Background: Measuring ankle range of motion (ROM) following injury or intervention is necessary for monitoring recovery as well as for calculating permanent impairment ratings in workers’ compensation cases. In recent years, smartphone application developers have created applications (apps) that emulate ROM measurement tools like the universal goniometer. This study assessed the correlation between smartphone ROM measurements and universal goniometer measurements, as well as the reliability and usability of these apps in clinical practice. Methods: Three raters used the Goniometer app (Gonio), Clinometer app (Clino), DrGoniometer app (DrG), and a universal goniometer (UG) to assess the ankle ROM in plantarflexion and dorsiflexion of 24 patients with ankle pathology. Each patient completed a survey on the usability of the apps. Results: Lin’s concordance correlation coefficient test showed moderate correlation between the smartphone and UG measurements (Lin‘s correlation coefficient [rLC] = 0.931, 95% confidence interval [CI] = 0.911-0.946 for UG-Gonio; rLC = 0.908, 95% CI = 0.881-0.929 for UG-Clino; rLC = 0.935, 95% CI = 0.915-0.950 for UG-DrG). A 2-way mixed model showed good to excellent interrater reliability for each app for plantarflexion and dorsiflexion (ICCp = 0.836, ICCd = 0.912, P < .001 for Gonio; ICCp = 0.788, ICCd = 0.893, P < .001 for Clino; ICCp = 0.777, ICCd = 0.897, P < .001 for DrG). Most participants surveyed were very comfortable with having their ankle ROM measured by a smartphone. Conclusion: Smartphone apps may be a more convenient way to measure ankle ROM than UG. Physicians can use these apps to measure a patient’s ROM in clinic, a patient could send a picture of his or her dorsiflexed or plantarflexed ankle to the physician to remotely track ROM, or a patient could measure his or her own ROM at home using a personal smartphone. Level of Evidence: Level IV, case series.

Background Repeated practice to acquire expertise could result in the structural and functional changes in relevant brain circuits as a result of long-term potentiation, neurogenesis, glial genesis, and remodeling. Purpose The goal of this study is to use task fMRI to study the brain of expert radiologists performing a diagnosis task where a series of medical images were presented during fMRI acquisition for 12s and participants were asked to choose a diagnosis. Structural and diffusion-tensor MRI were also acquired. Methods Radiologists (N = 12, 11M, 38.2±10.3 years old) and non-radiologists (N = 17, 15M, 30.6 ±5.5 years old) were recruited with informed consent. Medical images were presented for 12 s and three multiple choices were displayed and the participants were asked to choose a diagnosis. fMRI, structural and diffusion-tensor MRI were acquired. fMRI analysis used FSL to determine differences in fMRI responses between groups. Voxel-wise analysis was performed to determine if subcortical volume, cortical thickness and fractional anisotropy differed between groups. Correction for multiple comparisons used false discovery rate. Results Radiologists showed overall lower task-related brain activation than non-radiologists. Radiologists showed significantly lower activation in the left lateral occipital cortex, left superior parietal lobule, occipital pole, right superior frontal and precentral gyri, lingual gyrus, and the left intraparietal sulcus (p<0.05). There were no significant differences between groups in cortical thickness, subcortical volume and fractional anisotropy (p>0.05).

Background: In North Carolina, the Strengthen Opioid Misuse Prevention Act of 2017 (STOP Act) went into effect on January 1, 2018, intending to increase oversight over opioid prescriptions. This study compares postoperative narcotic prescription practices following operative fixation of ankle fractures before and after the STOP Act. Methods: This study was a retrospective review of patients 18 years and older who underwent operative fixation of ankle fractures between January 1 and June 30, 2017 (before STOP Act), and between January 1 and June 30, 2018 (after STOP Act). Variables of interest included demographics, amount of opioids prescribed postoperatively, number of prescription refills, and number of pain-related calls or visits to the emergency department (ED) or clinic after surgery. This study assessed 71 patients in the Pre group and 47 patients in the Post group. Results: There was a statistically significant decrease in the average number of postoperative narcotic pills prescribed after the STOP Act (52.7 vs 76.2, P < .001). There was also a statistically significant decrease in the average number of prescription refills (0.6 vs 1.0, P = .037). There were no significant changes in pain-related clinic calls (35.2% Pre vs 34.0% Post, P = .896), pain-related clinic visits ahead of schedule (4.2% Pre vs 6.4% Post, P = .681), or pain-related ED visits (2.8% Pre vs 10.6% Post, P = .113). Conclusion: In the postoperative period after operative fixation of ankle fractures, the volume of narcotic prescriptions decreased after the new legislation, without an associated strain on medical resources. Level of Evidence: Level III, therapeutic, comparative study.

Background:A reliable predictor of costs after trauma is hospital length of stay (LOS). This study sought to determine if differences exist in LOS after closed and isolated femoral and tibial shaft fractures between two level 1 trauma centers and to determine patient and hospital factors affecting LOS. Methods:Trauma registries at two centers from 2006 to 2011 were reviewed to identify eligible patients. The centers were an academic inner city hospital (HA) and a large community hospital (HB) in a major metropolitan area. Retrospective chart review identified variables of interest. Results:Ninety-nine patients met the inclusion criteria: 32 femoral fractures and 30 tibial fractures at HA, and 19 femoral fractures and 18 tibial fractures at HB. The average LOS after femoral fracture was 1.8 days shorter in HA than HB, and LOS after tibial fracture at HA was 2.3 days shorter than at HB (P < 0.05). Time from admission to surgery was significantly shorter at HA. Time from admission to surgery greater than 1 day was associated with significantly longer LOS. Patient-controlled analgesia for longer than 2 days also was correlated with significantly longer stays. Patients remaining on general trauma service after orthopaedic intervention at HB stayed 1.5 days longer than those on the orthopaedic service (P > 0.05). Differences in patient medical history between hospitals were not significant. Conclusions:Patients with identical injuries stayed significantly longer at HB than at HA. Standardizing discharge qualifications across hospital services, reducing time from admission to surgery delays with dedicated trauma operating room and adequate ancillary staff, and transitioning promptly from patientcontrolled analgesia use may reduce LOS.

Background Augmentation of soft tissue repairs has been helpful in protecting surgically repaired tissues as they heal. FlexBand (Artelon, Marietta, Georgia) is a synthetic, degradable, polycaprolactone-based polyurethane urea (PUUR) matrix that has been investigated and used for soft tissue repair in a variety of settings. The purpose of this study was to evaluate the safety profile of a PUUR matrix in a large cohort of patients undergoing soft tissue repairs about the foot and ankle. Methods A retrospective chart review of consecutive patients who underwent surgery using FlexBand to augment a soft tissue repair was performed to evaluate for major and minor complications related to the PUUR matrix. Results. A total of 105 patients with an average >6 months follow-up were included. The most common procedures were spring ligament repair, Achilles tendon repair, and Brostrom. There were 12 complications. Four major complications occurred with only 1 requiring PUUR matrix removal. Patients with wound complications had a higher body mass index (BMI) and rate of smoking. Conclusion Complication rates involving PUUR matrix in soft tissue foot and ankle reconstruction procedures are low and comparable with historical complication rates. The PUUR matrix is safe for use in a variety of soft tissue procedures about the foot and ankle. Level of Evidence: Level 4, Retrospective case-series