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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.)

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.)

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.)

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.)

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.

Staphylococcus aureus invades osteoblasts and can persist in the intracellular environment. The present study examined the role of osteoblast mitogen-activated protein kinase (MAPK) pathways in bacterial invasion. S. aureus infection of normal human and mouse osteoblasts resulted in an increase in the phosphorylation of the extracellular signal-regulated protein kinases (ERK 1 and 2). This stimulation of ERK 1 and 2 correlated with the time course of S. aureus invasion, and bacterial adherence induced the MAPK pathway. ERK 1 and 2 phosphorylation was time and dose dependent and required active S. aureus gene expression for maximal induction. The nonpathogenic Staphylococcus carnosus was also able to induce ERK 1 and 2 phosphorylation, albeit at lower levels than S. aureus. Phosphorylation of the stress-activated protein kinases was increased in both infected human and mouse osteoblasts; however, the p38 MAPK pathway was not activated in response to S. aureus. Finally, the transcription factor c-Jun, but not Elk-1 or ATF-2, was phosphorylated in response to S. aureus infection.

Staphylococcus aureus and Salmonella spp. are common causes of bone diseases; however, the immune response during such infections is not well understood. Colony-stimulating factors (CSF) have a profound influence on osteoclastogenesis, as well as the development of immune responses following infection. Therefore, we questioned whether interaction of osteoblasts with two very different bacterial pathogens could affect CSF expression by these cells. Cultured mouse and human osteoblasts were exposed to various numbers of S. aureus or Salmonella dublin bacteria, and a comprehensive analysis of granulocyte-macrophage (GM)-CSF, granulocyte (G)-CSF, macrophage (M)-CSF, and interleukin-3 (IL-3) mRNA expression and cytokine secretion was performed. Expression of M-CSF and IL-3 mRNAs by mouse osteoblasts was constitutive and did not increase significantly following bacterial exposure. In contrast, GM-CSF and G-CSF mRNA expression by mouse osteoblasts was dramatically upregulated following interaction with either viable S. aureus or Salmonella. This increased mRNA expression also translated into high levels of GM-CSF and G-CSF secretion by mouse and human osteoblasts following bacterial exposure. Viable S. aureus and Salmonella induced maximal levels of CSF mRNA expression and cytokine secretion compared to UV-killed bacteria. Furthermore, GM-CSF and G-CSF mRNA expression could be induced in unexposed osteoblasts separated by a permeable Transwell membrane from bacterially exposed osteoblasts. M-CSF secretion was increased in cultures of exposed human osteoblasts but not in exposed mouse osteoblast cultures. Together, these studies are the first to define CSF expression and suggest that, following bacterial exposure, osteoblasts may influence osteoclastogenesis, as well as the development of an immune response, via the production of these cytokines.