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Background: Total talus replacement (TTR) implants are designed to replace the diseased talar anatomy, reduce pain, maintain ankle range of motion, and restore ankle function after conservative treatments have failed. Currently TTR implants are produced by 3D printing a patient-specific implant designed from the patient's preoperative anatomy. TTR surgery using patient-specific implants is a relatively new technique that remains understudied in the literature. Therefore, the purpose of this investigation was to determine the early safety and potential benefit of the TTR implant in patients with talar avascular necrosis., Methods: This retrospective, multicenter, cohort study evaluates the safety and potential benefits of TTR using 3D-printed patient-specific implants across 4 US centers. The primary outcome was the occurrence of early adverse events after TTR surgery. Secondary outcomes including, pain, and physical function were assessed using the pain visual analog scale (VAS), and Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF), respectively., Results: The study team analyzed 15 patients with more than 1 year of follow-up. The mean duration of follow-up was 25.9 months (range: 18.3-41 months). Although 33.3% (5 of 15) of patients experienced adverse events, primarily occurring within the initial 6 months postoperatively, 93% (14 of 15) of patients reported implant survivorship. Of the 5 cases (33.3%) resulting in an adverse event, 3 (60.0%) were determined to be unrelated to the subject device, 2 (40.0%) were determined to be possibly procedure-related, and none (0%) were determined to be device-related., Conclusion: Although further studies are needed to compare TTR with the standard of care, the results of this study demonstrate the relative early safety of TTR surgery using a 3D-printed implant for the treatment of challenging talar pathologies. A larger and longer clinical study is required to see if the efficacy of this approach will be statistically and clinically meaningful., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Bijan Abar, PhD, reports consulting fees and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Restor3d. Michael Kim reports stock or stock options from Restor3d. Samuel B. Adams, MD, reports support for the present manuscript and royalties or licenses from Restor3d. William R. Adams, DPM, reports consulting fees and stock or stock options from Restor3d. John Kent Ellington, MD, reports royalties or licenses, consulting fees, and stock or stock options from Restor3d. Samuel E. Ford, MD, reports royalties or licenses and stock or stock options from Restor3d. Peter D. Highlander, DPM, MS, reports consulting fees and stock holder from Restor3d Inc, no fees or shares accepted for this manuscript/project. John Y. Kwon, MD, reports royalties or licenses and consulting fees from Restor3D, unrelated to this work. Christopher P. Miller, MD, MHS, reports support for the present manuscript from Restor3D. Selene G. Parekh, MD, MBA, reports grants or contracts, consulting fees, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events, and stock or stock options from Restor3d. Karl M. Schweitzer, MD, reports stock or stock options from Restor3D, Inc. Scott B. Shawen, MD, reports royalties or licenses, consulting fees, and stock or stock options from Restor3d. Tara Mann, PhD, reports stock or stock options, full-time employee of Restor3d, Inc. with equity in the form of stock and stock options and full-time salary from Restor3d, Inc. Cambre Kelly, PhD, reports leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid and stock or stock options from Restor3d. Disclosure forms for all authors are available online.

Background: Primary arthrodesis of Lisfranc fracture-dislocations is a reliable treatment option, yet concerns remain about nonunion. Nitinol staple use has recently proliferated in midfoot arthrodesis. The purpose of this study is to examine the union rate of primary arthrodesis of acute Lisfranc fracture-dislocations treated with nitinol staples compared with traditional plate-and-screw fixation. The secondary objective is to assess the difference in operative times and reoperation rates., Methods: Midfoot fracture-dislocations treated with primary arthrodesis by 7 foot and ankle orthopaedic surgeons were reviewed. Of 160 eligible patients, 121 patients (305 joints) met the required 4-month minimum radiographic follow-up. Radiographic outcomes were analyzed at the individual joint level. Each joint was classified as either staples alone (45 patients, 154 joints), staples plus plates and screws (hybrid) (45 patients, 40 joints), or plates and screws alone (31 patients, 111 joints). The primary outcome was arthrodesis union at each joint fused., Results: Nonunion was more common (9.0%, 10/111) among joints fixed with plate and screws than with hybrid (2.5%, 1/40) or staples only (1.3%, 2/154) ( P  = .0085). Multivariable regression demonstrated that autograft use was independent associated with union ( P  = .0035) and plate-and-screw only fixation was an independent risk factor for nonunion ( P  = .0407). Median operating room and tourniquet times were shorter for hybrid (92 and 83 minutes) and staple only (67 and 63 minutes) constructs compared to plate-and-screw only fixation (105 and 95 minutes) ( P   ≤  .0001 and .0003). There was no difference in reoperation rates among patients with different fixation types., Conclusion: We found that use of nitinol compression staple and bone autograft in primary arthrodesis of Lisfranc and midfoot fracture-dislocations was associated with both improved union rates and shorter tourniquet and operative times compared to traditional plate-and-screw fixation techniques., Level of Evidence: Level III, therapeutic., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Todd A. Irwin, MD, reports royalties or licenses and consulting fees from Paragon 28 and MEDLINE. Bruce E. Cohen, MD, reports royalties or licenses and consulting fees from Stryker. J. Kent Ellington, MD, reports royalties or licenses from Synthes, Stryker, and MEDLINE, and consulting fees from Stryker and MEDLINE. Carroll P. Jones III, MD, reports royalties or licenses and consulting fees from Stryker (EasyFuse Staples). Scott B. Shawen, MD, reports royalties or licenses; consulting fees; and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from CrossRoads Extremities, Synthes, J&J; Medline Industries; and patents planned, issued, or pending from CrossRoads Extremities. Samuel E. Ford, MD, reports consulting fees from Stryker. Disclosure forms for all authors are available online.

Background: Hallux interphalangeal joint arthrodesis (HIPJA) is indicated for a variety of pathologies. Despite high nonunion rates, techniques remain unchanged. The aim of this study is to examine nonunion and complication rates and describe risk factors for treatment failure., Methods: A query of an institutional database was performed to identify all patients undergoing HIPJA procedure over a 10-year period. Records were reviewed to the procedure, evaluate patient factors, indications, and radiographic/clinical arthrodesis. Radiographic union was defined as 2 cortical continuations or bridging at the arthrodesis site, absence of hardware failure, and the absence of lytic gapping of the arthrodesis. Clinical fibrous union was defined as radiographic nonunion with painless toe range of motion and physical examination consistent with fusion across the interphalangeal joint., Results: Two hundred twenty-seven primary HIPJA procedures were identified. Our cohort demonstrated a 25.5% nonunion rate (58/227) and 21.1% reoperation rate (48/227). Patients with diabetes were at higher risk for nonunion ( P = .014), but no significant differences were identified based on smoking status or diagnosis of inflammatory arthritis. No difference was seen between implant groups: single screw, multiple screws, screw plus other fixation, nonscrew fixation. Patients with prior hallux metatarsophalangeal joint arthrodesis did not have a significantly higher nonunion rate than patients without prior first metatarsophalangeal joint arthrodesis. Patients diagnosed with radiographic nonunion were at higher risk for reoperation ( P  < .0001)., Conclusion: Our cohort represents the largest single-center series of HIPJA procedures published to date. We found relatively high nonunion and reoperation rates with standard current techniques., Level of Evidence: Level III, retrospective case series., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online.

Background: The purpose of this study was to evaluate patients for intermediate-term pain relief, functional outcome, and changes in hallux alignment following isolated, complete fibular sesamoidectomy via a plantar approach for sesamoid-related pain recalcitrant to conservative treatment., Methods: A retrospective query of a tertiary referral center administrative database was performed using the Current Procedural Terminology code 28135 for sesamoidectomy between 2005 and 2016. Patients who underwent an isolated fibular sesamoidectomy were identified and contacted to return for an office visit. The primary outcome measure was change in visual analog pain score at final follow-up. Secondary measures included satisfaction, hallux flexion strength, hallux alignment, pedobarographic assessment, and postoperative functional outcome scores. Patients who met the 2-year clinical or radiographic follow-up minimum were included. Ninety fibular sesamoidectomies were identified. Thirty-six sesamoidectomies met inclusion criteria (median 60-month follow-up). The average patient was 36 years old and underwent sesamoidectomy 1.1 years after initial diagnosis., Results: Median visual analog scale scores improved 5 (6 to 1) points at final follow-up ( P < .001). Final postoperative mean hallux valgus angle did not differ from preoperative values (10.5 degrees/8.5 degrees, P = .12); similarly, the intermetatarsal angle did not differ (8.0 degrees/7.9 degrees, P = .53). Eighty-eight percent of patients would have surgery again and 70% were "very satisfied" with their result. Hallux flexion strength (mean 14.7 pounds) did not differ relative to the contralateral foot (mean 16.1 pounds) ( P = .23). Among the full 92 case cohort, 3 patients underwent 4 known reoperations., Conclusion: Fibular sesamoidectomy effectively provided pain relief (median 5-year follow-up) for patients with sesamoid pathology without affecting hallux alignment., Level of Evidence: Level IV, retrospective case series.

Background: The Broström procedure is the most commonly used lateral ligament repair for chronic instability, but there is concern about the strength of the repair and the risk of reinjury. Currently, the InternalBrace TM ligament augmentation repair is an accepted augmentation method for management of a Broström procedure. Our hypothesis was that augmentation of the Broström repair with an InternalBrace TM would allow accelerated rehabilitation and return to activity and would aid in stability of the repair without a tendency to stretch., Methods: Eighty-one patients with lateral ankle instability procedures repaired with a Broström and InternalBrace TM augmentation were evaluated at a one-time postoperative visit between 6 and 24 months. Outcomes included demographics, surgical time, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, Veterans Rand 12-Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), Visual Analog Scale (VAS), satisfaction, and objective clinical measurements. Eighty-one patients were analyzed including 30 males and 51 females. Median age was 34 years (range, 18-62 years) with a median return for follow-up of 11.5 months (range, 6-27 months)., Results: Average postoperative VAS and satisfaction were 0.8 ± 1.4 and 9.1 ± 1.6, respectively. Mean return to sport (n = 68) was 84.1 days. Average AOFAS Ankle-Hindfoot score was 94.3. A score of 90 or higher on the FAAM Sports subscale was seen in 79.0% of the subjects. The single-leg hop test (Limb Symmetry Index %) showed that 86.4% of patients returned to normal or near normal function. The tape measure method and ankle dorsiflexion comparisons showed a significant difference: 9.2 ± 3.3 cm (operative side) and 10.4 ± 3.7 cm (contralateral side) ( P = .034). Ankle plantar flexion comparison (goniometer) was 48.5 ± 11.5 degrees (operative side) and 49.7 ± 11.9 degrees (contralateral side), showing no difference ( P = .506)., Conclusion: These results suggest that InternalBrace TM augmentation of a Broström procedure is a safe and efficacious procedure that produces favorable outcomes in patients in terms of preventing recurrent instability in the ankle in the short term., Level of Evidence: Level IV, case series.

Background: The purpose of this study was to determine the radiographic union rate after midfoot and hindfoot arthrodeses using a new generation of nitinol staples, and to compare outcomes between a nitinol staple construct and a nitinol staple and threaded compression screw construct., Methods: A retrospective chart review was performed to identify patients who underwent hindfoot or midfoot arthrodesis using a new generation of nitinol compression staples with or without a partially threaded cannulated screw with minimum 3-month radiographic follow-up. The primary outcome variable was radiographic evidence of arthrodesis on radiographs and, when available, computed tomographic scan in patients who underwent midfoot or hindfoot arthrodesis using nitinol staples. Ninety-six patients and 149 joints were eligible for analysis. Median radiographic follow-up was 5.7 months., Results: Radiographic union was seen in 93.8% (60/64) of patients and 95.1% (98/103) of joints using the nitinol staple construct. Radiographic union was seen in 90.6% (29/32) of patients and 95.7% (44/46) of joints using the nitinol combined staple and screw construct. There was no significant difference in radiographic union rate or revision surgery between the 2 groups. Seven patients developed nonunion, 4 in the nitinol staple construct group and 3 in the staple and screw group., Conclusions: New-generation nitinol staples were safe and effective for hindfoot and midfoot arthrodeses, with a high radiographic union rate. The use of a partially threaded screw for additional fixation was not found to either significantly increase or decrease radiographic fusion with nitinol staple fixation., Level of Evidence: Level III, comparative cohort study.

Background: Determining the stability of ankle fractures, particularly Weber B fibula fractures, can be challenging. Ability to weight-bear after injury may be predictive of stability. We sought to determine whether patients' ability to weight-bear immediately after injury was an effective indicator for ankle stability following fracture., Methods: A prospective review was conducted of patients sustaining ankle fractures. Patients' ability to weight-bear after injury was elicited and correlated with ankle radiographs, which were deemed stable or unstable based on commonly used indices to assess stability., Results: For the entire cohort (n = 121), patients who were able to weight-bear immediately after injury were over 8 times more likely to have a stable fracture than those who could not (odds ratio [OR] = 8.6, P < .001). Positive predictive value (PPV) for being able to fully weight-bear as it related to stability was 73%. Inability to weight-bear was 85% specific among patients with an unstable fracture. When analyzing patients with radiographic isolated fibula fractures (n = 67), PPV = 82%, negative predictive value [NPV] = 53%, specificity = 79%, whereas the OR was 5.0 (P = .003) for those who could weight-bear having a stable fracture. When subanalyzing patients who presented with isolated fibula fractures and anatomic mortises (n = 43), PPV = 74%, NPV = 52%, specificity = 62%, whereas the OR was 3.6 (P = .07) for those who could weight-bear having a stable fracture., Conclusion: Patients' ability to weight-bear immediately after injury was a specific and prognostic indicator for stability across a range of ankle fracture subtypes. Patients with an isolated fibula fracture and anatomic mortise were 3.6 times more likely to have a stable fracture if they were able to fully weight-bear at the time of injury. Although a patient's history does not preclude the need for appropriate imaging studies and clinical judgment, it may aid in the assessment of ankle stability following fracture., Level of Evidence: Level II, clinical diagnostic., (© The Author(s) 2016.)

Background: Limited incision techniques for acute Achilles tendon ruptures have been developed in recent years to improve recovery and reduce postoperative complications compared with traditional open repair. The purpose of this retrospective cohort study was to analyze the clinical outcomes and postoperative complications between acute Achilles tendon ruptures treated using a percutaneous Achilles repair system (PARS [Arthrex, Inc, Naples, FL]) versus open repair and evaluate the overall outcomes for operatively treated Achilles ruptures., Methods: Between 2005 and 2014, 270 consecutive cases of operatively treated acute Achilles tendon ruptures were reviewed (101 PARS, 169 open). Patients with Achilles tendinopathy, insertional ruptures, chronic tears, or less than 3-month follow-up were excluded. Operative treatment consisted of a percutaneous technique (PARS) using a 2-cm transverse incision with FiberWire (Arthrex, Inc, Naples, FL) sutures or open repair using a 5- to 8-cm posteromedial incision with FiberWire in a Krackow fashion reinforced with absorbable sutures. Patient demographics were recorded along with medical comorbidities, activity at injury, time from injury to surgery, length of follow-up, return to baseline activities by 5 months, and postoperative complications., Results: The most common activity during injury for both groups was basketball (PARS: 39%, open: 47%). A greater number of patients treated with PARS were able to return to baseline physical activities by 5 months compared with the open group (PARS: 98%, open: 82%; P = .0001). There were no significant differences (P > .05) between groups in rates of rerupture (P = 1.0), sural neuritis (P = .16), wound dehiscence (P = .74), superficial (P = .29) and/or deep infection (P = .29), or reoperation (P = .13). There were no deep vein thromboses (DVTs) or reruptures in either group. In the PARS group, there were no cases of sural neuritis, 3 cases (3%) of superficial wound dehiscence, and 2 reoperations (2%) for superficial foreign-body reaction to FiberWire. In the open group, there were 5 cases (3%) of sural neuritis, 7 cases (4%) of superficial wound dehiscence, 3 cases (2%) of superficial infection, and 3 reoperations (2%) for deep infection., Conclusion: The present study reports the largest single-center series of acute Achilles tendon ruptures in the literature with lower complication rates for operatively treated Achilles ruptures compared with previous reports. The overall complication rate for all operatively treated Achilles ruptures was 8.5% with no reruptures, and most patients (88%) were able to return to baseline activities by 5 months after surgery. There were no significant differences in rates of postoperative complications between PARS and open repair for acute Achilles tendon ruptures., Level of Evidence: Level III, retrospective cohort study., (© The Author(s) 2015.)

Background: Preoperative computer navigation and patient-specific instrumentation have had promising results in total knee arthroplasty and in a previous cadaveric total ankle arthroplasty (TAA) study. Potential benefits of patient-specific guides include improved implant alignment and decreased surgical time. The purpose of this retrospective case series was to evaluate the accuracy, reproducibility, and limitations of TAA tibia and talar implant placement and radiographic alignment using preoperative computed tomography (CT) scan-derived instrumentation in a clinical setting., Methods: Between 2012 and 2014, 42 consecutive TAA cases in 42 patients using preoperative CT scan-derived patient-specific plans and guides (PROPHECY, Wright Medical Technology, Memphis TN) were reviewed from a single center of foot and ankle fellowship-trained orthopaedic surgeons. TAA implants used included 29 intramedullary referencing implants (INBONE II, Wright Medical Technology) and 13 low-profile tibia and talar resurfacing implants (Infinity, Wright Medical Technology). All patients had standardized preoperative CT scans before surgery that were used to create custom surgical plans and 3-dimensional solid cutting guides and models. All patients had a minimum 3-month follow-up with weightbearing postoperative radiographs. Patient demographics were recorded, and coronal and sagittal alignments were compared among weightbearing preoperative radiographs, CT scan-derived surgical plans, and weightbearing postoperative radiographs using a digital picture archiving and communication system., Results: Average age for all patients was 63 ± 9 years, with a body mass index of 29.8 ± 5.9. Average total surgical time for all TAAs was 100 ± 11 minutes, with Infinity TAAs taking less time than INBONE II TAAs (92 vs 104 minutes; P < .05). Average preoperative coronal alignment was 1.9 degrees varus ± 6.4 (range, 14 degrees valgus to 10 degrees varus). Postoperative weightbearing alignments for all TAA cases were within ±3° of the predicted coronal and sagittal alignments from the CT scan-derived surgical plans. There were no significant differences in pre- or postoperative weightbearing alignments between INBONE II and Infinity TAA cases. Neutral coronal and sagittal alignments were obtained for all TAA cases regardless of preoperative deformity. Patient-specific surgical plans were accurate to within 1 size for tibia and talar implants used. Surgical plans predicted the actual tibia implant size used in 100% of INBONE II cases and 92% of Infinity cases. Plans were less accurate for talar implants and predicted the actual talar implant size used in 76% of INBONE II cases and 46% of Infinity cases. In all cases of predicted tibia or talar size mismatch, surgical plans predicted 1 implant size larger than actually used., Conclusions: Results from this study provide early clinical evidence that preoperative CT scan-derived patient-specific surgical plans and guides can help provide accurate and reproducible TAA radiographic alignments. Talar implant sizing was not as accurate due to individual surgeon preference regarding the extent of gutter debridement. Similar to other modern computer navigation and patient-specific instrumentation systems, final coronal and sagittal alignments were within 3 degrees of the predicted surgical plans, and sizing was accurate within 1 implant size. Future studies are warranted to investigate the clinical and functional implications of patient-specific TAA and the overall cost-effectiveness of this technique., Level of Evidence: Level IV, retrospective case series., (© The Author(s) 2015.)

Background: There are conflicting data regarding the benefits of delaying operative fixation of calcaneus fractures to decrease wound complication rates. The purpose of this study was to examine the effect of delaying fixation on wound complication rates as well as to identify other risk factors., Methods: A retrospective review at 4 institutions, including 24 surgeons, identified 405 closed, operatively treated, intra-articular calcaneus fractures. We compared fractures with and without wound complications with regards to patient demographics, medical risk factors, fracture severity, time to fixation, operative approach, primary subtalar arthrodesis, and surgeon experience., Results: Wound complications were observed in 21% (87/405) of fractures, of which 33% (29/87) required operative intervention. Male sex (P = .032), smoking (P = .028), and the extensile lateral approach (P < .001) were associated with higher complication rates. Fractures treated with an extensile lateral approach had an overall wound complication rate of 32.1%, while those treated with a sinus tarsi or percutaneous approach had an overall wound complication rate of 8.3% (odds ratio [OR], 5.3; 95% confidence interval [CI], 2.9-9.5; P < .001). Among patients treated with an extensile lateral approach, delayed operative fixation did not decrease wound complication rates despite comparable fracture severity across time points. In contrast, among fractures treated with less invasive approaches, delayed fixation beyond 2 weeks resulted in a significantly increased wound complication rate of 15.2% as compared to a wound complication rate of only 2.1% among fractures treated within a week of injury (OR, 3.2; 95% CI, 1.3-9.5; P = .01). This was observed despite similar fracture severity across time points. Primary subtalar arthrodesis did not impact complication rates. A higher wound complication rate among senior surgeons was likely secondary to their predilection for the extensile lateral approach., Conclusion: Delaying definitive fixation of closed, intra-articular calcaneus fractures did not decrease wound complication rates when using the extensile lateral approach, and we found an increased wound complication rate when using less invasive approaches., Level of Evidence: Level III, observational study., (© The Author(s) 2015.)

Background: The purpose of this study was to determine whether obtaining a radiograph of the uninjured contralateral calcaneus (template) before surgery allowed for more precise restoration of Bohler's angle and calcaneal length when performing open reduction internal fixation (ORIF) of intra-articular calcaneus fractures., Methods: Patients who sustained an intra-articular calcaneus fracture requiring surgery who met inclusion criteria were prospectively randomized into those who had a preoperative template obtained for review at the time of ORIF (group 1) versus those who had the contralateral radiograph obtained after surgery (group 2)., Results: There was no benefit of the preoperative template in allowing for more anatomic restoration of Bohler's angle or calcaneal length. Operative time was decreased with the use of a preoperative template when using the extensile lateral or percutaneous approaches., Conclusion: Preoperative templating of the uninjured contralateral calcaneus did not allow for more anatomic reduction or restoration of pre-injury morphology of the calcaneus undergoing operative fixation as based on Bohler's angle and calcaneal length. Templating may be of benefit by reducing operative time., Level of Evidence: Level II, prospective comparative series., (© The Author(s) 2014.)

Background: Ball and socket ankle (BASA) deformity is a rare condition. Little is known about outcomes and treatments in the adult population., Methods: Retrospective comparative review was performed of 13 patients treated for BASA with a minimum follow-up of 2.5 years. Evaluation included clinical and radiographic review, outcome scores, a questionnaire, and a subjective satisfaction survey., Results: Nine patients with correctable valgus deformity not associated with arthritis of the ankle joint underwent a supramalleolar osteotomy (SMO). Four patients underwent arthrodesis-2 a tibiotalocalcaneal (TTC) arthrodesis and 2 a pantalar arthrodesis. AOFAS scores improved from 30.1 to 77.6 (range, 16-82) (P < .05) in the SMO group. AOFAS scores improved from 24 to 60.5 (range, 16-66) (P < .05) in the arthrodesis group. Arthritis grade in the SMO patients was unchanged in 4 patients at final follow-up and worsened in 5 patients by only 1 grade. Nine patients reported good results (all 4 arthrodesis patients, 5 SMO patients) and 4 reported fair results (all SMO patients)., Conclusions: BASA deformity and dysfunction can be improved with corrective surgery., Level of Evidence: Level III, prospective comparative study.

Background: Dorsal plate fixation is used commonly for arthrodesis of the hallux first metatarsophalangeal (MTP) joint. Custom dorsal plates incorporating locking technology have been developed recently for applications in the foot to provide relative ease of application and theoretically superior mechanical properties. The purpose of this study is to compare the radiographic and clinical outcomes of patients undergoing hallux MTP joint arthrodesis using a locked plate, or a nonlocked plate., Materials and Methods: We compared consecutive patients who underwent hallux MTP arthrodesis for a variety of diagnoses with either a precontoured locked titanium dorsal plate (Group 1) or a precontoured, nonlocked stainless steel plate (Group 2). All patients were evaluated with radiographs, visual analog pain scale, American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, and a detailed patient satisfaction survey., Results: There were 73 feet in Group 1 and 107 feet in Group 2. There was a trend toward a higher nonunion rate in Group 1 compared to Group 2. When considering only patients without rheumatoid arthritis (RA), the union rate was significantly higher in Group 2 compared to Group 1. Hardware failure and the overall complication rate was equivalent between the two Groups., Conclusion: As locked plate technology continues to gain popularity for procedures in the foot, it is important that clinical outcomes are reported. Locked titanium plates were associated with higher nonunion rates. Improved plate design, patient selection, and an understanding of plate biomechanics in this unique loading environment may optimize future outcomes for hallux MTP arthrodesis.

Background: The objective of this study was to evaluate the Lapidus procedure or it's modifications for treatment of recurrent hallux valgus (HV). Our hypothesis was that the Lapidus procedure would achieve good correction of recurrent HV and patients would be satisfied., Materials and Methods: A retrospective review of 32 feet (30 patients) treated with the Lapidus procedure for recurrent HV with at least 1-year followup was performed. Evaluation included radiographs, examination, and chart review. Outcomes were assessed with a pain visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, SF-12, Revised Foot Function Index (RFFI), and a survey. Twenty-three of 30 patients (25 feet) met the criteria for inclusion in the study and were available for followup evaluation. The average followup was 31.6 months., Results: Arthrodesis was present in 24 out of 25 feet (96%). The time from initial HV correction to revision surgery was 91 months. The initial surgery performed was a distal osteotomy (15), proximal osteotomy (five), exostectomy (two), diaphyseal osteotomy (two), and proximal/distal osteotomy (one). Preoperative evaluation revealed 96% of patients had clinical hypermobility of the first TMT joint and 52% had radiographic findings of instability. The average postoperative AOFAS hallux score was 82.8, SF-12 score was 94.5, and RFFI was 101. The average preoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) were 36.2, 13.6, 18.6 degrees, respectively, which corrected to an average of 15.2, 7.5, 11.7 degrees postoperatively (p < 0.001). The average shortening of the first ray was 2.9 mm. Average pain VAS was 2.4. Eighty-seven percent reported good to excellent results. Using a multivariable linear regression analysis, postoperative HVA along with change in length of the first ray were significant predictors of quality of life based on SF-12 (p < 0.05)., Conclusion: The Lapidus procedure corrected recurrent HV with a low nonunion rate and excellent radiographic correction and patients were satisfied with their outcome., Level of Evidence: IV, Retrospective Case Series

Background: The tibial neurovascular bundle and sural nerve are at risk with errant pin placement during transcalcaneal pin placement. The purpose of this study was to determine a relative safe zone using a single osseous landmark to establish a technique applicable in the presence of trauma. We describe the neural anatomy anatomically and radiographically, giving surgeons a reliable and relatively safe technique for transcalcaneal pin placement., Materials and Methods: Twenty-four cadavers were dissected for the major medial neurovascular structures and the sural nerve. The closest distance from the neurovascular structures to the posterior inferior calcaneus was measured., Results: The mean distance from the posterior inferior calcaneus to the closest major medial neurovascular structure was 3.4 cm (SD ± 0.36; range, 2.6 to 4.1 cm). The mean distance to the sural nerve was 3.4 cm (SD ± 0.54; range, 2.3 to 4.6 cm). According to the 95% confidence intervals, a relative safe zone of 3.1 cm as a radius from the posterior inferior calcaneus was determined., Conclusion: A relatively safe zone of 3.1 cm based on 95% confidence intervals as described as a radius from the posterior inferior calcaneus can be used for transcalcaneal pin placement in most cases without injury to the medial neurovascular bundle or sural nerve. However anatomic variation may result in the neurovascular bundle being within this zone., Clinical Relevance: We describe a surgical technique for reliable placement of a transcalcaneal pin within this relative safe zone and a safe distance from the closest neurovascular structure.

Background: Lesser toe deformities are frequent and bothersome conditions. Many options exist for the treatment of hammertoes and clawtoes. The purpose of this study was to review our experience with the use of an intramedullary fusion device., Materials and Methods: An IRB approved retrospective review was performed to identify 38 toes in 27 patients treated with the StayFuse (Nexa Orthopaedics) device with a mean followup of 31 months. The indications for surgery were primary deformity in 12 toes and recurrent deformities in 26 toes., Results: Union occurred in 23 of 38 (60.5%). The union rate was nine of 12 for primary procedures and 53.8% (14/26) for revisions. Coronal PIP alignment demonstrated no change in 33 of 38 cases (86.8%) and changed in five of 38 (13.2%). Sagittal PIP alignment demonstrated no change in 36 of 38 cases (94.7%), and changed in 2/38 (5.3%). Including nonunion, the overall complication rate was 55.3% (21/38) (15 nonunions; three hardware failures (two (bent) not requiring intervention and one (broke) leading to a rotational deformity requiring revision), one intraoperative fracture (without sequelae), one requiring MP surgery, and one requiring a larger implant. The index surgery for all three of the patients that required a second surgery was for a recurrent deformity. All three patients requiring a second surgery occurred in the nonunion group., Conclusion: The StayFuse intramedullary fusion device was efficacious in maintaining PIP alignment in the treatment of lesser toe deformities with a relatively low reoperation rate at mid-term followup.

Background: The purpose of this study was to retrospectively review the results of patients treated with hallux MTP joint arthrodesis using dome-shaped reamers for joint preparation and a precontoured dorsal stainless steel plate for internal fixation., Materials and Methods: A series of 145 patients (155 feet) were identified. Postoperative evaluation included weightbearing radiographs, physical examination, and chart review. Outcomes were assessed with a pain visual analog scale, AOFAS hallux score, as well as a detailed questionnaire and a subjective satisfaction survey., Results: Ninety-eight patients (107 feet) met the criteria for the study. The mean followup was 61 weeks. Revision cases accounted for 18.7% (20/107). Rheumatoid arthritis (RA) was present in 32.7% (35/107). The average postoperative AOFAS hallux score was 79.7 and pain VAS was 19. The average pre- and postoperative hallux valgus angle was 26.5 and 12.3 degrees, respectively (p < 0.05). Eighty-nine of 107 patients (83.1%) reported good to excellent results at final followup. Discomfort related to prominence of the plate occurred in 14.9% (16/107). The nonunion rate was 12.1% (13/107). The nonunion rate for patients with/without RA was 22.9% (8/35) and 6.9% (5/72), respectively (p < 0.05). Patients with a nonunion noted more hardware related pain than those with a union (p < 0.05)., Conclusion: First MTP joint arthrodesis using this technique achieves a high union rate. RA patients have a lower union and higher complication rate.

Background: Tibialis anterior tendon rupture is an uncommon injury that can cause significant functional deficit. Recent series have supported surgical reconstruction in younger, more active patients. We investigated our clinical outcomes of patients having undergone surgical management of tibialis anterior tendon ruptures., Materials and Methods: Fifteen tibialis anterior tendon ruptures in 14 patients were retrospectively reviewed after surgical management. Five had primary repair, while 10 had tendon transfers. Average age at time of surgery was 70.6 years with an average followup of 27.2 months. Patients were evaluated with American Orthopaedic Foot and Ankle Society (AOFAS) and SF-36 clinical outcome scores. Strength measurements utilizing a dynamometer and range of motion (ROM) were documented on the operative and non-operative ankles. Patient satisfaction surveys were performed., Results: Average postoperative AOFAS hindfoot score was 88.8 and SF-36 score was 76.4. There was a statistically significant difference in average dorsiflexion strength of 21.8 lbs/in(2) on the operative side and 28.8 lbs/in(2) on the non-operative limb, and in dorsiflexion ROM of patients that received a gastrocnemius recession. There was no statistically significant difference between primary tendon repair versus tendon transfer groups nor plantarflexion strength or ROM among any group. Patient surveys revealed that seven patients were completely satisfied, six had minor reservations, and one had major reservations. There were no complications., Conclusion: This study supports the surgical repair or reconstruction of the tibialis anterior tendon ruptures to restore functional strength and ROM.