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Zhu KY, Bobak L, Dorney I, Breslin MA, Hendrickson SB, Vallier HA. Risk of Fracture and Complications After Fixation in Patients With Pre-injury Psychiatric Illness: A Propensity-Matched Cohort Study. J Orthop Trauma 2024; 38:e142-e148. [PMID: 38381117 DOI: 10.1097/bot.0000000000002755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/27/2023] [Indexed: 02/22/2024]
Abstract
OBJECTIVES The purpose was to describe the frequency of orthopaedic trauma and postsurgical complications associated with psychiatric diagnoses. METHODS DESIGN Query of TriNetx Analytics Network. SETTING Participating hospitals. PATIENT SELECTION CRITERIA Those ≥18 years old with psychiatric illness and orthopaedic trauma. OUTCOME MEASURES AND COMPARISONS Fractures and postoperative complications were described. A 1:1 propensity score matching function was used. Odds ratios compared intercohort complications. RESULTS A total of 11,266,415 patients were identified with a psychiatric diagnosis, including bipolar disorder (8.9%), schizophrenia (3.3%), major depression (12.4%), stress-related disorder (9.6%), anxiety disorder (64.5%), borderline personality disorder (1.1%), or antisocial personality (0.2%). Prevalence of 30.2% was found for a fracture and at least 1 psychiatric diagnosis. Antisocial personality disorder had the highest risk ratio relative to people without that mental disorder (relative risk [RR] = 5.09) of having 1 or more associated fracture, followed by depression (RR = 3.03), stress-related disorders (RR = 3.00), anxiety disorders (RR = 2.97), borderline personality disorder (RR = 2.92), bipolar disorder (RR = 2.80), and schizophrenia (RR = 2.69). Patients with at least 1 psychiatric comorbidity had greater risk of pulmonary embolism, superficial and deep surgical site infections, pneumonia, urinary tract infection, deep venous thrombosis, osteonecrosis, and complex regional pain syndrome by 1 month after fixation, when compared with patients without psychiatric disorder. By 1 year, they were also at an increased risk for stroke and myocardial infarction. CONCLUSIONS All psychiatric comorbidities were associated with increased RR of fracture and higher odds of complications compared with patients without psychiatric comorbidities. Providers should be aware of preexisting psychiatric diagnoses during treatment of acute injuries because of these risks. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kevin Y Zhu
- Case Western Reserve University School of Medicine, Cleveland, OH
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Heimke IM, Furdock R, Simske NM, Swetz A, Simpson M, Breslin MA, Hendrickson SB, Moore TA, Vallier HA. Trauma recidivism is reduced with engagement in psychosocial programming following orthopaedic trauma. Injury 2023; 54:111129. [PMID: 37880032 DOI: 10.1016/j.injury.2023.111129] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Recidivism is common following injury. Interventions to enhance patient engagement may reduce trauma recidivism. Education, counseling, peer mentorship, and other resources are known as Trauma Recovery Services (TRS). The authors hypothesized that TRS use would reduce trauma recidivism. METHODS Over five years at a level 1 trauma center, 954 adults treated operatively for pelvic, spine, and femoral fractures were reviewed. Recidivism was defined as return to trauma center for new injury within 30-months. All patients were offered TRS. Multivariate logistic regression statistical analysis was used to identify predictors of recidivism. RESULTS Three hundred and ninety-seven of all patients (42 %) utilized TRS, including educational materials (n = 293), peer visits (n = 360), coaching (n = 284), posttraumatic stress disorder (PTSD) screening (n = 74), and other services. Within the entire sample, 136 patients (14 %) returned to the emergency department for an unrelated trauma event after mean 21 months. 13 % of TRS users became recidivists. Overall, 49 % of recidivists had history of pre-existing mental illness. High rates of TRS engagement between recidivists and non-recidivists were seen (75 %); however, non-recidivists were more likely to use multiple types of recovery services (49 % vs 34 %, p = 0.002), and were more likely to engage with trauma peer mentors (former trauma survivors) more than once (91 % vs 81 %, p = 0.03). After multivariable analysis, patients using multiple different recovery services had a lower risk of recidivism (p = 0.04, OR 0.42, 95 % CI [0.19-0.96]). CONCLUSIONS Multifaceted engagement with recovery programming is associated with less recidivism following trauma. Future study of resultant reductions in healthcare costs are warranted. LEVEL OF EVIDENCE Level II; Prognostic.
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Affiliation(s)
- Isabella M Heimke
- MetroHealth Medical Center, Western Reserve University, Cleveland, OH, United States
| | - Ryan Furdock
- MetroHealth Medical Center, Western Reserve University, Cleveland, OH, United States
| | - Natasha M Simske
- MetroHealth Medical Center, Western Reserve University, Cleveland, OH, United States
| | - Anna Swetz
- MetroHealth Medical Center, Western Reserve University, Cleveland, OH, United States
| | - Megen Simpson
- MetroHealth Medical Center, Western Reserve University, Cleveland, OH, United States
| | - Mary A Breslin
- MetroHealth Medical Center, Western Reserve University, Cleveland, OH, United States
| | - Sarah B Hendrickson
- MetroHealth Medical Center, Western Reserve University, Cleveland, OH, United States
| | - Timothy A Moore
- MetroHealth Medical Center, Western Reserve University, Cleveland, OH, United States
| | - Heather A Vallier
- MetroHealth Medical Center, Western Reserve University, Cleveland, OH, United States.
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Pelet S, Hardy A, Tremblay F, Lechasseur B, Rivard-Cloutier M. Prognostic Factors of Function in Nonoperatively Treated Radial Head Fractures: A Prospective Cohort Study. J Orthop Trauma 2023; 37:e429-e434. [PMID: 37448159 DOI: 10.1097/bot.0000000000002660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES To identify patient-related factors and fracture characteristics influencing the functional outcomes of nonoperatively treated radial head fractures and to determine function at 1 year. DESIGN Prospective cohort study. SETTING Academic Level 1 trauma center. PATIENTS/PARTICIPANTS Consecutive isolated radial head fractures fitting the inclusion criteria between May 2013 and July 2016. INTERVENTION Nonoperative treatment of isolated radial head fractures. OUTCOME MEASUREMENTS Logistic regressions between potential prognostic factors and function assessed with the Mayo Elbow Performance Score (MEPS), the Disabilities of the Arm, Shoulder, and Hand (DASH) score, and range of motion at 1.5-3-6-12 months. RESULTS One hundred fourteen patients were included (78% Mason I [OTA/AO 2R1B1], 20% Mason II [OTA/AO 2R1B3], and 2% Mason III [OTA/AO 2R1C3]). Mean MEPS and DASH score at the last follow-up were excellent [96.4 ± 7.6 and 3.7 ± 8.6] with, respectively, 79.8% and 92.7% of satisfactory results. Depressive symptoms at injury baseline (Quick Inventory of Depressive Symptomatology > 5) are a constant predictor of unsatisfactory function (MEPS <90 or DASH >17]). Older age and female sex were all linked to worse function at the first follow-ups ( P < 0.05), whereas lower socioeconomic class and receiving financial compensations were associated to unsatisfactory function at 1 year ( P < 0.05). CONCLUSIONS Although most nonoperatively treated radial head fractures heal with excellent function, some patients still exhibit unsatisfactory results at 1 year. Symptoms of depression at injury baseline are a constant and significant predictor of unsatisfactory function. Early detection of depressive symptoms would allow for interventions that may optimize function. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Stéphane Pelet
- Department of Orthopedic Surgery, CHU de Québec-Hôpital Enfant-Jésus, Québec, QC, Canada; and
- Centre de recherche FRQS du CHU de Québec, Québec, QC, Canada
| | - Alexandre Hardy
- Department of Orthopedic Surgery, CHU de Québec-Hôpital Enfant-Jésus, Québec, QC, Canada; and
| | - Félix Tremblay
- Department of Orthopedic Surgery, CHU de Québec-Hôpital Enfant-Jésus, Québec, QC, Canada; and
| | - Benoît Lechasseur
- Department of Orthopedic Surgery, CHU de Québec-Hôpital Enfant-Jésus, Québec, QC, Canada; and
| | - Maude Rivard-Cloutier
- Department of Orthopedic Surgery, CHU de Québec-Hôpital Enfant-Jésus, Québec, QC, Canada; and
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Heimke IM, Connelly M, Clarke A, DeMario B, Furdock R, Moore TA, Vallier HA. Trauma recidivism is pervasive and is associated with mental and social health opportunities. Injury 2023; 54:519-524. [PMID: 36372562 DOI: 10.1016/j.injury.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Recidivism after orthopedic trauma results in greater morbidity and costs. Prior studies explored the effects of social and medical factors affecting the frequency of return to the hospital with new, unrelated injury. Identification of mental, social and other risk factors for trauma recidivism may provide opportunities for mitigation. The purposes of this study are to determine the rates of subsequent, unrelated injury noted among orthopedic trauma patients at a large urban trauma center and to evaluate what patient and injury features are associated with greater rates of trauma recidivism. We hypothesize higher rates of new injuries will be related to ballistic trauma and other forms of assault, alcohol and recreational drug use, unemployment, and unmarried status among our trauma patients. METHODS A series of 954 skeletally mature patients at a level 1 trauma center over a 5 year period were included in the study. All were treated operatively for thoracolumbar, pelvic ring, acetabulum, and/or proximal or shaft femoral fractures from a high energy mechanism. Retrospective review of demographic, injury, medical, and social factors, and subsequent care was performed. Trauma recidivism was defined as returning to the emergency department for treatment of any new injury. A backward stepwise logistic regression statistical analysis was used to identify independent predictors of recidivism. RESULTS Mean age of all patients was 41.2 years, and 73.2% were male. 136 patients (14.3%) returned with a new injury within a mean of 21 months. These trauma recidivists were more likely to sustain a GSW (22.1% vs 11.4%, p = 0.001). They had higher rates of substance use, including tobacco (57.4% vs 41.8%, p = 0.001) and recreational drugs (50.7% vs 34.4%, p = 0.001), and were less likely to be married (10% vs 25.9%, p<0.001). Mental illness was pervasive, noted in 56.6% of patients with new injury (vs 32.8%, p<0.001). Medicaid insurance was most common in the trauma recidivist population (58.1% vs 35.0%, p = 0.001), and 12.5% were uninsured. Completing high school or more education was protective (93% non-recidivist (vs 79%, p = 0.001). Sixty-nine patients (50.7%) were repeat trauma recidivists within the study period. Independent predictors of new injury included recreational drug use (OR 1.64, p = 0.05) and history of assault due to GSW or other means (OR 1.67, p = 0.05). History of pre-existing mental illness represented the greatest risk factor for trauma recidivism (OR 2.55, p<0.001). DISCUSSION New injuries resulting in emergency department presentation after prior orthopedic trauma occurred in 14.3% and were associated with history of assault, lower education, Medicaid insurance, tobacco smoking and recreational drug use. Mental illness was the greatest risk factor. Over half of patients with these additional injuries were repeat trauma recidivists, returning for another new injury within less than 2 years. Awareness of risk factors may promote focused education and other interventions to mitigate this burden. LEVEL OF EVIDENCE Level 3 retrospective, prognostic.
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Affiliation(s)
- Isabella M Heimke
- MetroHealth Medical Center, Case Western Reserve University School of Medicine
| | - Madison Connelly
- MetroHealth Medical Center, Case Western Reserve University School of Medicine
| | - Amelia Clarke
- MetroHealth Medical Center, Case Western Reserve University School of Medicine
| | - Belinda DeMario
- MetroHealth Medical Center, Case Western Reserve University School of Medicine
| | - Ryan Furdock
- MetroHealth Medical Center, Case Western Reserve University School of Medicine
| | - Timothy A Moore
- MetroHealth Medical Center, Case Western Reserve University School of Medicine
| | - Heather A Vallier
- MetroHealth Medical Center, Case Western Reserve University School of Medicine.
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Kishawi SK, Badrinathan A, Thai AP, Benuska SE, Breslin MA, Hendrickson SB, Ho VP. Are trauma surgical societies adequately addressing mental health after injury? Surgery 2022; 172:1549-1554. [PMID: 35981920 PMCID: PMC9942601 DOI: 10.1016/j.surg.2022.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/11/2022] [Accepted: 06/16/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Survivors of physical trauma, their home caregivers, and their medical providers all have an increased risk of developing psychological distress and trauma-related psychiatric disease. The purpose of this study was to describe the frequency and change over time of trauma society research presentations regarding mental health to identify opportunities for growth. METHODS Archives from 2018 to 2020 from the American Association for the Surgery of Trauma, the Eastern Association for the Surgery of Trauma, and the Western Trauma Association were reviewed. The studies that measured mental illness, psychosocial distress, and other psychosocial factors were assessed: for (1) the use of patient-reported outcome measures ; (2) the association of psychosocial variables with outcomes; and (3) the interventions investigated. Change over time was assessed using χ2 analysis. RESULTS Of 1,239 abstracts, 57 (4.6%) addressed at least 1 mental health-related factor. Mental health was more frequently studied over time (2018 [3.2%]; 2019 [3.5%]; 2020 [7.7%]; P = .003). The most frequently measured factors were post-traumatic stress disorder, quality of life, general mental health, and depression. Seventeen (29.8%) abstracts addressed substance abuse, most commonly opioid abuse. Seven (12.3%) abstracts measured mental health in caregivers or medical providers. Patient-reported outcome measures were used in 32 studies (56.1%). Two-thirds of studies reported findings suggesting that mental illness impairs trauma-related outcomes. Only 5 (8.8%) investigated interventions designed to reduce adverse outcomes. CONCLUSION Although academic discussion of mental health after trauma increased from 2018 to 2020, the topic remains a limited component of annual programs, patient-reported outcome measures remain underutilized, and intervention studies are rare.
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Affiliation(s)
- Sami K Kishawi
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio; Case Western Reserve University, School of Medicine, Cleveland, Ohio. http://www.twitter.com/skkishawi
| | - Avanti Badrinathan
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio; Case Western Reserve University, School of Medicine, Cleveland, Ohio
| | - Anthony P Thai
- Case Western Reserve University, School of Medicine, Cleveland, Ohio
| | - Sarah E Benuska
- Department of Psychiatry, MetroHealth Medical Center, Cleveland, Ohio
| | - Mary A Breslin
- Institute for H.O.P.E.(TM), Center for Health Resilience, The MetroHealth System, Cleveland, Ohio. http://www.twitter.com/MaryA_Breslin
| | - Sarah B Hendrickson
- Institute for H.O.P.E.(TM), Center for Health Resilience, The MetroHealth System, Cleveland, Ohio; Department of Counselor Education and Supervision, Ohio University, Athens, Ohio. http://www.twitter.com/SHendricksonCLE
| | - Vanessa P Ho
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio.
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Abstract
Orthopaedic trauma patients have high rates of psychiatric disorders, which put them at risk for worse outcomes after injury and surgery, including worse pain. Mental health conditions, such as depression and anxiety, can affect the perception of pain. Pain can also exacerbate or contribute to the development of mental illness after injury. Interventions to address both mental health and pain among orthopaedic trauma patients are critical. Balancing safety and comfort amid a drug overdose epidemic is challenging, and many clinicians do not feel comfortable addressing mental health or have the resources necessary. We reviewed the literature on the complex relationship between pain and mental health and presented examples of scalable and accessible interventions that can be implemented to promote the health and recovery of our patients. Interventions described include screening for depression in the orthopaedic trauma clinic and the emergency department or inpatient setting during injury and using a comprehensive and evidence-based multimodal pain management regimen that blends pharmacologic alternatives to opioids and physical and cognitive strategies to manage pain.
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Abstract
SUMMARY Trauma is a major public health issue. Orthopaedic trauma surgeons are skilled in the acute management of musculoskeletal injury; however, formal training and resources have not been devoted to optimizing recovery after trauma. Recovery entails addressing the biomedical aspects of injury, as well as the psychological and social factors. The purposes of this study were to describe existing programs and resources within trauma centers, developed to promote psychosocial recovery. Supporting research data will be referenced, and potential barriers to program implementation will be discussed. The American College of Surgeons has mandated screening and treatment for mental illness after trauma, which will raise the bar to highlight the importance of these social issues, likely enabling providers to develop new programs and other resources within their systems. Provider education will promote the informing of patients and families, with the intent of enhancing the efficiency and scope of recovery.
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Sinkler MA, Furdock RJ, Vallier HA. Treating trauma more effectively: A review of psychosocial programming. Injury 2022; 53:1756-1764. [PMID: 35491278 DOI: 10.1016/j.injury.2022.04.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 02/02/2023]
Abstract
IMPORTANCE Traumatic events are the leading cause of life-altering disability in adults of working age. The management of patients with traumatic injury has substantially improved due to development of sophisticated trauma centers increasing survival after injury. Unlike the adoption of the trauma system framework, the same has not occurred with specialized trauma recovery services to include mental and social health needs. This literature review will discuss unique issues facing trauma survivors, some current recovery programs available, outcomes and benefits of these programs, and barriers that impair widespread incorporation. OBSERVATIONS Studies have shown that patients with traumatic injury experience reduction in quality of life and concurrent threats to mental health, including post-traumatic stress disorder (PTSD), alcohol use disorder, and recreational substance abuse. Patients with traumatic injury also have high recidivism rates, low pain management satisfaction, and poor engagement in care following injury. Screening efforts for PTSD, mental illness, and alcohol and substance abuse are more widely available interventions. Early coordinated efforts included dedicated multidisciplinary recovery teams. Recently, more methodical and organized programs, such as the Trauma Survivors Network, trauma collaborative care, Trauma Recovery Services, and Center of Trauma Survivorship, have been implemented. CONCLUSIONS AND RELEVANCE The enrollment of patients with traumatic injury in novel programs to enhance recovery has led to heightened self-efficacy, better coping mechanisms, and increased use of mental health services. Additionally, trauma recovery services have been shown to reduce recidivism and have generated cost savings for hospital systems. While positive outcomes have been demonstrated, they are not consistently predictable. Barriers for widespread implementation include limitations of time, funding, and institutional support. This article describes models of successful programs initiated within some trauma centers, which may be duplicated to serve future trauma survivors.
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Affiliation(s)
- Margaret A Sinkler
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Ryan J Furdock
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Heather A Vallier
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH.
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Bloomer AK, McKnight RR, Johnson NR, Macknet DM, Wally MK, Yu Z, Seymour RB, Hsu JR. Screws-Only Primary Subtalar Arthrodesis for Calcaneus Fractures. Foot Ankle Int 2022; 43:509-519. [PMID: 34996306 DOI: 10.1177/10711007211058689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The management of displaced intraarticular calcaneus fractures (DIACFs) is a difficult problem with disappointing results from open reduction internal fixation (ORIF). Alternatively, ORIF with primary subtalar arthrodesis (PSTA) has gained increasing popularity. The purpose of this study is to review patient-centered and radiographic outcomes of ORIF plus PSTA using only screws through a sinus tarsi approach. METHODS A retrospective study of patients who underwent ORIF+PSTA for DIACFs was conducted. The same surgical technique was used in all cases consisting of only screws; no plates were used. Delayed surgeries past 8 weeks were excluded. Demographic and radiographic data were collected including worker's compensation claims. Plain radiographs were used to characterize injuries and review outcomes. RESULTS Seventy-nine DIACFs underwent PSTA with a median follow-up of 200 days (n = 69 patients). Median time to weightbearing was 57.5 days postoperatively. Ten fractures were documented as Sanders II, 36 as Sanders III, and 32 as Sanders IV. Sixty-eight fractures (86.1%) achieved fusion on radiographs at a median of 126.5 (range, 54-518) days. Thirty-nine fractures (57.3%) demonstrated radiographic fusion in all 3 predefined locations. Nine of the 14 worker's compensation patients returned to work within the period of observation. There were 8 complications: 3 requiring a secondary operation. Eleven of 79 fractures treated did not go on to achieve radiographic union. CONCLUSION In this retrospective case series, we found that screws-only primary subtalar arthrodesis for the treatment of DIACFs through a sinus tarsi approach was associated with relatively high rates of return to work and radiographic fusion. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Ainsley K Bloomer
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - R Randall McKnight
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Nicholas R Johnson
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - David M Macknet
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Ziqing Yu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
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