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Background: Medial opening-wedge high tibial osteotomy (MOWHTO) in patients with varus knee osteoarthritis (OA) causes changes to ankle and hindfoot alignment. However, the compensatory ability of the ankle and hindfoot varies according to the severity of ankle OA. Purpose: To investigate whether the changes in ankle symptoms and ankle and hindfoot alignments differ after MOWHTO according to the severity of preoperative ankle OA. Study design: Case-control study; Level of evidence, 3. Methods: The data of 130 patients who were followed for ≥4 years were reviewed. Patients were classified into 2 groups according to their severity of ankle OA: group 1, modified Kellgren-Lawrence grade 0 and 1; group 2, grade ≥2. Four radiographic parameters were examined to evaluate ankle alignment: tibial plafond inclination, talar tilt, talar inclination, and tibial surface angle. The hindfoot alignment was evaluated using the varus-valgus angle (VVA) of the calcaneus. A visual analog scale (VAS) was used to evaluate ankle pain. The patient-reported outcome measure of the knee joint was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Results: There were 110 patients in group 1 and 20 patients in group 2. In group 2, the change in talar inclination after MOWHTO was significantly greater and the changes in tibial plafond inclination, talar tilt, and VVA were significantly smaller compared with in group 1 (all P <.05). Ankle pain VAS scores were more severe in group 2 than in group 1 pre- and postoperatively (all P <.05), and group 2 reported that ankle pain worsened postoperatively (P <.05). In both groups, knee WOMAC scores improved, and there were no differences between groups pre- or postoperatively (all P >.05). A multivariate regression analysis demonstrated that a small VVA change (odds ratio, 0.775; P =.027) and severe OA grade of the ankle joint preoperatively (Kellgren-Lawrence grades 2-4 vs 0 and 1; odds ratio, 4.241 [ P =.046]) predicted increased ankle pain VAS scores after MOWHTO. Conclusion: Although the patient-reported outcome measures for the knee joint improved irrespective of the presence of ankle OA, ankle pain worsened after MOWHTO in patients with ankle OA. Inadequate compensatory change in hindfoot alignment increased ankle pain in these patients. [ABSTRACT FROM AUTHOR]

Purpose: Calcaneonavicular coalition accounts for more than half of all tarsal coalitions. Resection of calcaneonavicular coalition by an open approach is the standard treatment. Treatment of calcaneonavicular coalition by an arthroscopic approach appears promising. The objective of our study was to compare the clinical outcomes of calcaneonavicular coalition resection by open approach versus arthroscopic approach. Methods: A retrospective cohort study was conducted to evaluate 127 patients who underwent a resection of calcaneonavicular coalition from 2009 to 2017. Patients were divided into two groups according to whether an arthroscopic approach or an open approach was used. Demographics, operative parameters, and clinical outcomes (foot and ankle ability measure score, subjective score, and global ankle estimation) were assessed. Results: Arthroscopic approach was used for 81 patients and open approach for 46 patients. Treatment with arthroscopic approach resulted in a shorter hospital stay (2.6±0.6days vs 3.0±0.7; p=0.02) and a longer operative time (24.5±8.1min vs 20.5±4.2; p<0.01) than with open approach. The foot and ankle ability measure sports subscale scored significantly higher in the arthroscopic approach group (90.9 vs 77.3; p=0.003). Revision rate was significantly higher in the arthroscopic approach group (12 (15%)) versus the open approach group (1 (2%)) (p=0.024). Persistent symptoms (n=12) were the main reason for revision. Conclusions: Arthroscopic treatment of calcaneonavicular coalition is associated with a higher revision rate than the open approach. [ABSTRACT FROM AUTHOR]

Category: Ankle; Sports Introduction/Purpose: Ankle sprains are highly prevalent injuries in athletes, whether amateurs or professionals. It is estimated that they cause around 5,000 sprains a day in the UK, while American data point to around 23,000 cases daily (1/10,000 individuals). The most current literature has pointed to early diagnosis followed by functional strategies as the approach with the highest success rate for lateral ankle sprains, thus contributing to the prevention of chronic instabilities. offering better quality of life and safety to patients are necessary. Objective: The objective of this work is to present the clinical results obtained from the prospective observation of a series of patients with lateral ankle sprains treated with the destabilization technique in Ankle Inversion added to the conventional treatment. Methods: Design: Comparative prospective study in a single center without a control group Location: The study was carried out at Hospital São Paulo – University Hospital of UNIFESP (HSP-UNIFESP), at the Orthopedics Ambulatory of the Department of Orthopedics and Traumatology (DOT)/EPM-UNIFESP. Inclusion criteria -Over 18 years old of both sexes; -Complaint of ankle sprain within 48 hours -Complete or partial injury to any of the ligaments of the lateral ankle complex; -Isolated or associated ligament injuries; Non-Inclusion Criteria -Past history of surgery on the affected foot or ankle; -Previous complaint in the ankle region; -Any fracture associated with sprains or injuries that influence; -Any condition that is a contraindication to the proposed therapies; -Refusal to participate in the study Sample size: 100 Individuals Results: We conclude that statistically we have a higher percentage of No Re-sprains with 94% against 6% of Re-sprains. This index has a CI (confidence interval) of 4.7%, that is, we have that the Reentorse index was 6.0% ± 4.7% which is the same as saying that the index can vary from 1.3% to 10.7% with 95% statistical confidence. Conclusion: Based on the findings of the present study, we concluded that in a 12-month follow-up, the ankle inversion destabilization maneuver proved to be effective in preventing new episodes of lateral ankle sprains. and in order to compare the maneuver described in the study with techniques already described in the literature and used by physiotherapists in their clinical practice, should be performed. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) is becoming an increasingly common procedure with high patient satisfaction and improved outcomes. Although previous studies have explored various patient outcomes, there is variability in reporting methods and acute and chronic complications following TAA are poorly described. The purpose of this study was to evaluate the acute and chronic postoperative complications in patients undergoing TAA at our institution. Methods: Following institutional board approval, a retrospective chart review was conducted for all patients who underwent TAA from 2002-2017 at our institution. Patients were followed from the time of surgery to their 1 year follow-up. Demographics and post-op complications were recorded at 2 weeks, 6 weeks, and 1 year following surgery. Results: At our institution from 2002-2017, a total of 187 patients underwent TAA. The mean age of our cohort was 62.8 (Range 20-68). In our cohort, 106 were male and 81 were female, and the mean patient BMI was 31.6 (Range 33-89). At 4 weeks post- operatively, the most common acute complication was superficial infection (4.8%). Within 6 weeks post-operatively, 1 patient had a VTE (0.53%). The highest chronic complication following TAA was post-operative pain – 12.3% patients reported significant post-operative pain 1 year following surgery. 9.6% patients required hardware removal greater than 1 year following TAA. Conclusion: At our institution the most common acute complication at 4 weeks following TAA was surgical site infection (4.8%). The most common chronic complication was post-operative pain (12.3%). Further investigation is needed to understand the greatest contributing factors to these complications and future studies will focus on methods to minimize surgical site infection and post-operative pain following TAA. [ABSTRACT FROM AUTHOR]

Category: Ankle; Trauma Introduction/Purpose: Opioid-centric pain management strategies have created an epidemic of prescription opioid abuse in the United States. Multimodal opioid-sparing analgesic regimens have spotlighted as alternatives to decrease postoperative pain. However there has been little study of the synergistic effect between naproxen and pregabalin. We aimed to compare the analgesic efficacy, adverse effects, and long-term functional outcomes between perioperative uses of naproxen only and naproxen with pregabalin. Methods: This study was designed in 70 patients belonging to the 19 to 65 age group indicated for operative fixation of a rotatory ankle fracture under general anesthesia in 3 different hospitals. Group A received naproxen 500mg only, Group B received naproxen 500mg with pregabalin 75mg 2 hour before surgery and 12 hourly for 3 days thereafter. Minimal clinically important difference of visual analog scale (VAS) for pain was set 13 mm out of 100 mm. VAS for pain, opioid consumption, time for first use of escape injection, and any adverse effect were recorded at 6-, 12-, 24-, 48-, and 72-hour postoperatively. VAS for pain was checked at 2-, 6-week, 3-, and 6-month afterward and functional outcomes including Olerud and Molander score and ankle- fracture outcome of rehabilitation measure (A-FORM) were measured at 3-month and 6-month postoperatively. Results: Sixty-two patients (33 in Group A and 29 in Group B) completed follow-up until 6 months. Demographic data were similar between the 2 groups. VAS for pain scale was not significantly different between 2 groups at each time point until 6 months (P ≥ 0.520). Ninety-five percent confidential interval (CI) were within 13 mm at every time point except for at 6- and 12-hour postoperatively (95% CI -1.6 – 0.8, -1.4 – 1.0, each). There were no significant differences in opioid consumption, time for first use of escape injection, and functional outcomes between groups (P ≥ 0.163). Any adverse event at 48-hour postoperatively was significantly higher in Group B (P = 0.017). Conclusion: There was no clinically significant effect of perioperative use of pregabalin in addition to naproxen to reduce pain after operative fixation of rotatory ankle fractures. Rather it significantly raised adverse events after 48-hour postoperatively. Therefore additional use of perioperative pregabalin should be cautiously decided. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Opioid pain medications are frequently prescribed after orthopedic surgery as effective tools for pain relief, but with adverse consequences such as addiction and overdose. Postoperative pain control can vary depending on patient opioid prescription history and pain expectations. There are limited studies regarding pain and anxiety levels following orthopedic foot and ankle trauma surgery, with a lack of formal guidelines in prescribing opioid medications to this patient population. The overall purpose of this study was to gain an understanding of postoperative pain and anxiety in patients undergoing outpatient foot and ankle trauma surgery. This study additionally sought to identify any risk factors that may predispose a patient to increased postoperative pain and anxiety, resulting in a potentially increased pain medication requirement. Methods: A subanalysis of 50 patients from a prospective, observational study was performed, examining adult patients undergoing outpatient foot and ankle trauma surgery performed by trauma fellowship-trained senior investigators. Patients were enrolled and given pertinent reference materials including access to an automated texting survey platform to collect data regarding their postoperative pain, anxiety, and opioid medication use. Patients were stratified by procedure type (irrigation & debridement/hardware removal, foot/syndesmosis ORIF, ankle ORIF, pilon ORIF) and by receiving perioperative regional anesthetic block versus local anesthetic. Pain and anxiety were measured with the Numeric Rating Scale for Pain (scale of 1-10) and the Visual Facial Anxiety Scale (scale of 1-5), respectively. The primary outcome measured was the number of days on average for a patient to discontinue opioid medication. Secondary endpoints consisted of pain level < 4, anxiety level < 2, patient-specific and surgery-related factors that may affect these variables. Results: Postoperatively, it took an average of 9.6 days until opioids were discontinued, 8.2 days for pain to subside below 4, and 6.6 days until anxiety reduced under 2. Foot/syndesmosis ORIF and older age were associated with prolonged pain medication use (p<0.05). Drug use and older age limited the chance of obtaining a pain score under 4 (p<0.05). Psychiatric history and older age decreased the odds of obtaining an anxiety score under 2 (p<0.05). White race improved the chance of obtaining an anxiety score under 2 and tapering off pain medications (p<0.05). When stratified by procedure type or analgesic adjuvants (regional block vs local), there were no significant differences in pain and anxiety scores. Conclusion: Our study shows that regardless of procedure type or analgesic adjuvant used, it takes approximately eight days for postoperative pain levels to decrease to 4 out of 10 and six days for anxiety levels to decrease to 2 out of 5, with patients requiring opioid pain medications for an average of 10 days. Risk factors such as older age, prior drug use, and psychiatric history increased postoperative pain, anxiety, and use of opioid pain medications. This data may be utilized by orthopedic surgeons in providing safe, effective, and evidence-based pain management prescribing practices in anticipating postoperative pain and anxiety. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Tarsal tunnel syndrome (TTS) is typically caused by an anatomical variant or mechanical compression of the tibial nerve (TN). It is critical then to understand the anatomy of the TN in relation to the tarsal tunnel to understand this condition more fully. Methods: 40 lower-leg specimens were obtained. Dissection started 20 centimeters proximal to the DellonMcKinnon (DM) line towards the medial aspect of the naviculo-cuneiform joint distally. Anteriorly, dissection began at the tibio-talar medial gutter until the medial aspect of the Achilles tendon posteriorly. The plantar aspect extended from medial to lateral within the parameters previously described, ending at the level of the second metatarsal. Results: The flexor retinaculum had a denser consistency in 22.5% of the cases and the average length was 51.9 mm. The flexor retinaculum as an independent structure was absent and 77.2% of cases as an undistinguished extension of the crural fascia. The lateral plantar nerve (LPN) and abductor digiti minimi (ADM) nerve shared the same origin in 80% of cases, 34.5% bifurcated proximal to the DM line, 31.2% distally and 34.3% at the same level. The medial calcaneal nerve (MCN) emerged proximal to the DM line in 100% of specimens. The medial plantar nerve (MPN) has its origin proximal to the DM line in 95% of cases. Conclusion: The flexor retinaculum is an extension of the crural fascia and not an independent structure. The LPN and ADM have the same origin in most cases and this presents as an important finding that must be studied in detail for clinical correlations between the motor ADM and sensory LPN affections. Finally, the branches of the MCN and MPN are the most constant in their distribution and proximal origin in relation to the DellonMcKinnon line. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Osteochondral lesions of the Talus are defined as any damage involving both articular cartilage and subchondral bone of the talar dome, and this condition is associated with persistent ankle pain and disability. The incidence of osteochondral lesions of the talus is increasing in the pediatric and adolescent population. There are a few studies regarding surgical treatment. The aim of this study is to report that need for surgical treatment is higher than expected in aforementioned lesions. Methods: Osteochondral lesions of the Talus are defined as any damage involving both articular cartilage and subchondral bone of the talar dome, and this condition is associated with persistent ankle pain and disability. The incidence of osteochondral lesions of the talus is increasing in the pediatric and adolescent population. There are a few studies regarding surgical treatment. The aim of this study is to report that need for surgical treatment is higher than expected in aforementioned lesions. Results: Average age was 14,5 (10-18) at beginning of the treatment. 69,2% of our patients were female. Foundation of conservative treatment was activity modification. 9 of our 13 patients were treated surgically. Arthroscopic debridement and microfracture surgery as well as various techniques were applied to all operated patients. In 7 of the operated patients (n=9), the lesion was on the right side and there was a history of trauma before the complaints started. While the mean AOFAS scores of the operated patients were 47 (24-75) before the operation, it was 83.8 in the last follow-up. While the mean AOFAS scores of our conservatively treated patients were 38.2 (21-74) before treatment, the mean AOFAS scores at the last follow-up after treatment (mean follow-up 2 years) were 70 (17-100). There were no minor and major postoperative complications and no need of reoperation. At the final follow up there was significant improvement in clinical results in all patients treated surgically and conservatively. Conclusion: Talus osteochondral lesions at younger ages is an increasing problem. Conservative management with close follow up is the mainstay of the treatment. However, need of surgical treatment may be higher than expected and the short-term results of surgical with various techniques are successful [ABSTRACT FROM AUTHOR]

Background: Total ankle arthroplasty (TAA) has become a successful treatment for end-stage ankle arthritis. Some patients may still have pain or may present with new pain. Suggested sources of medial pain include tibialis posterior tendonitis, impingement, or medial malleolar stress fracture. Etiology and treatment remain unclear. The objective of our study was to evaluate patients with delayed-onset medial malleolar pain following TAA who underwent treatment with percutaneous medial malleolar screw placement and propose an etiology. Materials and Methods: Patients who had undergone TAA at our institution were reviewed and those with medial malleolar pain were identified. Clinical and radiographic examinations were performed pre- and postoperatively. Radiographs were compared with those from a cohort of controls without a history of medial pain. All affected patients failed conservative therapy and were treated with percutaneous placement of medial malleolar screws positioned from the malleolar tip and extending proximally beyond the tibial component. Postoperatively, patients were placed in an ace wrap and allowed to be weightbearing to tolerance, except for 1 patient initially restricted to partial weightbearing. Visual analog scale (VAS) scores were recorded. Seventy-four (74) patients underwent TAA by the corresponding author. All (100%) were female with an average age of 66 (range, 57-73) years. Average follow-up since screw placement was 21.4 (range, 10-41) months. Results: Six (8.1%) underwent placement of 2 percutaneous medial malleolar screws. Patients presented with pain an average of 12 (range, 4-24) months postoperatively and underwent screw placement an average of 2.8 (range, 1-6) months after presentation. At the time of TAA, none had a coronal plane deformity and none underwent a deltoid ligament release as part of balancing. All (100%) patients had pain and swelling directly over the medial malleolus prior to screw placement. Postoperatively, 1 (17%) had mild pain clinically at this site and 2 (33%) had occasional pain medially with activity. Average VAS scores improved from 5.7 (range, 4-6) preoperatively to 1.3 (range, 0-3) postoperatively (P < .05). Three (50%) patients had a bone density test and all were normal. Prior to screw placement, radiographs demonstrated no signs of stress fracture or misalignment. Average minimum width of the medial malleolus at the level of the tibial component was 10.2 mm (range, 9.2-11.0), which was significantly less (P < .05) than the control group of 19 patients whose distance measured 12.2 mm (range, 8.5-14.8). Discussion: Patients who present with new-onset medial malleolar pain with normal radiographs following TAA may have medial malleolar insufficiency fracture. These patients can be treated successfully with minimal morbidity by placement of percutaneous medial malleolar screws. Etiology may be related to deltoid traction, subacute stress fracture, and/or impingement of the talus component on the medial malleolus. Medial malleolar pain may be misdiagnosed as tibialis posterior tendonitis, impingement, or implant failure. This diagnosis should be considered in patients who have pain at the medial malleolus, particularly if they are female or have medial malleolus thickness less than 11 mm at the level of the tibial implant. Placement of prophylactic medial malleolar screws may be considered at the time of TAA when these conditions exist. Level of Evidence: Level IV, case series. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Ankle fractures are among the most commonly surgically treated orthopaedic injuries, with debate regarding their long-term outcomes and the clinical benefit of contemporary fixation strategies. The purpose of this study was to retrospectively evaluate the functional outcomes of patients following surgical management of ankle fractures, and to determine what, if any, limitations and effects their injury has on their daily lives. The authors of this study hypothesized that despite patients having some degree of measurable impairments, these did not cause meaningful disruption in their everyday lives. Methods: We retrospectively reviewed a total of 259 patients who underwent surgical management of their ankle fractures between 2004 and 2012. Two separate patient reported outcome measures, the Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA) were obtained at a minimum of 5 years following time of surgery. Multivariate linear regression analysis was performed to compare FFI and SMFA against several patient and injury specific variables. Results: A total of 259 patients with ankle fractures were included in the study population. 7 of the demographic and injuryrelated variables were found to have a statistically significant relationship to both the FFI and SMFA scores. The multivariate linear regression analysis using these 7 variables in addition to both sub-group components of the SMFA to predict the total FFI score yielded an output adjusted-r2 = 0.78. The SMFA dysfunction sub-category was found to correlate with FFI (standardized beta 0.85, p<0.001), but the SMFA bothersome sub-category did not (p=0.866). Ankle pain limiting function and Medicaid insurance status were also predictive of higher FFI scores. Conclusion: Despite patients, at times, experiencing persistent issues with pain and mild activity limitations following surgical management of ankle fractures, these did not lead to measured burdens in daily activities. At a moderate-length follow-up, patients overall do well from a functional standpoint after sustaining ankle fractures treated surgically. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: The decision regarding total ankle replacement is challenging in inflammatory arthritis patients regarding more inferior bone quality, large bone cysts, and increased risk for infections. This systematic review aimed to compare the short and long-term results of total ankle replacement, including the revision rate and the patient-reported outcomes between inflammatory rheumatoid arthritis (RA) versus non-inflammatory ankle osteoarthritis (OA). Methods: All published clinical studies on total ankle arthroplasty were searched in the databases. We extracted the data, specifically the American Orthopaedic Foot & Ankle Society (AOFAS) improvement, complication rate, and the reoperation rate. The results were also analyzed based on the prosthesis type. Results: In total, 34 trials were included in our study. Out of 5,078 patients, the underlying condition was rheumatoid arthritis in 1,327 patients and was non-inflammatory osteoarthritis in 2,849 patients. There was statistically significant higher AOFAS improvement in the patients with RA vs. OA with a mean follow-up of 63 months (P=0.009). The rates of TAA removal or revision were estimated at 16% (95% CI, 10%-23%) in the OA and 13% (95% CI, 9%-18%) in the RA group. Overlapping confidence intervals showed no significant difference in the rate of failure between RA and OA. The survival rate was 66% in the OA group and 88% in the RA group during a 63-month follow-up. Conclusion: Total ankle replacement is a safe procedure in RA patients with fewer minor and major complications relative to other reasons for ankle osteoarthritis. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Ankle fractures are a common orthopedic injury observed in a wide variety of patient populations. Prior to being seen by an orthopedic specialist, patients with ankle fractures may have already undergone several procedures in the field or in the emergency department to stabilize or reduce the injured bone. While a paradigm that near-anatomic reduction improves outcomes in non-urgent ankle fractures exists, no study to date has shown objective evidence of this in postoperative patientreported outcomes. The present study aims to evaluate whether adequate reduction of non-emergent ankle fractures within 24 hours of inciting injury influenced postoperative outcomes. Methods: All non-emergent ankle fractures treated by a single foot and ankle, fellowship-trained surgeon were queried over a period of 5 years and retrospectively evaluated through the electronic medical record. 97 patients over the age of 18 years with traumatic ankle fracture etiologies were considered. Plain film radiographs from initial presentation to the emergency department or first visit to orthopedics clinic were evaluated by the attending physician for adequate reduction based on AP and lateral tibiotalar congruency. Patient demographics and surgical outcomes data were collected from electronic medical record review. In the cases deemed to be dislocated or subluxated on initial injury films, the days until adequate reduction were calculated along with patient-reported VAS and SF-36 scores. Non-continuous data were compared using chi-squared tests, while continuous, nonnormally distributed data were compared utilizing a Mann-Whitney U test. Alpha and beta for this study were assumed to be 0.05 and 0.8, respectively. Results: The average age was 46, with 68.9% of the patient population that was female. 51 patients were found to be adequately reduced within 24 hours, while 39 were not. The average time to final PRO follow-up was 12.6 months +- 1.9. No differences in preoperative VAS, SF-36 physical nor mental scores were noted between adequately and inadequately reduced cohorts (p= 0.654, p=0.262, p=0.760 respectively). Similarly, no differences in final postoperative follow up VAS, SF-36 physical nor mental scores were observed (p=0.503, p=0.252, p=0.296 respectively). VAS pain scores in both cohorts also improved to a similar degree over the preoperative to final postoperative follow up time point (p=0.261). Conclusion: These data show no difference in patient-reported pain or physical and mental functioning scores over 1 year after surgical fixation of the ankle, regardless of whether the ankle joint was adequately reduced within 24 hours of injury. We assert that anatomic reduction of the ankle joint following traumatic, non-emergent ankle fracture does not play a significant role in overall patient outcomes over 1 year following surgical correction. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Ankle arthritis can be a significant source of pain and disability showing similar morbidity as arthritis in other joints like hip and knee. Nevertheless, ankle arthritis differs from arthritis in other joints because patients are often younger and have higher expectations and demands. After joint-sparing options fail, patients are usually limited to an ankle fusion or total ankle arthroplasty. However, it is not infrequent that these ablative procedures appear too aggressive to treat the underlying condition. As either fusion or replacement is not without complications, an intermediate option that does not burn any bridge is desirable. Ankle hemiarthroplasty is a one-piece implant system replacing the talar side of the tibiotalar joint. It also offers limited bone resection and more straightforward revision surgery than ablating procedures Methods: Prospective, single-center, non-comparative, non-randomized clinical study. Clinical, radiological, and functional outcomes (FAOS, FAAM, SF-36, SMFA, and VAS pain scores) were obtained at 3, 12 months, and last follow-up (mean 31.9 months). Results: Ten patients met the inclusion criteria; three were converted to total ankle replacement at 14, 16, and 18 months. PROMs comparisons were made between preoperative status and 3, 12 months, and last FU. Pain VAS score improved from 6.8 to 4.8 (P = 0.044). SF-36 Physical Health Component improved from 25.03 to 42.25 (P=0.030). SMFA Dysfunction and Bother indexes improved from 46.36. FAAM sports improved from 12.5 to 34.5 (P = 0.023) Conclusion: Patients undergoing hemiarthroplasty of the ankle joint exhibited significant pain reduction, functional improvements, and better quality of life in the midterm follow-up. This procedure offers an intermediate alternative for cases in which joint ablative procedures appear to be excessive surgery for the underlying condition. [ABSTRACT FROM AUTHOR]

Background: Few reports have studied the treatment of osteochondral lesions of the talus (OLTs) in the setting of lateral ankle instability. Hypothesis: Arthroscopic treatment of an OLT and lateral ankle stabilization in the same sitting is safe and leads to reliable improvement of symptoms. Study Design: Case series; Level of evidence, 4. Methods: Of 37 patients who underwent concomitant treatment of an OLT and lateral ankle stabilization, 31 (84%) were evaluated at a mean of 7.3 years postoperatively. Patients were evaluated by physical examination, the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale, the modified Weber Scale, the Single Assessment Numeric Evaluation, the Berndt and Harty Scale, and the Medical Outcomes Study 36-Item Short-Form Health Survey. Results: The average postoperative ankle-hindfoot score was 89, the mean modified Weber score was 85, and the mean Single Assessment Numeric Evaluation was 86. In sum, 74% of patients had a good result on the Berndt and Harty Scale, 23% had a fair result, and 3% had a poor result. Of the short-form survey, the mean physical function score was 86.5, and the mean summary physical component score was 52.3. For the 13 patients for whom prospective ankle-hindfoot scores were available, a statistically significant improvement was seen, from 75 points preoperatively to 91 points postoperatively (P<.001). Conclusion: Simultaneous arthroscopic treatment of an OLT and open lateral ankle stabilization is a safe and effective procedure. The presence of an osteochondral lesion had a negative effect on the overall result when compared to that of patients who underwent lateral ankle stabilization as an isolated procedure. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Opioids can be an important tool in the management of postoperative pain, however, increased prescribing of these medications following orthopaedic procedures has significantly contributed to the current opioid crisis. Postoperative opioid utilization and duration varies greatly among surgeons, procedures, and patients. We sought to investigate patterns of opioid prescription following ankle arthroscopy and determine patient factors associated with increased postoperative opioid prescribing. Methods: A national claims-based database was queried for patients undergoing first-time ankle arthroscopy. Only patients with continuous database inclusion for at least one year prior to and one year after index ankle arthroscopy were included. Patients carrying an International Classification of Diseases (ICD)-9 or ICD-10 code(s) for diagnosis of septic ankle joint or a CPT code for total ankle arthroplasty prior to index ankle arthroscopy were excluded from the study. Patients who filled at least 1 opioid prescription between 1 and 4 months prior to surgery were defined as preoperative opioid-use group. Monthly relative risk ratios for filling an opioid prescription were calculated for the first year after surgery. Multiple logistic regression analysis was performed to identify factors associated with opioid prescription refills at 3, 6, 9, and 12 months after ankle arthroscopy. For analysis, P<0.05 was defined as significant. Results: We identified 6,039 patients who underwent primary ankle arthroscopy. The preoperative opioid-use group consisted of 1,514 patients (25.1%), of which 24 (1.6%) filled opioid prescriptions at 6 months postoperatively compared to 39 (0.9%) of opioid-naive patients (relative risk [RR], 1.84 95% confidence interval [CI], 1.11-3.05). Multivariate analysis determined that the preoperative opioid-use group was at increased risk of filling prescriptions at 3 (odds ratio [OR], 2.22; 95% CI 1.42-3.48) and 6 months (OR, 1.74; 95% CI, 1.01-2.95) postoperatively. Patients with Body Mass Index (BMI) > 30 were also at increased risk at 3 months (OR, 1.65; 95% CI, 1.04-2.62) and 6 months (OR, 2.01; 95% CI, 1.17-3.49) postoperatively. Comorbidities such as diabetes, hypertension, fibromyalgia, alcohol, and tobacco abuse were not associated with opioid filling (P>0.05). Conclusion: Preoperative opioid prescription filling and BMI 30 were associated with an increased risk of extended opioid prescription utilization following ankle arthroscopy. Overall, prolonged opioid prescribing was not widespread in either group postoperatively. This may represent the indications and outcomes of ankle arthroscopy. Patients presenting with preoperative opioid-use and increased BMI may benefit from multimodal pain management and additional perioperative education around nonpharmacologic pain-management strategies to decrease risk of prolonged opioid use. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Ankle fractures are common orthopedic injuries with complication rates fixation of up to 40%. Limited evidence exists in the literature regarding complications in the elderly population, and moreover, these studies frequently define elderly arbitrarily at 60-65 years old. The purpose of the present study was to utilize a large, validated database to evaluate whether there is an inflection point of age when postoperative complications after an ankle fracture significantly increase. Methods: A retrospective review of all patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent fixation of an ankle fracture between 2012-2018 was performed. Patients were identified within the database using the Current Procedural Terminology codes. Appropriate statistical analysis was performed with p-value less than 0.05 considered statistically significant. Results: A total of 27,633 fractures were including and comprised of 221 posterior malleolar, 1,567 medial malleolar, 8,495 lateral malleolar, 10,175 bimalleolar, and 7,175 trimalleolar. A total of 1,545 complications were encountered (5.6%). There was a statistically significant association between increasing age and complications (OR=1.03; p<0.001). Further analysis shows the largest spike in complications within the age 78+ bracket. There were no overall interaction effects between age and fracture subtype (p=0.223). Conclusion: ORIF of ankle fractures is a common orthopedic procedure performed on patients of all ages, with complications ranging in severity. In order to best counsel patients on their individual post-operative risks, large data sets are often necessary to prognosticate. This study found that postoperative complications increase with advanced age. The incidence of complications did not spike for patients around the age of 65, but rather followed an incremental linear pattern with the largest increase in odds ratio occurring at age 78 and above. Complication rate was not associated with specific fracture type based off of ICD codes. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Microfracture has been widely published as a treatment modality for osteochondral lesions of the talus (OLT). However, little is known about the outcome predictors following microfracture for smaller-sized OLT (<100mm2). This study sought to define the predictors of both clinical and magnetic resonance imaging (MRI) outcomes for small OLT treated with microfracture. Methods: A retrospective cohort study investigating patients who received arthroscopic microfracture for OLT (<10mm or 100mm2) between 2008 and 2017 were evaluated. Multivariate regression models were used to evaluate factors affecting postoperative Foot and Ankle Outcome Scores (FAOS) and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scores. Kaplan-Meier survival curves with log-rank test were constructed and endpoint was defined as the requirement of revision surgery. Results: Eighty-seven patients were included in the study. The mean follow-up time was 41.4+-28.7 months. The mean FAOS pain score significantly improved from 60.4+-14.8 preoperatively to 79.3+-12.8 at final follow-up (p<0.001). Patients with uncontainedtype OLT had an approximately 9-point worse FAOS pain score compared to contained-type OLT (p=0.036). Patients with cystic OLT also had an approximately 9-point worse pain FAOS compared to non-cystic OLT (p=0.026). Patients with larger lesion sizes had worse postoperative MOCART scores (p=0.012). Both Uncontained-Cyst and Uncontained-Noncyst groups had significantly worse FAOS pain than the Contained-Noncyst group (p<0.001, p=0.026). Survival rates in uncontained and contained lesions were 51.5% and 84.4%, respectively (p=0.616). Conclusion: Lesion uncontainment and the existence of cysts are independent predictors of poor clinical outcome following arthroscopic microfracture for smaller-sized OLT (<100mm2). [ABSTRACT FROM AUTHOR]

Introduction/Purpose: While it is a commonly accepted principle peroneal tendon (PT) tears are associated with cavovarus deformity, this is the first study that both quantifies deformity in patients with surgically proven tears using sophisticated and reproducible methods to compare radiographic measurements to a matched control group. Understanding of the anatomy and mechanism of injury affecting the PTs has led to greater recognition of PT tears as an important cause of lateral sided foot and ankle pain. The literature reports a presumed correlation between the cavus foot and PT tears. Little data exist quantifying the correlation between PT tears and the alignment of the foot. We hypothesize the cavovarus foot applies stress over the lateral border of the foot leading to degenerative changes in PTs. Methods: A cohort of 252 consecutive patients operatively treated for peroneal tendon tears (PT) were compared to an ageand sex-matched control (C) group of 104 outpatients treated for isolated forefoot problems. Calcaneal pitch, calcaneal - first metatarsal, talometatarsal, and talocalcaneal angles were compared on standing lateral radiographs. Talometatarsal and talocalcaneal angles, and talonavicular coverage, were compared on standing anteroposterior radiographs. Published radiographic criteria were used to determine cavovarus. ANOVA analysis detected statistically significant differences between patients and controls and a subsequent Tukey-Kramer test compared the control group with each type of PT tear. An a prioripower analysis was performed to calculate the minimum sample size in each cohort to detect a 90% effect size for a significance level of p<0.05. Results: Radiographic cavovarus was found in 9.4% (74/252) of PT group, and 6.7% (7/104) in controls. On lateral radiographs a significant greater calcaneal pitch (p=0.0001), and significant smaller calcaneal-first metatarsal angle (p=0.0084) was noted with PT tears (p=0.0001). On anteroposterior radiographs a significant smaller talometatarsal angle (p=0.0001) and talonavicular coverage (p=0.0001) were noted in PT tears. AP talocalcaneal and lateral talometatarsal and talocalcaneal angles were not correlated with PT tears. Patients treated for PT tears, isolated peroneus brevis tears (PB) accounted for 67.9% (171/252), isolated peroneus longus (PL) tendon tears were 7.5% (19/252), PB and PL tears accounted for 17.5% (44/252). A smaller talometatarsal angle on the AP was associated with PL (0.0098) and combined PB and PL tears (<0.0001) but not PB tears alone (0.1162). Conclusion: The correlation between cavovarus and peroneal pathology in the literature is highly anecdotal. Few studies report objective measures. This is the first study to our knowledge comparing nature and severity of cavovarus according to location of peroneal tear. This study proves and quantifies objective measures of cavovarus that correlate with peroneal tendon tears, when compared to a cohort of matched controls. [ABSTRACT FROM AUTHOR]

Background: Stress fractures of the talus are rare, and only a few small studies have been published. In the absence of follow-up studies, the outcomes of these injuries are unknown. Hypothesis: Traumatic fractures of the talus frequently heal poorly, and stress fracture healing might remain inadequate. The purpose of this study was to determine the outcome of stress fractures of the talus treated in the authors' institution with reduced exercise and nonweightbearing. Study Design: Case series (prognosis); Level of evidence, 4. Methods: Patients with a diagnosed stress fracture in the talus by magnetic resonance imaging between April 1997 and March 2005 were recalled for a follow-up inspection by an orthopaedic surgeon, magnetic resonance imaging, and plain radiographs to determine the outcome of the injury. Results: One of the 9 patients in our sample declined the invitation, leaving 8 patients with 9 stress fractures in the talus who participated in the follow-up examination. Five patients displayed subchondral degeneration and edema near the original injury area in the follow-up magnetic resonance imaging. In 2 patients, the degeneration was also visible on the plain radiographs. Three patients had mild and 2 moderate symptoms after the mean follow-up time of 45 months (range, 12-74 months). No serious complications in the healing process were seen. Conclusion: Stress fractures of the talus do not seem to seriously damage the foot. In a middle-term follow-up, however, minor to moderate symptoms and radiological degeneration of the injured area prevailed in roughly half of the patients. [ABSTRACT FROM AUTHOR]

Osteochondral lesions of the talus are well-recognized clinical entities; however, this report illustrates a rare case of an osteochondral defect in the distal fibula. A 15-year-old male was referred to the orthopaedic services with a 9-month history of persistent ankle pain following an initial inversion injury. Plain X-ray was unremarkable but magnetic resonance imaging and computed tomography revealed an osteochondral lesion at the level of the fibular physeal scar. The patient underwent an ankle arthroscopy where an unstable chondral flap was debrided and the associated fissure decompressed. The patient made an uneventful recovery and returned to normal sporting activities, symptom free. This diagnosis should be considered in patients presenting with chronic ankle pain particularly with a history of an inversion injury. The purpose of this report is to raise awareness of this condition.Levels of Evidence: Therapeutic, Level IV, Case study [ABSTRACT FROM PUBLISHER]

Introduction/Purpose: Maintaining physical activity (PA) is important for reducing the risk of lifestyle-related diseases and fundamental to keep healthy. PA is reduced in patients with knee and hip osteoarthritis, but PA of patients with ankle osteoarthritis has not been clarified. The purpose of this research is to compare PA level and proportion of patients who meet recommendations for health between ankle osteoarthritis and control patients. Methods: The subjects were 50 patients with ankle osteoarthritis (OA group), and 50 patients with minor hand disease matched by age and gender (control Group), who visited our outpatient clinic from October 2016 to April 2019. Both groups had 16 men and 34 women, with an average age of 68 years for the OA group and 66 years for the control group. The visual analogue scale for foot pain was 5.5 on average in the OA group and 0.3 in the control group. The physical activity for one week was measured using a tri-axial accelerometer. Unpaired t-tests were used to compare the number of steps per day and moderate or higher activity time between the OA group and the control group. The proportions of the OA group and the control group that met the recommendations set by Japan and the World Health Organization were compared using Fisher's exact test. Results: The number of steps per day was 4177 +- 2312 steps in the OA group and 6802 +- 2851 steps in the control group, which was significantly lower in the OA group (p <0.001). Moderate PA time was 448 +- 232 minutes in the OA group and 634 +- 336 minutes in the control group, OA group was significantly lower (p = 0.02). Vigorous PA time was no difference between the two groups. The WHO recommendations were met by 45 patients in the OA group and 48 in the control group, no difference. The Japanese criterion were met by 33 patients in the OA group and 46 in the control group, which was significantly lower in the OA group (p = 0.001). Conclusion: PA of patients with ankle osteoarthritis was less than control patients. The proportion of patients meeting recommendations for health was lower in the OA group than the control group. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Osteoarthritis (OA) is a chronic disease and a significant cause of joint pain, tenderness, and limitation of motion. At present, no specific treatment is available and mesenchymal stem cells (MSCs) have shown promising potentials in this regard. Herein, we aimed to evaluate the repairing potentials of stem cells derived from synovium and fat pad in treatment of OA in ankle joint. Methods: Twenty-eight male rats (220+-20 g, aged 10-12 weeks), were randomly divided into four groups (n=7): C1: nontreated, C2: Hyalgan treated, E1: Adipose-tissue derived stem cell treated, and E2: synovial-membrane based stem cell treated groups. Collagenase type II enzyme was injected into the left ankle; after eight weeks, OA was developed. Then, stem cells were injected and rats were followed for three months. Afterwards, rats were euthanized and specimens and radiological images were provided. P-value<=0.05 was set as statistically significant. Results: Compared to C1, E1 and E2 groups showed significantly better results in all pathological criteria including surface, matrix, cell distribution, cell population viability, subchondral bone, and cartilage mineralization as well as joint space width and osteophytes developed in the joint (p<=0.001). Similarly, compared to C2 group, E1 and E2 had better scores regarding surface, matrix, cell distribution, and cell population viability (p<0.05). E2 showed considerably higher scores compared to C2 regarding subchondral bone and cartilage mineralization (p<0.05). Joint space width was similar between C2 and E groups. Conclusion: Treatment of OA of ankle with MSCs, particularly synovial-membrane derived stem cells, not only prevented but also healed OA to some extent in comparison to Hyalgan and non-treatment groups. [ABSTRACT FROM AUTHOR]