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Background: Zone II and III fifth metatarsal (5-MT) fractures among athletes are typically managed with percutaneous fixation following anatomic reduction. However, screw head discomfort and refracture after bone union can occur because of the loads placed on the foot during play. Several hardware systems that use a smaller screw head compared to traditional hardware systems have been developed to minimize the rate of postoperative hardware complications. This study compares clinical and radiographic outcomes of 5-MT fractures in elite athletes treated with a solid headless screw vs a solid headed screw. We hypothesized that the headless screw would be associated with faster union rates, faster clearance times, and lower incidence of symptomatic hardware compared to the headed screw. Methods: Athletes competing at a collegiate level or higher treated for a zone II or III 5-MT fracture between 2016 and 2022 by 2 surgeons fellowship-trained in foot and ankle orthopaedics were screened. Operative notes were reviewed to determine the hardware system used. Subjects were divided based on the hardware system used during operation: headed screw and headless screw. Time to radiographic union, time to full clearance, and return to competition were determined. Postoperative complications, including nonunions, need for revision, need for hardware removal, and refractures were also noted. Results: Forty eligible patients (44 feet) were identified. The solid headed screw group included 20 patients (21 fractures), and the solid headless screw group included 20 patients (23 fractures). Average time to union for the headed screw group was 11.78 (range, 5.86-19.00) weeks; average time to union for the headless screw group was 11.65 (range, 6.00-22.57) weeks ( P = .93). Nineteen out of twenty (95%) patients were able to return to competition in both groups. Average time to return to competition for the headed screw group was 26.9 (range, 10.00-47.86) weeks, while average time for the headless screw group was 21.2 (range, 6.86-55.00) weeks ( P = .55). The overall complication rate for the headed screw was 23.8%, which was not statistically different from the overall complication rate for the headless screw of 13.0% ( P = .35). Conclusion: In this relatively small sample of elite athletes undergoing operative fixation of a 5-MT fracture, fixation using either a headless or headed screw system had similar good outcomes in regard to times to union, return to competition, and complication rate regardless of solid screw head type used. Level of Evidence: Level III, retrospective cohort study.

Rehabilitation protocols post-Achilles tendon repair vary widely, particularly regarding weight bearing (WB) and immobilization duration, impacting recovery trajectories significantly. This commentary focuses on rehabilitation strategies following acute Achilles tendon repair (ATR), emphasizing early mobilization and progressive loading. Techniques such as blood flow restriction training (BFRT) and progressive loading to restore strength and tendon mechanical properties are discussed in the context of optimizing recovery, minimizing tendon elongation and facilitating safe return to sport (RTS). This manuscript highlights current evidence and clinical insights to guide practitioners in optimizing rehabilitation protocols for athletes recovering from ATR, aiming to improve functional outcomes and support safe return to athletic activity.

Sanitation is a critical issue in internally displaced people (IDP) camps, where the lack of proper infrastructure and services can pose major health and environmental dangers. This paper presents a comprehensive analysis of the sanitation situation in Kabarto 2 IDP Camp in Iraq using the Smart Sanitation Approach comprising of three tools: SFD (Shit Flow Diagram), CSDA (Citywide Sanitation Diagnostic Assessment), and ECAM (Energy and Carbon Assessment for Environmental Management). The results show that the camp's sanitation infrastructure is wholly unsafe, with faecal sludge (FS) not being properly contained, emptied, or treated. The operation of the desludging trucks and the incomplete treatment are the main causes of the sanitation system's greenhouse gas emissions. The paper offers recommendations for enhancing the design and construction of the containment systems and restoring or upgrading the treatment plant. In conclusion, the study suggests improving data collection and monitoring, clear roles and responsibilities for the developing a faecal sludge management policy. The paper also makes suggestions for potential future applications of these tools, including the use of these technologies in more IDP camps or humanitarian settings to produce more data and knowledge about the provision of sanitation services in these settings and promote service improvement in the region.

Category: Ankle Arthritis; Ankle Introduction/Purpose: As the frequency of total ankle arthroplasties (TAA) performed annually has increased significantly over the past decade, several novel TAA implants have entered the market. The Infinity TAA (Stryker, Mahwah, NJ) is a low-profile fixed- bearing implant that was approved for use in the United States in 2014. Although the short-term survivorship and complication rates of the Infinity TAA have been well documented in the literature, mid- to long-term outcome studies of this implant are limited. The aim of this study was to describe the survivorship, reoperation rate, and radiographic and clinical outcomes of the Infinity implant at minimum 5-year follow-up. We hypothesized that there would be no significant drop-off in clinical outcome or alignment from 2-year to 5-year follow-up. Methods: This is a single-institution retrospective review of patients who underwent primary TAA with the Infinity implant from July 2014 to April 2017. Four fellowship-trained foot and ankle surgeons contributed patients. Out of 74 identified ankles, 65 ankles in 64 patients had minimum clinical follow-up of 5 years (mean, 6.5; range, 5.0-8.0) and were included for analysis. Medical records were reviewed to record demographics, surgical data, complications, reoperations, and revisions. Radiographs were assessed to measure preoperative and postoperative alignment, and the incidence of postoperative peri-implant lucencies and cysts. Preoperative, 2-year, and 5-year postoperative Foot and Ankle Outcome Score (FAOS) subscores in the categories of Pain, Symptoms, Activities of Daily Living, Sports, and Quality of Life were obtained. The primary outcome was 5-year survivorship. Secondary outcomes were reoperations with retention of tibial and talar components, radiographic alignment, peri-implant lucencies/cysts, and clinical outcomes (FAOS) scores. Results: Implant survivorship at 5 years was 93.8%, with 4/65 revisions. Three revisions occurred less than 2 years from the index surgery (2/3 for tibial subsidence; 1/3 for tibial and talar subsidence). The fourth revision occurred at 7.1 years due to cystic changes with tibial and talar subsidence. There were 11 reoperations in 10 ankles. Alignment correction achieved surgically (preop coronal deformity 9.0 ± 6.8°; 1Y postop 1.6 ± 1.5°) was maintained at final radiographic follow-up (1.8 ± 1.7°; P = 0.32). There were 16 ankles (24.6%) with peri-implant radiographic abnormalities: 14 cases of lucency (14 tibia, 0 talus) and 3 cases of cysts. FAOS outcomes demonstrated significant improvement from preop to postop in all five domains at 2 years, which were maintained at 5 years. Conclusion: The mid-term outcomes of the Infinity implant in this single-institution study demonstrated good survivorship of 93.8% and improved clinical outcomes at mean 6.3-year follow-up. This was a mid-term follow-up to the 2-year outcome study published at this institution. Radiographic assessment at final follow-up demonstrated that alignment correction was maintained, and there was a 21.5% incidence of asymptomatic periprosthetic lucencies. These results demonstrate that there was no significant change in radiographic or clinical outcomes with this implant after 5 years, which is valuable for surgeons in terms of counseling and following patients in the immediate and mid-term postoperative period.

Background: We have recommended active surveillance as the preferred management option for clinical stage I (CSI) testicular germ cell tumors (GCTs) since 1980. Over time, the recommended intensity of surveillance has decreased; however, the impact on relapse detection has not been investigated. Objective: To examine relapse rate, time to relapse, extent of disease, and burden of treatment at relapse across decreasing surveillance intensity over time. Design, setting, and participants: CSI GCT patients under active surveillance from 1981 to 2021 were included in this study. Outcome measurements and statistical analysis: Through four major iterations in both nonseminomatous (NSGCT) and seminoma surveillance schedules, visit frequency, blood testing, and imaging have been decreased successively. Low-dose, noncontrast computed tomography (CT) scans were adopted in 2011. Categorical variables and time to relapse were compared using chi-square and Fisher’s exact or Kruskal-Wallis test, respectively. Results and limitations: A total of 1583 consecutive patients (942 with seminoma and 641 with NSGCT) were included. In seminoma, chest x-rays were reduced from 13 to one and CT scans were reduced from 20 to ten. Relapse rate, time to relapse, N or M category, and International Germ Cell Cancer Collaborative Group (IGCCCG) classification did not change. In NSGCT, chest x-rays were reduced from 27 to zero and CT scans were reduced from 11 to five. Relapse rate (from 46.2% to 21.2%, p = 0.002) and the median time to relapse (from 6.54 to 4.47 mo, p = 0.025) decreased. No difference in relapsed disease burden was identified by N, M, and S category or IGCCCG classification. Treatment burden at relapse and GCT cancer deaths remained similar for seminoma and NSGCT. Limitations include the retrospective design and large time period covered. Conclusions: Despite considerable reductions in surveillance intensity, we did not observe an increase in disease extent, treatment burden, or GCT cancer deaths upon relapse. These results support that our current lower-intensity active surveillance schedules are safe for managing CSI GCT. Patient summary: Our current reduced-intensity surveillance schedules for clinical stage I germ cell tumors appear to be safe.

Purpose Genetic studies of multiple sclerosis (MS) susceptibility and severity have focused on populations of European ancestry. Studying MS genetics in other ancestral groups is necessary to determine the generalisability of these findings. The genetic Association study in individuals from Diverse Ancestral backgrounds with Multiple Sclerosis (ADAMS) project aims to gather genetic and phenotypic data on a large cohort of ancestrally-diverse individuals with MS living in the UK.Participants Adults with self-reported MS from diverse ancestral backgrounds. Recruitment is via clinical sites, online (https://app.mantal.co.uk/adams) or the UK MS Register. We are collecting demographic and phenotypic data using a baseline questionnaire and subsequent healthcare record linkage. We are collecting DNA from participants using saliva kits (Oragene-600) and genotyping using the Illumina Global Screening Array V.3.Findings to date As of 3 January 2023, we have recruited 682 participants (n=446 online, n=55 via sites, n=181 via the UK MS Register). Of this initial cohort, 71.2% of participants are female, with a median age of 44.9 years at recruitment. Over 60% of the cohort are non-white British, with 23.5% identifying as Asian or Asian British, 16.2% as Black, African, Caribbean or Black British and 20.9% identifying as having mixed or other backgrounds. The median age at first symptom is 28 years, and median age at diagnosis is 32 years. 76.8% have relapsing–remitting MS, and 13.5% have secondary progressive MS.Future plans Recruitment will continue over the next 10 years. Genotyping and genetic data quality control are ongoing. Within the next 3 years, we aim to perform initial genetic analyses of susceptibility and severity with a view to replicating the findings from European-ancestry studies. In the long term, genetic data will be combined with other datasets to further cross-ancestry genetic discoveries.

Background: There has been a rapid increase in research applying artificial intelligence (AI) to various subspecialties of orthopaedic surgery, including foot and ankle surgery. The purpose of this systematic review is to (1) characterize the topics and objectives of studies using AI in foot and ankle surgery, (2) evaluate the performance of their models, and (3) evaluate their validity (internal or external validation). Methods: A systematic literature review was conducted using PubMed/MEDLINE and Embase databases in December 2022. All studies that used AI or its subsets machine learning (ML) and deep learning (DL) in the setting of foot and ankle surgery relevant to orthopaedic surgeons were included. Studies were evaluated for their demographics, subject area, outcomes of interest, model(s) tested, model(s)’ performance, and validity (internal or external). Results: A total of 31 studies met inclusion criteria: 14 studies investigated AI for image interpretation, 13 studies investigated AI for clinical predictions, and 4 studies were grouped as “other.” Studies commonly explored AI for ankle fractures, calcaneus fractures, hallux valgus, Achilles tendon pathologies, plantar fasciitis, and sports injuries. For studies reporting the area under the receiver operating characteristic curve (AUC), AUCs ranged from 0.64 (poor) to 0.99 (excellent). Two studies (6.45%) reported external validation. Conclusion: Applications of AI in the field of foot and ankle surgery are expanding, particularly for image interpretation and clinical predictions. Current model performances range from poor to excellent, and most studies lack external validation, demonstrating a need for further research prior to deploying AI-based clinical applications. Level of Evidence: Level III, retrospective cohort study.

Purpose: Iodinated contrast media is one of the most frequently administered pharmaceuticals. In Canada, over 5.4 million computed tomography (CT) examinations were performed in 2019, of which 50% were contrast enhanced. Acute kidney injury (AKI) occurring after iodinated contrast administration was historically considered a common iatrogenic complication which was managed by screening patients, prophylactic strategies, and follow-up evaluation of renal function. The Canadian Association of Radiologists (CAR) initially published guidelines on the prevention of contrast induced nephropathy in 2007, with an update in 2012. However, new developments in the field have led to the availability of safer contrast agents and changes in clinical practice, prompting a complete revision of the earlier recommendations. Information sources: Published literature, including clinical trials, retrospective cohort series, review articles, and case reports, along with expert opinions from radiologists and nephrologists across Canada. Methods: The leadership of the CAR formed a working group of radiologists and nephrologists with expertise in contrast administration and patient management related to contrast-associated AKI. We conducted a comprehensive review of the published literature to evaluate the evidence about contrast as a cause of AKI, and to inform evidence-based recommendations. Based on the available literature, the working group developed consensus recommendations. Key Findings: The working group developed 21 recommendations, on screening, choice of iodinated contrast media, prophylaxis, medication considerations, and post contrast administration management. The key changes from the 2012 guidelines were (1) Simplification of screening to a simple questionnaire, and not delaying emergent examinations due to a need for creatinine measurements (2) Prophylaxis considerations only for patients with estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73 m2 (3) Not recommending the routine discontinuation of any drugs to decrease risk of AKI, except metformin when eGFR is less than 30 mL/min/1.73 m2 and (4) Not requiring routine follow up serum creatinine measurements post iodinated contrast administration. Limitations: We did not conduct a formal systematic review or meta-analysis. We did not evaluate our specific suggestions in the clinical environment. Implications: Given the importance of iodinated contrast media use in diagnosis and management, and the low risk of AKI after contrast use, these guidelines aim to streamline the processes around iodinated contrast use in most clinical settings. As newer evidence arises that may change or add to the recommendations provided, the working group will revise these guidelines.

Category: Midfoot/Forefoot Introduction/Purpose: Hallux rigidus is a common arthritic condition seen by foot and ankle specialists. Historically, surgical treatment options have varied from an isolated cheilectomy to first metatarsophalangeal joint fusion. More recently, first metatarsophalangeal (MTP) joint hemiarthroplasty with a polyvinyl alcohol (PVA) hydrogel implant (Cartiva) has become a popular surgical option. A randomized clinical trial sponsored by the manufacturers of the implant showed equivalent pain relief and functional outcome scores at 2 year follow-up when compared to patients undergoing first MTP fusion. In addition, the study reported no bone loss, implant wear or loosening. We retrospectively reviewed 1 year PROMIS score outcomes, clinical outcomes and implant survivorship of patients treated with first MTP hemiarthroplasty with the Cartiva implant at an academic, multi-surgeon center. Methods: We retrospectively reviewed 54 consecutive patients that underwent first MTP hemiarthroplasty with Cartiva for hallux rigidus between January 1, 2017 and December 1, 2017. Minimum follow-up criteria was 1 year, with the average being 1.37 years and maximum follow-up of 1.9 years. The Coughlin radiographic grading of disease severity averaged 2.18 at the time of implantation on a scale of 0 to 4. Surgery was performed by 8 fellowship-trained orthopedic foot and ankle surgeons at an academic institution. Baseline PROMIS scores (physical function, pain interference, global function, global mental, depression) and PROMIS scores acquired at 1 year postoperative were compared and evaluated using the Wilcoxon signed t-test. Clinical outcomes and postoperative complications/events were documented through review of electronic medical records. At the time of the study, 49 patients had reached 1 year follow-up with an average age of 56 (range, 33 - 74) years at the time of implantation. Results: Physical function, pain interference, global function and depression scores all demonstrated clinically and statistically significant improvement at 1 year postoperative. Global mental score did not show significant improvement at the one year follow-up. One patient underwent revision surgery to a 1st MTP fusion for persistent pain. Three patients had postoperative soft tissue swelling requiring prolonged retained sutures. Five patients underwent therapeutic injection with steroid between 2 - 11 months postoperative for persistent discomfort which improved. Five patients were prescribed orthotics between 3 - 6 months follow-up. One patient sustained a metatarsal fracture during the application of the implant requiring ORIF but retained the implant. Implant retention at 1 year was 98% (48/49). No correlation between preoperative radiographic grading and the incidence of poor clinical outcomes. Conclusion: To our knowledge, this is the first study that demonstrates the outcomes of synthetic cartilage implants using a large series of surgeons without affiliation or consultation for the implant company. One year following first MTP hemiarthroplasty with PVA hydrogel implant (Cartiva), functional and pain scores improved significantly, but did not show significant improvement with global mental scores. The implant displayed excellent survivorship at the 1 year time point, with only one patient undergoing surgical revision. Treatment of hallux rigidus with the PVA hydrogel implant - Cartiva, shows improved patient outcomes and has reassuring results at one year.

Category: Ankle Arthritis Introduction/Purpose: Determining the etiology of pain after total ankle replacement (TAR) often serves as a diagnostic dilemma for many surgeons, particularly in the setting of normal appearing radiographs. Single photon emission computed tomography (SPECT CT) has been identified as a potentially useful tool to evaluate pain after TAR. However, prior research has been limited by a lack of comparison to clinical findings as well as comparison to other imaging modalities. Our study aims to add to the current understanding of the role of SPECT CT as a diagnostic tool in TAR. It is our hypothesis that SPECT CT would be predictive of clinical and intraoperative findings in patients with pain after TAR. Methods: A retrospective review was undertaken of SPECT CT imaging performed at our institution for the evaluation of painful TAR from January 2014 to November 2018. There were 35 patients identified during this time period who underwent SPECT CT to evaluate pain after TAR. The average length of time from index surgery to SPECT CT was 17.2 months. Of this cohort, 18 patients also had an MRI during the same time frame and images were available for comparison. Findings on the imaging studies were compared to clinical findings as documented in the medical record, as well as intraoperative findings at the time of revision surgery when one was performed. SPECT CT results, as well as MRI results when available, were evaluated for their consistency with documented clinical and intraoperative findings. Results: Of the 35 patients, 91.4% (32/35) had SPECT CT results that were consistent with clinical findings. Amongst the diagnoses for which SPECT CT was useful in this cohort, loosening (12/32) and impingement (10/32) were most common. Other diagnoses included malalignment (4/32), cyst formation (2/32), subtalar arthritis (2/32), and infection (2/32). In our cohort, 25 patients underwent revision surgery, and SPECT CT imaging was consistent with ultimate intraoperative findings in 24 (96.0%) cases. Procedures performed were revision for aseptic loosening (11/25), gutter debridement (5/25), revision for malalignment (2/25), hindfoot reconstruction (2/25), implant removal for infection (2/25), cyst grafting, subtalar arthrodesis, and conversion to ankle arthrodesis. In the 18 patients who also underwent MRI, these results were consistent with clinical findings 38.9% (7/18) of the time. Conclusion: In this cohort, there was a high consistency between SPECT CT results and documented clinical diagnoses. Additionally, in those patients who ultimately underwent revision surgery, SPECT CT demonstrated high consistency with intraoperative findings. When compared to MRI, SPECT CT proved more useful in helping to establish a diagnosis for pain after TAR in our cohort. Our series serves to highlight the utility of SPECT CT as an additional tool in evaluating the painful TAR. Further investigation into the interpretation of SPECT CT after TAR, including changes in physiologic postoperative uptake that occur over time, is warranted.

Category: Midfoot/Forefoot Introduction/Purpose: Surgical planning based on angular measurements obtained on conventional radiographs is challenging due to perspective distortion and operator bias. Novel weightbearing CT (WBCT) three-dimensional (3D) measurements using coordinate systems may represent a more reliable and accurate evaluation of this 3D deformity. The objective of this study was to compare the M1-M2 intermetatarsal angle (IMA) obtained manually on WBCT digitally reconstructed 2D radiographs versus a set of coordinates from the full 3D dataset, in patients with hallux valgus (HV) deformity and in healthy controls. We hypothesised that the 3D measurements would be more reliably obtained, demonstrating different values when compared to 2D radiographic measurements. Methods: In this multicenter retrospective comparative study, 83 feet that underwent WBCT of the foot were included (41 HV: mean age 59, 81% female, 42 controls: mean age 52, 80% female). Datasets were analysed by three independent trained foot and ankle surgeons using the same protocol. Coordinates in three planes (x, y, z) of four different landmark points were harvested: center of the heads and midpoint of the proximal metaphysis of the 1st and 2nd metatarsal. The IMA measurements were then performed in reconstructed radiographic images (DRR-IMA). The data collected was then analyzed by a single 4th independent and blinded investigator who calculated the 3D angle (3D-IMA) and its projection on the weightbearing plane (2D-IMA). Intra-observer realiability was assessed by Pearson/Spearman’s correlation. Intermethod correlation was evaluated by intraclass correlation coefficient (ICC). Mean values for measures were comparared by One-way ANOVA. P-values of less than 0.05 were considered significant. Results: Intraobserver reliability was excellent for radiographic DRR-IMA (0.95) and 3D coordinates assessment (0.99). Intermethod correlation between the three different imaging modalities (DDR, 2D and 3D), considering bias and interactions, were respectively 0.71 and 0.51 in control and HV patients. IMA measurements were found to be similar when measured in DRR, 2D and 3D WBCT images, for both controls and HV patients. Mean values and confidence intervals (CI) for controls were 8.8 degrees (CI, 7.9-9.7) in DDR images, 9.8 degrees (CI, 8.7-10.9) in 2D images and 10.6 degrees (CI, 9.5-11.8) in 3D images. When compared to controls, HV patients demonstraded significantly increased IMA (p

Category: Sports Introduction/Purpose: Adequate evaluation of foot and ankle problems in elite athletes is paramount for planning the correct treatment, predicting clinical prognosis and supporting decision making. A complete physical examination that includes the assessment of foot alignment during weightbearing is mandatory. The three-dimensional evaluation provided by weightbearing CT imaging (WBCT) represent an important diagnostic tool for foot and ankle surgeons when dealing with these extremely physically active patients. The purpose of this study was to assess different WBCT measurements of hindfoot and forefoot alignment in injured high-level football and basketball players. We hypothesized that specific patterns of hindfoot alignment and height of the longitudinal arch of the foot could be identified. Methods: In this single center retrospective comparative study, 80 professional male athletes - 47 basketball and 33 American football players from College, NBA and NFL leagues - that underwent WBCT as part of the clinical investigation for different injuries of the foot and ankle were included in the study. WBCTs images were evaluated by a blinded board-certified foot and ankle orthopedic surgeon. Multiple measurements used for assessment of hindfoot valgus and longitudinal arch height were assessed and included: foot and ankle offset (%), calcaneal offset (mm), hindfoot alignment angle (°), navicular-floor distance (mm), medial cuneiform-floor distance (mm), forefoot arch angle (°), inferior talar-superior talar angle (°), and subtalar horizontal angle (°). An unpaired Student’s t test was performed to evaluate any differences in the measurements when comparing professional basketball and football patients. P-values less than 0.05 were considered significant. Results: A summary of demographic characteristics and each measurement’s distributions and standard deviations, as well as p-values for the analysis between groups, is given in table 1. No significant differences were found between basketball and American football elite athletes when comparing the mean values of measurements evaluated (mean differences): foot and ankle offset (0.26%), calcaneal offset (0.58 mm), hindfoot alignment angle (0.73°), navicular-floor (0.35 mm) and medical cuneiform-floor distances (0.38 mm), forefoot arch angle (0.74°), inferior talar–superior talar angle (0.83°) and subtalar horizontal angle (0.1°). Conclusion: Although we did not find significant differences in foot alignment when comparing basketball and American football professional athletes, the results of our study highlight some of the important foot alignment parameters and establish distributions in an extreme but important population. Further studies correlating foot alignment with the incidence of some of the most common pathologies diagnosed in elite athletes, such as the ones reported in our study, can help in the understanding and prevention of those injuries.

Category: Ankle Arthritis Introduction/Purpose: With the increasing use of total ankle arthroplasty (TAA), new implants with varied configurations are being developed every year. This study aims to provide the early complications, reoperations and radiographic and clinical outcomes of the Infinity TAA. To date, clinical results of this novel fixed-bearing implant have not been published. Methods: A retrospective analysis of 64 consecutive ankles that underwent a primary Infinity TAA from July 2014 to April 2016 was performed. Patients had an average follow-up of 24.5 (range, 18-39) months. Medical records were reviewed to determine the incidence of complications, reoperations and revisions. Radiographic outcomes included preoperative and postoperative tibiotalar alignment, tibial implant positioning, the presence of periprosthetic radiolucency and cysts, and evidence of subsidence or loosening. Additionally, patient-reported outcomes were analyzed with the Foot and Ankle Outcome Score (FAOS) preoperatively and 1-year postoperatively. Results: Survivorship of the implant was 95.3%. Fourteen ankles (21.8%) presented a total of 17 complications (Table 1). A total of 12 reoperations were necessary in 11 ankles (17.1%). Revision surgery was indicated for 3 ankles (4.7%) due to isolated subsidence of the tibial implant in 2 cases and due to subsidence of both the tibial and talar components in 1 case. Tibiotalar coronal deformity was significantly improved after surgery (P < .0001) and maintained during latest follow-up (P = .81). Periprosthetic radiolucent lines were observed around the tibial component in 20 ankles (31%) and around the talar component in 2 ankles (3.1%). A tibial cyst was observed in 1 ankle (1.5%). Outcome scores were significantly improved for all FAOS components analyzed (P < .0001). Conclusion: Most complications observed in the study were minor and successfully treated with a single reoperation procedure or nonoperatively. Failures and radiographic abnormalities were most commonly related to the tibial implant. Further studies with longer follow-up are needed to evaluate the survivorship of the tibial implant in the long-term.

Category: Pain Management, Anesthetic Advances Introduction/Purpose: The number of opioid prescriptions in the United States has significantly increased over the past 20 years, including those given after low-risk surgery. Unintentional opioid overdoses have also dramatically risen. Excess pills are widely acknowledged as a source of diversion, which accounts for up to 40% of opioid-related overdoses. In the foot and ankle literature, there are no studies looking at the quantity of pain medications that should be prescribed following outpatient surgery. Furthermore, with the increasing use of peripheral nerve blocks, their effect on quantities of narcotics needed after these surgeries have not been explored. This study aims to determine prescribing patterns for common outpatient foot and ankle surgery and whether patients are over or under-prescribed opioids and if so, by how much. Methods: 57 patients undergoing outpatient foot and ankle surgeries were prospectively enrolled. Patients received a spinal neuraxial block and a long-acting popliteal peripheral nerve block, and did not receive ketorolac perioperatively. Patients were excluded if they had a history of chronic pain, or were currently using opioids or muscle relaxers. Enrolled patients received a standard post-operative prescription regimen of 60 tablets of narcotics, 3 days of scheduled ibuprofen, aspirin 81 mg twice a day (or alternate based on risk factors) for DVT prophylaxis, and ondansetron taken as needed. Patients used a pain diary to record when their block wore off and the quantity of narcotic taken. They received surveys at post-operative day (POD) 3, 7, and 14 detailing how many days they took the medication and how many pills were consumed, how their actual pain compared to their expected level of pain, and if they were satisfied with their pain control. Results: At POD 3, compared to their expected level of pain 36 patients had less pain, 15 had the same pain, and 3 had more pain than expected. The mean pain score was 4. Patients first started feeling the block wear off at 0.9 days. Patients averaged 10.3 pills of narcotics in the first 3 days and rated their overall satisfaction with pain control at 8.5. Between days 4-7, patients took an average of 7 pills, and on POD 7, 22 patients were still taking narcotics. At POD 14, patients experienced 74.4% relief of pain compared to their expected pain, and rated their overall satisfaction at 8.2. Patients had an average of 33.5 remaining pills on POD 14 and 13 patients (22.8%) were still taking narcotics. Conclusion: Patients receiving spinal and long-acting popliteal blocks, followed by the prescription regimen described above had excellent pain control after outpatient foot and ankle surgeries. Patients had a high level of satisfaction with their pain control, with many patients describing better pain relief than expected. However, 60 tablets of narcotics were excessive in most cases. We suggest that in patients receiving spinal and long-acting popliteal blocks, 30 tablets of a narcotic would cover the pain needs of most patients. This would provide a small excess in case of need, but would help minimize the risk of narcotic related complications and diversion.

Category: Sports Introduction/Purpose: Anterior tibial tendon ruptures are rare orthopedic injuries but can cause significant dysfunction and may need surgery to correct. Often conservative measures have been prescribed due to the morbidity of a tendon transfer as a surgical solution. The aim of this report is to present a novel reconstruction technique using hamstring autograft and provide an outcome analysis using subjective and objective criteria in order to demonstrate the safety and efficacy of this novel procedure which may obviate the need for tendon transfer or long term bracing. Methods: Patients who underwent tibialis anterior reconstruction with hamstring autograft between 2011 and 2015 by a fellowship-trained orthopedic surgeon were screened for inclusion. 10 patients were enrolled in the study, and 1 was later excluded due to concomitant conditions in her foot and ankle. Retrospective chart review was performed and functional outcomes were assessed pre- and postoperatively using the Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) general health questionnaire. Postoperative isokinetic testing and range of motion (ROM) using a dynamometer (Biodex System 4 Pro) was performed for inversion/eversion and plantarflexion/dorsiflexion on the involved and uninvolved ankles at a minimum of 6 months post operatively. Testing was performed at two different speeds, 60 degrees/sec and 120 degrees/sec, to determine postoperative strength and endurance of the repaired tendon, respectively. Peak torque, Max rep total work, average power, and total work were measured. Results: The average follow-up was 17.3 (range 6.0-40.0) months. Average postoperative scores improved for the VAS, SF-12 and all subscales of the FAOS. Range of motion was similar between the uninvolved and involved ankles for inversion/eversion and plantarflexion/dorsiflexion with slightly decreased measures for both inversion and dorsiflexion. Strength and endurance testing was categorized by the percent difference between the operative and non-operative side. Patients showed only small deficits in inversion strength and endurance in all measures tested. Patients showed more deficits in dorsiflexion strength and endurance, with the majority of patients showing less than 50% deficits in average power and torque for both strength and endurance (Table). All patients were able to ambulate without a brace or noticeable limp. There were no infections. Conclusion: Use of hamstring autograft for tibialis anterior reconstruction resulted in improved functional outcomes and few postoperative complications. Our results show that this procedure successfully restores ankle range of motion postoperatively. In addition, the procedure successfully restores tendon strength in inversion, with most repaired ankles showing little deficit in the involved side as compared to the uninvolved side. This is a reproducible technique with minimal morbidty and excellent clinical outcomes.

Category: Ankle Introduction/Purpose: There are few prior investigations that report the clinical and radiographic outcomes of juvenile allogenic chondrocyte implantation with autologous bone marrow aspirate in the ankle. Reports that do exist have offered conflicting results and suggest that this relatively new technique has no significant advantage over current repair techniques. The purpose of this study was to compare the functional and radiographic outcomes of patients who received juvenile allogenic chondrocyte implantation with autologous bone marrow aspirate for treatment of talar osteochondral lesions with those of patients who underwent microfracture. Methods: After approval was obtained from our institutional review board, the institution’s foot and ankle registry was searched using relevant Current Procedural Terminology codes for all patients who underwent either microfracture or juvenile allogenic chondrocyte implantation with bone marrow aspirate concentrate for an osteochondral lesion of the talus between 2006 and 2014. Ninety-six patients fit the inclusion criteria and composed the study cohort. Of these 96 patients, 50 had undergone microfracture treatment and 46 had received DeNovo NT for juvenile allogenic chondrocyte implantation with bone marrow aspirate concentrate treatment, composing the microfracture (MF) and JACI-BMAC groups, respectively. Retrospective chart review was performed and functional outcomes were assessed pre- and postoperatively using the Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) general health questionnaire. Postoperative magnetic resonance (MR) images were reviewed and evaluated using a modified Magnetic Resonance Observation of Cartilage Tissue (MOCART) score. Results: The average followup was 40.0 (range 5.0 to 113.6) months with the MF group having an average followup of 40.3 months (range 5 to 133.6) and the JACI-BMAC group averaging a 18.6 month followup (range 9.1 to 39.6). Both the JACI-BMAC and MF groups had significant pre-to-postoperative improvements in Pain, Daily Activities, Sports, Quality of Life, and overall FAOS Scores; however, there were no significant differences in any patient reported outcomes between the groups. SF-12 scores were improved in both JACI-BMAC and MF groups, however the MF change from pre- to-postoperative did not reach significance (p = 0.214). Radiographically, both the JACI-BMAC and MF groups produced reparative tissue that exhibited a fibrocartilage composition. The JACI-BMAC group tended to have more patients with hypertrophy exhibited on MR imaging than the MF group (p = 0.030). Conclusion: Juvenile allogenic chondrocyte implantation and microfracture resulted in improved functional outcomes. However, none of the differences in FAOS scores between groups achieved the minimal clinically important difference, suggesting there may not be enough of a difference between these treatments to distinguish them in terms of patient outcomes in the short term. Both techniques produced reparative tissue that exhibited fibrocartilage composition radiographically. Based on our results, juvenile allogenous cartilage has not demonstrated a significant advantage over the microfracture technique in the treatment of talar osteochondral lesions. Longer term studies will be needed to see if these findings are maintained over time.

Category: Sports. Introduction/Purpose: Proximal fractures (Zones II and III) of the fifth metatarsal are common in the elite athlete population with basketball players being especially prone to developing these injuries. Fractures in Zones II and III of the fifth metatarsal can be difficult to treat due to tendency toward delayed union, nonunion, or refracture. The purpose of this case series is to report our experience in treating 10 professional basketball players from the National Basketball Association (NBA) for proximal fifth metatarsal fractures and determine the healing rate, return to play, refracture rate and role of foot type in these athletes. Methods: The records of 10 professional basketball players who were treated for fifth metatarsal fractures between September 2008 and October 2014 were retrospectively reviewed. Seven athletes underwent standard percutaneous internal fixation with bone marrow aspirate concentrate (BMAC) while the other 3 had open bone grafting primarily in addition to fixation and BMAC. Radiographic features associated with recurrent fifth metatarsal fractures were reported including fourth-fifth intermetatarsal (IMA4-5), fifth metatarsal lateral deviation (MT5-LD), calcaneal pitch (CP), and metatarsus adductus (MAA) angles. Differences in clinical and radiographic features were assessed between athletes who refractured (n=3) and those who did not (n=7). Results: Radiographic healing was observed at an overall average of 7.5 weeks and return to play was 9.8 weeks. Three athletes experienced refractures. When comparing the refracture group (n=3) with the control group (n=7), there were no significant differences in clinical features or radiographic measurements except that the refracture group had the highest measured MAA. Four of 10 fit the criteria for having metatarsus adductus as measured by the Sgarlato method (MAA greater than 14 degrees) while 5 of 10 had metatarsus adductus using the Engel method (greater than 24 degrees). All refractures had an abnormal angle using the Engel method. Seven of the 10 athletes were classified as pes planus and 9/10 had a bony prominence under the proximal base of their fifth metatarsals styloid. Conclusion: This is the largest series of operatively treated professional basketball players that possess a unique foot type that seems to be associated with increased risk of fifth metatarsal fracture and refracture. This foot type is one which has forefoot metatarsus adductus and a fifth metatarsal that is curved with a prominent base. We continue to use standard internal fixation with bone marrow aspirate but advocate additional prophylactic open bone grafting in patients with high IMA4-5, MT5-LD and MAA angles as well as prominent fifth metatarsal styloids in order to improve fracture healing and potentially decrease the risk of refracture.