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The number of female orthopaedic surgeons is increasing. They face unique health concerns, which include cancer risk, pregnancy and fertility problems, musculoskeletal issues, and mental health disorders. In 2010, a survey study showed a 2.9-fold increased prevalence of breast cancer in female orthopaedic surgeons, compared with women in the general US population. A follow-up study 13 years later showed a 3.97-fold higher prevalence of breast cancer in female orthopaedic surgeons compared with matched women in the US general population. Surveys on fertility have also reported that orthopaedic surgery is one of three surgical subspecialty fields with the highest rates of fertility difficulty. In addition, the rate of pregnancy loss in female surgeons was twice the rate compared with that of the general population. There is an increased risk of preterm delivery in female orthopaedic surgeons. Awareness, education, and preventive measures may help reduce these issues and thereby promote the recruitment, retainment, and success of female surgeons in orthopaedic surgery.

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INTRODUCTION: Cancer is the second leading cause of death among women in the United States. Previous studies demonstrate a higher prevalence of cancer among female orthopaedic surgeons. This study aimed to provide an updated prevalence of breast and all-cause cancer among female orthopaedic surgeons using a larger and more current study population. METHODS: We distributed surveys to female orthopaedic surgeons in national orthopaedic specialty societies. Six hundred seventy-two survey responses were collected. We calculated standardized prevalence ratios (SPRs) and 95% confidence intervals (CIs) based on gender-specific, race-specific, and age-specific cancer prevalence statistics in the US population. We compared the distribution of breast cancer risk factors with that of women in the 2018 and 2009 California Health Interview Survey. RESULTS: Fifty-one of the 672 surveyed surgeons reported a diagnosis of invasive cancer. Twenty reported breast cancer with a prevalence higher among female orthopaedic surgeons compared with the US female population (SPR: 2.89, 95% CI: 2.16 to 3.81, P < 0.001). The breast cancer prevalence was also higher among orthopaedic surgeons compared with the US female population (SPR: 3.97, 95% CI: 2.43 to 6.14, P = 0.003). DISCUSSION: The increased prevalence of breast and all-cause cancer among a larger and more diverse cohort of female orthopaedic surgeons confirms previous studies and provides an update regarding a concerning public health issue within this specialty.

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PURPOSE: Patient-reported outcome measures are tools for evaluating symptoms, magnitude of limitations, baseline health status, and outcomes from the patient's perspective. Healthcare professional organizations and payers increasingly recommend PROMs for clinical care, but there lacks guidance regarding effective communication of PROMs with orthopedic surgery patients. This qualitative study aimed to identify (1) patient attitudes toward the use and communication of PROMs, and (2) what patients feel are the most relevant or important aspects of PROM results to discuss with their physicians. METHODS: Participants were recruited from a multispeciality orthopedic clinic. Three PROMs: the EuroQol-5 Dimension, the Patient-Specific Functional Scale, and the Patient-Reported Outcome Measurement Information System Physical Function Computer Adaptive Test were shown and a semi-structured interview was conducted to elicit PROMs attitudes and preferences. Interviews were transcribed and inductive-deductively coded. Coded excerpts were aggregated to (1) identify major themes and (2) analyze how themes interacted. RESULT: Three themes emerged: (1) Beliefs toward the purpose of PROMs, (2) PROMs as a reflection of self, and (3) PROMs to facilitate communication and guide healthcare decisions. These themes informed a framework outlining the patient perspective on communicating PROMs during clinical care. CONCLUSION: Patient attitudes toward the use and communication of PROMs start with the incorporation of patient beliefs, which can facilitate or act as a barrier to engagement. Patients should ideally believe that PROMs are an accurate reflection of personal health state before incorporation into care. Clinicians should endeavor to communicate the purpose of a chosen PROM in line with a patient's unique needs and what they feel is most relevant to their own care. Aspects of PROMs results which may be helpful to address include providing context for what scores mean and how they are calculated, and using scores as a way to weigh risks and benefits of treatment and tracking progress over time. Future research can focus on the effect of communication strategies on patient outcomes and engagement in care.

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Background: The risks of radiation exposure in orthopaedic surgery have become a topic of increasing interest in the setting of widespread fluoroscopy use and concern for an increased prevalence of breast cancer among female orthopaedic surgeons. The aim of this national study of 31 female orthopaedic surgeons was to achieve a deeper understanding of fluoroscopic use in the OR and its associated exposure to radiation, by comparing female orthopaedic trauma and arthroplasty surgeons. Methods: A total of 31 surgeons wore dosimeters for 10 operating days each to track cumulative radiation exposure. Surgeons were not asked to modify their practice in any way, with no requirement that the operating days had to be chosen with the knowledge that fluoroscopy would be used. Participants were also asked to fill out a form at the end of each day, detailing the number of cases that day, the number of hours spent in the OR, and the total amount of time using fluoroscopy. Results: Trauma surgeons received significantly higher radiation doses in the OR (p=0.01) and reported longer use of fluoroscopy (p<0.001). Trauma surgeons also spent more time per day in the OR and had more cases per day compared to arthroplasty surgeons, but this difference was not significant. Radiation dose penetrating through protective equipment remained minimal. Conclusion: Although the female trauma surgeons in the study operated longer and performed more procedures per day, the higher radiation exposure was best explained by the amount of time fluoroscopy is used in the OR. The fluoroscopic times in this study therefore may be a useful self-assessment tool for attending trauma and arthroplasty surgeons. Awareness of these differences will hopefully increase an individual surgeon's mindfulness toward the length of fluoroscopy use in each case, regardless of orthopaedic subspecialty.Level of Evidence: IV.

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BACKGROUND: Postoperative pain after fixation of ankle fractures has a substantial effect on surgical outcome and patient satisfaction. Patients requiring large amounts of narcotics are at higher risk of long-term use of pain medications. Few prospective studies investigate patient pain experience in the management of ankle fractures. METHODS: We prospectively evaluated the pain experience in 63 patients undergoing open reduction and internal fixation of ankle. The Short-Form McGill Pain Questionnaire was administered preoperatively and postoperatively (PP) at 3 days (3dPP) and 6 weeks (6wPP). Anticipated postoperative pain (APP) was recorded. RESULTS: No significant differences were found between PP, APP, and 3dPP; however, 6wPP was markedly lower. Significant correlations were found between PP and APP and between preoperative and postoperative Short-Form McGill Pain Questionnaire scores. PP and APP were independent predictors of 3dPP; however, only APP was predictive of 6wPP. Sex, age, and inpatient versus outpatient status were not notable factors. No statistically significant differences were found in pain scores between fracture types. CONCLUSIONS: Both preoperative pain severity and anticipated postoperative pain are predictive of postoperative pain levels. Orthopaedic surgeons should place a greater focus on the postoperative management of patient pain and expectations after surgical procedures.

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BACKGROUND: Exposure to ionizing radiation from fluoroscopy performed during surgery, although low and within established limits, remains a health concern among surgeons. Estimates of breast cancer prevalence among women across surgery specialties with different patterns of fluoroscopy use are needed to evaluate this concern. METHODS: Female U.S. surgeons in urology, plastics, and orthopedics were identified using national directories and mailed surveys to collect information on occupational and medical history, including cancer diagnoses. Standardized prevalence ratios (SPRs) and 95% CIs were calculated by dividing the observed number of cancers among female surgeons in each specialty by the expected number, based on the gender-specific, age-specific, and race-specific cancer prevalence statistics in the general U.S. RESULTS: Standard fluoroscopy use more than once per week was common among urologists (54%) and orthopedists (37%); the same frequency of mini fluoroscopy use was only common among orthopedics (31%) and hardly ever used by urologists. Plastic surgeons reported very infrequent use of any fluoroscopy. For orthopedic surgeons, a significantly greater than expected prevalence of any cancer (SPR, 1.85; 95% CI, 1.19-2.76) and breast cancer (SPR, 2.90; 95% CI, 1.66-4.71) were observed. There was no difference between the observed and expected prevalence of any cancer or breast cancer for urology or plastics. CONCLUSIONS: Using the first available cancer prevalence data comparing female surgeons across three specialties, we report that orthopedic surgeons have a greater than expected prevalence of cancer that may or may not be owing to occupational exposure to ionizing radiation.

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BACKGROUND: First metatarsophalangeal (MTP) arthrodesis using dorsal plate fixation is a common procedure for painful conditions of the great toe. Locked plates have become increasingly common for arthrodesis procedures in the foot, including the hallux MTP joint. The biomechanical advantages and disadvantages of these plates are currently unknown. The purpose of this study was to compare locked and nonlocked plates used for first MTP fusion for strength and stiffness. MATERIALS AND METHODS: The first ray of nine matched pairs of fresh-frozen cadaveric feet underwent dissection, preparation with cup-and-cone reamers, and fixation of the MTP joint with a compression screw and either a nonlocked or locked stainless steel dorsal plate. Each specimen was loaded in a cantilever fashion to 90 N at a rate of 3 Hz for a total of 250,000 cycles. The amount of plantar MTP gap was recorded using a calibrated extensometer. Load-to-failure testing was performed for all specimens that endured the entire cyclical loading. Stiffness was calculated from the final load-to-failure test. RESULTS: The locked plate group demonstrated significantly less plantar gapping during fatigue endurance testing from cycle 10,000 through 250,000 (p < .05). Mean stiffness was significantly greater in the locked plate group compared with the nonlocked plate group (p = .02). There was no significant difference in load to failure between the two groups (p = .27). CONCLUSION: Compared with nonlocked plates, locked hallux MTP arthrodesis plates exhibited significantly less plantar gapping after 10,000 cycles of fatigue endurance testing and significantly greater stiffness in load-to-failure testing. CLINICAL RELEVANCE: As the use of locked plate technology is becoming increasingly common for applications in the foot, a thorough understanding of the biomechanical characteristics of these implants may help optimize their indications and clinical use.

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BACKGROUND: Following successful orthopaedic surgical procedures, implant removal is generally not necessary or recommended. However, patients with pain related to implants may benefit from this elective procedure. The foot and ankle may be more symptomatic from retained implants because of weight-bearing activities, shoe wear, and limited soft-tissue cushioning. In such cases, implant removal may provide good and reliable relief of symptoms. METHODS: A prospective study of sixty-nine patients who underwent elective removal of symptomatic implants from the foot and ankle was undertaken to evaluate the patients' pain experience. The short-form McGill pain questionnaire was administered preoperatively and six weeks postoperatively. Postoperatively, patients were also asked whether they would repeat the procedure and whether they were satisfied with the results. RESULTS: Patients reported significantly less pain following the procedure, with the average rating of pain on the visual analog scale (VAS) decreasing from 3.06 to 0.88 and the average rating of present pain intensity decreasing from 2.03 to 0.58 (p < 0.05 for both). Sixty-five percent of the patients reported no pain on either measure at six weeks postoperatively. Preoperative pain was correlated with postoperative pain (r = 0.24 and p < 0.05 for VAS, and r = 0.16 and p > 0.05 for present pain intensity).With the small sample size, preoperative and postoperative pain did not show a significant difference on the basis of implant location or patient age or sex. Ninety-four percent of patients said they would repeat the procedure under the same circumstances, and 91% of patients were satisfied with the results. CONCLUSIONS: Following successful orthopaedic surgical procedures, removal of implants causing symptoms can result in pain relief and a high rate of patient satisfaction. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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The purpose of this study was to provide a comprehensive analysis of the Orthopaedic In-Training Examination's (OITE's) questions, question sources, and resident performance over the course of residency training.The authors analyzed all OITE questions pertaining to foot and ankle surgery between 2006 and 2010. Recorded data included the topic and area tested, imaging modality used, tested treatment method, taxonomic classification, cited references, and resident performance scores. Foot- and ankle-related questions made up 13.9% (186/1341) of the OITE questions. Thirteen general topic areas were identified, with the most common being foot and ankle trauma, the pediatric foot, and foot and ankle deformity. Imaging modalities were tested in approximately half of the questions. Knowledge of treatment modalities was required in 58.1% (108/186) of the questions. Recall-type questions were the most common. Trends existed in the recommended references, with 2 journals and 1 textbook being commonly and consistently cited: Foot and Ankle International, The Journal of Bone and Joint Surgery American Volume, and Surgery of the Foot and Ankle, respectively. Resident performance scores increased with each successive level of training.An understanding of the topics and resources used for OITE foot and ankle questions is an important aid in creating or improving residency programs' foot and ankle education curricula. With knowledge of question content, source, and resident performance, education can be optimized toward efficient learning and improved scores on this section of the examination.

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BACKGROUND: As a result of low-dose ionizing radiation exposure during clinical practice, female orthopaedic surgeons may be at increased risk for breast cancer. METHODS: The 2009 American Academy of Orthopaedic Surgeons (AAOS) membership directory was used to mail a survey to all female AAOS fellows. Survey responses were collected between June 2009 and June 2010 among 505 (69.7%) of the eligible women. We calculated standardized prevalence ratios (SPRs) and 95% confidence intervals (CIs) by dividing the observed number of cancers among female orthopaedic surgeons by the expected number, based on the gender-specific, age-specific, and race-specific cancer prevalence statistics in the general U.S. population. We compared the distribution of breast cancer risk factors in our study population to that of the women in the 2007 California Health Interview Survey (CHIS, n=30,541). RESULTS: Twenty-four women reported a prior diagnosis of invasive cancer. Female orthopaedic surgeons had a prevalence of cancer that was 85% higher than that of the general U.S. female population (SPR 1.85, 95% CI 1.19-2.76). Orthopaedic surgeons in our study also had a statistically significant 2.9-fold higher prevalence of breast cancer compared to the general U.S. female population (SPR 2.9, 95% CI 1.66-4.71). Survey respondents had a higher prevalence of both protective and predisposing breast cancer factors compared to California women. CONCLUSIONS: Our findings confirm that breast cancer prevalence is elevated among female orthopaedic surgeons. Although further research is needed to determine the factors behind this population's hypothesized increased risk, taken together, our results and others suggest that the orthopaedic community consider educating current practitioners of the use of protective shielding and other modifiable breast cancer risk factors.

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BACKGROUND: Osteochondral lesions of the talus (OLTs) are a common cause of ankle pain and disability. Current clinical guidelines favor autogenous or allogenic osteochondral grafting procedures for lesions larger than 10 mm in diameter because of increased failure rates in these larger lesions with arthroscopic debridement, curettage, and microfracture. There are currently no biomechanical data nor level I clinical data supporting this size threshold. PURPOSE: The purpose of this study was to determine the effect of OLT defect size on stress concentration, rim stress, and location of peak stress and whether a threshold defect size exists. STUDY DESIGN: Descriptive laboratory study. METHODS: Progressively larger medial OLTs were created (6, 8, 10, and 12 mm) in 8 fresh-frozen cadaveric ankle joints. With a calibrated Tekscan pressure sensor in the tibiotalar joint, an axial load of 686 N was applied, and pressure was recorded in neutral and 15° of plantar flexion with each defect size. Peak stress, contact area, peak and average rim stresses, and location of peak stress were determined. RESULTS: The distance between peak stress and defect rim was significantly decreased with increasing defect size for lesions of 10 mm and larger. Total tibiotalar contact area was significantly decreased with increasing defect size and with ankle plantar flexion. While peak joint stress and peak rim stress were not affected by defect size or plantar flexion, average rim stress was significantly increased by plantar flexion. CONCLUSION: Reduction in contact area and shift in the location of peak stress with increasing defect size may contribute to articular cartilage degeneration, pain, and defect enlargement in patients with OLTs. There appears to be a threshold of 10 mm after which the distance between the rim of the defect and the peak stress decreases; however, there is no change in peak stress magnitude with increasing defect size. CLINICAL RELEVANCE: The location of peak stress in the ankle joint becomes closer to the rim of the defect in OLTs at a threshold of 10 mm and greater in diameter. These data may have implications toward OLT size thresholds for surgical decision making in symptomatic lesions (ie, primary osteochondral transplantation procedure vs curettage and debridement). The ultimate goal is to determine whether there is a threshold defect size for primary osteoarticular graft techniques.

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BACKGROUND: Controversy exists on stretching and warm-up in injury prevention. We hypothesized that warm up has a greater effect on Achilles tendon biomechanics than static stretching. This study investigated static stretching and warm-up on Achilles tendon biomechanics in recreational athletes, in vivo. MATERIALS AND METHODS: Ten active, healthy subjects, 5 males, 5 females, With a mean age of 22.9 years with no previous Achilles tendon injuries were recruited. Typical stretching and warm-up routines were created. Testing was performed in a randomized cross-over design. A custom-built dynamometer was utilized to perform controlled isometric plantarflexion. A low profile ultrasound probe was utilized to visualize the musculotendinous junction of the medial gastrocnemius. An eight-camera motion capture system was used to capture ankle motion. Custom software calculated Achilles tendon biomechanics. RESULTS: Achilles tendon force production was consistent. No statistically significant differences were detected in stretch, stiffness, and strain between pre-, post-stretching, and post-warm-up interventions. CONCLUSION: Stretching or warm-up alone, and combined did not demonstrate statistically significant differences. Stretching and warm-up may have an equivalent effect on Achilles tendon biomechanics. Prolonged and more intense protocols may be required for changes to occur. CLINICAL RELEVANCE: Stretching and warm-up of the Achilles before exercise are commonly practiced. Investigating the effect of stretching and warm-up may shed light on potential injury prevention.

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BACKGROUND: Tibiocalcaneal arthrodesis is an uncommon salvage procedure used for complex problems of the ankle and hindfoot. A biomechanical evaluation of the fixation constructs of this procedure has not been studied previously. The purpose of this study was to compare intramedullary nail to blade plate fixation in a deformity model in fatigue endurance testing and load to failure. MATERIALS AND METHODS: Nine matched pairs of fresh frozen cadaveric legs underwent talectomy followed by fixation with a blade plate and 6.5-mm fully threaded cancellous screw or an ankle arthrodesis intramedullary nail. The specimens were loaded to 270 N at a rate of 3 Hz for a total of 250,000 cycles, followed by loading to failure. RESULTS: Intramedullary nail fixation demonstrated greater mean stiffness throughout the fatigue endurance testing, from cycles 10 through 250,000 (blade plate versus intramedullary nail; cycle 10, 93 +/- 34 N/mm versus 117 +/- 40 N/mm (t = 2.33, p = 0.04); cycle 100, 89 +/- 34 N/mm versus 118 +/- 42 N/mm (t = 3.16, p = 0.01); cycle 1000, 86 +/- 32 N/mm versus 120 +/- 45 N/mm (t = 3.52, p = 0.01); cycle 10,000, 83 +/- 36 N/mm versus 128 +/- 50 N/mm (t = 3.80, p = 0.01); cycle 100,000, 82 +/- 34 N/mm versus 126 +/- 52 N/mm (t = 3.70, p = 0.01); cycle 250,000, 80 +/- 31 N/mm versus 125 +/- 49 N/mm (t = 4.2, p = 0.003). There was no statistically significant difference between the intramedullary nail and blade plate fixation in cycle one or in load to failure; cycle 10, blade plate 70 +/- 38 N/mm and intramedullary nail 67 +/- 20 N/mm (t = 0.60, p = 0.56); load to failure, blade plate 808 +/- 193 N, IMN 1074 +/- 290 N) (p = 0.15). CONCLUSION: Intramedullary nail fixation was biomechanically superior to blade plate and screw fixation in a tibiocalcaneal arthrodesis construct. CLINICAL RELEVANCE: The ankle arthrodesis intramedullary nail provides greater stiffness for fixation in tibiocalcaneal arthrodesis, which may improve healing.

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BACKGROUND: Both primary and metastatic tumors in the foot and ankle have been reported as rare. The purpose of this study was to describe 153 cases of foot and ankle tumors from a 20-year experience in a tertiary referral center specializing in orthopaedic oncology. It is the largest reported series of both bone and soft tissue tumors in the foot and ankle. MATERIALS AND METHODS: Between 1986 and 2006, a retrospective chart review was performed of a total of 2,660 tumors surgically treated in all anatomic sites by a single surgeon at a musculoskeletal tumor referral center. RESULTS: One hundred fifty-three patients (5.75%) with bone and/or soft tissue tumors of the foot and ankle were treated. There were 84 women and 69 men. The patients' ages ranged from 1 to 84, with a median age of 30 and mean of 33.2. The tissue types included 80 soft tissue and 73 bone tumors. Overall, 60 (39.2%) were malignant, and 93 (60.8%) were benign. The most common diagnosis was giant cell tumor. In addition, giant cell tumor was the most common bone tumor, while pigmented villonodular synovitis and giant cell tumor of the tendon sheath were the most common soft tissue tumors. CONCLUSION: The incidence of tumors of the foot and ankle in this series of a single surgeon over a 20-year practice was 5.75%. The results of this study reaffirm that awareness, correctly diagnosing, and appropriately treating or referring to an orthopaedic oncologist may help with an improved outcome for patients.

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BACKGROUND: Mobile-bearing ankle replacements have become popular outside of the United States over the past two decades. The goal of the present study was to perform a prospective evaluation of the safety and efficacy of a mobile-bearing prosthesis to treat end stage ankle arthritis. We report the results of three separate cohorts of patients: a group of Scandanavian Total Ankle Replacement (STAR) patients and a control group of ankle fusion patients (the Pivotal Study Groups) and another group of STAR total ankle patients (Continued Access Group) whose surgery was performed following the completion of enrollment in the Pivotal Study. MATERIALS AND METHODS: The Pivotal Study design was a non-inferiority study using ankle fusion as the control. A non-randomized multi-centered design with concurrent fusion controls was used. We report the initial perioperative findings up to 24 months following surgery. For an individual patient to be considered an overall success, all of the following criteria needed to be met: a) a 40-point improvement in total Buechel-Pappas ankle score, b) no device failures, revisions, or removals, c) radiographic success, and d) no major complications. In the Pivotal Study (9/00 to 12/01), 158 ankle replacement and 66 arthrodesis procedures were performed; in the Continued Access Study (4/02 to 10/06), 448 ankle replacements were performed, of which 416 were at minimum 24 months post-surgery at time of the database closure. RESULTS: Major complications and need for secondary surgical intervention were more common in the Pivotal Study arthroplasty group than the Pivotal Study ankle fusion group. In the Continued Access Group, secondary procedures performed on these arthroplasty patients decreased by half when compared with the Pivotal Arthroplasty Group. When the Pivotal Groups were compared, treatment efficacy was higher for the ankle replacement group due to improvement in functional scores. Pain relief was equivalent between fusion and replacement patients. The hypothesis of non-inferiority of ankle replacement was met for overall patient success. CONCLUSION: By 24 months, ankles treated with STAR ankle replacement (in both the Pivotal and Continued Access Groups) had better function and equivalent pain relief as ankles treated with fusion.

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BACKGROUND: Orthopaedic procedures have been reported to have the highest incidence of pain compared to other types of operations. There are limited studies in the literature that investigate postoperative pain. MATERIALS AND METHODS: A prospective study of 98 patients undergoing orthopedic foot and ankle operations was undertaken to evaluate their pain experience. A Short-Form McGill Pain Questionnaire (SF-MPQ) was administered preoperatively and postoperatively. RESULTS: The results showed that patients who experienced pain before the operation anticipated feeling higher pain intensity immediately postoperatively. Patients, on average, experienced higher pain intensity 3 days after the operation than anticipated. The postoperative pain intensity at 3 days was the most severe, while postoperative pain intensity at 6 weeks was the least severe. Age, gender and preoperative diagnosis (acute versus chronic) did not have a significant effect on the severity of pain that patients experienced. Six weeks following the operation, the majority of patients felt no pain. In addition, the severity of preoperative pain was highly predictive of their anticipated postoperative pain and 6-week postoperative pain, and both preoperative pain and anticipated pain predict higher immediate postoperative pain. CONCLUSION: The intensity of patients' preoperative pain was predictive of the anticipated postoperative pain. Patients' preoperative pain and anticipated postoperative pain were independently predictive of the 3-day postoperative pain. The higher pain intensity a patient experienced preoperatively suggested that their postoperative pain severity would be greater. Therefore, surgeons should be aware of these findings when treating postoperative pain after orthopaedic foot and ankle operations.

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BACKGROUND: Hallopeau's nerve is a branch of the lateral plantar nerve that supplies the flexor hallucis brevis muscle while also forming an anastomosis with the medial plantar nerve. In this study, the presence of this neural anastomosis was determined through dissection of cadaveric specimens. MATERIALS AND METHODS: Twenty-six fresh-frozen adult feet (13 matched pairs) were dissected to assess the presence or absence of Hallopeau's nerve. RESULTS: Dissections revealed four out of 26 specimens had this anastomosis. CONCLUSION: This study confirms this anatomic variation. CLINICAL RELEVANCE: The clinical significance of these anastomoses remains unknown. These anastomoses are analogous to some in the hand and forearm.

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