Adam P. Henderson

Background: Computer-assisted navigation (CAN) offers dynamic intraoperative guidance in total ankle arthroplasty (TAA). Although laboratory data suggest superior precision, in vivo evidence is lacking. This study used weightbearing computed tomography (WBCT) to evaluate CAN accuracy of postoperative TAA implant position relative to the plan. We hypothesized that absolute discrepancies would be <3 mm or <3°. Methods: Thirteen consecutive patients (November 2024–November 2025) underwent TAA using CAN. Preoperative computed tomography–based 3D models were used for templating. Postoperative WBCT scans were used to measure final implant seating, and computerized measurements were used to identify implant placement discrepancy. We analyzed absolute discrepancies between planned vs final postoperative positions. Results: Tibial absolute discrepancies were within desired limits for varus/valgus (1.65° ± 1.43°), slope (1.87° ± 1.34°), and cut height (0.68 ± 0.62 mm) but not for axial rotation (3.97 ± 2.64). For the talus, varus/valgus (2.93° ± 1.86°) and cut height (0.66 ± 0.71 mm) absolute discrepancies were within desired limits. The increased talar slope deviation (3.90 ± 2.89) in the final position may be due to non-navigated implant impaction. Conclusion: Although discrepancies persisted in tibial rotational alignment and talar positioning, the low variability across measurements suggests that CAN may support accurate implant positioning. These short-term positioning accuracy findings support the utility of CAN as a potential tool for enhancing implant positioning reproducibility in TAA. Level of Evidence: Level IV, case series.

Purpose Tibiotalocalcaneal (TTC) arthrodesis is a limb-salvaging procedure for end-stage ankle and hindfoot pathology but carries substantial risks of nonunion and complications. Minimally invasive approaches may reduce surgical morbidity while maintaining fusion outcomes. Methods This was a retrospective case series of patients who underwent TTC arthrodesis with percutaneous joint preparation between January 2020 and March 2025 at a single academic Level II trauma center. The primary outcome was radiographic or clinical fusion at final follow-up. Secondary outcomes included alignment, operative variables, complications, and functional recovery as measured by Patient Reported Outcomes Measurement Information System (PROMIS) domains. Results Thirteen patients (six females) met inclusion criteria with a mean age of 74.0 years and body mass index of 27.1 kg/m². The mean time from injury to surgery in trauma patients was 6.2 days. Fibular fixation was performed in six cases (46.2%), with additional fixation necessary in select patients. Mean clinical follow-up time was 15.0 ± 4.3 months. Most patients advanced to weightbearing in supportive footwear and reported functional improvement. PROMIS Pain Interference averaged 56.8 ± 10.9, Physical Function 37.7 ± 12.2, and Global Pain 38.7 ± 28.9. Radiographs and computed tomography demonstrated moderate fusion rates in this cohort. Complications included wound issues (23.1%), hardware problems (46.2%), and one tibial shaft fracture after a fall; five patients required secondary screw removal. Conclusion Percutaneous TTC arthrodesis demonstrated moderate radiographic fusion rates, functional improvement, and an acceptable complication profile for this cohort of predominantly elderly, medically complex patients.

Primary sternal osteomyelitis (PSO) is an exceptionally rare infection of the sternum, typically occurring in the context of trauma, surgery or immunocompromise. We report the case of a previously healthy adolescent boy in his second decade of life presenting with fever, chest pain and localised tenderness without any identifiable risk factors. Initial workup, including a chest X-ray and echocardiogram, was unremarkable, but persistent bacteraemia with methicillin-sensitive Staphylococcus aureus prompted further imaging. MRI revealed sternal osteomyelitis with a small parasternal abscess. The patient was successfully treated with intravenous antibiotics alone, avoiding surgical intervention. This case highlights the importance of thorough physical examination and maintaining a high index of suspicion for PSO in patients with unexplained fever and chest wall tenderness, even in the absence of traditional risk factors. Early diagnosis and targeted therapy are essential to optimise outcomes in this rare condition.

BACKGROUND Endovascular aneurysm repair (EVAR) effectively treats abdominal aortic aneurysms but risks complications, including endoleak and graft infection. CASE REPORT A 74-year-old man with EVAR, complicated by endoleak the following month with persistent pain following endoleak repair, presented with multiple abscesses (epidural, psoas, and disc space) and an aorto-disc fistula 7 months after the endoleak repair. Long-term corticosteroid use and an interleukin-6 inhibitor for presumed polymyalgia rheumatica contributed to immunosuppression. This misdiagnosis, along with immunosuppression and inconclusive outside imaging, diagnostic tunneling contributed to a delayed diagnosis until discitis, osteomyelitis, and abscesses were discovered on computed tomography (CT). This case is a rare presentation, and there is scant literature on spinal abscess from EVAR. Given the uniqueness and complexity of the presentation, a multidisciplinary approach was required for a better outcome, including multiple surgery teams and multiple medical teams. Management included abscess drainage, EVAR explant with rifampin-soaked Dacron graft reconstruction, surgical debridement, antibiotic beads, and 6 weeks of intravenous daptomycin for coverage of previously positive spinal tissue cultures (methicillin-sensitive Staphylococcus aureus and Cutibacterium acnes) with a plan for lifelong suppression with doxycycline. The patient ultimately had a new endoleak requiring repair, but was doing well as of his last appointment 8 months after his presentation to our facility. CONCLUSIONS This case demonstrates the need for postoperative vigilance and multidisciplinary care for patients undergoing EVAR. Comprehensive source control and close follow-up have thus far yielded a successful clinical outcome.

Background: Total wrist arthrodesis is a well-established procedure providing pain relief and stability for patients with symptomatic radiocarpal arthritis refractory to nonoperative measures. Little research exists on reimbursement and utilization trends for this procedure. This study aimed to characterize Medicare reimbursement trends for total wrist arthrodesis, along with trends in Medicare utilization and comparison with Medicaid reimbursement. Methods: Medicare reimbursement for Current Procedural Terminology codes 25800, 25805, and 25810 were collected from the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule from 2000 to 2025. Rates were inflation-adjusted to 2025 dollars, and percentage changes were calculated. Medicare utilization trends from 2000 to 2022 were analyzed using CMS Part B data. Most recent Medicaid reimbursement was collected from online state fee schedules and compared with 2025 Medicare rates, with additional analyses of variability and adjustment for work Relative Value Units. Results: Inflation-adjusted Medicare reimbursement for total wrist arthrodesis decreased by 49.1% from 2000 to 2025 ( P < .0001), averaging a 1.96% annual decline. Utilization trends remained stable, with wrist arthrodesis with iliac or other autograft (CPT 25810) being the most commonly billed procedure. Medicaid reimbursed 13.6% less than Medicare on average, with substantial state variability, ranging from 44.7% (New Hampshire) to 135.4% (Alaska) of Medicare reimbursement. Conclusion: Reimbursement for total wrist arthrodesis has declined significantly despite stable utilization in the Medicare population. Medicaid reimbursement is consistently lower and highly variable by state, potentially impacting access to care. Given the effectiveness of wrist arthrodesis, policymakers should advocate for equitable reimbursement for this procedure.

Background and Objectives: Medicaid reimbursement to physicians has been demonstrated to be lower than reimbursement from Medicare and private insurance. Studies on Medicaid reimbursement for orthopedic oncology procedures, however, are limited. This study compares Medicaid reimbursement rates to Medicare for 38 common musculoskeletal oncology procedures and assesses variability among states.Methods: We collected 38 current procedural terminology (CPT) codes for commonly performed orthopedic oncology procedures. Medicare rates were obtained from the 2023 Centers for Medicare and Medicaid physician (CMS) fee schedule. Medicaid rates were collected from electronic state website fee schedules. Reimbursement for the two insurance types were compared with state and national averages. Dollar differences were adjusted for work relative value units (RVU) to ascertain procedural variability. The Medicare Wage Index, representing differences in wages across states, was used to adjust medicaid rates to compare more accurately to medicare. Coefficient of variation values, calculated by dividing the standard deviation by the mean, were calculated to assess variation among procedures.Results: Medicaid reimbursed orthopedic oncologists 22.1% less than medicare on average, increasing to 33.0% when adjusting for wage differences. State Medicaid reimbursement ranged from 37% to 131% of Medicare, with 38 states reimbursing less than Medicare on average. The coefficient of variation for Medicaid procedures ranged from 0.24 to 0.46, indicating wide variability among states and procedures, while for Medicare, the coefficient of variation was low at 0.06 to 0.07.Conclusions: Medicaid reimbursement for common orthopedic oncology procedures is substantially lower and more variable than Medicare, despite the often urgent nature of these surgeries. Disparities in reimbursement may impact access to care for this population, highlighting the need for policy reform.

Background: Medicaid reimbursement to physicians is often perceived to be lower than Medicare, but little is known about orthopaedic foot and ankle reimbursement. This study sought to compare Medicare and Medicaid reimbursement for the 20 most common foot and ankle procedures. Methods: Medicare reimbursement rates for common foot and ankle codes were obtained from the online Centers for Medicare & Medicaid fee schedule, while Medicaid rates were found from individual state fee schedule websites. Medicaid rates were compared by state and pooled to obtain national differences. The Medicare Wage Index was used to adjust Medicaid rates by state wages to ensure a more accurate comparison. Variability between states was measured using state percentages of Medicare and coefficient of variation values. Results: Medicaid reimbursed physicians higher than Medicare in 31 states overall, with average reimbursement ranging from 37% to 324% of Medicare. Nationally, Medicaid reimbursed 8.8% higher than Medicare, but Medicare reimbursed 3.7% higher when adjusted for the Medicare Wage Index. The Current Procedural Terminology ( CPT ) codes with the highest ratio of Medicaid to Medicare reimbursement were CPT 28002 for incision and drainage of the foot (176.6%) and CPT 28820 for toe amputation (167.6%). Five codes had lower relative Medicaid reimbursement on average: CPT 27687 for repair procedures on the leg and ankle joint, CPT 28810 for amputation procedures on the foot and toes, CPT 28010 for toe tenotomy, CPT 28005 for incision procedures on the foot and toes, and CPT 28470 for closed treatment of a metatarsal fracture. The coefficient of variation values ranged from 0.34 to 0.84 in the Medicaid group and 0.40 to 0.78 in the adjusted group, indicating high variability between states and between procedures. Conclusion: Medicaid reimbursement is highly inconsistent between states, ranging from 37% to 324% of Medicare. Medicaid reimbursed more than Medicare overall, which is in contrast with most published findings that tend to show higher reimbursement for Medicare when compared to Medicaid. When adjusting for wage differences between states, Medicare reimbursed slightly higher than Medicaid. Level of Evidence: Level IV, economic analysis.

Purpose: To compare Medicaid and Medicare rates for the 20 most commonly billed orthopaedic sports medicine procedures. Methods: Medicaid reimbursement rates were obtained from state‐specific fee schedules. Medicare rates were collected from the Centers for Medicare & Medicaid Services Physician Fee Schedule, along with relative value units for each procedure. State rates were compared using averages and dollar differences. Reimbursement rates were adjusted for cost of living using the Medicare Wage Index. Variability between states and between procedures was assessed using coefficients of variation. Results: Mean Medicaid reimbursement was lower than that of Medicare for 19 of the 20 procedures. In total, Medicaid reimbursed surgeons 14.9% less when data were unadjusted and 26.0% less when data were adjusted for cost of living. Variation in Medicare rates between states was constant, with a coefficient of variation of 0.06. For Medicaid, the coefficients of variation ranged from 0.27 to 0.70 for unadjusted data and from 0.35 to 0.69 for adjusted data. Conclusions: On average, Medicaid reimburses orthopaedic sports medicine specialists less than does Medicare, with substantial variability between states. Adjustment for cost of living increases the percentage difference and the variability between states’ Medicaid reimbursement rates. Level of Evidence: Level IV, economic analysis.