinic visit to MRI order (p = 0.044) and from clinic visit to MRI completion (p = 0.047). Each 10-point increase in SDI (0-100) was associated with a delay of 7.2 days on average. SDI itself was found to be associated with a patient's race (p < 0.001), ethnicity (p < 0.001), and insurance category (p < 0.001). Conclusion Increased SDI is independently associated with longer time from clinic visit to knee MRI order and longer time from clinic visit to knee MRI completion in our pediatric population. Recognizing potential barriers to orthopedic care can help create the change necessary to provide the best possible care for all individual patients.

Purpose: To examine the available literature to better understand the objective and patient‐reported outcomes using peroneus longus tendon (PLT) autograft compared with more commonly used autografts, such as the quadrupled hamstring tendons (HT), in patients undergoing primary for anterior cruciate ligament reconstruction (ACLR). Methods: A comprehensive search of published literature in PubMed, Web of Science, Cochrane Library, Ovid, and EMBASE databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. Inclusion criteria included patients undergoing ACLR with PLT autograft, inclusion of patient‐recorded outcome measures, and availability in English language. Publications that included only biomechanical analysis or ACLR with use of allograft or combination grafts were excluded. Results: A total of 16 studies (Level of Evidence range: I‐IV) met inclusion criteria, with follow‐up ranging from 3 months to 5 years. In the available case series, patient‐reported outcomes ranged from Lysholm = 80.7 to 95.1, International Knee Documentation Committee 78.1 to 95.7. In prospective cohorts and randomized controlled trials, PLT performance was comparable with HT autografts (PLT/HT: Lysholm = 88.3‐95.1/86.5‐94.9, International Knee Documentation Committee = 78.2‐92.5/87.4‐93.4). The majority of PLT grafts diameters were equal or greater than HT counterparts with a mean of >8 mm (PLT/HT: 7.0‐9.0 mm/7.65‐8.5 mm). There was minimal donor‐site morbidity associated with PLT harvest. Conclusions: Although limitations exist within the available literature, existing evidence suggests that PLT autograft routinely produces adequately sized grafts with comparable early outcomes to HT autograft and low risk of donor‐site morbidity. However, the PLT autograft is yet to demonstrate superiority to any of the more‐traditional autograft selections. Level of Evidence: Level IV, systematic review of Level I‐IV studies.

Purpose: As high rates of vitamin D deficiency have been demonstrated in orthopedic patient cohorts, this study aimed to characterize the association between a diagnosis of hypovitaminosis D and primary rotator cuff tear (RCT), primary rotator cuff repair (RCR), and postoperative complications in different sex and age cohorts. Methods: In this retrospective cohort study using PearlDiver, a nationwide administrative claims database, records for all patients aged 30 to 89 yr who received a diagnosis of hypovitaminosis D between January 1, 2011, and October 31, 2018, were queried. Rates of primary RCT, primary RCR, and postoperative complications including subsequent surgery were calculated within sex- and age-specific cohorts and compared with matched control cohorts using multivariable logistic regression. Results: Among the 336,320 patients included in the hypovitaminosis D cohort, these patients were significantly more likely to experience an RCT (odds ratio (OR), 2.70; 95% confidence interval (CI), 2.55–2.85) as well as a full-thickness RCT (OR, 2.36; 95% CI, 2.17–2.56) specifically within 2 yr of their diagnosis. Women with hypovitaminosis D were more likely to undergo surgery to address their full-thickness tears (OR, 1.37; 95% CI, 1.09–1.74). There was no difference in the rates of revision RCR or irrigation and debridement. However, women with hypovitaminosis D were significantly more likely to undergo manipulation under anesthesia (OR, 1.16; 95% CI, 1.03–1.31). Conclusions: Patients diagnosed with hypovitaminosis D were significantly more likely to suffer from a primary RCT and to undergo manipulation under anesthesia within a year of their RCR. Although many risk factors for RCT are unmodifiable, vitamin D deficiency is a readily modifiable risk factor with several treatment regimens demonstrating positive effects on musculoskeletal health.