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Objective: To compare the rates of revision surgery for symptomatic neuromas in patients undergoing primary transtibial amputations with and without targeted muscle reinnervation (TMR). Design: Retrospective cohort study. Setting: Level I trauma hospital and tertiary military medical center. Patients/Participants: Adult patients undergoing transtibial amputations with and without TMR. Intervention: Transtibial amputation with targeted muscle reinnervation. Main Outcome Measurements: Reoperation for symptomatic neuroma. Results: During the study period, there were 112 primary transtibial amputations performed, 29 with TMR and 83 without TMR. Over the same period, there were 51 revision transtibial amputations performed, including 23 (21%) in the patients undergoing primary transtibial amputation at the study institution. The most common indications for revision surgery were wound breakdown/dehiscence (42%, n = 25), followed by symptomatic neuroma 18% (n = 9/51) and infection/osteomyelitis (17%, n = 10) as the most common indications. However, of the patients undergoing primary amputation at the study's institution, there was no difference in reoperation rates for neuroma when comparing the TMR group (3.6%, n = 1/28) and no TMR group (4.0%, n = 3/75) (P = 0.97). Conclusions: Symptomatic neuroma is one of the most common reasons for revision amputation; however, this study was unable to demonstrate a difference in revision surgery rates for neuroma for patients undergoing primary transtibial amputation with or without targeted muscle reinnervation. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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INTRODUCTION: The aim of this study was to address and enhance our ability to study the clinical outcome of limb salvage (LS), a commonly referenced but ill-defined clinical care pathway, by developing a data-driven approach for the identification of LS cases using existing medical code data to identify characteristic diagnoses and procedures, and to use that information to describe a cohort of US Service members (SMs) for further study. METHODS: Diagnosis code families and inpatient procedure codes were compiled and analyzed to identify medical codes that are disparately associated with a LS surrogate population of SMs who underwent secondary amputation within a broader cohort of 3390 SMs with lower extremity trauma (AIS > 1). Subsequently, the identified codes were used to define a cohort of all SMs who underwent lower extremity LS which was compared with the opinion of a panel of military trauma surgeons. RESULTS: The data-driven approach identified a population of n = 2018 SMs who underwent LS, representing 59.5% of the combat-related lower extremity (LE) trauma population. Validation analysis revealed 70% agreement between the data-driven approach and gold standard SME panel for the test cases studied. The Kappa statistic (κ = 0.55) indicates a moderate agreement between the data-driven approach and the expert opinion of the SME panel. The sensitivity and specificity were identified as 55.6% (expert range of 51.8-66.7%) and 87% (expert range of 73.9-91.3%), respectively. CONCLUSIONS: This approach for identifying LS cases can be utilized to enable future high-throughput retrospective analyses for studying both short- and long-term outcomes of this underserved patient population.

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OBJECTIVE: Medical students pursuing orthopedic surgery residency build foundational knowledge during clinical rotations. Most clinical rotations, home and away, were paused during the COVID-19 pandemic. Given the lack of structured fourth-year medical student (MS4) education for basic orthopedics, educators developed the Ortho Acting-Intern Coordinated Clinical Education and Surgical Skills (OrthoACCESS) curriculum in 2019. This study demonstrates the accessibility and usability of a MS4 virtual orthopedic curriculum and examines the curriculum's role in increasing learner familiarity with basic orthopedic topics in 2020. DESIGN: OrthoACCESS faculty presented weekly lectures from July to October 2020 using Zoom Webinar. Website content included recorded webinars, external resources, and skills videos. Registrants were anonymously surveyed after each webinar characterizing the knowledge and utility of individual lectures. After the webinar series, registrants were emailed an anonymous post-curriculum survey characterizing their experience using the OrthoACCESS curriculum. RESULTS: OrthoACCESS had 1062 registrants, with 59% (624/1,062) MS4s. 4528 users accessed the OrthoACCESS website from 66 countries. The 15 lectures were viewed 3743 times, 1553 live views and 2190 asynchronous views. 444 postwebinar surveys were completed. Weekly response rates ranged from 18% to 45%. Respondents felt more knowledgeable and more able to apply their knowledge after viewing each lecture (p < 0.001), and found the webinars to be well-organized, well-paced, enthusiastically taught, and level-appropriate. 122/976 (13%) students and 45/291 (15%) faculty completed the postcurriculum survey. Faculty reported that OrthoACCESS was "quite useful" (4 [3-5]) for providing knowledge for an incoming orthopaedic intern. Faculty and students would recommend OrthoACCESS to future learners (5 [4-5]). CONCLUSIONS: OrthoACCESS delivered foundational musculoskeletal instruction during a period of increased need. In its initial iteration, this virtual curriculum demonstrated high utilization in the United States and internationally and improved participants' self-reported topical knowledge and ability to apply it clinically.

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In response to increasing rates of self-reported latex allergies, changes have been made to prevent anaphylaxis in the operating room, including the use of latex-free gloves. However, the impact of these changes on the risk of prosthetic joint infection (PJI) after arthroplasty is unclear. This study evaluated whether documented latex allergy is an independent risk factor for PJI and aseptic revision surgery after total hip arthroplasty (THA) and total knee arthroplasty (TKA). A retrospective matched cohort study was conducted with an administrative claims database. A total of 17,501 patients who underwent TKA and had documented latex allergy were matched 1:4 with 70,004 control subjects, and 8221 patients who underwent THA and had documented latex allergy were matched 1:4 with 32,884 control subjects. Multivariable logistic regression showed that patients who had TKA and had a latex allergy showed significantly higher risk of PJI at both 90 days (odds ratio [OR], 1.26) and 1 year (OR, 1.22) and significantly higher risk of aseptic revision TKA at 1 year (OR, 1.21) after surgery compared with control subjects. Patients who had THA and had a latex allergy had significantly higher risk of PJI at 1 year (OR, 1.19) compared with control subjects. Rates of aseptic revision THA were higher in the latex allergy cohort but statistically comparable (P>.05). Latex allergy was associated with significantly increased risk of PJI and aseptic revision after TKA and significantly increased risk of PJI after THA. More work is needed to determine whether these risks can be mitigated or if latex allergy is an inherent, nonmodifiable risk factor requiring modification to typical arthroplasty pathways. [Orthopedics. 2022;45(4):244-250.].

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BACKGROUND: When the symptoms of hallux valgus persist despite nonoperative management, surgical intervention may be considered to improve pain and restore function. Although most patients return to full or near-full activity after surgery, this is not always the case in higher-demand populations. In fact, little is known about the likelihood of a military servicemember returning to running or military duty, which is analogous to a recreationally active adult, after hallux valgus correction. QUESTIONS/PURPOSES: (1) What percentage of military servicemembers are able to return to full duty, including the ability to run 1.5 to 2 miles, 1 year after hallux valgus surgery? (2) What demographic, radiographic, and surgical variables are associated with an increased likelihood of return to full duty? METHODS: This was a retrospective study of all military servicemembers who underwent surgical correction of hallux valgus deformities at a single tertiary institution from January 2005 to December 2016. We considered military servicemembers who were treated by four fellowship-trained foot and ankle orthopaedic surgeons and who had at least 1 year time-in-service remaining as potentially eligible. A total of 229 people underwent hallux valgus correction during this timeframe, but only 28% (64 of 229) of patients remained eligible: 41% (93 of 229) were excluded because they were not military members, 28% (64 of 229) were ineligible because they had less than 1 year remaining in service, 2% (4 of 229) were excluded because of prior surgery on the ipsilateral extremity, and 2% (4 of 2292) had an incomplete dataset. Interventions included a modified McBride procedure (9% [6 of 64]), distal metatarsal osteotomies (51% [33 of 64]), proximal metatarsal osteotomies (13% [8 of 64]), and Lapidus procedures (27% [17 of 64]). No bilateral procedures were performed. The mean age of our patients was 40 ± 10 years, and the mean BMI was 28 ± 9 kg/m 2 . In addition, 23% (15 of 64) of patients were nicotine users, 38% (24 of 64) were officers, and 45% (29 of 64) were women. The indication for surgery was functionally limiting pain that persisted despite 4 to 6 months of activity modifications, accommodative footwear, and orthotics. Cosmesis was not an indication for surgery. Before surgery, all patients were unable to complete a 1.5- to 2-mile timed run due to pain. The primary outcome measure was the proportion of patients who returned to full duty, which was defined as the ability to complete a 1.5-mile to 2-mile run for a military fitness test in a fixed time allotment, which varies by age and gender, and the ability to perform military-specific physical tasks at 1 year postoperatively. A secondary analysis according to demographic, radiographic, and surgical variables sought to determine any differences between those who did and did not return to full duty; this was assessed using univariable statistical comparisons at a p value of less than 0.01. RESULTS: A total of 28% (18 of 64) of patients who underwent surgery returned to full duty by 1 year after surgery as determined by the ability to complete a time-allotted 1.5- to 2-mile fitness test run. Of the factors we explored, we did not identify any variables associated with return to full duty. We note that our analysis may have been underpowered to detect differences among factors that could be clinically important, like BMI, age, and comparisons of officers versus enlisted servicemembers. CONCLUSION: Although this study analyzed the functional outcomes of a group of military servicemembers after hallux valgus correction, we believe our findings may also apply to recreationally active adults in the general population. Only a minority of military servicemembers (28% [18 of 64]) returned to duty 1 year after hallux valgus correction, as determined by the ability to complete a timed 1.5- to 2-mile run. We believe surgeons can use the findings of this study to set realistic expectations for recreationally active adults, particularly runners, after hallux valgus correction. LEVEL OF EVIDENCE: Level III, therapeutic study.

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INTRODUCTION: After elective orthopaedic surgery, many individuals go on to become long-term opioid users. Mitigating this risk has become a priority for surgeons, other members of the medical care team, and healthcare systems. The purpose of this study was to compare opioid utilization after lower extremity orthopaedic surgery between patients who received an interactive video education session highlighting the risks of opioid use and those who did not. METHODS: Patients undergoing elective surgery of the lower extremity in the orthopaedic clinic at the Brooke Army Medical Center between July 2015 and February 2017 were recruited at their preoperative appointment and randomized in a 1:1 ratio to receive a one-time interactive opioid education session or usual care education. Unique days' supply of opioids and unique prescriptions were compared using a generalized linear model. Individuals were also grouped by whether they had become long-term opioid users after surgery, and frequencies within each intervention group were compared. RESULTS: There were 120 patients, 60 randomized to each group and followed for 1 year. There were no significant differences between opioid days' supply (mean diff = 8.33, 95% confidence interval -4.21 to 20.87) and unique prescriptions after surgery (mean diff = 0.45, 95% confidence interval -0.25 to 1.15). Most participants did not have any opioids past the initial 30 days after surgery, regardless of intervention (n = 77), and only three became long-term opioid users (one in usual care and two in interactive education). Sixteen in usual education and 18 in enhanced education filled at least one prescription in 6 months or later after the surgical procedure. CONCLUSION: Opioid use beyond 30 days of surgery was no different for participants who received enhanced education compared with usual education. Few became long-term opioid users after surgery (2.5%), although 28.3% were still filling opioid prescriptions 6 months after surgery.

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INTRODUCTION: Rates of osteoporosis evaluation and management after primary fragility fractures have remained low in recent years. The extent to which this treatment gap affects patients with diabetes is unclear. This study aimed to compare the risk of secondary fractures and rates of osteoporosis diagnosis and management after sentinel fractures in patients with and without diabetes. METHODS: A propensity score-matched cohort study was conducted using the PearlDiver database. Patients aged 50 years and older with primary fragility fractures of the hip, wrist, spine, pelvis, humerus, and other locations were identified. Rates of secondary fractures, dual radiograph absorptiometry (DXA) scans, charted osteoporosis diagnoses (International Classification of Diseases, Ninth and Tenth Revisions), and osteoporosis pharmacotherapy within 2 years were compared for patients with and without diabetes using multivariable logistic regression. RESULTS: Matching yielded 27,052 patients in each cohort. Index humerus fractures were more common in the diabetic cohort (15.0% versus 11.6%, P < 0.001), whereas wrist fractures were more prevalent among the nondiabetic cohort (15.2% versus 19.3%, P < 0.001). Incidence of secondary fractures at 2 years was higher for diabetic patients than nondiabetic patients (5.2% versus 4.7%; odds ratio [OR] 1.08; 95% confidence interval [CI], 0.99 to 1.17). Diabetic patients were significantly less likely to receive a DXA scan (13.2% versus 13.5%; OR 0.93; 95% CI, 0.88 to 0.98), be diagnosed with osteoporosis (9.3% versus 11.9%; OR 0.77; 95% CI, 0.73 to 0.82), or start pharmacotherapy (8.1% versus 8.7; OR 0.93; 95% CI, 0.87 to 0.99). CONCLUSION: Despite diabetes being a well-established risk factor for fragility fractures, diabetic patients were significantly less likely to receive DXA scan evaluation, be formally diagnosed with osteoporosis, or be treated with osteoporosis pharmacotherapy after a sentinel fragility fracture. Incidence of secondary fractures within 2 years was also higher among diabetic patients.

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Osteochondral lesions of the talus (OLT) are often associated with ankle pain and dysfunction. They can occur after ankle trauma, such as sprains or fractures, but they usually present as a continued ankle pain after the initial injury has resolved. Chronic ankle ligament instability and subsequent microtrauma may lead to insidious development of an OLT. Medial-sided lesions are more common (67%) than lateral-sided lesions. For acute lesions that are nondisplaced, nonoperative management is initially performed, with a 4-6 week period of immobilization and protected weight bearing. Symptomatic improvement results in more than 50% of patients by 3 months. Acute osteochondral talus fractures, which have a bone fragment thickness greater than 3 mm with displacement will benefit from early surgical intervention. These injuries should undergo primary repair via internal fixation with bioabsorbable compression screws 3.0 mm or smaller using at least 2 points of fixation. Acute lesions that are too small for fixation can be treated with morselization and reimplantation of the cartilage fragments. If OLTs are persistently symptomatic following an appropriate course of nonoperative treatment, various reparative and restorative surgical options may be considered on the basis of diameter, surface area, depth, and location of the lesion. A small subset of symptomatic osteochondral lesions of the talus involve subchondral pathology with intact overlying articular cartilage; in these cases, retrograde drilling into the cystic lesion can be employed to induce underlying bony healing. Cancellous bone graft augmentation may be used for subchondral cysts with volume greater than 100 mm3 or with those with a depth of more than 10 mm. Debridement, curettage, and bone marrow stimulation is a reparative technique that may be considered in lesions demonstrating a diameter less than 10 mm, with surface area less than 100 mm2, and a depth less than 5 mm. This technique is commonly performed arthroscopically using curettes and an arthroscopic shaver to remove surrounding unstable cartilage. A microfracture awl of 1 mm or less is used to puncture the subchondral bone with 3-4 mm of spacing between to induce punctate bleeding. Initial (<5 year) results are good to excellent in 80% of cases, with some deterioration of improvement over time. Factors contributing to poor results include surface area greater than 1.5 cm2, overall osteochondral lesion depth over 7.8 mm, smoking history, age over 40, and uncontained lesions. Lesions greater than 1.29 cm2, cystic lesions, and lesions that have failed prior treatment are potential candidates for osteochondral autograft transplantation. The autograft is typically harvested from the lateral femoral condyle of the ipsilateral knee with an optimal plug depth and diameter of 12-15 mm. Transplantation often involves open technique and may even require malleolar osteotomy for perpendicular access to the defect, as well as visualization of a flush, congruent graft fit. Good to excellent outcomes have been reported in up 87.4% of cases with the most common complication being donor site morbidity in up to 15% of cases. Failure rates increased significantly in lesions larger than 225 mm2. Scaffold-based therapies, such as matrix-associated chondrocyte implantation, can be employed in primary or revision settings in lesions larger than 1 cm2, including uncontained shoulder lesions with or without cysts. Lesions with greater than 4 mm of bone loss following debridement may require bone grafting to augment with the scaffold. This technique requires an initial procedure for chondrocyte harvest and a secondary procedure for transplantation of the scaffold. Outcomes have been good to excellent in up to 93% of cases; however, this technique requires a two-stage procedure and can be cost-prohibitive. Particulated juvenile cartilage is a restorative technique that employs cartilage allograft from juvenile donors. The cartilage is placed into the defect and secured with fibrin glue in a single-stage procedure. Studies have shown favorable outcomes in 92% of cases, with lesions between 10 and 15 mm in diameter, but increased failure rates and poorer outcomes in lesions larger than 15 mm. This may be an alternative option for contained lesions between 10 and 15 mm in diameter. Osteochondral allograft plugs are an option for larger contained lesions (>1.5 cm in diameter) and in patients with knee osteoarthritis (OA) and concern for donor site morbidity. Furthermore, bulk osteochondral allograft from a size-matched talus can also be used for even larger, unstable/uncontained shoulder lesions. An anterior approach is often employed and fixation is achieved via placement of countersunk headless compression screws. Failure of the aforementioned options associated with persistent pain or progressive OA would then lend consideration to ankle arthroplasty versus ankle arthrodesis.

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Fragility fractures are often sentinel events in documenting new cases of osteoporosis. Numerous analyses have demonstrated low rates of adequate osteoporosis evaluation and treatment following primary fragility fractures. The purpose of this study was to quantify the incidence of primary fragility fractures in America and the rates of osteoporosis screening and management before and after fracture. METHODS: A retrospective review of the PearlDiver database was conducted using the International Classification of Diseases, Ninth Revision (ICD-9) and ICD, Tenth Revision (ICD-10) and Current Procedural Terminology codes. Patients who were 60 to 80 years of age and had primary fragility fractures of the hip, wrist, spine, pelvis, humerus, and other unspecified locations were included. The rates of dual x-ray absorptiometry (DXA) screening and osteoporosis pharmacotherapy were assessed for 2 years before and 2 years after the primary fracture. RESULTS: In this study, 48,668 patients with a primary fragility fracture were identified. Within this cohort, 25.8% (12,573 of 48,668) had received osteoporosis screening or treatment in the prior 2 years. In the 36,095 patients with no management before the fracture, 19% (6,799 patients) were diagnosed with osteoporosis and 18.4% (6,653 patients) received a DXA scan and/or filed claims for pharmacotherapy in the following 2 years. Patients with an osteoporosis diagnosis were more likely to receive both types of management (odds ratio [OR], 11.55 [95% confidence (CI), 10.31 to 12.95]), and male patients were less likely to receive both types of management (OR, 0.23 [95% CI, 0.17 to 0.27]). Secondary fragility fractures within the next 2 years were diagnosed in 8.4% (3,038 of 36,095) of patients at a mean of 221 days following the primary fracture. CONCLUSIONS: The rates of appropriate osteoporosis evaluation, diagnosis, and management following primary fragility fractures remain unacceptably low. Less than one-third of patients with primary fragility fractures had been evaluated or treated for osteoporosis in the 2 years prior to fracture. Furthermore, among patients without pre-fracture management, <20% received osteoporosis screening or treatment within the next 2 years. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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BACKGROUND: Despite the literature on acute Achilles tendon ruptures, there remains a lack of consensus regarding the optimal treatment. The purpose of this survey study was to investigate treatment preferences among Army orthopaedic surgeons when presented with a standardized case of an acute Achilles rupture and determine if surgeon factors correlated with treatment preference. METHODS: A hypothetical case of a 37-year-old male with history, physical exam, and imaging consistent with an Achilles rupture was sent to board-certified Army orthopaedic surgeons to determine their preferred management. Demographic data was collected to include: practice setting, years from residency graduation, and completion of fellowship. Correlations analyzed between demographics and treatment preferences. RESULTS: Sixty-two surgeons responded. 62% of respondents selected surgical intervention. Of these, 59% chose a traditional open technique. 50% of respondents were general orthopaedic. There was a correlation between fellowship training and operative management (P = 0.042). Within the operative management group there was no statistical difference (P > 0.05) in need for further imaging, technique used, post-operative immobilization, length of immobilization, weight-bearing protocol, and time to release to running. The majority of non-operative responders would splint/cast in plantarflexion or CAM boot with heel lift for < 3 weeks (50%) and keep non-weight bearing for < 4 weeks (63%). Only 38% of respondents would use DVT chemoprophylaxis. CONCLUSION: When provided with a hypothetic case of an acute Achilles tendon rupture, queried Army orthopaedic surgeons would more often treat with a surgical procedure. This difference in treatment is secondary to training, fellowship or other. This propensity of surgical management, likely stems from the highly active population and the desire to return to duty.

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BACKGROUND: Competency-based education (CBE) seeks to determine resident proficiency in the knowledge, skills, and behaviors required for independent patient care. Multiple assessment instruments evaluate technical skills or direct patient care in the clinic setting, but there are few reports incorporating both within an orthopedic specialty rotation. This study reports a residency program's comprehensive CBE initiative using formative assessments in the clinic and operating room during a sports medicine rotation. MATERIALS AND METHODS: The sports medicine rotation used validated formative assessments to evaluate resident performance during clinic encounters and program-defined surgical entrustable professional activities (EPAs). Junior resident (postgraduate year [PGY] 1-2) EPAs included basic knee/shoulder arthroscopic procedures. Senior resident (PYG 5) EPAs comprised anterior cruciate ligament reconstruction, biceps tenodesis, shoulder stabilization, and rotator cuff repair. Assessment scores were compared between individuals and PGY groups. RESULTS: Sixty-six clinical skills (CS) and 106 surgical skills assessments were conducted for 22 residents in one academic year. Surgical skills assessments demonstrated significant differences between each PGY group (P < 0.01). All PGY2 and PGY5 residents achieved independence on the evaluated EPAs. PGY5s earned higher scores in CS assessments than the other classes (P < 0.01). PGY2 residents scored higher than PGY1s in 7 of 9 CS domains. CS independence was achieved by 21 of 22 residents by the end of the rotation. CONCLUSIONS: The CBE program effectively quantified expected differences in resident performance by PGY for clinic and surgical assessments on a sports medicine rotation. Assessments built an environment where feedback was more structured and standardized, creating a culture to improve resident education.

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BACKGROUND: Osteochondral lesions of the talus (OLTs) are common injuries in young, active patients. Microfracture is an effective treatment for lesions less than 150 mm2 in size. Most commonly employed postoperative protocols involve delaying weightbearing for 6 to 8 weeks (DWB), though one study suggests that early weightbearing (EWB) may not be detrimental to patient outcomes. The goal of this research is to compare outcomes following EWB and DWB protocols after microfracture for OLTs. METHODS: We performed a prospective, randomized, multicenter clinical trial of subjects with unilateral, primary, unifocal OLTs treated with microfracture. Thirty-eight subjects were randomized into EWB (18 subjects) and DWB (20 subjects) at their first postsurgical visit. The EWB group began unrestricted WB at that time, whereas the DWB group were instructed to remain strictly nonweightbearing for an additional 4 weeks. Primary outcome measures were the American Academy of Orthopaedic Surgery (AAOS) Foot and Ankle score and numeric rating scale (NRS) pain score. RESULTS: The EWB group demonstrated significant improvement in AAOS Foot and Ankle Questionnaire scores at the 6-week follow-up appointment as compared to the DWB group (83.1 ± 13.5 vs 68.7 ± 15.8, P = .017). Following this point, there were no significant differences in AAOS scores between groups. At no point were NRS pain scores significantly different between the groups. CONCLUSIONS: EWB after microfracture for OLTs was associated with improved AAOS scores in the short term. Thereafter and through 2 years' follow-up, no statistically significant differences were seen between EWB and DWB groups. LEVEL OF EVIDENCE: Level II, prospective randomized trial.

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This article provides a review of the existing literature regarding driving limitations following lower extremity orthopedic surgery. Medicolegal requirements and insurance recommendations are often vague and subject to interpretation. Several studies have examined the impact of surgery and immobilization on brake reaction time. This study summarizes the findings of these studies. Additionally, the authors consider the impact of lower extremity amputations and peripheral vascular disease on driving. Literature regarding opioid use, obesity, sleep apnea, increasing age, and distraction is also reviewed. An improved understanding of these topics will enhance the orthopedic surgeon's ability to counsel patients and optimize their safety.

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PURPOSE: In July 2015, all children aged younger than 6 years gained free access to daytime and out-of-hours general practice services in the Republic of Ireland. Although 30% previously had free access, 70% did not. METHODS: To examine subsequent changes in service use, we retrospectively analyzed anonymized visitation data from 8 general practices in North Dublin providing daytime service and their local out-of-hours service, comparing the 1 year before and the 1 year after introduction of free care. RESULTS: In the year after granting of free general practice care for children younger than 6 years, 9.4% more children attended the daytime services and 20.1% more children were seen in the out-of-hours services. Annual number of visits by patients increased by 28.7% for daytime services and by 25.7% for out-of-hours services, translating to 6,682 more visits overall. Average visitation rate for children this age increased from 2.77 visits per year to 3.25 visits per year for daytime services, but changed little for out-of-hours services, from 1.52 visits per year to 1.59 visits per year. CONCLUSIONS: Offering free childhood general practice services led to a dramatic increase in visits. This increase has implications for future health care service planning in mixed public and privately funded systems.

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Children frequently refrain from disclosing being bullied. Early identification of bullying by healthcare professionals in children may prevent adverse health consequences. The aim of our study was to determine whether Health Care Utilisation (HCU) is higher in 9-year-olds who report being bullied and factors influencing type of HCU. The study consists of cross-sectional surveys of Child Cohort of Irish National Longitudinal Study of Children (Wave 1), 8,568 9-year-olds, and their carers. Being bullied was assessed by a self-reported questionnaire completed by children at home. HCU outcomes consisted of the following: visits to GP, Mental Health Practitioner (MHP), Emergency Department (ED), and nights in hospital by parent interview. Bivariate logistic regression and gender-stratified Poisson models were used to determine association. Victimisation by bullying independently increased visits to GP (OR 1.13, 95% confidence interval (CI): 1.03 to 1.25; p = 0.02), MHP (OR 1.31, 95% CI: 1.05 to 1.63; p = 0.02), though not ED visits (OR 0.99, 95% CI: 0.87 to 1.13; p = 0.8) or nights in hospital (OR 1.07 95% CI: 0.97 to 1.18; p = 0.2), adjusting for underlying chronic condition(s) and socio-demographic confounders. Victimised girls made higher GP visits (RR 1.14, 95% CI: 1.06 to 1.23; p < 0.001) and spent more nights in hospital (RR 1.10, 95% CI: 1.04 to 1.15; p < 0.001). Victimised boys were more likely to contact MHPs (RR 1.21, 95% CI: 1.02 to 1.44; p = 0.03). 9-year-old bullied subjects were more likely to utilise primary care services than non-bullied 9-year-olds. Different HCU patterns were observed according to gender and gender differences in the presentation of victimisation. Our findings may lead to the development of clinical practice guidelines for early detection and appropriate management of bullied children.

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Blood flow restriction (BFR) training is a technique shown to be safe and effective at increasing muscular strength and endurance in healthy fitness populations and is under study for its use in postinjury rehabilitation. BFR stimulates muscular strength and hypertrophy gains at much lower loads than traditional methods, allowing patients to begin the rehabilitation process much sooner. We report on 2 patients who incorporated BFR training into their traditional rehabilitation program after Achilles tendon ruptures. Patient 1 was a 29-year-old active duty soldier who sustained a left Achilles tendon rupture while playing competitive football. After operative repair and traditional rehabilitative measures, he was unable to ambulate without assistive devices owing to persistent weakness. The patient subsequently started a 5-week "return to run" program using BFR training. He experienced plantarflexion peak torque improvements of 522% and 108.9% and power gains of 4475% and 211% at 60°/s and 120°/s, respectively. He was able to ambulate without assistive devices at the 5-week follow-up examination. Patient 2 was a 38-year-old male soldier who experienced a complete left Achilles tendon rupture while exercising. After nonoperative treatment with an accelerated rehabilitation program, the patient still experienced significant strength and functional deficits. He was subsequently enrolled in a 6-week course of BFR training. He experienced plantarflexion strength improvements of 55.8% and 47.1% and power gains of 68.8% and 78.7% at 60°/s and 120°/s, respectively. He was able to return to running and sports on completion of 6 weeks of BFR-assisted therapy. Incorporating tourniquet-assisted blood flow restriction with rehabilitation programs can improve strength, endurance, and function after Achilles tendon rupture.

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BACKGROUND: Talus fractures are infrequent injuries that are often associated with poor clinical outcomes. Literature reviewing talus fractures is limited to a civilian population, with few studies characterizing these injuries sustained in active duty personnel. The aim of this study was to characterize talus fractures sustained in combat trauma by reporting their surgical outcomes. METHODS: The Department of Defense Trauma Registry (DoDTR) was queried to identify US service members who sustained talus fractures in battle conditions between 2001 and 2014. These patients underwent a retrospective chart review. Injury and fracture patterns were characterized. We examined the incidence of secondary surgical procedures and reviewed patients undergoing early and late transtibial amputations. Forty-eight talus fractures were identified. RESULTS: All injuries were related to high-energy trauma: 43 (90%) resulting from improvised explosive devices (IED), 3 (6%) from gunshot wounds (GSW), and 2 (4%) from propelled explosive devices. Ten (20.8%) patients underwent early transtibial amputation. Early amputations were associated with calcaneus fractures (10/10 vs 16/38, P = .0009) but not with open fractures (8/10 vs 20/38, P = .163). Twenty-six fractures were available with longer term follow-up. Twenty-three fractures had associated injuries to the ipsilateral lower extremity. Sixteen (61.54%) injuries underwent a total of 26 additional surgical procedures. Eight fractures required secondary fusions (30.8%). Subtalar fusions were associated with ipsilateral calcaneus fractures (5/6 vs 2/10, P = .03). One patient underwent a delayed transtibial amputation 17 months after injury. CONCLUSIONS: Talus fractures sustained within the combat environment were associated with high rates of early amputations and secondary surgical intervention. When the limb was salvaged, patients could expect the need for additional procedures to address ongoing issues. LEVEL OF EVIDENCE: Level IV, case series.

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OBJECTIVE: The purpose of this study was to measure the prevalence of burnout among military orthopaedic residents and staff surgeons at the U.S. Army Medical Center. METHODS: 37 residents and 21 staff surgeons of a military orthopaedic residency program were asked to voluntarily complete an anonymous electronic survey. The survey consisted of two parts: first, a demographic section including questions about relationship status, work hours, deployment history, medical education debt, mentorship, and job satisfaction and second, the Maslach Burnout Inventory. RESULTS: 27 residents and 11 staff completed the survey for a 67% response rate. The rate of burnout among military orthopaedic surgeons in our study was 7.7% (3.7% of residents and 16.7% of staff surgeons). In addition, 25.6% of surgeons (33% of residents and 8.3% of staff) were found to be at risk of burnout. CONCLUSIONS: Future studies should focus on causal relationships among specific aspects of the work environment and possible preventive or protective measures. Expanding future studies to include multiple study sites would improve the quality and generalizability of the results.

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The purpose of this article is to update the orthopedic community on the planning and implementation of tendon transfers in the foot and ankle. This information will serve to reinforce those principles and factors that are inherent in successful performance of tendon transfer. In addition, the authors highlight recent updates that impact decision-making for these procedures.

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