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Background: The preferred method of fixation and surgical treatment for ligamentous Lisfranc injuries is controversial. Transarticular screws, bridge plating, fusion, and flexible fixation have been described, yet none have demonstrated superiority. Furthermore, screw fixation and plating often require secondary surgery to remove implants, leading surgeons to seek alternative fixation methods. Purpose: To compare transarticular screws and a fiber tape construct under a spectrum of biomechanical loads by evaluating the diastasis at 3 joints in the Lisfranc complex. Study Design: Controlled laboratory study. Methods: Eight matched pairs of fresh, previously frozen lower extremity cadaveric specimens were fixed with either 2 cannulated transarticular crossed screws or a fiber tape construct with a supplemental intercuneiform limb. The diastasis between bones was measured at 3 midfoot joints in the Lisfranc complex: the Lisfranc articulation, the second tarsometatarsal joint, and the intercuneiform joint. Measurements were obtained for the preinjured, injured, and fixation conditions under static loading at 50% donor body weight. Specimens then underwent cyclic loading performed at 1 Hz and 100 cycles, based on 100-N stepwise increases in ground-reaction force from 100 to 2000 N, to simulate postoperative loading from the partial weightbearing stage to high-energy activities. Failure of fixation was defined as diastasis ≥2 mm at the Lisfranc articulation (second metatarsal–medial cuneiform joint). Results: There were no significant differences in diastasis detected at the Lisfranc articulation or the intercuneiform joint throughout all loading cycles between groups. All specimens endured loading up to 50% body weight + 1400 N. Up to and including this stage, there were 2 failures in the cannulated transarticular crossed-screw group and none in the fiber tape group. Conclusion: The fiber tape construct with a supplemental intercuneiform limb, which does not require later removal, may provide comparable biomechanical stability to cannulated transarticular crossed screws, even at higher loads. Clinical Relevance: Ligamentous Lisfranc injuries are common among athletes. Therefore, biomechanical evaluations are necessary to determine stable constructs that can limit the time to return to play. This study compares the biomechanical stability of 2 methods of fixation for ligamentous injury through a wide spectrum of loading, including those experienced by athletes.

Background: Osteochondral lesions of the talus (OLT) often require advanced imaging if they prove to be refractory to preliminary microfracture. Orthopedic surgeons may misinterpret the size and morphology of the OLT when evaluating through conventional methods. The purpose of this study was to evaluate MRI as a modality for calculating true-volumes and compare its utility to that of CT true-volume and conventional methods of measuring lesion size. Methods: With IRB approval, an institutional radiology database was queried for patients with cystic OLT that had undergone and failed microfracture and had compatible CT and MR scans between 2011 and 2016. Five lesions, previously analyzed and described in the literature using CT true-volume, were selected. 10 orthopedic surgeons independently estimated the volume of these 5 OLT via standard MRI. Next, 3D reconstructions were created and morphometric true-volume (MTV) analysis measurements of each OLT were generated. The percent change in volumes from CT and MR was compared based upon MTVs determined from 3D reconstructive analysis. Results: The volume calculated using conventional methods in CT and MR scans grossly overestimated the size by of the OLT by 285-864% and 56-374% respectively when compared to 3D true-volume analysis of those CT and MR scans. Conclusions: This study demonstrates that true-volume is more accurate for calculating lesion size than conventional methods. Additionally, when comparing MRI and CT, thin slice CT true-volume is superior to MRI true-volume. True-volume calculation improves accuracy with CT and MRI and should be recommended for use in revision OLT cases. Levels of Evidence: Level III: Case control study

Category: Ankle; Hindfoot; Midfoot/Forefoot Introduction/Purpose: Adult-acquired flatfoot deformity (AAFD) is a complex pathology of the foot that often results from dysfunction of the posterior tibial tendon (PTTD) and encompasses a wide spectrum of deformity. A high-degree of continued morbidity following flatfoot reconstruction exists for which prognostic indicators of future poor outcomes are uncertain. AP and lateral weight-bearing radiographs are commonly utilized to assess the severity of deformity including forefoot abduction, medial arch collapse, and hindfoot valgus. However, the relationship between pre-operative radiographic severity of deformity and predilection for future surgical treatment failure remains uncertain. The purpose of this study was to perform pre-operative radiographic measurements of patients with stage IIb PTTD and determine which preoperative radiographic parameters, if any, predict future surgical treatment failure. Methods: Following IRB approval, an institutional electronic medical record database was queried from January 2000-2014 to identify all patients undergoing surgical correction for stage IIb PTTD. 256 patients with stage IIb PTTD underwent medial displacement calcaneal osteotomy and flexor digitorum longus transfer, with possible spring ligament repair and/or Achilles lengthening. Patients undergoing concomitant lateral column lengthening or midfoot fusion, patients with previous hardware, and patients with incomplete medical records were excluded. Preoperative radiographs were retrospectively analyzed to assess preoperative deformity. Talonavicular coverage angle was measured using AP radiographs. Lateral radiographs were used to measure talar-1st metatarsal angle (Meary’s) angle, calcaneal pitch and medial cuneiform-floor height. Patient charts were also reviewed to determine whether patients experienced treatment failure, defined as return to the operating room for unplanned revision surgery (e.g. broken/painful hardware, nonunion, residual deformity, infection, nerve damage, blood clot/DVT). The degree of pre-operative deformity was compared between treatment failure and non-failure groups. Results: Out of the 256 patient cohort, a total of 58 patients (22.7%) experienced treatment failure indicated by the need for an unplanned revision surgery, while 198 patients (77.3%) did not experience failure. There were no significant differences in the severity of pre-operative radiographic deformity between the treatment failure and non-failure groups including Meary’s angle (p = 0.93), calcaneal pitch (p = 0.70), talonavicular coverage angle (p = 0.99), and medial cuneiform height (p = 0.52, Table 1). Conclusion: The results of this study show that there is no significant difference in pre-operative radiographic deformity between patients who experienced failure versus non-failure following surgical flatfoot correction suggesting that the degree of pre- operative deformity is not significantly associated with an increased risk for future surgical failure. The analysis of these results, may underscore the relative importance of the physical exam in the evaluation of patients with symptomatic stage IIb PTTD and a relative lack of prognostic value in radiographic parameters commonly used to describe patients’ deformity. [Table: see text]

Category: Ankle; Sports Introduction/Purpose: Augmentation of the Broström procedure with FiberTape device has been described for the treatment of chronic ankle instability. However, it has yet to be determined if the cost of the implant is negated by the benefits to the patient. The purpose of this study was to perform a comprehensive cost analysis by comparing the cost of surgical procedure, physical therapy visits, time off work, and any costs related to revision surgery between the Broström reconstruction with suture anchors alone versus augmentation with a FiberTape device. Methods: 166 patients undergoing lateral ankle ligament repair were analyzed retrospectively. Patients underwent either a modified Broström ligament repair with two suture anchors or Broström ligament repair with FiberTape augmentation. All patients followed the same post-operative protocol for early weight bearing and initiation of physical therapy once the wound was healed. Timing of return to work and the total number of visits of physical therapy before discharge were recorded. Implant costs, facility charges and professional fees were obtained from billing records. Lost income for missed days of work was based on the Pennsylvania Bureau of Labor Statistics. Complications requiring return to the operating room were recorded. Patients were followed out to one year. Results: Aggregate cost in the modified Broström group was $2,219 more expensive than when augmenting with FiberTape ($20,970 vs. $18,751) despite an increased implant cost of $900. This difference was the result of a greater number of therapy visits and days out of work in the modified Broström group versus the augmentation group (14.9 vs 12.4) as well as a significantly higher amount of days out of work in the modified Broström group versus augmentation (63.3 vs. 53.8 days respectively). No statistically significant difference was found for operation time between groups, and failure rates were similar; 2.0% (1/49) for FiberTape and 3.4% (4/117) for modified Broström. Conclusion: The aim of this study was to explore the cost comparison of the modified Broström procedure for chronic ankle instability versus the FiberTape augmentation. Despite an upfront increase in implant costs, the average cost per procedure was lower for the augmentation group. The majority of cost savings occurred in decreases in the number of physical therapy visits and faster return to work times. The results of this study suggest that the use of FiberTape to augment modified Broström repair may have a financial benefit and cost savings to patients and the healthcare system.

Category: Lesser Toes; Midfoot/Forefoot Introduction/Purpose: Hammertoe deformities are the most common pathology of the forefoot, accounting for up to 48% of all forefoot operations. There is currently limited evidence documenting differences in foot radiographs and radiographic measurements that may represent a predisposition to developing hammertoe deformity. The purpose of this study was to investigate whether patients with hammertoe deformity demonstrate increased radiographic measurements of first, second, or third metatarsal (MT) lengths as well as Meary’s angle compared to a healthy control group. Methods: Following IRB approval, an institutional radiology database was queried from January 2009-2018 for patients with ICD- 9 and ICD-10 diagnosis codes for hammertoe deformity of the 2nd or 3rd phalange. Control cases were selected using diagnosis codes for acute plantar fascial pain in the same timeframe with medical record review to exclude patients with prior lower extremity injury, surgery or pathology. 234 hammertoe and 110 control patients met inclusion and exclusion criteria. Automated 1:1 case-control matching was performed to control for age, sex and laterality. Following matching, the sample size consisted of 80 patients in each cohort. Proximal to distal end-to-end articular surface radiographic lengths were documented for metatarsals and phalanges of the 1st, 2nd and 3rd rays on anteroposterior radiographs. Lateral talar-first metatarsal (Meary’s) angle was measured using weightbearing sagittal radiographs by calculating the angle formed by lines that bisect the talar neck and anatomic neck of the first metatarsal. Results: A total of 160 patients (80 cases and 80 controls) were included in the study. Mean age was 47.7 years among hammertoe cases and 47.5 years among controls (p=0.92). 54 of 80 cases in each group were female. There was a statistically significant increase in the average Meary’s angle among hammertoe patients (5.23 +- 8.60°) compared to controls (2.15 +- 5.96°) (pConclusion: Patients with hammertoe deformity were associated with an increased length on the 1st, 2nd and 3rd metatarsals. Also, these patients demonstrated an increased Meary’s angle creating pes planus deformity. These results illustrate the importance of both medial column instability and long metatarsal length in the development of hammertoe deformity. [Table: see text]

Charcot neuropathic arthropathy is a debilitating, rapidly destructive degenerative joint disease that occurs in diabetic, neuropathic midfoot. Clinicoradiologic assessment for Charcot neuropathic arthropathy previously relied on Eichenholtz stage. There is limited histopathologic data on this entity. We wanted to independently develop a histopathologic scoring system for Charcot neuropathic arthropathy.Retrieval of surgical pathology midfoot specimens from Charcot patients (2012-2019) were analyzed to evaluate joint soft tissue and bone. Considering progression from large (≥half 40× hpf) to small (half 40× hpf) periarticular bone fragments to resolution, we devised and applied a Charcot neuropathic arthropathy novel FEMASK-score (named after coauthors: Fanburg-Smith, Frauenhoffer, Flemming, Fritsche, Elfar, Murie, Aynardi, Stauch, Smith, King, and Klein): 0 (initial) = the observed intraneural arteriolosclerosis in all diabetic neuropathic patient specimens (not observed in other diabetic nerves); and finally scored with the most destruction observed: 1 = large bone fragments without host histiocytic response; 2 = mixed bone fragments with host histiocytic response; 3 = small minute bone spicules resorption to fibrosis. Eichenholtz stage and outcome were then compared.Forty-eight cases of Charcot neuropathic arthropathy included 34 males and 14 females, mean age 60.3 and age range 28-83 years, with clinical diabetes mellitus (predominantly Type II) and longstanding neuropathy. Elevated HbA1C, Eichenholtz stage, American Society of Anesthesia score, and Charlson comorbidity index indicated initial clinical amputation. Pathologic specimens varied from fixation tissue to amputation. In addition to neurotraumatic, neurovascular and inflammatory findings, a distinctive intraneural hyalinized arteriolosclerosis was observed. FEMASK-scores: 1 = 10%, 2 = 58%, and 3 = 32%. Score comparisons were 98% accurate compared with Eichenholtz and 98% reproducible among pathologists. FEMASK 2 and 3 correlate with clinical need for amputation.Our novel Charcot neuropathic arthropathy FEMASK-score classification, derived from the largest cohort of diabetic neuropathic specimens, is reproducible, explains pathophysiologic progression of destructive phase of Charcot, correlates with Eichenholtz, and predicts progression to or clinical need for amputation. The unique intraneural vasculopathy observed contributes to Charcot neuropathic arthropathy etiology.

Objectives: Use of Cannabis is common amongst athletes and the U.S. population at large. Use of Cannabinoid Oil is being increasingly utilized for a number of different pathologies, injuries, and ailments due to anecdotal evidence of its efficacy. Due to the current United States Opioid crisis, Δ9-Tetrahydrocannabinol (THC) and Cannabidiol (CBD), the two major constituents of cannabis, are currently being evaluated as potential safer alternatives to narcotic pain medicines. The effects of recreational and/or therapeutic THC and CBD on musculoskeletal injury and healing however remain largely unknown. Our purpose was to evaluate the biomechanical effects of THC and CBD on tendon to tendon healing in a Sprague Dawley Achilles Tendon injury and surgical repair model. Methods: 33 Sprague Dawley rats were randomly assigned into control (1 ml/kg/day of vehicle containing 5% Cremaphor, 5% ethanol, and 0.9% saline n=12), THC (3 mg/kg/day n = 12), or CBD (3 mg/kg/day n=9) treatment groups. Surgical transection and repair of the Achilles tendon was performed and all rats began subcutaneous administration of their respective drug treatment the day of surgery and for 4 subsequent days, followed by sacrifice. Load to failure and stiffness were calculated from load displacement data during tensile load testing on a MTS machine. One-way ANOVA with heterogeneous variance was utilized for evaluation. Means and 95% confidence intervals were also determined. Results: The CBD group demonstrated the highest mean load to failure of 17.5 N (15.1-19.8 N), with the THC group having the second highest mean load to failure at 17.3 N (15.3-19.2 N), and the control group reporting the lowest at 15.2 N (12.1-18.3 N). No statistical difference was observed between CBD/control (p = 0.25), THC/control (p = 0.29), or CBD/THC groups (p = 0.92, Figure 1A). The THC group reported the highest mean stiffness of 3.9 N/mm (2.7-5.1 N/mm). The CBD and control groups demonstrated mean stiffness values of 3.5 N/mm (2.9-4.1 N/mm) and 3.5 N (2.7-4.3 N/mm), respectively. No statistically significant differences were observed between THC/control (p = 0.51), THC/CBD (p = 0.50), or CBD/control groups (p = 0.96) for stiffness (Figure 1B). Conclusion: Our investigation demonstrates that subcutaneous administration of CBD resulted in the highest mean load to failure while THC administration resulted in the highest mean stiffness of the three groups. This did not result however in a statistically significant difference between groups. In our small animal tendon-to-tendon repair model, use of THC or CBD did not result in decreased biomechanical characteristics, and there was a trend toward improved ultimate strength and stiffness as compared to control. Further evaluation with larger numbers of animals, and evaluating the potential synergistic effects of THC and CBD administered together are warranted. [Figure: see text]

Tibiotalocalcaneal (TTC) arthrodesis with a nail can be an effective salvage procedure for several foot and ankle pathologies, but has a relatively high complication rate. The purpose of this study is to investigate risk factors associated with complications after TTC arthrodesis with a nail.Clinical and radiographic outcomes for 82 patients from 2012 to 2016 who underwent TTC arthrodesis with a nail were retrospectivelyevaluated to determine if patient or surgeon specific variables offered prognostic value in predicting negative outcomes.Diabetes, diabetic neuropathy, high (2) American Society of Anesthesiologists (ASA) classification, and Charcot neuroarthropathy all were predictive of developing a nonunion in either the subtalar ortibiotalar joints (p0.05). Diabetic neuropathy was predictive ofreoperation, and along with HbA1C7.5 was also predictive of hardwarefailure. The odds ratio (OR) for diabetic neuropathy was 2.99 (p0.05)for nonunion in the tibiotalar or subtalar joints, 3.46 (p0.05) for reoperation,and 4.11 (p0.05) for hardware failure. High ASAclassification had an odds ratio of 3.93 (p0.05) for nonunion in the tibiotalar or subtalar joints as well. Diabetes had an odds ratio of 2.57 (p0.05) for nonunion.Patients with diabetic neuropathy, Charcot neuroarthropathy, elevated HbA1C, and ASA classification2 demonstrated a higher complication rate in patients undergoing TTC arthrodesis with a nail.

Category: Midfoot/Forefoot Introduction/Purpose: Outcomes following surgical reconstruction for acquired flatfoot deformity secondary to posterior tibial tendon dysfunction have been well described. However, the majority of studies have a limited number of patients or short to mid- term follow-up. The purpose of this study was to report the natural history, demographics, and mechanisms of treatment failure for patients undergoing flatfoot reconstruction at a single institution by a single surgeon. Methods: With IRB approval, 321 consecutive patients undergoing flatfoot reconstruction during a 14-year period were included in this study (February 2002 through October 2016). All procedures were performed by a single surgeon (PJJ) at our institution. Demographic data, surgical data, clinic notes, and radiographs were available for review. Exclusion criteria included patients without electronic records or incomplete data. Failure was defined as a need to return to the operating room for revision surgery. Statistical analysis was performed. Results: 321 consecutive patients underwent flatfoot reconstruction from 2002-2016. The majority of patients were female (83.2%) with left laterality (58.6%) & a body mass index classified as overweight (21.5%) or obese (56.4%). 13.7% of patients were diabetics, and 18.4% were current smokers. 54 patients (16.8%) experienced treatment failure. Painful calcaneal hardware requiring removal occurred in 11.8% of patients, conversion to triple arthrodesis occurred in 3.45%, and wound complications or infection requiring irrigation & debridement occurred in 1.87%. There were no mortalities reported within 90 days. There were 3 symptomatic deep vein thromboses, none requiring surgical intervention, & no pulmonary embolisms. A significant increase in relative risk of treatment failure was calculated for female gender, current cigarette use, & age under 60 (3.4 p=0.0005/1.9 p=0.0081/1.8 p=0.042). Conclusion: This study represents the largest series of patients undergoing flatfoot reconstruction by a single surgeon at a single institution. Although retrospective, the results provide valuable insight to the natural history of patients undergoing this procedure. The overall complication rate and treatment failure rates are low and similar to those previously reported in the literature. Patients with female gender or under 60 years of age should be notified of their increased relative risk of treatment failure & counseled accordingly. Smoking cessation is recommended to reduce the risk of treatment failure.

Category: Diabetes, Hindfoot, Midfoot/Forefoot, obesity Introduction/Purpose: In recent decades, the prevalence of obesity in the United States has increased dramatically. This can be attributed in-part to the high-fat “Western Diet”. Consequentially, the economic burden of obesity to the healthcare system has rapidly increased, accounting for more than 10 percent of all medical spending in America. Furthermore, with regards to orthopedics, obesity has been shown to be a strong risk factor for musculoskeletal pain, injury, and post-operative complications. The purpose of this study was to determine the effects of high intensity cardiovascular training and controlled dietary intake on body weight, body fat percentage (BFP), and bone mineral density (BMD) in obese and non-obese mice. These results will provide a better understanding of how to optimally facilitate weight loss in obese patients. Methods: Following IAUCUC approval, 8 diet-induced obesity (DIO) C57BL/6 mice were obtained along with 6 non-obese C57BL/6 control mice. DIO mice were fed a high-fat diet (60% fat by kcal) ad libitum starting at the age of 6 weeks. Control mice were fed a standard low-fat diet (10% fat by kcal) ad libitum from birth. Starting at the age of 14 weeks, all mice underwent a controlled high intensity cardiovascular training protocol using a treadmill four times per week at 30 minute intervals. This was carried out for seven weeks including a one-week acclimation period. Speed, distance, and time spent running were all constant between groups. Mouse body weights were recorded several times per week throughout the study. Additionally, BFP and BMD were obtained bi-weekly using dual energy X-ray absorptiometry (DEXA) to assess morphophysiological changes longitudinally. Results: Preliminary investigations with a controlled exercise regimen reveal that obese mice, when fed a high-fat diet, continue to gain weight rapidly despite high intensity cardiovascular training whereas control mice maintain their weight. Following the seven-week training period, control mice gained an average of 1.25 g (p=0.41), while DIO mice gained an average of 8.55 g (pConclusion: The results of this study support the hypothesis that a controlled exercise regimen alone is ineffective for facilitating weight loss. In fact, obese mice administered a high-fat diet actually gain weight despite undergoing a rigorous exercise program. Additionally, simple differences in dietary intake have significant effects on body weight, body fat percentage, and bone mineral density. This suggests that while exercise may play a small role in maintaining a normal weight, obesity is irreversible with exercise alone. Obese orthopedic patients should be counseled on dietary modifications before engaging in an exercise program.

Category: Hindfoot Introduction/Purpose: The pathophysiology of adult-acquired flatfoot deformity (AAFD) is not fully explained by degeneration of the posterior tibial tendon alone. While a shortened or dysplastic lateral column has been implicated in flatfoot deformity in pediatric population, there is no study that has quantified the degree of shortening or dysplasia in adults with a stage IIb flatfoot deformity, or if any exists at all. The purpose of this study was to use reconstructive 3D modeling from computed tomography (CT) scans of the calcaneus in order to perform three-dimensional morphometric measurements of the lateral column in patients with stage IIb posterior tibial tendon dysfunction (PTTD) compared to controls in an effort to better understand the morphology of patients with AAFD. Methods: After IRB approval, an institutional radiology database was queried for patients with PTTD who had CT performed between January 2011 and June 2016. Controls were patients receiving CT scan for an intraarticular distal tibia fracture without preexisting foot or calcaneal pathology. Clinical office notes, physical examination, and weight-bearing radiographs were used to identify patients that met clinical criteria for stage IIb PTTD. A 1:1 match was performed using age, laterality, gender, and BMI. Morphometric measurements of the calcanei were performed involving the length of the calcaneal axis (LCA), height of the anterior process (HAP), and length of the anterior process (LAP) (Figure 1). Linear mixed-effects models were used to assess the differences between control and PTTD patients with respect to LAP, HAP, and LCA measurements, with also considering measurements from 3 independent observers. We considered a difference of ± 4 mm as our threshold of clinical significance. Results: Of the 3586 CT within our institutional database, a total of 14 patients were available for reconstruction and analysis. There were no statistical differences detected between patient characteristics or demographics between these groups. On average, the long axis of the calcaneus (LCA) was 3.1 mm shorter (95% confidence interval: 0.43-5.76 mm) in patients with stage IIb PTTD compared to controls (pConclusion: Our results support the hypothesis that the calcaneus of adult patients with stage IIb AAFD is, indeed, dysplastic when compared to healthy controls, which further supports the utility of LCL. Analysis of these results, taken together with previous literature, may suggest the use of a smaller graft between 4-6 mm as ideal when performing this procedure.