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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: The traditional lateral extensile approach to the calcaneus allows for excellent visualization but is associated with high wound complication rates. The sinus tarsi approach has been shown to produce similar radiographic outcomes with much lower rates of wound complications. The purpose of this study is to prospectively determine clinical and radiographic outcomes in calcaneus fractures treated with a sinus tarsi approach., Methods: Twenty-nine patients with 30 calcaneus fractures underwent operative fixation through a sinus tarsi approach and were prospectively evaluated. Routine pre- and postoperative radiographs were obtained, in addition to computed tomography (CT) scans at 6 weeks and 12 months after surgery. Patient-reported outcomes including American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) pain score, Veterans Rand 12-Item Health Survey (VR-12), and Foot Functional Index (FFI) were recorded. Patients were followed for a minimum of 1 year postoperation., Results: Twenty-one patients with 22 calcaneus fractures completed 1 year of follow-up. At 12 months postoperation, 20 of 22 patients (91%) had 0 to 2 mm of fracture displacement at the posterior facet on CT scans whereas 2 of 22 patients had 2 to 4 mm of fracture displacement. There was no significant change in posterior facet fracture displacement comparing 6-week and 12-month postoperative CT scans ( P  > .99). Mean postoperative Bohler angle was 26.1 degrees compared to 13.2 degrees preoperatively. All patients had complete union of fracture site. There were no major wound complications. Four of 22 patients (18.2%) had minor wound complications. AOFAS, FFI, and VAS pain scores improved postoperatively but were not found to correlate with Bohler angle or critical angle of Gissane., Conclusion: We found that in select patients excellent anatomic alignment and good clinical outcomes with low wound complication rates can be achieved when fixing calcaneus fractures through the sinus tarsi approach., Level of Evidence: Level II, prospective cohort study., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: from Acumed (funded current study). ICMJE forms for all authors are available online., (© The Author(s) 2023.)

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.

This multicenter prospective cohort study assessed the safety and performance of the Trabecular Metal Total Ankle System (TM Ankle; Zimmer) for primary total ankle arthroplasty (TAA)., Methods: One hundred and twenty-one consecutive patients qualifying for primary TAA were enrolled in the study. All patients received the TM Ankle implant. Clinical outcome examinations and radiographic evaluations were conducted at 6 weeks, 6 months, 1 year, 2 years, and 3 years. Patient-reported outcome measures (PROMs) were evaluated with use of the EuroQol-5 Dimensions questionnaire (EQ-5D), Ankle Osteoarthritis Scale (AOS), American Orthopaedic Foot & Ankle Society questionnaire (AOFAS), and patient satisfaction at each time point. Complications were classified according to the Canadian Orthopaedic Foot and Ankle Society (COFAS) system., Results: The average AOFAS, EQ-5D, AOS pain, and AOS difficulty scores showed significant improvement at 6 weeks, 6 months, 1 year, 2 years, and 3 years as compared with the preoperative baseline (p < 0.001). The Kaplan-Meier survival estimate for revision when used in primary cases was 97.35% at 3 years. During the 3 years of follow-up, 9 patients showed abnormal radiographic findings. Two ankles had intraoperative complications, 38 had complications that were non-surgical or device-related, and 3 ankles underwent revision., Conclusions: The results of the present study indicated that patient well-being significantly increased following TAA with use of the TM Ankle. Radiographic parameters also demonstrated a low incidence of abnormal findings., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A417)., (Copyright © 2022 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

One of the most challenging problems facing orthopedic surgeons is persistent pain after surgery and certainly is just as frustrating following hindfoot fusion. The hindfoot joints consist of the subtalar, talonavicular, and calcaneocuboid (CC) joints. These joints are commonly fused for degenerative changes, deformity correction, inflammatory or neuropathic arthropathy, tarsal coalition, or primarily after trauma. Goals of hindfoot fusion are a painless plantigrade foot capable of fitting in shoes without orthotics or a brace. Many believe that deformity correction is achievable without inclusion of the CC joint. Managing patient expectations is important when counseling a patient especially regarding potential complications., Competing Interests: Disclosure J.K. Ellington is a paid consultant for Medshape, Inc., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To evaluate the rate of subtalar arthrodesis based on a computed tomography (CT) scan after open reduction and primary subtalar arthrodesis for acute, displaced, intra-articular calcaneal fractures., Design: Retrospective chart review., Setting: Single tertiary care practice., Patients: A retrospective chart review was performed to identify patients who sustained an acute, displaced, intra-articular calcaneal fracture and underwent open reduction and primary subtalar arthrodesis. Thirty-five patients participated in the study., Intervention: Each patient included in the study was treated with open reduction and primary subtalar arthrodesis., Main Outcome Measures: All patients were evaluated with CT for arthrodesis of the posterior facet of the subtalar joint, which was quantitated. Other outcome measures included radiographic parameters, the Veterans RAND Item Health Survey, and the Foot and Ankle Ability Measure., Results: The median patient age was 47.8 years (range 21.5-79.5 years). The median patient follow-up was 34.4 months (range 4.6-104.1 months). The Sanders classification was as follows: 3% (1/35) type II, 40% (14/35) type III, and 57% (20/35) type IV. Based on a CT scan, primary subtalar union occurred in 94.3% (33/35) of patients., Conclusions: Open reduction and primary subtalar arthrodesis for acute, displaced, intra-articular calcaneus fractures has a high rate of union and good pain and function outcomes. It should be strongly considered for patients with significant cartilage injury and comminution of the posterior facet., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: For hallux rigidus, dorsal cheilectomy remains a treatment option even with advances in interposition techniques and devices. Cheilectomy aims to alleviate dorsal impingement and improve pain and function as well as range of motion. Cryopreserved umbilical cord allograft, with properties to mitigate inflammation and scar formation, has theoretical benefit for improving outcomes following cheilectomy. In this first prospective randomized and blinded cheilectomy study reported, we aimed to compare outcomes between cheilectomy alone and cheilectomy with umbilical cord allograft., Methods: Patients were randomized to cheilectomy alone (CA) or cheilectomy with cryopreserved umbilical cord (ie, amniotic membrane-umbilical cord [AM-UC]). Patients were evaluated with American Orthopaedic Foot & Ankle Society (AOFAS), Foot Function Index (FFI), and visual analog scale (VAS) pain outcomes collected preoperatively and at 6 months and 1 year postoperatively. In addition, radiographic range of motion data were collected using stress radiographs. Fifty-one patients (26 AM-UC, 25 CA) completed the study, with 5 bilateral surgeries in the AM-UC group and 2 in the CA group, totaling 31 and 27 feet, respectively., Results: The AM-UC group had statistically significant improved AOFAS and FFI scores at 1 year compared with the CA group, but there was no difference at 6 months. There was no significant difference between groups for VAS-pain scores at any time point, but overall VAS-pain improved in both groups from preoperative values. There was no significant difference in range of motion (total arc) between groups and changes in range of motion (total arc) in both groups from preoperative to 1 year postoperative were small., Conclusion: We present the results of the first randomized and blinded prospective study of cheilectomy surgery patients. When appropriately selected, cheilectomy remains a good option for patients with symptomatic hallux rigidus. Cryopreserved umbilical cord is a potential adjuvant to cheilectomy, with 1-year results showing improvements in functional outcome scores., Level of Evidence: Level II, prospective comparative study., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: W. Hodges Davis, MD, reports grants from Tissue Tech, during the conduct of the study; other from Amniox; and Amniox: Paid consultant; Research support. Robert Anderson, MD, reports grants from Tissue Tech, during the conduct of the study; other from Amniox; and Amniox: Paid consultant. Bruce E. Cohen, MD, reports grants from Tissue Tech, during the conduct of the study; other from Amniox, other from Tissue Tech; and Amniox: Paid consultant. Tissue Tech: Stock or stock Options. Carroll P. Jones, MD, reports grants from Tissue Tech, during the conduct of the study; Amniox, outside the submitted work; Amniox: Paid consultant. J. Kent Ellington, MD, reports other from Amniox, during the conduct of the study. Susan Odum, PhD, reports grants from Tissue Tech, during the conduct of the study. ICMJE forms for all authors are available online., (© The Author(s) 2021.)

Surgical management of osteochondral lesions of the talus without an osteotomy depends on the size, location, and chronicity of the lesion. Bone marrow stimulation techniques, such as microfracture, can be performed arthroscopically and have consistently good outcomes in lesions less than 1 cm in diameter. For lesions not amenable to bone marrow stimulation, one-stage techniques, such as allograft cartilage extracellular matrix and allograft juvenile hyaline cartilage, may be used. Arthroscopy may be used in many cases to address these lesions; however, an arthrotomy may be required to use osteochondral autograft and allograft transplantation techniques., Competing Interests: Disclosure M. S. Conti: This author has nothing to disclose. J.K. Ellington: Amniox: paid consultant; Arthrex: IP royalties; Kinos: stock or stock options; Medline: IP royalties, paid consultant, paid presenter or speaker; Medshape: stock or stock options; Nuvasive: paid consultant; Synthes: IP royalties, paid consultant, paid presenter or speaker; Wright Medical Technology: paid consultant. S.B. Behrens: This author has nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Tibio-talo calcaneal (TTC) arthrodesis is increasingly performed for hindfoot arthrosis and other indications. Peri-implant fracture around hindfoot fusion nails has been previously reported and can be problematic to treat given multiple surgical considerations including the status of hindfoot arthrodesis at time of fracture. We present a systematic review of the literature regarding peri-implant fractures around hindfoot fusion nails and propose a classification system to help guide treatment based on findings from the current literature as well as the collective experience of the senior authors., Methods: A review of the literature was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify clinical investigations in which peri-implant fractures or other hardware failures were observed as complications following TTC arthrodesis using hindfoot nails. The electronic database of PubMed/Medline/Cochrane Library was explored using specific search terms. Inclusion criteria was any clinical investigation that reported on outcomes after TTC arthrodesis using a hindfoot nail in at least one patient. Cadaveric and non-clinical investigations were excluded., Results: A total of 36 studies were identified which met inclusion criteria and reported clinical outcomes after TTC arthrodesis using a hindfoot fusion nail. Of the 36 studies, there was a total of 13 intraoperative fractures, 43 tibial stress fractures and 24 peri-implant fractures recorded in 12 of the 36 studies., Conclusion: Peri-implant fracture following tibio-talo calcaneal arthrodesis using a hindfoot intramedullary nail is an uncommon but problematic condition to treat. General heterogeneity of patients and indications as well as a lack of descriptive detail in the current literature makes meta-analysis difficult. Given the lack of consensus on treatment, a classification system may be helpful to guide clinical practice., Competing Interests: Declaration of Competing Interest The Authors declare that there is no conflict of interest., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Pediatric talus fractures are rare injuries that generally result from high-energy trauma. The relative elasticity of pediatric bone is thought to contribute to the lower rate of fracture in children. Although these injuries are rare, complications of talar body fractures, including avascular necrosis, collapse of the talar dome, and tibiotalar arthrosis, are well described. In the pediatric patient, these complications can result in poor outcomes and a disabling position for the patient. There is a relative paucity of data given the low incidence of these injuries and lack of consensus on operative versus nonoperative management. The authors present the case of an 11-year-old female with a combined talar neck and body fracture. The patient underwent open reduction internal fixation of her fractures with combined cannulated screw and Kirshner wire fixation. She was followed to 7 years postoperatively with excellent functional outcome and no evidence of avascular necrosis or collapse of the talar body., (Copyright © 2019 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

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.

Nitinol compression implants are fast and simple to insert and have a high radiographic union rate for midfoot and hindfoot arthrodeses. Applications of nitinol technology in orthopedic surgery are rapidly expanding with the improved and broadened portfolio of implants available., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Ankle fractures are among the most common injuries treated by orthopaedic surgeons. Various postoperative rehabilitation strategies have been promoted, but the ability to improve patient-reported functional outcome has not been clearly demonstrated. We aim to evaluate outcomes associated with clinic-based, physical therapist-supervised rehabilitation (Formal-PT) compared to surgeon-directed rehabilitation (Home-PT)., Methods: This prospective observational study included patients with operative bimalleolar or trimalleolar ankle fractures with or without dislocation (n = 80) at a Level I trauma center. Patients were prescribed PT per the surgeon's practice pattern. Patient-reported functional outcomes at 6 months and complication rates were compared between groups., Results: Of the 80 patients, 38 (47.5%) patients received Formal-PT; the remaining received Home-PT. Thirty-four patients (89.5%) attended ≥1 PT session. Number of sessions attended ranged from 1 to 36 (mean = 16). Receipt of Formal-PT did not differ by injury characteristics or demographics. Of patients with private insurance, 57% were prescribed Formal-PT vs 7% of uninsured patients ( P  = .033). FAAM and Combination SMFA scores at 6 months were similar between groups (Formal-PT: 69.7, 20.1; Home-PT: 70.9, 24.4; P  = .868, .454, respectively). Postoperative complications were rare and equivalent between groups., Conclusions: Comparison of outcomes between patients with operatively treated displaced ankle fractures/dislocations with Formal-PT vs Home-PT showed no difference in SMFA and FAAM scores. These findings suggest patients receiving supervised PT produced a similar outcome to those under routine physician-directed rehabilitation at 6 months. The cost for therapy averaged $2012.96 per patient receiving Formal-PT., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Nitinol has been shown to generate durable compression under loading via pseudoelastic shape memory. The purpose of this study was to evaluate the effectiveness of a hindfoot arthrodesis nail with an internal pseudoelastic nitinol compression element. Patients who had undergone tibiotalocalcaneal arthrodesis from 2013 to 2016 were identified at 2 tertiary referral centers (12-week follow-up minimum). Patients managed with a tibiotalocalcaneal nail with an internal nitinol compression element were identified for review. Sagittal computed tomographic scan reformats were reviewed to calculate a percentage of joint surface bony union. Intraoperative and postoperative radiographs were compared to calculate postoperative screw position change generated by the nitinol element, a surrogate for postoperative unloading of compressive forces. Thirty-three patients were included in analysis and 81% of patients had successful union of both tibiotalar and subtalar joints. Overall, 90% of all arthrodesis surfaces united. The union rate of arthrodesis surfaces among patients without Charcot osteoarthropathy was 94%. A history of Charcot was identified as a risk factor for subtalar nonunion (p = .04) and was associated with less complete computed tomography-based tibiotalar union: 94% versus 71% (p < .01). The posterior-to-anterior screw translated an average of 3.9 mm proximally relative to the rigid portion of the nail from intraoperative to initial postoperative radiographs (p < .0001). High rates of computed tomography-confirmed union were demonstrated in the face of challenging clinical scenarios. Shortening of the pseudoelastic nitinol element occurs early in the postoperative period, indicating continued unloading of the nitinol compression element through the arthrodesis sites after initial implantation., (Copyright © 2018 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

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.

Difficult problems that are faced when reconstructing severe pilon fractures include filling metaphyseal defects and supporting an impacted, multifragmented articular surface. Supplements to plate fixation currently available in a surgeon's armamentarium include cancellous bone autograft, structural bone allograft, demineralized bone matrix, and calcium-based cements. Cancellous autograft possesses limited inherent mechanical stability and is associated with graft site morbidity. Structural allografts incorporate inconsistently and are plagued by late resorption. Demineralized bone matrix also lacks inherent structural stability. Calcium phosphate cements are not rigidly fixed to bone unless fixation is applied from cortical bone or through a plate, which must be taken into consideration when planning fixation. The Conventus DRS (Conventus Orthopaedics, Maple Grove, MN) implant is an expandable nitinol scaffold that takes advantage of the elasticity and shape memory of nitinol alloy. Once deployed and locked, it serves as a stable intramedullary base for fragment-specific periarticular fracture fixation, even in the face of metaphyseal bone loss. Two cases of successful implant use are presented. In both cases, the implant is used to fill a metaphyseal void and provide stable articular support to the distal tibial plafond., Levels of Evidence: Therapeutic Level V: Case Report, Expert Opinion.

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.)

Unlabelled: Management of large structural defects of the ankle and hindfoot is challenging with modest outcomes in the literature. Tibiotalocalcaneal (TTC) arthrodesis using a retrograde intramedullary nail has been used for the treatment of talar avascular necrosis, severe tibial plafond fractures, ankle and hindfoot nonunions, Charcot arthropathy, and failed total ankle arthroplasty. External fixators and spatial frames provide robust multiplanar correction of deformity, but little is known in the literature regarding the salvage treatment of persistent nonunion refractory to frame treatment. In this report, we present the case of an open tibial plafond fracture with nonunion despite 1 year of fixator and frame management that was successfully treated using a patient-specific 3-dimensional printed titanium truss cage in combination with a retrograde TTC nail. At most recent 1-year follow-up, the patient had minimal pain, no wound complications, and was able to ambulate and work independently without an assistive device for the first time in 2 years since his original injury. The case presented here serves as a proof of principle that requires future research to determine its long-term clinical benefits, cost-effectiveness, and complications., Level of Evidence: Level V: Expert Opinion., (© 2015 The Author(s).)

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.)

Unlabelled: Tibiotalocalcaneal (TTC) arthrodesis using an intramedullary hindfoot nail is a common procedure for deformity correction and the treatment of combined tibiotalar and subtalar end-stage arthritis. Nonunion at one or both fusion sites is a difficult complication that can result in reoperation, significant morbidity, and below-knee amputation. There is currently a need for sustained compression across fusion sites using a TTC hindfoot nail with good mechanical stability. The DynaNail TTC Fusion System (MedShape, Inc, Atlanta, GA) uses an internal nitinol compression element to apply sustained compression across the tibiotalar and subtalar joints after surgery. In preliminary clinical cases, we have found that the nail is safe, reliable, and has promising clinical and radiographic results in settings of hindfoot arthritis, complex deformity, Charcot arthropathy, and talar avascular necrosis., Levels of Evidence: Expert opinion, Level V., (© 2015 The Author(s).)

Posterior tarsal tunnel syndrome is the result of compression of the posterior tibial nerve. Anterior tarsal tunnel syndrome (entrapment of the deep peroneal nerve) typically presents with pain radiating to the first dorsal web space. Distal tarsal tunnel syndrome results from entrapment of the first branch of the lateral plantar nerve and is often misdiagnosed initially as plantar fasciitis. Medial plantar nerve compression is seen most often in running athletes, typically with pain radiating to the medial arch. Morton neuroma is often seen in athletes who place their metatarsal arches repetitively in excessive hyperextension., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Hallux rigidus is the most common arthritic malady to afflict the foot. A host of nonoperative measures can alleviate pain, and with failure of conservative treatment, joint preserving and joint sacrificing procedures can be used to treat persistent symptoms. Although arthrodesis is an effective pain-relieving operation, loss of motion at the hallux metatarsophalangeal joint may limit the patient's function and can be an unacceptable solution. Various types of interposition arthroplasty can offer a motion-preserving alternative to arthrodesis., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The preferred surgical approaches to subtalar fusion are the sinus tarsi incision, the medial incision, and the extensile lateral approach. The choice of one over the other depends on the underlying pathology, previous surgeries, associated foot pathologies, soft tissue quality, and medical comorbidities. This article reports on several cases of subtalar joint fusion., (Copyright © 2015 Elsevier Inc. All rights reserved.)

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.)

Training reactions are the most common criteria used for training evaluation, and reaction measures often include opportunities for trainees to provide qualitative responses. Despite being widely used, qualitative training reactions are poorly understood. Recent trends suggest commenting is ubiquitous (e.g., tweets, texting, Facebook posts) and points to a currently untapped resource for understanding training reactions. In order to enhance the interpretation and use of this rich data source, this study explored commenting behavior and investigated 3 broad questions: who comments, under what conditions, and how do trainees comment? We explore both individual difference and contextual influences on commenting and characteristics of comments in 3 studies. Using multilevel modeling, we identified significant class-level variance in commenting in each of the 3 samples of trainees. Because commenting has only been considered at the individual level, our findings provide an important contribution to the literature. The shared experience of being in the same class appears to influence commenting in addition to individual differences, such as interest in the topic (Studies 1 and 2), satisfaction (Studies 2 and 3), and entity beliefs (Study 3). Furthermore, we demonstrated that item wording may have an impact on commenting (Study 3) and should be considered as a potential lever for training professionals to influence commenting behavior from trainees. Training professionals, particularly those who regularly administer training evaluation surveys, should be aware of nonresponse to open-ended items and how that may impact the information they collect, use, and present within their organizations., ((c) 2015 APA, all rights reserved.)

Introduction: The technique for revision total ankle replacement described in this article addresses the subsidence and loosening that occur when an Agility total ankle replacement fails., Step 1 Indications and Contraindications: The main indications for revision total ankle arthroplasty include loosening and subsidence of the talar component, with no limit to the extent of subsidence or loss of talar bone stock as neither precludes use of a revision system, particularly when a flat cut on the talus can be made., Step 2 Anterior Incision and Joint Exposure: Make the incision employing the prior anterior midline incision, create full-thickness flaps of tissue to diminish the risk of wound dehiscence, and completely expose and debride the joint as this is critical to revising the total ankle replacement correctly., Step 3 Remove the Talar Component and Polyethylene: Remove the talar component, which is rarely difficult as it is usually loose., Step 4 Remove the Tibial Component: When removing the tibial component, it is critical to preserve as much of the anterior tibial cortex as possible to provide support for the revision tibial component., Step 5 Make the Tibial Bone Cut: Tibial cuts can be made proximal or distal to tibial osseous defects., Step 6 Make the Talar Bone Cut: It is preferable to use a cutting block for the talus that attaches to the tibial guide., Step 7 Managing Loosening and Cavitary Defects: If there is substantial bone loss around the tibia after component removal, consider impaction bone-grafting, as better bone quality makes it is easier to obtain a press fit and allow immediate weight-bearing., Step 8 Place Trial Components: Size the tibia and talus and subsequently insert the tibial and talar trials and polyethylene simultaneously., Step 9 Cementing Technique: In revision settings, manual cement insertion is important because there is no medullary canal to work around., Results: We previously reported the outcomes of revision of failed Agility total ankle replacements (DePuy, Warsaw, Indiana) in forty-one patients.Pitfalls & Challenges.

Unlabelled: The distal tibial blind spot represents an area where improperly measured long screws may pose a risk to surrounding anatomic structures and is not well visualized on AP, mortise, and lateral radiographs. Awareness of this area as well as the use of a 45° external rotation oblique view when placing fixation in this area may prevent iatrogenic injury., Levels of Evidence: Level V, Expert Opinion., (© 2014 The Author(s).)

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.)