Mostafa M. Abousayed

Evaluating the Quality, Accuracy, and Readability of Online Resources Pertaining to Hallux Valgus

Background. The Internet is one of the most widely utilized resources for health-related information. Evaluation of the medical literature suggests that the quality and accuracy of these resources are poor and written at inappropriately high reading levels. The purpose of our study was to evaluate the quality, accuracy, and readability of online resources pertaining to hallux valgus. Methods. Two search terms (“hallux valgus” and “bunion”) were entered into Google, Yahoo, and Bing. With the use of scoring criteria specific to hallux valgus, the quality and accuracy of online information related to hallux valgus was evaluated by 3 reviewers. The Flesch–Kincaid score was used to determine readability. Statistical analysis was performed with t tests and significance was determined by P values <.05. Results. Sixty-two unique websites were evaluated. Quality was significantly higher with use of the search term “bunion” as compared to “hallux valgus” (P = .045). Quality and accuracy were significantly higher in resources authored by physicians as compared to nonphysicians (quality, P = .04; accuracy, P < .001) and websites without commercial bias (quality, P = .038; accuracy, P = .011). However, the reading level was significantly more advanced for websites authored by physicians (P = .035). Websites written above an eighth-grade reading level were significantly more accurate than those written at or below an eighth-grade reading level (P = .032). Conclusion. The overall quality of online information related to hallux valgus is poor and written at inappropriate reading levels. Furthermore, the search term used, authorship, and presence of commercial bias influence the value of these materials. It is important for orthopaedic surgeons to become familiar with patient education materials, so that appropriate recommendations can be made regarding valuable resources. Levels of Evidence: Level IV

Musculoskeletal Health Literacy in Patients With Foot and Ankle Injuries A Cross-Sectional Survey of Comprehension

Purpose. Approximately 33% of Americans have inadequate health literacy, which is associated with decreased medical knowledge, increased hospitalization and use of emergency care, and worse control of diseases. In this study, the Literacy in Musculoskeletal Problems (LiMP) questionnaire was used to evaluate the prevalence of limited musculoskeletal literacy in patients presenting to the emergency department (ED) with foot and ankle–related complaints, as these individuals may be at increased risk for inferior outcomes. Methods. In this cross-sectional study, individuals ≥18 years of age presenting with foot and ankle–related complaints to the ED were invited to participate. Participants completed a demographic survey and the LiMP questionnaire, with scores ≥6 indicative of adequate musculoskeletal literacy. The prevalence of adequate health literacy and the influence of demographic parameters was assessed. P values <.05 were considered significant. Results. The mean LiMP score was 5 ± 2.06. Limited musculoskeletal health literacy was seen in 32% of participants (18/56). Although gender (male), a current or prior employment in a health care field, and having previously seen a physician for a musculoskeletal complaint correlated with higher literacy rates, these values did not reach statistical significance (P > .05). However, Caucasians and those with higher levels of education (equal to or more than college) were significantly more likely to possess adequate literacy (P = .008, P = .04, respectively). Conclusions. Approximately one third of patients presenting to the ED with foot and ankle–related complaints have limited musculoskeletal literacy and may lack the necessary skills required for making informed decisions regarding their care. This is concerning and has tremendous socioeconomic implications, as more than 23 000 people per day require medical care for ankle sprains in the United States, with average treatment costs for this injury in the ED setting estimated at

Classifications in Brief: Johnson and Strom Classification of Adult-acquired Flatfoot Deformity

1498. Identification of those most at risk is thus crucial and will facilitate the development of interventions geared toward those most vulnerable. Levels of Evidence: Prognostic, Level IV study

Classifications in Brief: Lauge-Hansen Classification of Ankle Fractures.

Adult-acquired flatfoot deformity is characterized by collapse of the medial longitudinal arch (Fig. 1) with failure of the supporting posterior medial soft tissue structures of the ankle and hindfoot [26]. Although pes planus can be attributed to arthritic, developmental, neuromuscular diseases, and traumatic conditions [1, 2, 4–6, 11, 15, 18, 21, 26], posterior tibial tendon dysfunction remains the mostcommon etiology. Posterior tibial tendon dysfunction includes a wide spectrum of conditions affecting the tendon, with rupture, deformity, and secondary arthritis being among the more-severe sequelae. This condition has been estimated to affect approximately 5 million people in the United States [14]. In 1936, Kulowski was the first to describe posterior tibial tendinitis [18]. However, it was not before 1986 when Funk et al. [11] described the signs and symptoms associated with posterior tibial tendon rupture. From this work, the classic appearance of a valgus hindfoot and abducted forefoot was elucidated, as was the ‘‘too many toes’’ sign (Fig. 2), and the importance of a single-leg heel rise (Fig. 3) as an indicator of posterior tibial tendon dysfunction [11, 15, 18, 20]. The posterior tibial tendon functions mainly as a dynamic support of the medial arch. It also inverts the foot and aids in ankle plantar flexion. Dysfunction of the posterior tibial tendon usually manifests early with pain and swelling along themedial aspect of the foot and behind themedialmalleolus. The pain is worse with prolonged standing and activities, and usually is associated with tenderness along the length of the tendon. In advanced posterior tibial tendon dysfunction, collapse of the medial arch occurs, leading to the characteristic pes planus deformity with hindfoot valgus; initially, this deformity is flexible, but in more-advanced stages it can become fixed and associated with forefoot abduction. The single-heel rise test can assess the function of the tendon, where varus alignment of the hind foot is indicative of a healthy tendon. Lateral-sided ankle pain occurs eventually in some patients, a result of subfibular impingement. In 1989, Johnson and Strom created a three-stage posterior tibial tendon dysfunction classification system based on the condition of the posterior tibial tendon, the position of the hindfoot, and flexibility of the deformity [17]. Although a fourth stage in this system is commonly attributed to Myerson [24], this stage was described in the original article by Johnson and Strom [17]. It helps guide treatment in patients with deltoid ligament insufficiency and ankle joint involvement. Better understanding of the biomechanics of the foot, particularly the medial arch and its supporting structures, has led to more precise understanding of the development of adult-acquired flatfoot deformity [3–5, 7, 10, 13, 15, 20, 25, 27]. Although numerous authors have devised their own classification systems [4, 5, 15, 25], all used the original structure described by Johnson and Strom [17]. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Spontaneous heparin-induced thrombocytopenia presenting as bilateral adrenal hemorrhages and pulmonary embolism after total knee arthroplasty

HistoryAnkle fractures are common musculoskeletal injuries thatoccur in a bimodal distribution, with peaks in younger menand older women [2], the former related to high-energytrauma and the latter to osteopenia and osteoporosis.Although ankle fractures currently account for 9% offractures, incidence and severity are increasing [1]. This isattributed to the increased life expectancy among olderindividuals and improved survival of patients with severefoot and ankle trauma [23, 26].The first ankle fracture classification, credited to Perci-val Pott, described three types of ankle fractures based onthe number of malleoli involved: unimalleolar, bimalleolar,and trimalleolar [21]. Despite its ease of use and repro-ducibility, the classification did not effectively guidemanagement, as it failed to differentiate stable from un-stable injuries.This was the impetus for the work of Niel Lauge-Hansen(1899–1976), a Danish physician who studied ankle frac-tures during the 1940s and 1950s, ultimately creating aclassification system based on a rotational mechanism ofinjury [11–15]. Lauge-Hansen’s classification, which waspublished in a 1950 issue of Archives of Surgery, has be-come one of the most widely used ankle fractureclassification systems [12]. Although still considered alandmark work regarding the biomechanics and deformingforces of ankle fractures, the quality, validity, and repro-ducibility of the Lauge-Hansen classification have beenchallenged [17, 19, 22, 25].PurposeAn ideal fracture classification would be reproducible,widely recognized, relevant for prognosis, and useful interms of clinical decision-making, documentation, andresearch.The primary normal motion of the ankle is dorsiflexionand plantar flexion, with osseous anatomy and ligamentouscomplexes that provide stability in all planes and axes ofrotation. When these structures are injured, there is sub-stantial risk of instability. Appropriate reconstructiontherefore is important, and a classification scheme thatidentifies injury patterns and guides treatment would bedesirable.Description of the Lauge-Hansen SystemNiel Lauge-Hansen used freshly amputated limbs to de-velop an ankle fracture classification based on foot positionat the time of the traumatic event (supination or pronation)and the direction of the deforming forces (abduction, ad-duction, or external rotation) [12].Cadaveric tibias were fixed with a vice and nails while arotational deforming force was applied by hand with the

Trends in Urgent Care Utilization Following Ankle Fracture Fixation

Heparin-induced thrombocytopenia syndrome is an acquired potentially life-threatening prothrombotic disorder caused by antibodies that recognize complexes of platelet factor 4 bound to heparin or heparin-like molecules. It typically occurs after exposure to unfractionated heparin, to a lesser extent after exposure to low-molecular-weight heparins, and rarely after exposure to fondaparinux. Herein, we report the case of a 48-year-old woman who developed severe thrombocytopenia, bilateral pulmonary embolism, and bilateral adrenal hemorrhages after total knee arthroplasty without evidence of heparin exposure. Antibodies to the heparin-platelet factor 4 complex and serotonin-release assay were positive. Spontaneous heparin-induced thrombocytopenia syndrome should be considered in patients with unexplained thrombocytopenia after knee replacement surgery even without heparin exposure, and a high index of suspicion for adrenal hemorrhage is needed in patients with fever, abdominal pain, and shock.

Classifications in Brief: Garden Classification of Femoral Neck Fractures

Background: The Centers for Medicare and Medicaid services (CMS) have implemented initiatives to improve postdischarge care and reduce unnecessary readmissions. Readmissions within 30 days are frequent and represent an economic burden on both patients and the healthcare system. The aim of this study was to evaluate the frequency and causes for urgent care visits within 30 days of discharge after ankle open reduction and internal fixation (ORIF) and determine factors correlated with such visits. Methods: This was a retrospective analysis of prospectively collected data. All patients who underwent ankle ORIF at our institution between July 1, 2016, and June 30, 2017, were included. Patients were identified using Current Procedural Terminology (CPT) codes for ankle ORIF. Patients’ demographics including age, sex, race, body mass index, occupation, insurance payer, and comorbidities were documented. Results: Thirty-five patients (10.51%) had urgent care visits within 30 days of discharge. Patients presented at a mean of 11.8 days after the day of surgery. Sixteen patients (45.71%) had cast/splint-related issues, 7 (20%) presented with pain, and 7 (20%) with increased operative site drainage. Univariate analysis demonstrated a statistically significant association between postoperative urgent care visits and patients with diabetes (P = .03) or underlying psychiatric disorders (P = .03). Conclusion: In this population study of patients undergoing ankle fracture surgery, we found that the rate of urgent care visits within 30 days of discharge exceeded the rate of inpatient readmission. Additionally, patients with diabetes and psychiatric disorders were significantly more likely to present to an urgent care facility postoperatively, potentially accounting for increased expenditures of the healthcare system. Level of Evidence: Level III, comparative series.

Bilateral Distal Tibial Transitional Ankle Fractures

The incidence of femoral neck fractures in the United States is approximately 63.3 per 100,000 person/years in women and 27.7 per 100,000 person/years in men [11, 40]. There are many risk factors for femoral neck fractures, including female gender, low bone density, and reduced mobility [12, 27]. Fracture risk increases dramatically with age, with the majority of fractures occurring in older white women secondary to low-energy falls [29]. In younger patients, highenergy trauma is responsible for most of these injuries [38]. Femoral neck fractures initially were classified by Sir Astley Cooper in 1823 as either intracapsular or extracapsular, which he felt had prognostic implications [10]. As reported by Bartonicek [4], it was only later in 1935 that a biomechanical classification was presented [37]. The Pauwel classification, as it has come to be called, stratified fractures in three groups based on inclination of the fracture line relative to the horizontal: Type I, less than 30°; Type II, 30° to 50°; and Type III, greater than 50°. As the angle of inclination increases, the forces transition from being compressive to shearing [4]. An increase in vertical shearing forces results in higher risks of displacement, postreduction nonunion, and failure of fixation [37]. In 1961, Robert Symon Garden, a British orthopaedic surgeon with a focused interest in the femoral neck, described a more-comprehensive classification [19]. The Garden classification incorporates displacement, fracture completeness, and relationship of bony trabeculae in the femoral head and neck. Gardens’ originally reviewed 80 patients with femoral neck fractures, which he classified in Types I to IV, and he followed these patients for at least 12 months postoperatively. He found that Types I and II fractures had a 100% union rate. Types III and IV had lower union rates of 93% and 57% respectively. Purpose

Recent Advances in Egypt for Treatment of Talar Osteochondral Lesions

A 13-year-old boy presented to the emergency department with bilateral ankle pain and swelling following a 5-foot fall from a swing set.