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This literature review examines the relative placement of the interbody cage with respect to the unilateral screw construct to address the need for bilateral screw placement versus unilateral screw placement. Transforaminal lumbar interbody fusion (TLIF) has become a widely used technique for correcting lumbar intervertebral pathologies. This review addresses the necessity for further study on the effects of the relative position of intervertebral cage placement on the outcome of lumbar spine surgery after TLIF with unilateral pedicle screw fixation. Previous studies have addressed various factors, including posterior screw fixation, cage size, cage shape, and number of levels fused, that impact the biomechanics of the lumbar spine following TLIF. A simple survey of the literature was conducted. A search of the English literature was conducted using the keywords ‘TLIF,’ ‘transforaminal lumbar interbody fusion,’ ‘graft placement,’ ‘graft position,’ ‘cage position,’ ‘cage placement,’ ‘unilateral pedicle screw,’ ‘unilateral TLIF cage placement,’ ‘lumbar biomechanics,’ ‘lumbar stability,’ ‘lumbar fusion,’ and ‘lumbar intervertebral cage’ with various combinations of the operators ‘AND’ and ‘OR’ and no date restrictions. Seventeen articles in the English literature that were most relevant to this research question were identified. To the best of our knowledge, there are no published data addressing the effects of cage placement relative to the unilateral screw on lumbar stability in TLIF with unilateral pedicle screw fixation. Investigation of the effects of cage placement is, thus, warranted to achieve optimal clinical outcomes in patients undergoing TLIF with unilateral pedicle screw fixation.

Category: Other Introduction/Purpose: Studies have shown that patients enrolled in Medicaid have difficulty obtaining access to care compared to patients with private insurance. Whether variables such as geographic location, state expansion vs. non-expansion, and private versus academic affiliation affect access to care among foot and ankle surgery patients enrolled in Medicaid has not been previously established. Methods: Twenty providers from each of five Medicaid-expanded and five non-expanded states in different U.S. geographic regions were randomly chosen via the American Orthopaedic Foot & Ankle Society (AOFAS) directory. One investigator contacted each office requesting the earliest available appointment for their fictitious relative’s acute Achilles tendon rupture or hallux valgus. Investigator insurance was stated to be Medicaid for half of phone calls, and Blue-Cross Blue-Shield (BCBS) for the other half. Appointment success rate and average time to appointment were compared between private insurance and Medicaid. Results were further compared across geographic regions, between private and academic practices, and between urgent acute injury (Achilles rupture) and chronic non-urgent injury (hallux valgus). Results: Appointments were successful for all 100 (100%) calls made with BCBS, in comparison to 73 of 100 calls (73%) with Medicaid (p

Category: Sports, Trauma, Cadaver study Introduction/Purpose: Jones fractures are fractures of the proximal fifth metatarsal involving the metaphyseal-diaphyseal junction. They have an increased risk for refracture, delayed union and nonunion secondary to poor blood supply to this área. They are usually treated conservatively, but when chosen for surgical treatment percutaneous fixation with screws is the most used. Few studies have evaluated the complications of injury to nearby structures during the percutaneous fixation. It has been shown, however, that the peroneal brevis and longus, the cuboid, and the sural nerve lie in close proximity to this starting point and are, therefore, at theoretical risk of injury. The study aims to evaluate the presence of injury of the structures at risk and to measure the distance of these structures to the entry point. Methods: Eleven fresh-frozen below-the-knee specimens underwent standard operative fixation for a Jones fracture via the “High and inside” percutaneous technique. A guide wire was placed through the medullary canal and confirmed on fluoroscopy. The cannulated drill with drill sleeve was then placed over the wire and advanced to the diaphysis. The guide wire was left and the skin and subcutaneous tissues were carefully removed from the lateral midfoot to fully expose the structures at risk. The guidewire was then removed, and then the solid screw was placed. Neurovascular and tendinous structures were assessed for any injury. The distance of the wire in the base of fifth metatarsal and these structures was measured and documented, including the branches of the sural nerve, cuboid, fourth metatarsal, peroneus longus, and peroneus brevis tendons. Results: The structure with the shortest average distance from the pin was the peroneus brevis, measuring 0.91 mm (±1.22 mm S.D.), followed by the cuboid articular surface, sural nerve, peroneus longus, and base of the fourth metatarsal, respectively. The pin had damaged the peroneus brevis in 5 of 11 cadavers. However, it did not damage at the tendon insertion point in any specimen. The average distance from the tendon insertion point was 7.2 mm. The furthest measured distance was 10 mm, while the closest was 3 mm. The screw head contacted the articular surface of the cuboid in 3 of 11 cadavers. There were no instances of pin contact with or damage to the peroneus longus, sural nerve, or fourth metatarsal head. Conclusion: This is the only study that evaluated the risk of injury the structures after a procedure that simulated an actual surgical act. It is also the only one that was aware of the risk of tendon injury not only in its insertion but also in its path during the placement of the wire and drill. We conclude that percutaneous fixation of fractures of the base of the fifth metatarsus presents a risk of partial lesion of the peroneus brevis tendon and lateral aspect of the cuboid. Therefore, specific care with these structures can be taken during the procedure.

Category: Ankle, Arthroscopy, Basic Sciences/Biologics Introduction/Purpose: Subtalar fusion is the treatment of choice for subtalar arthritis when conservative management fails. Subtalar fusion can be done through open approach or arthroscopic technique. Arthroscopic technique is associated with rapid recovery; however, it requires adequate training and skill. Arthroscopic technique can be done through lateral or posterior portals. Sometimes it may be necessary to use accessory portal to open or distract the joint for adequate joint preparation. Use of accessory portal may result in injury to the neurovascular structure. Whatever the technique, one of the most important aspects of fusion is adequate preparation of the joint. Aim of our study is to compare the preparation of subtalar joint using sinus tarsi open approach and posterior subtalar scopy using 2 portal technique in cadaveric specimens. Methods: We used 20 below knee fresh-frozen cadaver legs for this cadaveric study. Subtalar joints of ten specimens were prepared through the lateral approach, while the remaining ten joints were prepared using sinus tarsi incisions. After the completion of preparation, all ankles were dissected open, photographic images of calcaneal and talar articular were taken. (Image)Surface areas of each articular facet and prepared area of the talus, distal tibia, and distal fibula were measured and analyzed. Results: Open technique results in better preparation of joint surface in calcaneus and overall. While open technique results in preparation of 92% joint surface (combined talus and calcaneus), arthroscopic technique results in in 80% of joint surface. Open technique results in better preparation of calcaneus (79vs 94%). The anterolateral corner of calcaneus was difficult to be reached using the scope and unprepared in most cases. There was no significant difference in the preparation of talar articular surface. (Table 1) Conclusion: Open sinus tarsi results in more joint preparation compared to 2 portal posterior arthroscopic technique. The less amount of joint preparation in arthroscopic technique is mostly due to less preparation of AL corner. Of calcaneus. When using posterior arthroscopic technique, it is advisable to use accessory portal to distract the joint to aid in adequate preparation.

Category: Ankle, Arthroscopy, Basic Sciences/Biologics, Sports Introduction/Purpose: The Broström Gould procedure is the gold standard for repair of lateral ankle ligament injury and ankle instability. This procedure has demonstrated excellent short- and long-term outcomes in the orthopaedic literature. Arthroscopic Broström Gould techniques have become increasingly popular among some foot and ankle orthopaedic surgeons. Typically, this technique requires standard medial and lateral portals along with an accessory lateral working portal. The exact location of this portal is variable within the available described surgical techniques. The objective of this cadaveric study is to establish a standard entry point for and to assess the safety of the accessory lateral portal with respect to nearby anatomical structures. Methods: Ten fresh-frozen below-knee cadaver specimens were used. The location of the accessory portal was created 1.5 cm anterior to the distal tip of the fibula. A small vertical incision was made at this point, followed by insertion of a Kirschner wire into the joint. The wire was then gently impacted into the fibula. Superficial dissection was subsequently carried out around the entry point to identify the peroneal tendons, superficial peroneal nerve branches, and sural nerve branches. Structures were marked with colored push pins, and distance was measured between the nearest edge of the Kirschner wire and each of the three anatomic structures listed. Any instances of structural contact or damage were documented. Results: The average distance from the Kirschner wire to the peroneal tendon was 16.1 (±4.41) mm. The average distance from the wire to the superficial peroneal nerve and sural nerve was 13.11 (±6.79) mm and 12.33 (±4.08) mm, respectively. There were no instances of injury to any of the studied structures. However, there was a notable amount of variability in the proximity of structures in question for each cadaver. A branch of the superficial peroneal nerve was measured as close as 2 mm and as far as 24 mm in separate cadaver specimens. Conclusion: Arthroscopic Broström Gould procedures are a safe and effective method for lateral ankle ligamentous repair but are not without risk. Accessory lateral portal placement is relatively safe but should be meticulously executed to avoid damage to nearby anatomical structures.

Category: Post-operative Driving Introduction/Purpose: For many patients, returning to driving after right foot and ankle surgery is a concern, and it is not uncommon for patients to ask if driving may be performed with their left foot. A paucity of literature exists to guide physician recommendations for return to driving. The purpose of this study is to describe the driving habits of patients after right-sided foot surgery and assess the safety of left foot driving using a driving simulator. Methods: Patients who underwent right foot or ankle operations between January 2015 and December 2015 were retrospectively identified. A survey assessing driving habits prior to surgery and during the recovery period was administered via REDCap database through email or telephone. Additionally, simulated driving scenarios were conducted using a driving simulator in 20 patients to compare characteristics of left versus right foot driving. Results: Thirty six of 96 (37%) patients who responded to the survey reported driving with the left foot postoperatively. No trends were found associating left foot driving prevalence and socioeconomic status. In driving simulations, patients exceeded the speed limit significantly more (p