Objective To identify the differences in three-dimensional kinematic and kinetic gait characteristics in individuals with plantar fasciitis (PF) compared to healthy controls. Methods Searches were performed at CINAHL, Cochrane Library, Embase, Europe PMC, MEDLINE, SciELO, and Scopus databases. Studies comparing kinetic and/or kinematic aspects of gait between patients with plantar fasciitis and a control group were included. Data regarding the main characteristics and results of each study were extracted. The Newcastle-Ottawa Scale for Non-randomized Trials was used for quality assessment. The review was registered at PROSPERO (omitted for review). A meta-analysis was performed when two or more studies presented similar variables. Results Eleven studies fulfilled the inclusion criteria with both male and female participants (294 subjects, mean age 21-59 years). The PF group presented greater forefoot plantarflexion at initial contact (IC) during gait. Concerning kinetic forces, there was a statistically significant increase in peak instantaneous vertical impact load rate in runners with a history of plantar fasciitis. There were no significant differences in spatiotemporal parameters. The main limitation of the review is the considerable variability among studies regarding foot segmentation methods and variables assessed. Conclusion Plantar fasciitis may lead to increased forefoot plantarflexion at IC during gait as a compensatory mechanism to avoid greater strain at the plantar fascia; additionally, runners with plantar fasciitis exhibit increased vertical impact load rate.

BACKGROUND:Little is known regarding the circulating metal levels in patients following total ankle arthroplasty (TAA). Also unknown is the impact of implant modularity. The purpose of this study is to quantify the postoperative serum metal levels in patients who have undergone primary TAA and to evaluate the impact of tibial component design. METHODS:A cross-sectional study was conducted of patients who had undergone primary TAA during 2010-2023. Ten patients with the Stryker INFINITY System were included in the nonmodular tibia group, 10 patients with the Stryker INBONE System were included in the modular tibia group, and 21 patients without implants were included as a control group. Subjects attended a 1-time visit at minimum 12 months postoperative. Outcome measures included serum cobalt, chromium, and titanium levels measured by inductively coupled plasma mass spectrometry. RESULTS:There were no differences in age, gender, body mass index, or follow-up between the nonmodular tibia, modular tibia, and control groups. Serum titanium levels were greater in the nonmodular tibia group (0.619 µg/L) and modular tibia group (0.993 µg/L) than in the control group (0.150 µg/L) (P < .001 and P < .001, respectively). Serum titanium levels were greater in the modular tibia group than in the nonmodular tibia group (P = .003). Serum cobalt and chromium levels did not differ between groups (P > .05). No associations were found between metal levels and clinical or radiographic outcomes. CONCLUSION:Results from this study provide the first evidence that TAA is associated with elevated serum metal levels. Serum titanium levels were elevated, whereas chromium and cobalt levels were not. Patients with modular tibial implants had higher titanium levels than patients with nonmodular tibial implants. Possible explanations for these findings may be related to the greater surface area of the modular implants or greater release of metallic debris from tribocorrosion at the numerous modular junctions. These findings regarding implant modularity are hypothesis-generating and require further study.

Calcaneonavicular coalition is a congenital coalition caused by failure of embryonic segmentation, leading to an abnormal connection between the calcaneus and the navicular bones. If symptomatic with no evidence of arthritis, surgical excision is thought to be the best operative option. Extensor digitorum brevis interposition is a well-described technique to reduce the risk of recurrence. Previous retrospective reviews cite a high rate of wound complications and a symptomatic bony prominence over the lateral border of the foot after extensor digitorum brevis interposition. This manuscript modifies the previously described technique for extensor digitorum brevis interposition to only transpose the dorsal/medial half of the muscle. This allows for anatomic repair of the fascia and a more normal anatomy of the lateral border of the foot.

The use of minimally invasive techniques in the treatment of primary Achilles rupture has become more popular in the past few decades as they have been associated with a lower wound complication rate. Most of the techniques demand the use of procedure-specific instruments and are designed mainly for midsubstance lesions. This article aims to present a novel technique for Achilles tendon repair that can be used for both insertional and midsubstance ruptures, using a mini-incision and with no special instruments required.Level of Evidence: Diagnostic Level V.

Category: Ankle Arthritis; Basic Sciences/Biologics Introduction/Purpose: Wear debris from metal implants can result in local and systemic complications and has become a growing concern. Potential complications include implant loosening, peri-implant osteolysis, adverse local tissue reaction with destruction of surrounding soft tissues, and end-organ deposition leading to cardiac and neurologic compromise. Implant modularity is known to be an important factor in the development of elevated serum metal levels and associated complications. Such components are susceptible to mechanically assisted crevice corrosion and fretting damage that results in metal ion release. Little is known regarding circulating metal levels in patients following total ankle arthroplasty (TAA). The purpose of this study is to quantify post-operative serum metal levels in patients who have undergone primary TAA and to evaluate the impact of tibial component design. Methods: Twenty patients having undergone primary, unilateral TAA at a single institution from January 2010–January 2023 were recruited. Ten patients with a non-modular tibial component using the Stryker INFINITY Total Ankle System were included in the resurfacing cohort, and 10 patients with a modular tibial component using the Stryker INBONE Total Ankle System were included in the stemmed cohort. A control group consisted of 21 patients without implants from a previous study at the same institution. The tibial components of both implant systems are composed of titanium, aluminum, vanadium and plasma spray coated with unalloyed titanium. Talar components are fabricated from cobalt, chromium, molybdenum alloy. An ultra-high molecular weight polyethylene insert was used in both cohorts. Following study enrollment, subjects attended a one-time visit at minimum 12 months post-operative. Primary outcome measures included serum cobalt, chromium, and titanium levels measured by ICP-MS. Secondary outcome measures included patient-reported outcome measurement surveys. Results: There were no differences in age, gender, body mass index, or follow-up between the control, resurfacing implant, and stemmed implant cohorts. Serum titanium levels were greater in the resurfacing cohort (0.619 µg/L) and stemmed cohort (0.993 µg/L) than in the control cohort (0.150 µg/L) (p< 0.001 and p< 0.001 respectively; Table 1). Serum titanium levels were greater in the stemmed group than in the resurfacing group (p=0.003; Table 1). Serum cobalt and chromium levels did not differ between study cohorts or controls (p>0.05; Table 1). Patient-reported outcomes did not differ between groups (p>0.05). Conclusion: Results from this study provide the first evidence that TAA is associated with elevated serum metal levels. In this study, serum titanium levels were elevated following TAA while chromium and cobalt levels were not elevated. Patients with stemmed implants demonstrated higher titanium levels than patients with resurfacing implants. Possible explanations for these findings may be related simply to the greater surface area of the stemmed implants or greater release of metallic debris from tribocorrosion at the numerous modular junctions. These findings prompt the need for additional research in this area.

Graphical Abstract This is a visual representation of the abstract.

BACKGROUND:Poor sleep quality is associated with metabolic dysregulation and impaired healing. The purpose of the current study was to quantify the prevalence of poor sleep in patients with atraumatic foot and ankle (F&A) conditions and determine whether surgical treatment is associated with sleep quality improvement.METHODS:Patients scheduled for surgical management of atraumatic F&A conditions were enrolled by 4 fellowship-trained orthopaedic F&A surgeons between May 2018 and April 2019. Patients completed the Pittsburgh Sleep Quality Index (PSQI) pre- and postoperatively. The PSQI ranges from 0 to 21, with a score ≥5 indicative of poor sleep quality. Patients also reported their perception of how their current F&A pain influenced their sleep quality on a scale of 0 to 10, where 0 indicated no influence and 10 indicated a strong influence (pain perception score [PPS]). Patients with known sleep disorders, acute surgical trauma, and infection were excluded.RESULTS:A total of 115 patients were enrolled. The mean preoperative PSQI and PPS were 8.1 ± 3.6 (range, 2-19) and 3.1 ± 2.7 (range, 0-10), respectively. Overall, 86.1% of patients had poor sleep quality (PSQI score ≥5). Similarly, 64.3% of patients had a PPS ≥1, indicating the belief that F&A pain contributed to sleep disturbance. A minimum of 6 months of follow-up was collected for 72 (62.6%) patients. On average, these 72 patients experienced significant improvements in sleep quality (mean PSQI decreased from 7.8 ± 3.2 to 5.4 ± 3.1, P < .001). Of these patients, 59.7% continued to experience poor sleep quality (PSQI ≥5), and 55.6% perceived that F&A pain contributed to sleep disturbance (PPS ≥1).CONCLUSION:In this series, 86.1% of patients presenting for management of atraumatic F&A conditions had poor sleep quality at the time of their initial visit, with 64.3% perceiving their F&A conditions to influence their sleep quality. Improvements in sleep quality were observed at 6 months postoperatively, though over half of patients continued to experience poor sleep quality. The location of pathology and procedure performed was not associated with sleep quality.LEVELS OF EVIDENCE:Level IV: Prospective case series.

Background: Hallux valgus (HV) is a common cause of pain and deformity of the forefoot. Minimally invasive chevron Akin (MICA) bunionectomy is a method for HV correction associated with less pain and swelling, with early return to weightbearing in a regular shoe. The purpose of this study was to determine how the MICA procedure affects forefoot width. Methods: Twenty-eight patients (26 female, 2 male; 9 left, 19 right) at a single institution who underwent primary MICA for HV correction by 3 treating surgeons were retrospectively reviewed. Pre- and postoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), bony forefoot width, and soft tissue forefoot width were measured by 2 independent observers. Radiographic measurements were calibrated using fifth metatarsal length. Wilcoxon signed rank test compared changes in HVA, IMA, DMAA, and forefoot widths. Pearson correlation coefficient evaluated association between HVA, IMA, DMAA, and changes in forefoot width. Results: At mean follow-up of 5.4 (range 3-13.7) months, bony forefoot width decreased significantly by 3.7 mm (4%, P < .001) and soft tissue forefoot width decreased by 2.5 mm (2%, P < .01). Decrease in HVA was moderately correlated with change in bony forefoot width ( r = .38, P < .05) and change in soft tissue forefoot width ( r = .45, P < .05). Decrease in IMA was moderately correlated with change in bony forefoot width ( r = .45, P < .05) and change in soft tissue forefoot width ( r = .44, P < .05). Conclusion: The MICA procedure resulted in modest, yet significant, decrease in both bony and soft tissue forefoot width. Decrease in HVA and IMA demonstrated moderate correlation with changes in forefoot width. Patients can be counseled on these changes leading up to, and after, MICA bunionectomy surgery. Level of Evidence: Level III, retrospective comparative series.

Background: Foot pathologies can affect the kinetic chain during gait, leading to altered loading at other joints that can lead to subsequent pathologies. Although hallux valgus is the most common foot disease, little has been discussed about the biokinetic effects of hallux valgus on the foot and lower limb. This systematic review evaluated the kinematic, kinetic, and pedobarographic changes of the hallux valgus foot compared to a healthy one. Methods: Several electronic databases were searched up to January 2022, including only cross-sectional studies with clearly defined isolated hallux valgus diseases and healthy groups. Two investigators independently rated studies for methodological quality using the NIH Study Quality Assessment Tool for cross-sectional studies. Kinetic data were extracted, including temporal data, kinematics of the foot joint, kinematics of the proximal lower limb, and pedobarography. We did meta-analyses tests with a random effects model using the metafor package in R. Results: Hallux valgus patients walk slower compared to a disease-free control group −0.16 m/s (95% CI −0.27, −0.05). Hallux valgus patients exhibited significantly reduced coronal plane motion of the hindfoot-shank during preswing 1.16 degrees (95% CI 0.31, 2.00). Hallux valgus patients generated less force in the hallux region 33.48 N (95% CI 8.62, 58.35) but similar peak pressures in the hallux compared to controls. Hallux valgus patients generated less peak pressure at the medial and lateral hindfoot as compared to controls: 8.28 kPa (95% CI 2.92, 13.64) and 8.54 kPa (95% CI 3.55, 13.52), respectively. Conclusion: Although hallux valgus is a deformity of the forefoot, the kinematic changes due to the pathology are associated with significant changes in the range of motion at other joints, underscoring its importance in the kinetic chain. This is demonstrated again with the changes of peak pressure. Nevertheless, more high-quality studies are still needed to develop a fuller understanding of this pathology.

BACKGROUND: Few contemporary studies have assessed physicians' knowledge of radiation exposure associated with common imaging studies, especially in trauma care. The purpose of this study was to assess the knowledge of physicians involved in caring for trauma patients regarding the effective radiation doses of musculoskeletal (MSK) imaging studies routinely utilized in the trauma setting. METHODS: An electronic survey was distributed to United States orthopaedic surgery, general surgery, and emergency medicine (EM) residency programs. Participants were asked to estimate the radiation dose for common imaging modalities of the pelvis, lumbar spine, and lower extremity, in terms of chest X-ray (CXR) equivalents. Physician estimates were compared to the true effective radiation doses. Additionally, participants were asked to report the frequency of discussing radiation risk with patients. RESULTS: A total of 218 physicians completed the survey; 102 (46.8%) were EM physicians, 88 (40.4%) were orthopaedic surgeons, and 28 (12.8%) were general surgeons. Physicians underestimated the effective radiation doses of nearly all imaging modalities, most notably for pelvic computed tomaography (CT) (median 50 CXR estimation vs. 162 CXR actual) and lumbar CT (median 50 CXR estimation vs. 638 CXR actual). There was no difference between physician specialties regarding estimation accuracy (P=0.133). Physicians who regularly discussed radiation risks with patients more accurately estimated radiation exposure (P=0.007). CONCLUSION: The knowledge among orthopaedic and general surgeons and EM physicians regarding the radiation exposure associated with common MSK trauma imaging is lacking. Further investigation with larger scale studies is warranted, and additional education in this area may improve care.

Tibialis anterior tendon (TAT) transfer to the lateral cuneiform is commonly utilized to treat dynamic supination for relapsed clubfoot deformity. Traditional suture button fixation (SBF) may lead to skin necrosis at the button/skin interface. While interference screw fixation (ISF) would mitigate this concern, this fixation method has not been investigated in clubfoot patients. This study aims to investigate the performance of ISF versus SBF for TAT transfer in a cadaveric model. Ten matched pairs of cadaveric feet were obtained. One of each matched specimen underwent TAT transfer to the lateral cuneiform using ISF and the other underwent TAT transfer using SBF. For each ISF specimen, the tension of the transferred TAT required to bring the ankle to neutral was measured. This tension was then applied to both matched specimens using an MTS machine. Tension dissipation was measured after a 20-minute interval. In specimens with SBF, a load cell was positioned between the plantar skin and suture button to determine plantar skin pressure at the time of initial tension application. Average tension necessary to achieve neutral dorsiflexion was 49.4 N. Average tension dissipation after 20 min was significantly less in the IFS group (20 N versus 23.6 N, P = 0.02). No fixation failures occurred in either group. Average plantar foot skin pressure was 196.5 mmHg at initial tension application, exceeding thresholds for tissue ischemia. ISF allows for tendon tensioning at forces beyond those expected to result in skin necrosis with SBF with less dissipation of tension over time.

BACKGROUND:Periprosthetic fractures following total hip arthroplasty (THA) often occur in the early postoperative period. Recent data has indicated that early revisions are associated with higher complication rates, particularly periprosthetic joint infection (PJI). The purpose of this study was to assess the effect of timing of periprosthetic fracture surgery on complication rates. We hypothesized that complication rates would be significantly higher in revision surgeries performed within 3 months of the index THA. METHODS:The Medicare Part A claims database was queried from 2010 to 2017 to identify patients who underwent surgery for a periprosthetic fracture following primary THA. Patients were divided based on time between index and revision surgeries: <1, 1 to 2, 2 to 3, 3 to 6, 6 to 9, 9 to 12, and >12 months. Complication rates were compared between groups using multivariate analyses to adjust for demographics, comorbidities, and types of revision surgery. RESULTS:Of 492,340 THAs identified, 4,368 (0.9%) had a subsequent periprosthetic fracture requiring surgery: 1,725 (39.4%) at <1 month, 693 (15.9%) at 1 to 2 months, 202 (4.6%) at 2 to 3 months, 250 (5.7%) at 3 to 6 months, 134 (3.1%) at 6 to 9 months, 85 (19.4%) at 9 to12 months, and 1,279 (29.3%) at >12 months. The risk of PJI was 11.0% in the <1 month group, 11.1% at 1 to 2 months, 7.9% at 2 to 3 months, 6.8% at 3 to 6 months, 8.2% at 6 to 9 months, 9.4% at 9 to 12 months, and 8.5% at >12 months (P = .12). Adjusting for confounding factors, risk of PJI following periprosthetic fracture surgery was similar regardless of timing (P > .05). Rates of subsequent dislocation and aseptic loosening were also similar regardless of timing. CONCLUSIONS:The risk of PJI following repeat surgery for a periprosthetic fracture was strikingly high regardless of timing (6.8 to 11.1%), underscoring the high-risk of complications.

Hypoalbuminemia is a potentially modifiable risk factor associated with adverse events following total knee arthroplasty. The present study aimed to evaluate whether hypoalbuminemia similarly predisposes to adverse events following unicompartmental knee arthroplasty (UKA). Patients who underwent UKA during 2006-2018 were identified through the American College of Surgeons National Surgical Quality Improvement Program. Only patients with preoperative serum albumin concentration were included. Outcomes were compared between patients with and without hypoalbuminemia (serum albumin concentration < 3.5 g/dL). All associations were adjusted for demographic, comorbidity, and laboratory differences between populations. A total of 11,342 patients were identified, of whom 6,049 (53.3%) had preoperative serum albumin laboratory values available for analysis. After adjustment for potential confounders, patients with hypoalbuminemia had a greater than 2-fold increased probability for occurrence of any complication (7.02% vs. 2.23%, p = 0.009) and a 4-fold increased probability of receiving a blood transfusion (1.81% vs. 0.25%, p = 0.045). Among procedures performed as inpatients, mean postoperative length of stay (LOS) was longer in patients with hypoalbuminemia (2.2 vs. 1.8 days; p = 0.031). Hypoalbuminemia is independently associated with complications and increased LOS following UKA and a marker for patients at higher risk of postoperative complications. Patients should be screened for hypoalbuminemia and nutritional deficiencies addressed prior to UKA.

Category: Ankle; Hindfoot; Sports Introduction/Purpose: Surgical reconstruction for the complete loss of both peroneal tendons is challenging, with no established standard. This is true both for concomitant tears that extend superior to the superior peroneal retinaculum, and for nonfunctioning, unsalvageable peroneal tendons after prior repair or reconstruction, which have recurrent tears, tendon degeneration, scarring, and stretching. These cases have in common that there is no option for retention of the native tendons. Allograft reconstruction can bridge long defects, reestablishing the insertion of the proximal musculo-tendinous unit to the lateral foot. However, there are limited published data on allograft reconstruction, and series are small and heterogenous. This study reports the results of allograft reconstruction at a mean of 4.1 years follow-up (range 1.5-7.3 years). Methods: A retrospective study reviewed patients who had allograft reconstruction for unsalvageable or recurrent tears of both the peroneus brevis and peroneus longus tendons. In all cases, the unsalvageable segments of both peroneal tendons were excised. A hamstring allograft tendon with width of >6mm was pre-stretched, then anchored to the proximal 5thmetatarsal, and also sutured to itself and the adjacent brevis stump, if viable. The peroneal retinaculae were reconstructed over the allograft tendon. The peroneal muscle-proximal tendon units were extensively stretched inferiorly using suture loops in the tendons. They were maximally tensioned and anastomosed to the maximally tensioned allograft while holding the hindfoot in maximum eversion. Of the 14 eligible patients, 13 had minimum one-year follow-up and constituted the study population. Mean age was 50.7 years (range 26.3-68.6 years). Ten patients had at least one prior peroneal tendon surgery; four patients had at least two. Results: At mean follow-up of 4.1-years, seven patients were 'very satisfied,' one 'satisfied,' one 'neutral,' and two 'dissatisfied.' Ten stated they would have the procedure again, one would not. Two could not be reached to answer these questions. Visual analogue scale pain score decreased from 4.6 to 3.4 (p=0.150), ankle osteoarthritis scale (AOS) pain subscale decreased from 36.2 to 13.8 (p=0.013), AOS disability subscale decreased from 42.8 to 21.9 (p=0.032), and AOS total score decreased from 39.5 to 17.8 (p=0.014). No statistical change in SF-36 physical function score (p=0.547) or PROMIS physical function score (p=0.580) was detected. At last examination, 12 of 13 patients had active eversion and a palpable, tensioned graft. The patient without active eversion underwent triple arthrodesis; no other patient had additional peroneal or hindfoot surgery. Conclusion: Allograft interposition is effective to reconstruct unsalvageable concomitant tears of both peroneal tendons as well as the most difficult revision cases of nonfunctioning, unsalvageable peroneal tendons after prior repair or reconstruction, which have recurrent tears, tendon degeneration, scarring, and stretching. There is a high rate of restoration of peroneal function, a reasonable rate of patient satisfaction, and statistically significant improvements in ankle-specific patient-reported outcomes.

Modern improvements in total ankle arthroplasty (TAA) have increased the performance of this procedure for treatment of end-stage ankle arthritis. A common finding after TAA is the formation of periprosthetic bone cysts, which can be clinically silent or result in TAA failure. The exact cause of periprosthetic bones cysts has not been established, but major theories are related to osteolysis secondary to implant wear, micromotion, and stress shielding. Treatment can be nonoperative with clinical observation for small, asymptomatic cysts. Large, progressive, and symptomatic cysts often merit surgical treatment with debridement and grafting, revision TAA, or salvage arthrodesis.

Background:In the United States, the COVID-19 pandemic led to a nationwide quarantine that forced individuals to adjust their daily activities, potentially impacting the burden of foot and ankle disease. The purpose of this study was to compare diagnoses made in an orthopaedic foot and ankle clinic during the shelter-in-place period of the COVID-19 pandemic to diagnoses made during the same months of the previous year.Methods:A retrospective review of new patients presenting to the clinics of 4 fellowship-trained orthopaedic foot and ankle surgeons in a major United States city was performed. Patients in the COVID-19 group presented between March 22 and July 1, 2020, during the peak of the quarantine for this city. Patients in the control group presented during the same period of 2019. Final diagnosis, chronicity of symptoms (acute: ≤1 month), and mechanism of disease were compared between groups.Results:A total of 1409 new patient visits were reviewed with 449 visits in the COVID-19 group and 960 visits in the control group. The COVID-19 group had a significantly higher proportion of ankle fractures (8.7% vs 5.4%, P = .020) and stress fractures (4.2% vs 2.2%, P = .031), but a smaller proportion of Achilles tendon ruptures (0.7% vs 2.5%, P = .019). The COVID-19 group had a higher proportion of acute injuries (35.4% vs 23.5%, P < .001).Conclusion:There was a shift in prevalence of pathology seen in the foot and ankle clinic during the COVID-19 pandemic, which may reflect the adoption of different activities during the quarantine period and reluctance to present for evaluation of non-urgent injuries.Level of Evidence:Level III, retrospective cohort study.

Objective: The purpose of this study was to systematically review the literature regarding the use of hamstring tendon (HT) autograft for extensor hallucis longus (EHL) reconstruction. Methods: A systematic search for studies addressing the use of HT autograft for reconstruction of nonrepairable EHL tendon injuries was performed in December 2021. The databases searched include Embase, Medline, Europe PMC, Cochrane, and Scopus. Predetermined inclusion and exclusion criteria were implemented, and appropriate studies were selected for review. Results: The database search resulted in one study that met the inclusion and exclusion criteria. Three additional studies met inclusion and exclusion criteria after screening the references of the selected study. A total of four studies were included in the final review. Clinical presentation, surgical technique, postoperative rehabilitation, clinical follow-up, and outcomes were recorded. All four studies reported single cases of EHL tendon reconstruction using a semitendinosus autograft with satisfactory clinical results and no complications. Patients may experience a five degrees decrease in range of motion or minimal decrease in hallux extension strength; however, all patients were asymptomatic and reported no limitations. Conclusion: Four case reports regarding EHL tendon reconstruction were reviewed and demonstrated using a semitendinosus autograft as a viable option with favorable outcomes and no complications. Level of Evidence IV; Systematic Review

Achieving an adequate cast mold is critical for successful nonoperative management of pediatric forearm fractures. A high cast index (>0.8) is as- sociated with an increased risk of loss of reduction and failure of conservative management. Waterproof cast liners offer improved patient satisfaction compared to conventional cotton liners, however they may carry different mechanical properties compared to traditional cotton liners. The purpose of this study was to determine whether the cast index differs between waterproof and traditional cotton cast liners when used to stabilize pediatric forearm fractures. We retrospectively reviewed all forearm fractures casted in a pediatric orthopedic surgeon's clinic between December 2009 and January 2017. Either a waterproof or cotton cast liner was utilized according to parent and patient preferences. The cast index was determined on follow-up radiographs and compared between groups. Overall, 127 fractures met the criteria for this study. Twenty-five fractures had waterproof liners and 102 fractures had cotton liners placed. Waterproof liner casts showed a significantly higher cast index (0.832 vs 0.777; p=0.001), with a significantly higher proportion of casts with index greater than 0.8 (64.0% vs 35.3%; p=0.009). The use of waterproof cast liners is associated with a higher cast index compared to traditional cotton cast liners. Although waterproof liners may be associated with higher patient satisfaction scores, providers should be aware of this difference in mechanical properties and may consider altering their casting technique accordingly.

BACKGROUND:Virtual scribe services (VSS) are a contemporary take on the in-person scribes utilized as a means to reduce administrative burden on physicians and enhance the physician-patient interaction. The purpose of this study was to determine whether VSS use could decrease the time an orthopaedic foot and ankle surgeon spends on documentation without diminishing the patient experience as compared with traditional postencounter dictation (TD). METHODS:Fifty patients presenting for first-time visits with a single orthopaedic foot and ankle surgeon were prospectively enrolled and randomized to VSS or TD prior to the physician-patient encounter. Time spent with the patient in the exam room and time spent documenting away from the patient were recorded. A postencounter survey assessed patient satisfaction, perception of physician empathy, understanding of the plan, and perception of the amount of time spent with the physician. RESULTS:Of 50 patients enrolled, 25 were randomized to VSS. Time spent documenting away from the patient differed significantly between VSS and TD (1.2 ± 0.7 minutes for VSS vs 5.8 ± 1.7 minutes for TD, P < .001) as did time elapsed between the end of the visit and the start of dictation (0 ± 0 for VSS vs 118.2 ± 72.7 minutes for TD, P < .001). There was a trend toward more time spent with the patient in the VSS group than in the TD group (14.2 ± 5.9 minutes for VSS vs 11.4 ± 5.1 minutes for TD, P = .069). There were no differences between groups in survey responses regarding satisfaction, empathy, understanding, or perception of sufficient time spent with the physician (P > .05 for each). CONCLUSIONS:VSS use in an orthopaedic foot and ankle practice significantly decreased documentation time and allowed for completion of documentation during patient visits without differences in quality metrics as compared to TD. Orthopaedic surgeons can consider VSS a HIPAA-compliant documentation option with time savings and no measurable difference in patient satisfaction. LEVELS OF EVIDENCE:Level II: Randomized controlled trial.