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Category: Sports; Ankle Introduction/Purpose: A symptomatic os trigonum is a common cause of posterior ankle pain that has been traditionally managed with open excision. Minimally invasive surgery (MIS) has been proposed as an alternative to open excision for improved outcomes and decreased complication rates; however, no systematic review to date has examined the utilization of MIS for a symptomatic os trigonum. The purpose of this study was to examine patient outcomes, return to sport, and complications associated with MIS for a symptomatic os trigonum. Methods: A systematic review was performed on February 22, 2023, using the PubMed, CINAHL, MEDLINE, and Web of Science databases from database inception until February 22, 2023, on the topic of MIS for a symptomatic os trigonum. Results: From initial search, 17 articles (N = 435 patients) met inclusion criteria. Mean age of the cohort was 26.01 ± 4.68 years, with a mean follow-up time of 34.63 ± 18.20 months. For MIS patients, the mean preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score was 55.85 ± 12.75, the mean final postoperative AOFAS score was 94.88 ± 4.04, the mean preoperative visual analog scale pain score was 7.20 ± 0.43, and the mean final postoperative visual analog scale score was 0.71 ± 0.48. The mean time to return to sport for patients undergoing MIS was 7.76 ± 1.42 weeks. MIS had an overall complication rate of 5.0%, the majority of which consisted of transient neurapraxia of the sural or superficial peroneal nerve. Conclusion: Minimally invasive management of a symptomatic os trigonum appears to be a viable alternative to open surgery in terms of outcomes, return to sport, and complication rates. More high-quality evidence will be required to definitely recommend minimally invasive approaches as the standard of care over open surgery. [ABSTRACT FROM AUTHOR]

Category: Ankle; Sports Introduction/Purpose: Osteochondral Defects (OCD) can be a painful condition that frequently affect the ankle joint, with talar OCD being more frequent than the tibia ones. Changes in bone density (BD) have been described around the lesion, particularly with sclerosis at the subchondral and cancellous bone of the talus. However, there is a paucity of data describing what happens with the distal tibia bone adjacent to a talar OCD. Weightbearing computed tomography (WBCT) offers a method for quantifying BD via calculation of tomographic Hounsfield units (HU), a quantitative scale for describing radiodensity. The aim of this study was to assess WBCT HU around talar OCD, investigating the pattern of BD distribution in the talus and adjacent tibia secondary to locally altered mechanics and stress concentration. Methods: In this retrospective comparative study, we included patients with talar OCD, either as primary diagnosis or as incidental finding, that underwent WBCT imaging of the foot and ankle. The Volume of Interest (VOI) represented a cube positioned around the talar OCD (width/depth) and length expanding 5mm below the OCD, the OCD, the joint space, and 5mm above the tibial plafond. The HU distribution was obtained along three parallel lines (anterior, central, and posterior aspects of the OCD) positioned inside the VOI, and aligned perpendicular to the joint surface. The same VOI and exact same process was then repeated on the opposite non-lesion side of the talus, that served as a control for normal HU distribution of talus, joint space and tibia. Graphical plots for HU distributions were generated for each line, separating the HU values and distributions in 3 control or 4 segments: talus, osteochondral lesion, joint space and tibia. Results: Thirty-two talar OCD patients (10 males, 22 females) were included. The mean age was 54 years old (range: 22-82 years). Fifty-two percent were symptomatic, and 48% had an incidental OCD finding. There was not significant difference in mean HU along the three lines (anterior, central, and posterior) in any segment (talus, OCL, joint space and tibia) when comparing the symptomatic and incidental OCD patients. However, when comparing talar OCD patients and controls, the mean HU followed a different distribution pattern. In controls, the talus had higher HU average than the tibia, but in OCD patients the tibia demonstrated higher HU than the talus. When comparing the HU in the tibia between OCD and controls, the OCD patients demonstrated significantly increased BD (p<.0001). Conclusion: Our study provides a novel understanding about BD changes in the subchondral bone of the distal tibia in talar OCD patients, with significantly increased bone density when compared to controls, even among asymptomatic cases. The observed increase in bone density in the distal tibia of OCD patients probably demonstrates the local mechanical derangement secondary to the talar OCD, and the tibial response to this derangement, what could potentially explain the pain symptoms in talar OCD patients, as well as the subsequent occurrence of concomitant mirror OCD in the tibia (kissing lesion). Future studies are necessary to further elucidate this issue. [ABSTRACT FROM AUTHOR]

Category: Midfoot/Forefoot; Other Introduction/Purpose: High heeled shoes (HH) have historically been thought to worsen existing hallux valgus (HV). However, no studies have shown if HH contribute to the pathophysiology of HV development. Weightbearing computed tomography (WBCT), distance mapping (DM), and coverage mapping (CM) allows for three- dimensional analysis of the forefoot and has been previously able to detect subtle differences in joint mechanics. However, no study has used WBCT to study 1st metatarsophalangeal (MTP) joint mechanics in HH. The aim of this study was to describe and compare DM and CM of the 1st MTP at varying HH heights. Methods: 10 non-frequent HH wearing volunteers with no underlying foot/ankle pathology received bilateral WBCT scans at four different HH heights: 0 cm, 3 cm, 6 cm, 9cm. A semi-automatic software was used to segment the 1st MTP. Manual selection of the 1st metatarsal head and proximal phalangeal surface was performed. DM and CM differences were statistically evaluated using One-Way ANOVA test and Wilcoxon rank sum test. P values < 0.05 were considered statistically significant. Results: For both DM and CM, there was a statistically significant difference when comparing all HH height parameters to one another (p < 0.0001). When comparing each HH height individually to the 0 cm condition, all heights demonstrated a statistically significiant difference (p < 0.0001). More specifically, the plantar lateral aspect of the 1st MTP joint space demonstrated the greatest change in both DM and CM compared to the control at all HH heights. Conclusion: This study demonstrates for the first time that HH may contribute to the development of HV in previously healthy feet. Interestingly, the plantar lateral aspect of the 1st MTP was the most affected with increasing HH heights. Further research is needed to elucidate the long term effects of HH shoes on forefoot deformity development. [ABSTRACT FROM AUTHOR]

Category: Hindfoot; Trauma Introduction/Purpose: Calcaneal fractures are a common work-related injury that can be treated both operatively and nonoperatively. Operative management typically consists of open reduction with internal fixation via either an extensile lateral or sinus tarsi approach. Conservative treatment employs a combination of immobilization, rest, and elevation. Given that return to work is a critical milestone for many of these patients, it is crucial that the best management option is chosen. While there have been studies that compared operative versus conservative treatment, there has been no summative review on this topic. Thus, the goal of this study was to conduct a systematic review and meta-analysis on the impact of operative versus nonoperative management on return to work outcomes. Methods: MEDLINE (PubMed), Embase (Elsevier), and Cochrane Library were searched for the concepts of calcaneal fracture and return to work. Inclusion criteria consisted of studies that reported on operative or nonoperative treatment of calcaneal fractures and outcomes relating to timing of return to work. Abstract only studies, biomechanical studies, cadaveric studies, case reports, studies involving pediatric patients, and non-English texts were excluded. Factors that were extracted included fracture type, pre-injury workload, mechanism of injury, treatment, return to work, functional outcomes, and complications. Revman 5.3 software was used for meta-analysis. Studies that did not qualify for meta-analyses were described qualitatively. Results: 2462 studies were identified on initial search. 52 texts met inclusion and exclusion criteria. A total of 3338 patients were included. Operative management had significantly improved return to work outcomes compared to nonoperative treatment, with an overall mean difference of 40.79 days [95% Confidence Interval (CI), -69.55 to -12.03, p < 0.05]. Operative treatment was also associated with significantly lower pain scores [Mean difference: -1.14; 95% CI, -2.24 to -0.04, p < 0.05] and higher SF-36 scores [Mean difference: 13.89; 95% CI, 7.69 to 20.10, p < 0.0001]. Operative treatment did have expectedly higher risk of all complications compared to the nonoperative group [Risk Ratio: 1.80; 95% CI, 1.22 to 2.66, p < 0.05]. Conclusion: While operative management was associated with higher risk of complications, patients had improved return to work, pain, and functional outcomes compared to nonoperative treatment. Careful consideration should be taken when determining treatment options for calcaneal fracture patients. Further research is needed to better elucidate differences between operative treatment options. [ABSTRACT FROM AUTHOR]

Category: Sports; Ankle Introduction/Purpose: Ankle sprains are one of the most common acute injuries amongst ballet dancers and may lead to chronic ankle instability. Certain ballet positions, if performed incorrectly or with inadequate technique, can further increase the risk of bone and soft tissue injuries. Dancing en pointe, which forces the foot and ankle into extreme plantar flexion, has been reported as the most common mechanism of injury. While these injuries occur frequently, little research has been done to understand the biomechanics of the foot and ankle in ballet. The aim of this study was to use weightbearing computed tomography (WBCT) and distance mapping to describe ankle joint mechanics in various ballet positions. Methods: This was an institutional review board approved case study analyzing five healthy professional ballerinas. WBCT scans were taken bilaterally in five different positions: a control/neutral position, first position, fifth position, plié, and relevé (en pointe). A semi-automatic software was used to segment models of all bones proximal to the first distal phalanx. Talar dome and gutter articulations were selected manually, and distances along the entire tibiofibular interface and gutter articulations were calculated using a previously published protocol. The mean syndesmosis width was calculated at 1 cm, 3 cm, and 5 cm from the tibiotalar joint. Results: Syndesmotic widening was greatest in first position at 5 cm above the tibiotalar joint (Mean: 9.39 mm). The relevé position consistently had the greatest syndesmotic narrowing at all heights along the syndesmosis. The anteromedial gutter had the largest range in regard to distance mapping, with greatest joint space width in fifth position (Mean: 4.99 mm) and narrowest joint space in plié (Mean: 2.68 mm). More specifically, in fifth position the anteromedial gutter space was 71% wider than the control position. Conclusion: This study is the first of its kind to mechanistically describe the ankle as it relates to ballet dancing. Interestingly, syndesmotic and tibiotalar joint space widening was greatest in first and fifth position, which may suggest that external rotation plays a greater contributing role in ankle instability compared to plantarflexion in ballet. Future research with larger cohorts and more WBCT stress positions is needed to comprehensively understand the foot and ankle joint mechanics in this demanding sport. [ABSTRACT FROM AUTHOR]

Category: Other Introduction/Purpose: The increasing prevalence of foot and ankle procedures in the United States has coincided with rising costs of care, exposing socioeconomic disparities within this area of orthopedics. Insurance payor status is one such factor that can affect the quality and accessibility of medical care and has been implicated in orthopedic patient outcomes. While previous studies in other fields of orthopedics have demonstrated an association between insurance status and access to treatment, length of hospital stay, postoperative outcomes and complication rates, no comprehensive review has explores this relationship in foot and ankle surgery. Thus, the goal of this study is to examine the association between insurance payor status and outcomes in foot and ankle procedures. Methods: A systematic review of five databases was conducted, focusing on the interplay between insurance coverage and foot/ankle procedures. Included studies reported on insurance payor status and patient outcomes following foot and ankle surgery. Extracted outcomes included time to be seen by a provider, complication and revision rates, post-operative Emergency Department (ED)/Urgent Care utilization, readmission rates, hospital length of stay, pain, functional scores, discharge destinations, return to work/activity, and follow-up. Meta-analyses were performed using the Revman 5.3 software. Studies that did not qualify for meta-analyses were described qualitatively. Results: Of 1401 studies identified, 24 texts met inclusion and exclusion criteria. Across the 24 studies, there were a total of 20,950 patients. Noninsured patients had a 59% higher risk of ED/urgent care utilization within 30 days of surgery compared to insured patients [Risk Ratio (RR) = 1.59, 95% Confidence Interval (CI) = 1.18 to 2.12, p < 0.05]. Privately insured patients were seen 3.65 days earlier than patients with government insurance [95% CI = 2.02 to 5.27, p < 0.0001]. Worker's Compensation patients tended to have poorer outcomes, higher pain scores, and lower functional scores. Similarly, Medicaid patients also fared worse on functional scores and had delayed access to appointments and treatments. Conclusion: Patients without private insurance have worser pain and functional outcomes, delayed access to care, and increased utilization of emergency resources following foot and ankle procedures. It is crucial for providers to be cognizant of these discrepancies when caring for patients. Further research is needed to better understand the nuances of these insurance-related disparities within foot and ankle subspecialties. [ABSTRACT FROM AUTHOR]

Category: Hindfoot; Ankle Arthritis Introduction/Purpose: Patients with ankle arthritis often present with concomitant subtalar joint deformity, as the subtalar joint may compensate for ankle malalignment. This compensation in the subtalar joint may manifest as joint space narrowing and sinus tarsi impingement. The objective of this study was to use 3D distance maps (DMs) from weightbearing computed tomography (WBCT) images to see if altering alignment of the tibiotalar joint with total ankle arthroplasty alters alignment of the subtalar joint. We hypothesized that, in patients with ankle arthritis, improving alignment of the tibiotalar joint from total ankle arthroplasty would increase the mean distances across the subtalar joint, indicative of improved alignment. Methods: A retrospective review of WBCT data of randomly selected patients who underwent total ankle arthroplasty between February 2022-July 2023 was performed as a pilot study. Using principal components analysis, the calcaneus was divided into 9 regions on the posterior facet, 4 regions in the sinus tarsi, 1 region in the middle facet, and 1 region in the anterior facet of the subtalar joint, as shown in Figure 1. 3D distance technique was used to objectively measure joint space across the subtalar joint. DMs were measured in millimeters, and DMs of the posterior facet and sinus tarsi were also averaged. Descriptive analysis was performed. Results: A total of 15 patients were included – 10 patients with preoperative and 5 patients with postoperative WBCT scans. The mean DMs in all regions increased postoperatively, showing a trend toward improved alignment. The greatest change in mean DM was seen in the middle facet articulation, from 1.78 mm preoperatively to 2.44mm postoperatively. The sinus tarsi was the second highest change, from a mean DM of 2.45 mm preoperatively to 2.80 postoperatively. Conclusion: This pilot study demonstrates that improved tibiotalar alignment through total ankle arthroplasty results in changes in the subtalar joint. Further study with adequate power is warranted to quantify the effect that improved tibiotalar alignment has on subtalar alignment. [ABSTRACT FROM AUTHOR]

Category: Ankle; Ankle Arthritis Introduction/Purpose: While the utilization of total ankle arthroplasty (TAA) for managing severe ankle osteoarthritis has become increasingly common, there has been a subsequent increase in the occurrence of revision TAA procedures due to implant failure. The INBONE II system has risen in popularity specifically for the use in revision TAA cases, however there has been limited patient performance data for this specific indication. Given the growing number of TAA revision procedures and increasing focus on motion-preserving salvage options, this study aims to comprehensively examine the clinical outcomes associated with revision TAA using the INBONE II system. Methods: A retrospective analysis was conducted on a group of 60 patients who underwent revision TAA with the INBONE II system. Detailed information was collected on patient demographics, implant characteristics, concurrent procedures, and complications. The implant survival was estimated using Kaplan-Meier analysis. Results: The study revealed high complication rates but generally fair clinical outcomes for revision TAA utilizing the INBONE II system. Complications were observed in 22 patients (36.7%), including persistent pain (n=6), nerve injury/impingement (n=5), infection (n=3), fracture (n=3), implant failure (n=3), impaired wound healing (n=2), and osteolysis (n=3). The three-year implant survivorship rate from reoperation was 92.0% [82.7%-100.0%] while the three-year survivorship rate from major complications was 90.4% [80.8%-100.0%]. Conclusion: Our study demonstrates that revision TAA is an option to preserve joint function following primary TAA failure. Although there are high complication rates associated with revision TAA, patients generally fair clinical outcomes for revision TAA using the INBONE II system. Further study with longer-term follow-up is needed to ensure that revision TAA is durable at longer time intervals and remains a favorable option for the salvage of the failed total ankle. [ABSTRACT FROM AUTHOR]

Category: Ankle; Midfoot/Forefoot Introduction/Purpose: The literature demonstrating outcomes after foot and ankle surgery has traditionally focused on clinical and functional outcomes. Recent interest has increased regarding the contribution of racial and ethnic factors on outcomes after foot and ankle surgery. However, the existing research is limited. The purpose of this systematic review and meta-analysis was to evaluate outcome metrics based on race and ethnicity after foot and ankle surgery. Methods: Outcomes after foot and ankle surgery based on race and ethnicity were searched in MEDLINE, Embase, Cochrane, Web of Science, SportsDISCUS, and Scopus from the date of inception to March 23, 2023. Inclusion criteria consisted of studies that directly evaluated the outcomes of race or ethnicity on foot and ankle surgery, including the risk or need for an index procedure. Manuscripts in non-English languages and isolated abstracts were excluded. We collected Visual Analog Scale (VAS), Patient-Reported Outcomes Information System (PROMIS) pain scale, and Short Musculoskeletal Function Assessment (SMFA) from the included studies for pooled meta-analysis. Results: The literature search identified 33 relevant studies from an initial pool of 3,451 references. These studies included a diverse demographic of 557,734 patients, assessing outcomes in foot and ankle surgery across various racial and ethnic groups. Due to heterogeneity in outcome reporting, only six studies were included in the finalmeta-analysis. Functional scores from the VAS, PROMIS pain scale, and SMFA varied in their assessment of pain and functional outcomes based on ethnicity. Resource utilization studies indicated disparities in the rates of surgical fixations and arthroplasties based on race. Conclusion: Non-White and minority patients exhibited higher rates of foot and ankle fractures, lower limb surgeries, worse functional outcomes, increased pain, longer hospital stays, and a higher incidence of complications compared to their White counterparts. While consistent with existing literature in various orthopaedic specialties, some studies contradicted these findings, suggesting the need for further research to better understand these discrepancies. [ABSTRACT FROM AUTHOR]

Category: Ankle; Ankle Arthritis Introduction/Purpose: Infection is a serious complication of primary total ankle arthroplasty (TAA) and can lead to implant failure and revision surgery. While various patient demographics, comorbidities, and surgical factors have been associated with an increased risk of infection, evidence is limited, and further research is required to better understand infection in TAA. This study aims to analyze risk factors of infection and explore outcomes following infected TAA. Methods: A retrospective cohort study was conducted using data from a single institution from 2002 to 2022. Patients who underwent primary TAA and had subsequent infection were identified and matched using propensity-score matching (PSM) based on various demographic, comorbidity, and surgical factors. Demographics were compared between the matched groups using Mann-Whitney U test and Fisher's exact test. The outcomes following infection were identified and summarized using descriptive statistics. Results: A total of 1,863 patients who underwent primary TAA were identified, and 19 (1%) were diagnosed with an infection. After PSM, there were no significant differences in age, gender, BMI, and smoking status between the cohorts. There was a statistically significant increase in the rate of diabetes in the infected cohort (26.3 vs. 15.3; p =0.01). Subsequent surgical intervention resulted in limb salvage in 18 (94.7%) cases. Two-stage revision to total ankle replacement was performed in 7 cases (36.8%), while revision to arthrodesis and isolated polyethylene exchange were each carried out in 4 cases (21.1%). One patient had to undergo amputation, however, at the time of the most recent follow-up (5.3%). All patients were found to be free of infection. Conclusion: This study demonstrated significantly increased rates of smoking and diabetes in the infected TAA cohort. Two-stage revision to TAR and revision to arthrodesis with isolated polyethylene exchange were successful in eradicating infection. Overall, a high rate of limb salvage was reported. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Interpositional arthroplasty (IPA) is a motion-preserving surgery in patients with advanced hallux rigidus. Literature displays several complications after the procedure including transfer metatarsalgia, cock-updeformity and infection. In a finite element model, shortening of the first metatarsal was associated with increased plantar pressure on lateral rays during gait. Additionally, there are reports of a positive correlation between first metatarsal shortening after hallux valgus surgery and transfer metatarsalgia of the second, third and fourth metatarsophalangeal joints. The goals of this study were to report the outcomes and complications of IPA using acellular dermal allograft (IPA-ADA) as well as study the changes in the length of the proximal phalanx of the hallux (P1) and the first metatarsal (M1) following the procedure. Methods: In this IRB-approved retrospective study, we assessed patients who underwent IPA-ADA in a single academic institute from 2019-2022. All patients' demographic data, surgical details, complications, and patient-reported outcomes (PROs) were extracted. On standing conventional anteroposterior (AP) foot views, we measured the lengths of the first metatarsal (M1), the second metatarsal (M2), the proximal phalanx of the big toe (P1), and the entire length of the hallux (HX). The ratio of M1/M2 and P1/HX were calculated. The first metatarsophalangeal joint space was measured at the medial and lateral aspects of the joint on the APview. All measurements were recorded pre-operatively, at six weeks follow-up, and at the final follow-up. Descriptive statistics were performed, and comparison between groups was performed using analysis of variance(ANOVA) or Kruskal Wallis test according to data normality. The Dunn-Bonferroni test was then performed for pairwise group comparisons. A p-value < 0.05 was considered significant. Results: Eleven patients were included, 9 being females (81.81%). Six were hallux rigidus Coughlin grade III (54.55%), and 5 were grade IV (45.45%). The average age was 59 years (SD±6.78), and the body mass index (BMI) was 26 (SD±4.79). At the final followup, there was significant shortening of the first ray in comparison to the pre-operative length evidenced by lower M1/M2 (82.63 SD±2.29 versus 75.42 SD±5.1; p=0.001) and P1/HX ratio53.38 ± 2.29 versus 48.98 SD ± 7.92; p=0.001). Although there was no significant difference between M1/M2 at 6 weeks and at the final follow-up (p=0.716), there was a significant negative correlation between follow-up length and M1/M2 (r= -0.76, p=0.003). Follow-up was (19.95 months; range 3-39). Complications and PROs are listed in Figure 1. Conclusion: Interposition arthroplasty using dermal allograft for HR is associated with progressive shortening of the first ray at the level of the first metatarsal as well as the proximal phalanx. Although the study did show shortening of the first ray, the small sample size didn't allow for a correlation between this shortening and complications such as transfer metatarsalgia and cock-up toe deformity. The potential shortening should be considered in the selection of patients, particularly in the setting of an already short first metatarsal or when simultaneous Akin/Moberg osteotomy is planned. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Evidence in the literature suggests the negative effects of using High Heels (HH), becoming a challenge for clinicians and researchers since they are welcomed by women worldwide, mainly due to the subjective power of attractiveness given to them. Although some people blame HH as one of the causes of Hallux Valgus (HV), until now, there are no studies in the literature that effectively prove a cause-effect relationship between HH and HV. The objectives of this study are: (1) to analyze whether the increase in heel height can lead to HV and (2) to evaluate whether HV can increase in severity with increasing heels. We hypothesized that an increase in heel height could cause and increase the severity of HV deformity. Methods: Comparative cross-sectional study. Forty-one feet from twenty-one participants (11 males and 10 females, aged 30.8 ± 8.9 years, and with Body Mass Index 25.5 ± 2.0 m kg2) were recruited. HH shoes were designed for this study with three heights for each participant: 3, 6, and 9 cm. The inclusion criteria were: no regular wearing of heels. The exclusion criteria were: Hallux Valgus diagnosis and/or any orthopedic conditions that affect the Foot and Ankle joints. Hallux Valgus Angle (HVA), Intermetatarsal Angle (IMA), First-Metatarsal Phalangeal Angle, 1st-to-5th Intermetatarsal Angle, First Tarsometatarsal Angle (axial), Second tarsometatarsal angle (axial), Hindfoot Moment Arm (HMA) (mm), Saltzman 45 angle and, Foot Ankle Offset (FAO) were measurement using semiautomated software analysis. Multiple comparisons were performed (Bonferroni's for normal distributions and Wilcoxon test for no normal distributions) when there was a main effect on an outcome (p < 0.05). Results: With the increase in HH, we noticed a progressive increase in HVA (p < 0.001), IMA (p < 0.001), First-Metatarsal Phalangeal Angle (p < 0.001), First Tarsometatarsal Angle (axial) (p < 0.001), and the Second tarsometatarsal angle (axial) (p < 0.001). The Hindfoot Moment Arm (HMA) (mm), Saltzman 45 angle, and Foot Ankle Offset (FAO) had hindfoot varization behavior. When we stratified the groups and compared them, we noticed that an increase of 3 cm in heels slightly increased HVA and IMA (p > 0.05). However, heel increases above 6 cm significantly increased HVA and IMA (p > 0.001). Based on Coughlin's classification, a 3 cm heel increase promoted a mild HV and increases above 6 cm caused a moderate HV. Conclusion: Based on data from our study with patients without Hallux Valgus through analysis with WBCT versus high heels, we conclude that increasing heel height can lead to Hallux Valgus and can progressively increase the severity with increasing high heels. High heels above 6 cm can lead to moderate Hallux Valgus. These findings may be an essential step toward a better understanding of the effects of increasing high heels on Hallux Valgus pathology. [ABSTRACT FROM AUTHOR]