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Category: Midfoot/Forefoot; Other Introduction/Purpose: Morton's neuroma, also known as interdigital neuroma, is an enlargement of the plantar digital nerve between the metatarsal head, and a well-recognized source of metatarsalgia. Surgical treatment becomes a viable option when nonsurgical methods are ineffective, and neurectomy of the affected nerve has been the predominant and standard procedure for Morton's neuroma. There are several surgical approaches commonly used for Morton's neuroma neurectomy, including dorsal longitudinal approach, plantar longitudinal approach, and plantar transverse approach. Current literature lacks comprehensive information comparing the clinical outcomes of the plantar and dorsal approach for Morton's neuroma neurectomy. This systematic review and meta-analysis was conducted to evaluate and compare the clinical outcomes of neurectomy for Morton's neuroma, focusing on the differences between the plantar and dorsal approach. Methods: This comprehensive literature review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and utilized databases including PubMed, Embase, Web of Science, and the Cochrane Library. The search was carried out on June 16th, 2023. The inclusion criteria for articles in this study were as follows: (1) Patients diagnosed with Morton's neuroma who underwent surgical excision; (2) Studies that compared clinical outcomes following Morton's neuroma excision between the dorsal and plantar approaches, and reported on at least one of these outcome measures: postoperative visual analog scale (VAS) pain scores; postoperative clinical functional scores; postoperative scar tenderness; postoperative sensory loss; histopathology; patient satisfaction; time to weight bearing; reoperations; and any other postoperative complications, such as infection. Our review was focused on the comparison of postoperative clinical outcomes and complications associated with neurectomy for Morton's neuroma, between the plantar and dorsal approach. Results: Total eight studies were included in this study. 237 neuromas underwent excision using the plantar approach, while 312 neuromas were treated via the dorsal approach. A significantly higher rate of postoperative reduced sensory was found in the dorsal group: 48.5% (64/132) Vs. 62.0% (80/129) with the relative ratio (RR) of 0.79 (95% CI, 0.64-0.97). A significantly higher rate of postoperative scar tenderness was noted in the plantar group: 6.7% (32/192) Vs. 6.2% (14/225) with the RR of 2.27 (95% CI, 1.28-4.04). Regarding the histopathology findings, 99.3% (143/144) and 97.1% (134/138) accuracy rate was confirmed in the plantar group and dorsal group, respectively, with the RR of 1.02 (95% CI, 0.98-1.07). No significant difference in reoperation rates and postoperative complications was observed between the two groups. Conclusion: This study compared postoperative outcomes following Morton's neuroma excision between the dorsal and plantar approach. Our findings indicated a notably higher incidence of scar tenderness in patients with the plantar approach, whereas sensory loss was more prevalent in those with the dorsal approach. Additionally, the plantar approach showed a tendency of more precise removal of Morton's neuroma based on histopathological evaluation. We recommend detailed discussions with patients prior to surgery to weigh the advantages and disadvantages of each approach. Further RCTs with larger cohorts are necessary to reach a strong consensus. [ABSTRACT FROM AUTHOR]

Objectives: The use of web-based technology in healthcare delivery is ubiquitous. ChatGPT, a readily available artificial intelligence (AI) chatbot, has the potential to augment current practice. ChatGPT has shown rudimentary promise as a source of information for orthopaedic patients. The use of ChatGPT in foot and ankle surgery, particularly for acute Achilles tendon ruptures (AATR), has not been described. The purpose of this study was to assess the quality of information provided by ChatGPT in response to frequently asked questions about AATR. Methods: ChatGPT was posed 10 frequently asked questions about AATR in a conversational thread. Responses were recorded and no follow-up queries or clarification was obtained. The responses were subsequently graded "A," "B," "C," or "F," corresponding with "excellent response," "adequate response needing mild clarification," "inadequate response needing moderate clarification," and "poor response needing severe clarification." Results: Of the 10 responses, 2 were grade "A," 6 were grade "B," 1 was grade "C," and 0 were grade "F." Overall, ChatGPT provided good quality responses to the posed questions. Conclusions: ChatGPT responded well to questions regarding AATR, using simple language to provide responses representative of the current literature surrounding AATR. Overall, ChatGPT performed well providing good-to-great quality responses to frequently-asked questions about AATR. This study emphasized the potential role of ChatGPT as a source of information for patients who suffer AATR. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis Introduction/Purpose: The purpose of this systematic review and meta-analysis was to compare the volume of blood loss, transfusion rates and complication rates between patients who were administered tranexamic acid (TXA) versus patients who were not administered TXA during total ankle arthroplasty (TAA). Methods: During January 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies comparing outcomes between patients who were administered TXA versus patients who were not administered TXA during TAA. Data regarding surgical characteristics, subjective clinical outcomes, total blood loss, intra-operative blood loss, total complications and wound complications rates were extracted and analysed. In total, 5 comparative clinical studies were included in this review. Results: 194 patients received TXA and 187 patients did not receive TXA during TAA. There was a statistically significant reduced volume of total blood loss in favor of patients who received TXA compared to patients who did not receive TXA during TAA (SMD:-0.7832; p< 0.0001). A statistically significant reduced volume of intra-operative blood loss between the TXA cohort and the control cohort was also observed in favor of the TXA cohort (SMD:-1.14; p< 0.0001]. A statistically significant reduced volume of hemoglobin loss was found in favor of patients who received TXA compared to the control cohort (SMD: -0.9548; p< 0.02). A higher transfusion rate was found in the control cohort (1.1%) compared to the TXA cohort. No difference in complication rates was observed between the cohorts. Conclusion: This systematic review and meta-analysis found that patients who received peri-operative TXA had statistically significant reduced total blood volume loss, intra-operative blood volume loss, hemoglobin loss together with no statistically significant difference in complication rates following TAA. Further randomised control trials with improved data collection are necessary to elucidate the optimal dosage, frequency and role of TXA in the peri-operative setting for TAA. [ABSTRACT FROM AUTHOR]

Category: Ankle; Sports Introduction/Purpose: Chronic ankle instability occurs in 15-20% of patients with ankle sprains who do not recover following conservative management and typically requires surgical intervention. There is recent interest in Anterior Talofibular Ligament (ATFL) Repair techniques that may improve outcomes and expedite recovery. Evidence for the use of suture-tape as an internal in ATFL Repair is limited in the literature. The purpose of this study was to retrospectively assess outcomes and return to sport following ATFL Repair with and without suture-tape (ST) augmentation at greater than 1-year follow-up. Methods: Chart review was conducted to identify patients who underwent Anterior Talofibular Ligament (ATFL) Repair with a minimum of 1-year follow-up. Data collected and assessed included: patient demographics, pathological characteristics, treatment characteristics, Foot and Ankle Outcome Score (FAOS), visual analog scale (VAS) scores, return to sport (RTS), complications, and failures. Linear regression was performed to identify potential predictors of outcomes. Results: Eighteen cases of ATFL repair augmented with suture-tape (ST) and 20 cases of ATFL repair alone were included. The mean follow-up in the ST cohort was 20.8 ± 7.9 months and the mean follow-up time in the ATFL repair alone cohort was 25.3 ± 13.2 months. Improvements in FAOS and VAS scores were observed in both cohorts at final follow-up (p < 0.01). No statistically significant difference in FAOS and VAS scores at final follow up was found between the 2 cohorts. The mean time to RTS was 8.6 ± 3.3 weeks in the ST cohort and 13.3 ± 2.7 weeks in the ATFL repair alone cohort (p < 0.01). No statistically significant difference in complication rates nor failure rates was observed between the 2 cohorts. Conclusion: This retrospective study found that ATFL Repair with and without suture-tape augmentation produced comparable subjective clinical outcomes, complication rates and failure rates at short-term follow-up. A superior mean time to RTS was found in the ST cohort. The early results of this surgical technique are promising, but further studies with larger patient cohorts and longer follow-up times are needed to determine the optimal role of suture-tape augmentation of ATFL repair. [ABSTRACT FROM AUTHOR]

Category: Midfoot/Forefoot; Other Introduction/Purpose: The purpose of this systematic review was to examine the clinical and radiological outcomes of various surgical treatments for symptomatic accessory naviculars. Methods: During February 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following surgical treatment for symptomatic accessory navicular. Data regarding surgical characteristics, subjective clinical outcomes, radiological outcomes, complications and failure rates were extracted and analyzed. 26 studies were included for review. Results: In total, 520 patients (614 feet) underwent surgical treatment for the management of symptomatic accessory navicular. The weighted mean age was 28.18 ± 8.18 and the weighted mean follow-up time was 46.23 ± 34.76 months. The mean AOFAS score was 49.9 ± 7.39 preoperatively and 88.9 ± 5.61 postoperatively. The mean complication rate at final follow-up was 9.02% and the failure rate was 4.23%, with only 2.7% of patient ultimately requiring a further procedure. We also compared outcomes in patient who underwent a Kidner or Modified Kidner procedure (n=245) with those treated with a different surgical technique such as fusion or simple excision (n=275). There was no significant difference in outcome scores, complication rates, failure rates, or secondary surgical procedure rates between these cohorts. Conclusion: This systematic review demonstrated improvement in clinical outcomes following surgical treatment for symptomatic accessory naviculars. The markedly low complication and failure rates further indicate that surgical intervention is beneficial in the management of symptomatic accessory naviculars. Kidner and Modified Kidner procedures resulted in equivocally good outcomes compared with other surgical approaches such as fusion and simple excision. However, the marked heterogeneity between the included studies and few high level comparative studies limits the generation of any robust conclusions for optimal surgical technique. Further research is warranted to determine whether the Kidner procedure confers any particular advantages over other approaches. [ABSTRACT FROM AUTHOR]

Category: Midfoot/Forefoot; Other Introduction/Purpose: The purpose of this systematic review was to evaluate the clinical and radiological outcomes together with the complication rates and failure rates following surgical intervention for hallux varus deformity. Methods: During January 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following surgical intervention for hallux varus deformity. Data regarding study characteristics, patient demographics, osteoarthritis severity, subjective clinical outcomes, radiological outcomes, complications and failure rates were extracted and analysed. In addition, the level of evidence and quality of evidence for each individual study was also assessed. Results: Twelve studies were included. In total, 168 patients (186 feet) underwent surgical intervention for hallux varus deformity. at a weighted mean follow-up of 49.6±36.6 months. The weighted mean AOFAS score improved from a pre-operative score of 60.5±18.4 to a post-operative score of 83.9±9.0. The weighted mean hallux valgus angle improved from a pre-operative angle of 16.9±6.5° of varus to a post-operative angle of 5.9±6.6° of valgus. The weighted mean inter-metatarsal angle improved from a pre- operative angle of 12.7±10.0° to a post-operative angle of 7.7±3.4°. The complication rate was 21.5%, the most common of which was 1st MTPJ joint pain and stiffness. Eleven failures (5.9%) were observed at a mean time of 25.0 months following the index procedure. Conclusion: This systematic review demonstrated improvements in subjective clinical outcomes together with a low failure rate following surgical intervention for hallux varus deformity at mid-term follow-up. A high complication rate was recorded. However, the marked heterogeneity between included studies and paucity of high quality comparative studies limits the generation of any robust conclusions. Further research with a longer follow-up is warranted to determine the optimal surgical technique for hallux varus deformity correction. [ABSTRACT FROM AUTHOR]

Category: Lesser Toes; Other Introduction/Purpose: The purpose of this systematic review was to evaluate the clinical and radiological outcomes together with the complication rates and failure rates following surgical intervention for Freiberg's Infraction. Methods: During December 2022, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following surgical intervention for the management of Freiberg's Infraction. Data regarding study characteristics, patient demographics, lesion characteristics, subjective clinical outcomes, radiological outcomes, complications and failure rates were extracted and analysed. In addition, the level of evidence and quality of evidence for each individual study was also assessed. Results: Eighteen studies were included. In total, 299 patients (302 feet) underwent surgical intervention for the management of Freiberg's Infraction at a weighted mean follow-up of 49.9±45.1 months. The distribution of patients by Smillie's (SI-V) classification was recorded in as follows: SI (0 patients), SII (20 patients), SIII (42 patients), SIV (69 patients), SV (54 patients). The most common surgical procedure was dorsal closing wedge metatarsal osteotomy. The weighted mean AOFAS score improved from a pre-operative score of 60.3±9.0 to a post-operative score of 84.3±24. The weighted mean total ROM improved from 46.4±11.7° pre-operatively to 66.2±15.1° post-operatively. The weighted mean time to osseous union was 7.4±3.6. The complication rate was 5.2%, the most common of which was pain. Four failures (1.6%) were observed. Conclusion: This systematic review found improvements in subjective and objective clinical outcomes together with a low complication rate following surgical intervention for Freiberg's infraction at mid-term follow-up. However, the level and quality of evidence of the included studies were low and there was marked heterogeneity and under-reporting of data between the included studies. Although surgical intervention appears to is the mainstay treatment option for Freiberg's infraction, further higher quality comparative studies are warranted to determine the optimal surgical technique for Freiberg's infraction. [ABSTRACT FROM AUTHOR]

Category: Midfoot/Forefoot; Other Introduction/Purpose: The purpose of this systematic review was to evaluate outcomes following polyvinyl alcohol hydrogel implant for the management of hallux rigidus. Methods: During January 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies evaluating outcomes in patients who underwent polyvinyl alcohol hydrogel implant for the management of hallux rigidus. Data regarding surgical characteristics, subjective clinical outcomes, radiographic outcomes, failure rates and complications were extracted and analysed. In total, 15 studies were included in this review. Results: In total, 1536 patients (1578 feet) underwent polyvinyl alcohol hydrogel implant for the management of hallux rigidus at a weighted mean follow-up of 39.4 ± 17.3 months. The weighted mean VAS score improved from a pre-operative score of 6.2 ± 1.3 to a post-operative score of 3.0 ± 1.6. There was limited data regarding improvements in range of motion. The complication rate was 15.7% and the failure rate was 9%. Conclusion: This systematic review demonstrated improvement in subjective clinical outcomes following PVA hydrogel implant for the management of hallux rigidus. A moderate complication rate and failure rate was noted at short term follow-up. Further studies with longer follow-up periods are warranted to elucidate the precise outcomes following PVA hydrogel implant for the management of hallux rigidus. [ABSTRACT FROM AUTHOR]

Category: Other; Ankle Introduction/Purpose: The purpose of this systematic review was to evaluate the clinical and radiological outcomes at short-term follow-up following peroneal tendoscopy for the treatment of peroneal tendon disorders. Methods: During October 2022, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following peroneal tendoscopy for the treatment of peroneal tendon disorders. Data regarding patient demographics, pathological characteristics, subjective clinical outcomes, radiological outcomes, complications and failure rates were extracted and analysed. Results: Nine studies were included. In total, 264 patients (269 tendons) underwent peroneal tendoscopy for the treatment of peroneal tendon disorders at a weighted mean follow-up of 30.5±11.4 months. The peroneal tendon disorders included: peroneal tendon tear (89 patients), peroneal tenosynovitis (85 patients), low lying muscle belly (54 patients) and peroneal tendon subluxation (17 patients). The weighted mean AOFAS score improved from a pre-operative score of 76.0 to a weighted mean post-operative score of 96.0. The complication rate was 3.8%, the most common of which was persistent lateral ankle pain (1.1%). Two failures (0.007%) were reported, both of which underwent repeat peroneal tendoscopy, tenosynovectomy and low lying muscle belly resection. Conclusion: This systematic review demonstrated improvement in subjective clinical outcomes together with a low complication rate and low failure rate at short-term follow-up following peroneal tendoscopy for the treatment of peroneal tendon disorders. However, the level of evidence was low and the quality of evidence was poor. In addition, there was significant heterogeneity between the included studies. Further higher quality studies are warranted to determine the optimal role of peroneal tendoscopy for the management of peroneal tendon disorders. [ABSTRACT FROM AUTHOR]

Category: Ankle; Basic Sciences/Biologics Introduction/Purpose: The purpose of this systematic review was to evaluate the clinical and radiological outcomes together with the complication rates and failure rates at short-term follow-up following Particulated Juvenile Allograft Cartilage (PJAC) for the management of osteochondral lesions of the talus (OLT). Methods: During November 2022, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following PJAC for the management of OLTs. Data regarding study characteristics, patient demographics, lesion characteristics, subjective clinical outcomes, radiological outcomes, complications and failure rates were extracted and analysed. In addition, the level of evidence and quality of evidence for each individual study was also assessed. Results: Twelve studies were included. In total, 241 patients underwent PJAC for the treatment of OLT at a weighted mean follow-up of 29.0±24.9 months. The weighted mean lesion size was 138.3±59.6 mm2 and 69.4% of OLTs were located at the medial talar dome. Prior surgical intervention was recorded in 7 studies, the most common of which was microfracture (65.9%). Concentrated bone marrow aspirate was utilized in 66 patients (27.3%). The weighted mean AOFAS score improved from a pre- operative score of 58.5±3.2 to a post-operative score of 83.9±5.3. The weighted mean post-operative MOCART score was 48.2±3.3. The complication rate was 16.5%, the most common of which was graft hypertrophy (7.0%). Thirty failures (12.4%) were observed at a weighted mean time of 9.8±9.6 months following the index procedure. Conclusion: This systematic review demonstrated a moderate improvement in subjective clinical outcomes following PJAC for the treatment of OLT at short term follow-up. However, post-operative MOCART scores were reported as poor. In addition, a moderate complication rate (16.5%) and a moderate failure rate (12.4%) was observed, calling into question the efficacy of PJAC for the treatment of large OLTs. Further studies are warranted to identify the optimal role of PJAC in the management of OLTs. [ABSTRACT FROM AUTHOR]

Category: Midfoot/Forefoot; Other Introduction/Purpose: The purpose of this systematic review and meta-analysis is to compare outcomes between patients who underwent open chevron osteotomy (OCO) and minimally invasive Chevron osteotomy (MICA) for the management of hallux valgus deformity. Methods: During January 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies comparing outcomes between patients who underwent open chevron osteotomy (OCO) and minimally invasive Chevron osteotomy (MICO) for the management of hallux valgus deformity. Data regarding surgical characteristics, subjective clinical outcomes, radiographic outcomes, failure rates and complications were extracted and analysed. In total, 6 comparative studies were included in this review. Results: In total, 183 patients (208 feet) underwent OCO and 209 patients (244 feet) MICA for the management of hallux valgus deformity. Meta-analysis demonstrated no difference in post-operative MOFXQ scores (SMD: 0.0849, [-0.2584, 0.4282], p = 0.6277), hallux valgus angle (SMD: -0.1245, [-0.4204, 0.1715], p = 0.4099), intermetatarsal angle (SMD:-0.2565, [-0.5539, 0.0408], p = 0.909) and failures (RR: 1.0765, [0.0993, 11.6760], p = 0.9278) between the OCO cohort and the MICO cohort. There was a lower complication rate in the OCO cohort compared to the MICO cohort (RR: 0.2614, [0.1453, 0.4704], p < 0.0001). Conclusion: This systematic review found comparable improvements in subjective clinical outcomes, functional outcomes and radiographic outcomes following both OCO and MICO at short-term follow-up. However, a lower RR with respect to complications was found in the OCO cohort compared to the MICO cohort. Despite the significant heterogeneity across the included studies, the similar outcomes between the 2 cohorts reinforces that further research is warranted to determine the optimal role of OCO and MICO in the management of hallux valgus deformity. [ABSTRACT FROM AUTHOR]

Category: Midfoot/Forefoot; Other Introduction/Purpose: The purpose of this systematic review was to evaluate outcomes following intra-articular 1st MTPJ hyaluronic acid injection for the management of hallux rigidus. Methods: During January 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies evaluating outcomes in patients who underwent intra-articular 1st MTPJ hyaluronic acid injection for the management of hallux rigidus. Data regarding injection characteristics, subjective clinical outcomes, failure rates and complications were extracted and analysed. Results: In total, 5 studies were included in this review. In total, 209 patients underwent intra-articular 1st MTPJ hyaluronic acid injection for the management of hallux rigidus at a weighted mean follow-up of 4.4 ± 1.4 months. The weighted mean VAS improved from a pre-injection score of 6.4 ± 0.3 to a post-injection score of 2.8 ± 0.4. A 10.1% complication rate was noted, the most common of which was transient 1st MTPJ swelling. One infection (0.5%) was reported. A symptomatic recurrence rate of 18.6% was observed at a weighted mean time of 7.3 ± 4.2 months Conclusion: This systematic review demonstrated that intra-articular 1st MTPJ hyaluronic acid injection for the management of hallux rigidus led to a reduction in pain and a moderate complication rate at short-term follow-up. In addition, intra-articular 1st MTPJ hyaluronic acid injection for the management of hallux rigidus produced a symptomatic recurrence rate of 18.6% at approximately 7.3 months, suggesting that HA provides short-term relief. The lack of quality comparative studies limits the generation of robust conclusions, reinforcing the need for further research to identify the optimal role of HA in the management of hallux rigidus. [ABSTRACT FROM AUTHOR]

Category: Lesser Toes; Other Introduction/Purpose: The purpose of this systematic review was to compare the clinical and radiological outcomes between K- Wire fixation and implant device fixation for the management of hammertoe deformity. Methods: During November 2022, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following either K-Wire fixation and implant device fixation for the treatment of hammertoe deformity at a minimum of 1-year follow-up. Data regarding surgical characteristics, subjective clinical outcomes, radiological outcomes, complications and failure rates were extracted and analysed. 19 studies were included for quantitative analysis, of which 4 studies were included for qualitative analysis. Results: In total, 1343 patients (3468 feet) underwent K-Wire fixation and 456 patients (664 feet) underwent implant device fixation for the management of hammertoe deformity.The osseous union rate in the K-wire cohort was 71.3% versus 74.8% in the implant device cohort. The complication rate in the K-wire cohort was 9.7% versus 29.3% in the implant device cohort. The failure rate in the K-wire cohort was 8.6% versus 6.5% in the implant cohort. The secondary surgical procedure rate in the K-wire cohort was 8.3% versus 3.6% in the device cohort. Qualitative analysis found no difference in osseous union rates (RR=0.5832; 0.0830-4.0985; p=0.3562), complication rates (RR=1.12; 0.11-11.34; p=0.8571), failure rates (RR=0.87; 0.04-21.86; p=0.8746) nor secondary surgical procedure rates (RR=1.05; 0.06-18.32; p=0.9487) between the K-wire cohort and device cohort. Conclusion: This systematic review and meta-analysis demonstrated improvement in clinical and radiographic outcomes following both K-wire fixation and implant device fixation for hammertoe deformity. Qualitative analysis found no significant difference in osseous union rates, complication rates, failure rates nor secondary surgical procedure rates between the 2 cohorts. However, the marked heterogeneity between the included studies and few high level comparative studies limits the generation of any robust conclusions. Further research is warranted to determine the optimal role of both K-wire fixation and implant device fixation in the management of hammertoe deformity. [ABSTRACT FROM AUTHOR]

Category: Ankle; Basic Sciences/Biologics Introduction/Purpose: Extracorporeal shockwave therapy (ESWT) is a non-invasive treatment modality that is utilized in the treatment of chronic Achilles tendinopathy (AT). The purpose of this study was to retrospectively assess outcomes following ESWT for both NAT and IAT at greater than 1-year follow-up, and to identify potential predictors of outcomes. Methods: Chart review was conducted to identify patients who underwent ESWT for AT with a minimum of 1-year follow-up. Data collected and assessed included: patient demographics, pathological characteristics, treatment characteristics, Victorian Institute of Sports Assessment-Achilles (VISA-A) and visual analog scale (VAS) scores and failures. Linear regression was performed to identify potential predictors of outcomes. Survival analysis was conducted using Kaplan Meier curves. Fifty-two cases of IAT and 34 cases of NAT were included. The mean follow-up in the NAT cohort was 22.3±10.2 months and the mean follow-up time in the IAT cohort was 26.8±15.8 months. Results: Improvements in VISA-A and VAS scores were observed in the NAT cohort at 6 months follow-up and at final follow-up (p < 0.01). Improvements in VISA-A scores and VAS scores were recorded in the IAT cohort at 6 months follow-up which subsequently deteriorated at final follow-up. In the NAT cohort, the failure rate at 6 months follow-up was 11.8% which increased to 29.4% at final follow-up. In the IAT cohort, the failure rate at 6 months follow-up was 32.7% which increased to 59.6% at final follow-up. Predictors of poor outcomes in the NAT cohort included pre-ESWT subjective clinical score, male, presence of cardiovascular risk factor, and increasing MRI severity. Predictors of poor outcomes in the IAT cohort included pre-ESWT subjective clinical score and increasing MRI severity. Conclusion: This study found that superior subjective clinical outcomes together with a lower failure rate maintained over 1 year in the NAT cohort compared to the IAT cohort. This may implicate ESWT as a temporising treatment in IAT and a longer term solution in patients with NAT. [ABSTRACT FROM AUTHOR]

Category: Other Introduction/Purpose: The purpose of this study was to utilize finite element analysis to evaluate progressive bone removal from the calcaneus at various angles and its effect on the mechanical stress distribution at the calcaneus, and potential increase in fracture risk. Methods: A calcaneus CT scan was imported into Autodesk Fusion360 (Autodesk, v.2.0.14569). After rendering the initial mesh body using tetrahedral elements, a copy of the calcaneus was made. A simulated force equal to the average weight of person (876N) was applied to the middle and posterior talus facets while the calcaneus was oriented in the heel strike position during gait, with constraints applied around the heel. The initial harvest site was modelled as a 6mm diameter 30mm deep cylinder. From this center point, the diameter of the harvest site was increased to 8, and 10mm, with the depth being adjusted such that there was no risk of breaching the cortex on the opposite side. For each iteration, the safety factor, stress (MPa), and strain were recorded. This was repeated at an angle of 90°, 45° and a combination of 45° and 90°. Results: The 90° model demonstrated that as the diameter of the harvest site increased, there was a reciprocal increase in stress across the calcaneus. The number of cycles to failure (fracture) for all diameters was 10^6-10^7. The 45° model demonstrated that as the diameter of the harvest site increased, there was a reciprocal increase in stress applied across the calcaneus with a corresponding decrease in stress at the harvest site. The number of cycles to failure increased from 10^3 at 6mm to 10^4-10^5 at 10mm. The combination of the 45°-90° model demonstrated that as the diameter of the harvest site increased, there was a reciprocal increase in stress applied across the calcaneus. The cycles to failures decreased as the diameter of the harvest site increased. Conclusion: This finite element analysis demonstrated that an increase in the diameter of the harvest site led to an increase in stress along the calcaneus. There was variation in the correlation between size of the diameter and the number of cycles to failure depending on the angle of the harvest. The greatest amount of stress applied at the calcaneus was with the 45°-90° model. It was determined that harvesting at an angle of 45° at 6mm produced the lowest number of cycles to failure. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis; Other Introduction/Purpose: End stage ankle osteoarthritis is a significantly debilitating pathology that is most commonly preceded by trauma. The emergence of 3rd and 4th generation total ankle arthroplasty (TAA) implant designs have led to more favorable outcomes compared to its predecessors. TAA implants can be broadly divided into fixed bearing and mobile bearing implant designs, however, no consensus has been reached regarding the optimal TAA implant design for the management of end stage ankle arthritis. The purpose of this systematic review and meta-analysis was to compare outcomes between patients who received fixed bearing TAA implants and mobile bearing TAA implants. Methods: During January 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies comparing outcomes between patients who underwent fixed bearing TAA implant and patients who underwent mobile bearing TAA implant for the management of end stage ankle arthritis. Data regarding surgical characteristics, subjective clinical outcomes, radiographic outcomes, failure rates and complications were extracted and analysed. Results: Overall, 13 studies were included in this review. In total, 2793 patients underwent mobile bearing TAA implant and 2241 patients underwent fixed bearing TAA implant for the management of end stage ankle arthritis. No difference existed between the 2 cohorts with regards to post-operative subjective clinical outcome scores nor radiological outcomes. The mobile bearing TAA implant cohort was associated with higher complications (RR = 1.4710; [1.0375-2.0857]; p = 0.0373) and failures (RR = 1.3916; [1.2038 - 1.6086]; p = 0.0032) compared to the fixed bearing TAA implant cohort. Conclusion: This systematic review and meta-analysis found no difference in subjective clinical outcomes and radiological outcomes between patients who underwent mobile bearing TAA implant and fixed bearing TAA implant for the management of ankle arthritis. Interestingly, the mobile bearing TAA implant cohort was associated with higher complications and failures compared to the fixed bearing TAA implant cohort. Due to the marked under-reporting of data and significant heterogeneity between the included studies, further high quality research is warranted to determine the optimal TAA implant type for the management of end stage ankle arthritis. [ABSTRACT FROM AUTHOR]

Category: Ankle Arthritis; Other Introduction/Purpose: The purpose of this systematic review and meta-analysis was to evaluate potential predictors of failure following total ankle arthroplasty (TAA) for the management of end stage ankle arthritis. Methods: During January 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to evaluate potential predictors of failure following total ankle arthroplasty for the management of end stage ankle arthritis. Data regarding surgical characteristics, subjective clinical outcomes, radiographic outcomes, odds ratios, hazard ratios, correlation coefficients, failure rates and complications were extracted and analysed. Results: In total, 15117 patients (15198 ankles) underwent TAA at a weighted mean follow-up of 64.0 ± 21.8 months. Pooled Odds ratio found that diabetes was a statistically significant predictor of failures following TAA (OR: 2.1; [1.9861, 2.2284], p = 0.003). Other variables such as age, gender, body mass index, implant type and arthritis aetiology were not associated with failure. Conclusion: This systematic review and meta-analysis found that the presence of diabetes mellitus was a statistically significant predictor of failure following TAA. However, there was marked heterogeneity between the included studies with regards to statistical data collection which significantly limits the robustness of the conclusions of this study. Thus, further higher quality research with more consistent data collection is warranted to identify potential predictors of failure post TAA. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: The Achilles tendon is the most commonly ruptured tendon in the lower limb, and when left untreated for at least 4 weeks, these are classified as chronic or 'neglected' Achilles tendon ruptures (CATR). There is discordance on the optimal surgical treatment to treat CATR. Given the prevalence of this injury, there is a need to determine the best treatment modality. In this study, we performed a systematic review of the literature to compare the different treatment options for CATR, analyze the level of evidence (LOE) and quality of evidence (QOE) of the included studies, and recommend a literature-based algorithmic approach to the treatment of CATR. Methods: In July 2019, MEDLINE, EMBASE, and Cochrane Library databases were systematically reviewed by 2 independent reviewers based on the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. Full-length peer-reviewed studies in English with a sample size of 10 participants that reported functional outcome scores with a minimum follow-up of 24 months were included. We excluded systematic reviews, meta-analyses, review articles, cadaveric and animal studies, and case reports. The LOE and QOE of the included studies were evaluated using the Journal of Bone and Joint Surgery Criteria and the Modified Coleman Methodology Score, respectively. Patient demographic data, surgical procedure type, subjective outcomes, postoperative strength, range of motion, postoperative imaging, return to sports and work data, complications, failures, and reoperations were evaluated. Continuous variables were reported as weighted mean and estimated standard deviation, whereas categorical variables were reported as frequencies with percentages. Results: Thirty-one studies with 653 CATRs were included. Three studies were LOE III and 28 studies were LOE IV. A large variety of repair techniques were described and analyzed, and semitendinosus tendon grafting was the most frequently utilized technique (6 of 31 studies). The most commonly reported clinical outcome was the American Orthopaedic Foot and Ankle Society (AOFAS) score (58.6%). Most studies reported good postoperative subjective outcomes, strength outcomes, and return to sports data at mid-term follow-up. In total, 14.6% of patients experienced postoperative complications, where the most common was surgical wound complications (10.8%). Conclusion: Surgical management of CATR produces good clinical outcomes at mid-term follow-up, but a high complication rate (14.6%) was noted. This systematic review found that no evidence-based treatment guidelines exist for CATR. Future studies of higher QOE and LOE which focus on specific risk factors are warranted to determine in which case one particular technique would be suitable for CATR repair. Our proposed treatment algorithm (Figure 1) may assist in shared decision-making for this complex problem. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Acute Achilles tendon rupture (AATR) is a common injury of an incidence rate of up to 31 per 100,000 per year. The current meta-analyses on the treatment of AATR have conflicted data that may, in part, be due to the differences in their methodologies. The aim of this study is to systematically review and present the current meta-analyses for the treatment of AATR. The outcomes of this study can provide clinicians with a clear overview of the current literature to help decide on the optimal treatment for patients. Methods: Two independent reviewers searched PubMed and Embase on March 17, 2020 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Assessment of evidence was two-fold: level of evidence (LoE) and quality of evidence (QoE). LoE was evaluated using published criteria by The Journal of Bone and Joint Surgery and the QoE by the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) scale. Pooled complication rates were highlighted for significance in favor of 1 group or no significance. Statistical analysis was performed using a statistical software package (R version 3.5.1; R Foundation for Statistical Computing, Vienna, Austria). Descriptive statistics were calculated for each study and statistical parameters analyzed. Continuous variables were reported as mean +- standard deviation and categorical variables were reported as frequencies with percentages. P-values < 0.05 was considered statistically significant. Results: 21 meta-analyses were included in the study. Re-rupture rates ranged between 2.3% to 5.0% for open repair/MIS and 3.9% to 13% for conservative treatment (p < 0.05). Re-rupture rates were reported in 3 of 4 meta-analyses that ranged between 2.3% to 7.8% for conservative treatment earlier rehabilitation and 5.0% to 12.2% for conservative treatment later rehabilitation. Re-rupture rates were 2.5% for open repair earlier rehabilitation and 3.8% for open repair later rehabilitation. When comparing surgical techniques, re-rupture rates ranged between 1.4% to 3.1% for percutaneous repair/MIS and 2.2% to 2.7% for open repair. Infection rates ranged between 2.8% to 5.0% for open repair/MIS and 0% to 0.02% for conservative treatment. The majority of meta-analyses (3 of 5) significantly favored by effect size, open repair/MIS for total infection rates (p < 0.05). Conclusion: The results of this study demonstrate that operative repair reduced the rate of re-rupture when compared to conservative treatment. There is currently conflicting information on whether early functional rehabilitation reduces the difference between the two treatments. Operative treatment has been shown to have a higher rate of wound complications, although the rates of deep wound infections remains to be determined. Percutaneous repair resulted in similar re-rupture rates when compared to open surgery but for the rates of other complications including wound infections, this was diminished. Further metaanalyses which compare all cohorts are needed to ascertain best evidence. [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: Ankle limitation to dorsiflexion in an extended knee is observed during the second rocker of gait in patients with positive Silfverskiold test confirming an isolated gastrocnemius contracture (IGC). Tendons and muscles share intrinsic contractility and relaxation properties which can be modified during physiotherapy in comparison to the fascia which lacks it. The present study describes a case series of patients with positive Silfverskiold associated with various foot pathologies who underwent a selective fasciotomy of the postero-medial superficial portion of the crural fascia. The purpose of this study is to describe the surgical technique and clinical outcomes of this procedure. We hypothesize that this procedure can reach satisfactory clinical outcomes with the advantage of being a less invasive procedure. Methods: 26 patients treated with partial postero-medial superficial release (PMSR) of the crural fascia from January to October 2021 for IGC with associated chronic foot pain were included. Inclusion criteria considered patients with diagnosis of foot pain with IGC and positive Silfverskiold test. A transverse incision was made 2 cm distal to the flexion crease starting at the intermuscular line of the gastrocnemius muscle, 4 cm medially (Figure 1). Subcutaneous dissection was performed identifying the neurovascular bundle. A horizontal incision was performed to the superficial posterior fascia of the medial gastrocnemius head. The medial gastrocnemius muscle was not sectioned. Patients completed the FADI score previous to surgery and at final followup. Data was analyzed using SPSS 20. Paired samples T-tests were performed to identify significance of the difference in pain and function preoperatively and postoperatively with statistical significance set at p<0.05. Descriptive statistics were used for demographic variables. Results: 18 patients underwent partial PMSR of the crural fascia while 8 patients had additional procedures. Mean age of the included patients was 40.6 +/-18.5 years. Specifically, this included 4 feet with a diagnosis of metatarsalgia, 3 feet with metatarsalgia and plantar fasciitis, 6 feet with metatarsalgia, plantar fasciitis and cavus foot, 5 feet with plantar fasciitis, 3 feet with plantar fasciitis and insertional achilles tendinopathy, 4 patients with non-insertional achilles tendinopathy and 1 foot with flexor hallucis longus tendinopathy.The average ankle dorsiflexion increased significantly (p<0.0001) from -1.15 +/-2.15 degrees preoperatively to 10.65 +/-2.02 degrees post-operatively. The average FADI score significantly increased (p<0.0001) from 47.54 +/-12.26 preoperatively to 80.46 +/-14.04 post-operatively. The average follow-up was 9.38 +/-3.76 weeks. All patients had a negative Silfverskiold test at final follow-up. Conclusion: Partial postero-medial superficial release (PMSR) of the crural fascia was found to be an effective outpatient procedure when used to relieve foot pain in those patients with an isolated gastrocnemius contracture. Patients who have failed conservative treatment can expect notable improvement with satisfactory FADI scores after the procedure. Future prospective studies should involve a larger number of patients with no additional procedures to be compared with gastrocnemius muscle release procedure for isolated gastrocnemius contracture with associated foot pain. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this retrospective clinical study was to evaluate outcomes following extracorporeal shockwave therapy (ESWT) for the treatment of Achilles tendinopathy. Subgroup analysis was conducted to identify predictors of poor outcomes. Methods: This retrospective cohort study included existing clinical data from 74 patients from a single academic institution. Patients greater than 16 years of old who underwent ESWT for Achilles tendinopathy in the office setting between 3/3/2017 to 8/2/2022 were included. Data collected included: patient demographics, co-morbidities, treatment characteristics, Victorian institute of sports assessment - Achilles (VISA-A) scoring tool, visual analog scale (VAS), magnetic resonance imaging data, return to play (RTP) data and failures were recorded. Failure was defined as no improvement in VISA-A nor VAS scores or surgical intervention. For these data, mean and standard deviation were calculated, and paired samples T-tests and Welch's T-tests were performed on clinical outcome scores. Results: In total, 74 patients (91 heels) with a mean age of 54.1 ± 14.0 years and BMI of 27.3 ± 4.5 kg/m2 underwent ESWT for Achilles tendinopathy at a mean follow-up of 25.7 ± 15.0 months. Eighteen patients were in the non-insertional Achilles tendinopathy (NAT) cohort and 56 patients were in the insertional Achilles tendinopathy (IAT) cohort. Both NAT and IAT cohorts had a similar improvement in VISA-A score (p=0.365) and VAS scores (p=0.65). A shorter return to play time was found in the NAT cohort (1.1 ± 0.9 months) compared to the IAT cohort (2.6 ± 5.7 months) but this was not statistically significant (p=0.34). There was a higher failure rate in the the IAT cohort (50.0%) than the NAT cohort (38.9%). Patients who received platelet-rich plasma (PRP) had a higher failure rate (61.2%) than those who did not receive PRP (39.6%). In the NAT cohort, the failure rate in females was 0.0%. In the IAT cohort, the failure rate in females was 61.9%. Linear regression analysis found that elevated BMI and MRI severity were associated with worse post-ESWT outcomes. Conclusions: This retrospective study demonstrated a high failure rate at short-term follow-up in patients who underwent ESWT for Achilles tendinopathy. Higher failure rates were found in patients with IAT and those who received intratendinous PRP. Predictors of poor outcomes included elevated BMI and MRI severity. Further studies with larger patient cohorts and a longer follow-up are necessary to determine the role of ESWT in the treatment of Achilles tendinopathy. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Although rare, Tibialis Anterior Tendon (TAT) tears or ruptures can have a detrimental effect on patients' quality of life. There is no current consensus as to the most appropriate surgical treatment for TAT rupture, in part because of the paucity of data surrounding this condition. Therefore, this study attempts to address this deficiency by performing a systematic review of the literature of the different surgical interventions for TAT rupture, analyzing the level of evidence (LoE) and quality of evidence (QoE) of the included studies, and recommending an algorithm approach to the surgical treatment of TAT injury. Methods: In September 2021, the MEDLINE and EMBASE databases were systematically reviewed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following search terms were used: (anterior) AND (tibialis OR tibial) AND (tendon) AND (tear OR rupture) NOT (acl OR cruciate OR meniscal OR patellar). ??Full-length peer-reviewed studies in English with a sample size of 5 participants that reported functional outcome scores were included. We excluded systematic reviews, meta-analyses, review articles, and case series/reports with less than five participants. The LoE and QoE of the included studies were evaluated using the Journal of Bone and Joint Surgery Criteria and the Modified Coleman Methodology Score, respectively. In some cases, tabulated data from studies were analyzed to obtain relevant statistics for our analysis, including deriving descriptive statistics such as mean and standard deviation values, as well calculating p-values with twosample t-tests assuming either equal or unequal variance. Results: Twelve studies with 171 patients were included in this review, 11 with Level IV evidence and one with Level II evidence. Additionally, there were 17 different types of repair techniques used, where direct repair (including end-to-end repair and bone fixation) was performed on 33.5% of tendons, tendon transfers were performed on 20.8% of tendons, and grafts were performed on 45.7% of tendons. For the mean postoperative AOFAS Ankle-Hindfoot (AOFAS-AH) scores, both the direct repair and autograft cohorts had significantly higher mean scores than the allograft cohort (p=0.008 and p=0.002 respectively). The autograft cohort was also found to have significantly higher post-operative means AOFAS-AH than the tendon transfer cohort (p=0.047). We also found statistically significant improvements in dorsiflexion strength after surgical intervention in early intervention (<=6 weeks from injury to surgery) and delayed intervention cohorts. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Depending upon the site of injury, Achilles tendinopathy (AT) can be either Insertional (IAT) or NonInsertional (nIAT). AT has long been managed by conservative measures such as eccentric exercises, but now extracorporeal shock wave therapy (ESWT) has emerged as a non-invasive treatment to stimulate self-repair. However, the native biology at the insertion of the Achilles tendon and mid-substance are intrinsically different, with the mid-substance (2 to 6 cm above the insertion) being significantly less perfused. Thus, we performed a systematic review of the literature on shockwave therapy to determine if there was a difference in efficacy for patients who have undergone ESWT for IAT and nIAT. Methods: In January 2022, the MEDLINE and EMBASE databases were systematically reviewed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included randomized controlled trials, prospective and retrospective studies, published in English, with pre- and post-operative scores for at least either Visual Analogue Scale (VAS) or Victorian Institute of Sport Assessment - Achilles (VISA-A). We excluded basic science studies, systematic reviews and metaanalyses, retrospective studies, case reports, studies without pre-operative scores, studies that don't differentiate IAT and nIAT. The LoE and QoE of the included studies were evaluated using the Journal of Bone and Joint Surgery Criteria and the Modified Coleman Methodology Score, respectively. We calculated weighted mean values for age, body mass index (BMI), the number of ESWT sessions and their frequency, duration of symptoms prior to ESWT, follow-up time, as well as for each outcome score. Results: 16 studies were included in this review, six with Level I evidence, four with Level II, five with Level III, and one with Level IV. There were 505 cases of AT: 325 patients with IAT and 180 with nIAT. For the IAT cohort, the weighted mean (WM) duration of symptoms prior to treatment was 18.1 months, and WM follow-up was 8.1 months. For the nIAT cohort, the WM duration of symptoms prior to treatment was 15.0 months, and WM follow-up was 11.6 months. In terms of outcome scores, for VAS, the WM pre-operative scores were 6.89 for IAT and 7.76 for nIAT and the WM post-operative scores were 2.76 for IAT and 2.49 for nIAT. For VISA-A, the WM pre-operative scores were 49.3 for IAT and 42.8 for nIAT, and the WM post-operative scores were 75.4 for IAT and 75.7 for nIAT. Conclusion: As the mid-substance portion of the Achilles tendon has diminished blood supply compared to the insertional portion, we expected outcomes after ESWT to be inferior for the nIAT cohort. Interestingly, the VAS pain scores and VISA-A functional scores displayed similar positive results for both cohorts. We see that the virtually equivalent functional and pain outcomes mean that ESWT is stimulating cellular components of the tendon to promote healing regardless of injury location. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Subjective patient-reported outcome scores are routinely used to evaluate the efficacy of surgical interventions however to date none have been validated for ankle osteochondral lesions (OCL's). The foot and ankle outcome score (FAOS) is a 42 item subjective questionnaire consisting of 5 domains: pain, symptoms, function in daily activities, function in sports, and quality of life. It has been recently validated for flatfoot deformity and hallux valgus correction. The aim of this study was to validate the FAOS for ankle OCL's. Methods: Patients diagnosed with ankle OCL's from 2008 to 2013 were identified through the hospital foot and ankle registry. A retrospective analysis was performed to determine construct validity, where the FAOS subscales were compared with corresponding short form-12 (SF-12) subscales. Correlation was deemed moderate if the Spearman's correlation coefficient was .4 to .7. Preoperative and postoperative scores of 54 patients with OCL's were compared to determine responsiveness. Content validity was prospectively assessed in 20 patients by a separate questionnaire where patients rated the relevance of each FAOS question to their ankle OCL. A score of 2 or more was considered acceptable. Both retrospective analysis and prospective evaluation of 44 patients were used to assess test-retest reliability, which was measured using intraclass correlation coefficients (ICC's). Results: All of the FAOS subscales demonstrated moderate correlation with the physical health component of the SF-12. The FAOS symptoms subscale showed the least correlation, demonstrating the foot-specific nature of the questionnaire. Mental health related domains demonstrated poor correlation. All five FAOS domains are significantly responsive to change in postoperative patients (p<0.01). All domains have acceptable content validity overall, with quality of life (QoL) and function in sports the highest. Test-retest reliability was very good for all domains with ICC's above 0.8. Conclusion: Patient-based assessments have become increasingly important in evaluating treatment effectiveness. This study has shown that the FAOS has very good construct and content validity, reliability, and responsiveness in patients with ankle OCL's. We support its use and consider it a useful patient-based instrument for the assessment of surgical intervention. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Extracorporeal Shock Wave Therapy (ESWT) is one of the major advances in orthopedics over the last 20 years as a method for orthopedic surgeons to conservatively treat tendon pathologies such as Achilles tendinopathy (AT). Unfortunately, previous studies involve only a small number of cases, relatively short duration of symptoms, and simple measures of pain. The purpose of this study is to evaluate the impact of age, body mass index (BMI), and location of AT (Insertional (IAT) or Non-Insertional (nIAT)) on clinical outcomes and return to sport (RTS) time after ESWT. Methods: This is a retrospective cohort study that included existing clinical data from 40 patients from a single academic institution. Patients greater than 18 years of age who underwent ESWT for Achilles tendinopathy in the office setting between 8/1/2019 to 8/30/2021 were included. Clinical outcomes of patients were evaluated through the self-reported Visual Analogue Scale (VAS) and Victorian Institute of Sport Assessment-Achilles (VISA-A) scores for assessing pain and functional outcomes of Achilles Tendinopathy. Descriptive statistics were used to provide an overview of the patient characteristics, including sex, age, laterality of injury, BMI, duration of symptoms, RTS time, and follow-up. For these data, mean and standard deviation were calculated, and paired samples T-tests and Welch's T-tests were performed on clinical outcome scores. Results: This study included 48 patients (62 heels), with an average age of 50.8+-14.2 years, BMI of 27.3+-5.3, follow-up of 6.41+- 6.9 months, and RTP time of 5.39+-5.3 weeks. Patients with a BMI <25.0 had significantly higher post-operative VISA-A scores (p=0.007) compared to those with a BMI >25.0, and post-operative VAS scores displayed this trend without significance (p=0.07). Patients <=50 years old had significantly higher post-operative VISA-A scores (p=0.02) compared to those >50 years old, and post-operative VAS scores displayed this trend without significance (p=0.1). Pre- and post-operative VISA-A scores, and postoperative VAS scores, were not significantly different between IAT and nIAT cohorts, except for pre-operative VAS scores where nIAT was higher (p=0.03). Additionally, we found significant improvements in pre-operative to post-operative scores for VAS scores for IAT and nIAT cohorts (p<0.0001), as well for VISA-A for the IAT cohort (p=0.008), but no significant improvement in VISA for the nIAT cohort (p=0.119). Conclusion: Increased BMI and age are determinant factors that significantly adversely affect functional scores (VISA-A) in patients with AT treated with ESWT, but no significant differences were found for these risk factors in terms of pain improvement (VAS). Additionally, we found that the nIAT cohort had significantly higher pre-operative pain than IAT, and no significant improvement in VISA-A scores (though there was a trend of functional improvement). This aligns with the fact that the midsubstance of the Achilles tendon is a watershed area with relatively low vascularity compared to the insertional portion, where lower perfusion weakens the healing benefits of ESWT. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Osteochondral lesion of the talus (OLT) is a commonly occurring injury, typically treated with bone marrow stimulation (BMS) in the small to medium-sized lesions after a failed course of conservative treatment. The current evidence suggests that biologics can improve chondrocyte growth and differentiation. However, the lack of consensus to date on the efficacy of biologics + BMS for OLT has warranted further investigation. The purpose of this study is to clarify the effectiveness and safety of biologics as an augmentation in BMS by assessing complication rates, continuous functional outcome scores and return to play data compared to BMS alone for OLT. Methods: A systematic review and meta-analysis were performed. The PubMed and Embase databases were searched using specific search terms and eligibility criteria according to the PRISMA guidelines. The level of evidence was assessed using published criteria by The Journal of Bone & Joint Surgery and the quality of evidence using the Modified Coleman Methodology Score. Fixedeffects models were employed if heterogeneity was graded low (I2 <25%), and random-effects models if heterogeneity was graded moderate to high (I2>=25%). Results: For BMS versus BMS + hyaluronic acid (HA), the fixed-effects model for American Orthopaedic Foot and Ankle Society score revealed a mean difference increase that is an improvement of 4.88 (95% CI, 2.33 to 7.44; I2 = 0%; p = 0.0002) points, in favor of BMS + HA. The fixed-effects model for 10mm Visual Analog Scale pain revealed a mean difference decrease that is an improvement of 1.21 (95% CI, 0.70 to 1.73; I2 = 0%; p < 0.00001) points, also in favor of BMS + HA. For BMS versus BMS + concentrated bone marrow aspirate (CBMA), the pooled complication rate was 17/64 (26.6%) versus 11/71 (15.5%), respectively, with a chi-squared test of p = 0.11. The pool revision rate was 15/64 (23.4%) versus 6/71 (8.5%), respectively, with a chi-squared test of p = 0.016. Conclusion: Adjuvant biologic use with BMS may provide superior outcomes, notably that of HA and CBMA, based on the current evidence. Future studies must aim to establish the clinical superiority of the various other biologics + BMS versus BMS alone. These studies must compare the various biologics against one another to determine, if any, the optimal biologic for OLT. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: The World Health Organization declared the outbreak of COVID-19 a pandemic on March 11, 2020, leading to lockdowns, quarantines, and increased sedentary behaviors. As the general population as well as athletes returned to their normal physical activities or sport in 2021, the risk for musculoskeletal injury increases after inactivity. Thus, the purpose of this study was (1) to investigate the rates of AATR requiring repair in a single academic center in NYC, and (2) see if a corollary exists in the NFL. Our hypothesis is that after a decrease in AATRs in 2020 from decreased physical activity due to a combination of lockdown sanctions and COVID pandemic-induced fears, there is a rebound increase in AATRs in 2021, possibly even to greater than pre-pandemic levels. Methods: All study protocols were approved by the Institutional Review Board at the senior author's institution. A retrospective search was conducted using current procedural terminology to identify the total number of Achilles acute primary repair surgeries performed from years 2017 to 2021 at a sincle academic center. NFL data was obtained from publicly available sites according to previously validated studies. Chi-square analysis was conducted between proportion of Achilles surgeries performed in 2021 and 2017-2020 at a single academic center. Additional Chi-square analysis was performed in a similar manner, however between each year and 2021. Results: A total of 588 patients who sustained AATRs and underwent primary surgical repair were identified, primarily men (75.7%, n = 445), with an average age of 43.22+-14.4 years. The incidence of the total number of AATR repairs per year was: 2017: 21.1% (n = 124), 2018: 18.7% (n = 110), 2019: 22.1% (n = 130), 2020: 14.6% (n = 86), 2021: 23.5% (n = 138), indicating a 7.5% decrease in rate of AATRs from 2019 to 2020, followed by an 8.9% increase in incidence from 2020 to 2021. Within the NFL, the number of AATRs resulting in an IR stint increased every regular season from 2019-2020: 21.2% (n = 11), to 2020-2021: 32.7% (n = 17), to this past 2021-2022 season: 46.2% (n = 24). Conclusion: The main finding of our study is a decrease in the incidence of AATRs during the height of the COVID pandemic quarantine in 2020, with a 8.9% increase in 'post-COVID' 2021 at a single academic institution. There was also a 2.9% higher incidence of AATR in 2021 compared to 'pre-COVID' normal levels when averaged between 2017 to 2019, findings that are mirrored in the NFL. This information provides important information for providers when counseling patients and athletes on return to sport in this current pandemic, especially with possible future lockdowns or quarantines due to new variants such as Omicron. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Osteochondral lesions of the talus (OLT) are common injuries that are often found in patients with chronic disabling pain after ankle sprains. While OLT is becoming increasingly prevalent in the younger active population, there is disagreement and a lack of strong evidence about the impact of age on outcomes. The purpose of this study is to perform an Age- Based multivariate analysis to evaluate the clinical outcomes of Autologous Osteochondral Transplantation (AOT) for the treatment of OLT. The goals of this study are to examine trends in patient characteristics and clinical outcomes that occur with age as a statistical variable when performing AOT for the treatment of OLT. Methods: All study protocols were approved by the Institutional Review Board at the senior author's institution. A retrospective cohort study using chart review for AOT procedures on approximately 80 patients from 2006 to 2019 performed by a single surgeon. Clinical outcomes of patients were evaluated via FAOS scores for Symptoms, Pain, Activities of Daily Living, Sports and Quality of Life. A multivariable linear regression was used to assess the independent factors predictive of the first post-operative FAOS after AOT. The independent variables included in the model were pre-operative FAOS, age, defect size, whether the lesion was a shoulder lesion, cystic lesion, or a result of a traumatic injury, and whether the patient had a prior microfracture surgery. A p-value <.05 was considered significant and 95% confidence limits (95% CL) for regression coefficient estimates (est.) were calculated. Results: 78 patients were included in the analysis with an average age of 35.5 +- 13.6. The average follow-up was 54.4 months +- 18.9 months, average pre-operative FAOS was 54.3 +- 19.4 and the average post-operative FAOS was 83.4 +- 13.6. The average defect size was 109.3 mm2 (std. dev. = 62.4 mm). 56 patients had a shoulder lesion, 24 had a prior microfracture surgery, 42 had a cystic lesion, and 27 had a prior traumatic injury. The multivariable linear regression showed that the pre-operative FAOS was associated with a higher post-operative FAOS (est., 95% CL: 0.16, 0.012 - 0.307; p=0.034). Defect size (est., 95% CL: -0.05, -0.097 - -0.003; p=0.0358), having a shoulder lesion (est., 95% CL: -9.068, -15.448 - -2.688; p=0.006), or having a prior microfracture surgery (est., 95% CL: -7.07, -13.118 - -1.021; p=0.0226) were associated with a lower post-operative FAOS. Conclusion: The main finding of this study is patient age was not an independent risk factor for inferior clinical outcomes after AOT for OLT. Additionally, having a cystic lesion, or having a lesion because of a traumatic injury were not significantly associated with post-operative FAOS. Having a shoulder lesion had the largest marginal effect on post-operative FAOS. These findings provide important information for providers when counseling and selecting patients for AOT procedure for treatment of OLT. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: While surgery is often indicated in the treatment of chronic ankle instability (CAI), there lacks consensus on which procedure is preferable in light of the multiple different procedures available. In this systematic review, we evaluate the recent literature on the anatomical reconstruction of the lateral ligaments in the treatment of CAI in an effort to identify differences in clinical and radiological outcomes between allograft and autograft reconstruction techniques. Methods: A systematic search of PubMed, EMBASE, and Cochrane Library databases was performed in October 2019 resulting in 13 studies ranging from the years 1991 to 2017. The studies included were carefully evaluated with regards to the level of evidence (LOE) and quality of evidence (QOE), clinical and radiological outcomes, complications, revision rates and return to sport. Results: Thirteen studies including a total of 296 ankles were included; Within the autograft group, the weighted mean AOFAS improved from 66.9 to 95.9 at a weighted mean follow-up of 29.6 months, KPSSAF scores improved from 48 to 92.2 at a weighted mean follow-up of 37 months, VAS scores improved from 6.8 to 0.2 at a weighted mean follow up of 33.5 months, and the complication rate was 7.7% at a follow up of 31.2 months. Within the allograft group the AOFAS improved from 53.7 to 89.3 at a follow-up of 35.5 months, KPSSAF scores improved from 42.8 to 90.4 at a follow up of 34 months, VAS scores improved from 7.3 to 1.9 at a follow up of 38 months, and the complication rate was 7% at a follow up of 34.9 months. Conclusion: The current systematic review demonstrated that anatomical reconstruction of CAI resulted in favorable clinical and radiological outcomes, low complication and revision rates and excellent return to sport rates in the short-term follow-up. Comparison of autograft and allograft reconstruction techniques for chronic lateral ankle instability showed minor differences both clinically and radiologically but none which would suggest superiority of one technique over another. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: The purpose of this study is to evaluate the effectiveness of Extracellular Matrix Cartilage Allograft (EMCA) as an adjuvant to bone marrow stimulation (BMS) compared to BMS alone in the treatment of osteochondral lesions of the talus (OLT). Methods: A retrospective cohort study comparing patients treated with BMS with EMCA (BMS-EMCA group) and BMS alone (BMS group) between 2013 and 2019 was undertaken. Clinical outcome was evaluated with the Foot and Ankle Outcome Score (FAOS) pre-and postoperatively. Postoperative MRIs were evaluated using a modified Magnetic Resonance Observation of Cartilage Tissue (MOCART) score. Comparisons between groups were made with the Man-Whitney U test for continuous variables and the ?2 or Fisher exact test for categorical variables. Results: Twenty-four patients underwent BMS with EMCA (BMS-EMCA group) and 24 patients underwent BMS alone (BMS group). The mean age was 40.8 years (range, 19 to 60 years) in BMS-EMCA group and 47.8 years (range, 24 to 60 years) in BMS group (p=0.060). The mean follow-up time was 20.0 months (range, 12-36 months) in BMS-EMCA group and 26.9 months (range, 12 to 55 months) in BMS group (p=0.031). Both groups showed significant improvements in all FAOS subscales. No significant differences between groups were found in all postoperative FAOS. The mean MOCART score in BMS-EMCA group was higher (76.3 vs 66.3), but not statistically significant (p=0.176). The MRI analysis showed that 87.5% of BMS-EMCA group had complete infill of the defect with repair tissue, however less than half (46.5%) of BMS group had complete infill (p=0.015). Conclusion: BMS with EMCA is an effective treatment strategy for the treatment of OLT and provides better cartilage infill in the defect on MRI. However, this did not translate to improved functional outcomes compared with BMS alone in the short-term. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Ankle injuries commonly result in damage to the articular cartilage of the talus. The use of cylindrical osteochondral allografts (OCA) for osteochondral lesions of the talus (OLT) smaller than 1.5cm is increasingly common, particularly in cases whereby autologous osteochondral transplantation (AOT) is contraindicated. The primary aim of this study is to systematically review the outcomes of cylindrical OCA for OLT. The secondary aim of this study is to compare the outcomes of cylindrical OCA and AOT in the management of similar cases of OLT. Methods: Two independent reviewers searched the literature based on PRISMA guidelines, utilizing the EMBASE, MEDLINE, and The Cochrane Library Databases. Only studies that reported outcomes of cylindrical OCA in the management of OLT were included. Results: Overall, 4 studies with 100 patients including 101 ankles were included in this review. Pre-operative OLT characteristics showed 69.3% of OLT lesions were located medially, with a mean lesion size of 1.47cm2 (0.46 - 4.2 cm2). Overall, 16.8% of ankles required surgical revision following cylindrical OCA; 1.0% (1/101) underwent subsequent arthrodesis, 6.9% (7/101) underwent revision osteochondral grafting and 7.9% (8/101) underwent subsequent arthroscopic debridement. Radiological outcomes between the graft failure were reported as 10.0% (3/30), joint space narrowing as 30.4% (14/46), and cysts as 42.9% (27/63). Significantly higher revision rates were reported following cylindrical OCA when compared to AOT at over two years follow up (28.1% versus 6.7%, p = 0.02). Conclusion: Our systematic review established that although there are high rates of patient satisfaction following cylindrical OCA for OLT, these are less than those reported with AOT for the same condition. Concerns regarding the rates of radiological deterioration as well as the need for surgical revision may represent harbingers for poorer long-term outcomes. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Chronic Achilles tendon ruptures (CATR) are an uncommon injury compared to acute ruptures. Currently, no evidence-based guidelines exist for treating CATR. The purpose of this systematic review was to present the outcomes of the current treatment options for CATR and to analyze the level of evidence (LOE) and quality of evidence (QoE) of the included studies. Methods: In July 2020, MEDLINE, EMBASE and Cochrane Library databases were systematically reviewed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The LOE and QOE of the included studies was evaluated using the Modified Coleman Methodology Score. Studies reporting outcomes following repair of CATR were included. Results: Thirty-one studies with 653 CATRs were included. Three studies were LOE III and 28 studies were LOE IV. Six studies reported dual technique procedures and 23 studies reported single technique procedures. Semitendinosus graft was the most frequently utilized single technique procedure amongst the included studies. Most studies reported good postoperative subjective outcomes, strength outcomes, and return to sports data at mid-term follow-up. In total, 14.6% of patients experienced postoperative complications. The most common complication was surgical wound complications (10.8%). Conclusion: This systematic review found that no evidence-based treatment guidelines exists for CATR. Surgical management of CATR produces good clinical outcomes at mid-term follow up, but a high complication rate (14.6%) was noted. Future studies of higher QOE and LOE with improved data reporting are warranted to determine the optimal treatment strategy for CATR. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: The use of bulk osteochondral allograft (OCA) is often warranted in patients with a large osteochondral lesion of the talus (OLT). Previous literature reported that bulk OCA has high failure and revision rates, suggesting these procedures should be thought of as an intermediate step, buying time before arthrodesis or arthroplasty is required. However, recent studies suggest that the long-term survival of bulk OCA has improved and that these procedures may provide a definitive solution for large OLT. The purpose of this study was to systematically review the literature to ascertain the outcomes of bulk OCA for OLT. Methods: Two independent reviewers performed the literature search based on PRISMA guidelines, utilizing the EMBASE, MEDLINE, and The Cochrane Library Databases. Studies were included if they reported outcomes of OLTs which were managed by bulk OCA. Results: Overall, 9 studies with 112 patients (55.4% males) including 115 ankles with a mean follow-up of 72.7 (8 - 240) months were included in this review. Pre-operative OLT characteristics showed that 68.4% were medial lesions, with a mean lesion size of 3.04cm2 (0.7 - 6.1 cm2). Overall, 23.5% of patients required revision surgery following bulk OCA; 10.4% (12/115) underwent subsequent arthrodesis, 1.7% (2/115) underwent revision osteochondral grafting and 9.6% (11/115) underwent arthroscopic debridement. Radiological outcomes reporting graft failure was 21.3% (13/61), joint space narrowing was 25.2% (29/115) and cysts were present in 19.5% (15/77) of cases. Conclusion: Patients experience satisfactory patient-reported clinical outcomes in the medium term following bulk OCA in the management of OLT. Despite recent advances in graft procurement and storage radiological graft failure and the requirement for additional surgeries still remain. At this time can only be recommended in cases that are refractory to other treatments and where the patient is aware that this may be a temporizing procedure before arthroplasty or arthrodesis. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: The purpose of this systematic review was to evaluate changes in the alignment of the hindfoot following total knee arthroplasty (TKA), subjective clinical outcomes following surgical intervention and to analyze the level of evidence (LOE) and quality of evidence (QoE) of the included studies. Methods: MEDLINE, EMBASE, and Cochrane Library databases were systematically reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting changes in the postoperative alignment of the hindfoot following TKA were included. The level and quality of evidence were recorded and assessed. Results: Eleven studies with a total of 1142 patients (1358 knees) met the inclusion/exclusion criteria. Six studies were of level of evidence II and 5 studies were of level of evidence III. Patients with preoperative varus knee deformity and valgus hindfoot deformity demonstrated improvement in hindfoot alignment post-TKA. Patients with preoperative varus knee deformity and varus hindfoot deformity demonstrated no improvement in hindfoot alignment following TKA. Twelve different radiographic parameters were used to measure the alignment of the hindfoot across the included studies, with the tibio-calcaneal angle (TCA) most frequently utilized (27.3%). Conclusion: This systematic review demonstrated that the hindfoot may display compensatory changes in alignment following total knee arthroplasty in patients with knee osteoarthritis. However, the marked heterogeneity between the included studies and poor quality of evidence limits any meaningful cross-sectional comparisons between studies. Further, well-designed studies are necessary to determine the changes and outcomes of hindfoot alignment following total knee arthroplasty. [ABSTRACT FROM AUTHOR]