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Background: The lateral fibular stress test (LFST), also known as the hook or Cotton test, is commonly performed to assess syndesmotic instability intraoperatively. Several studies have used 100 N as the force applied when performing the LFST to detect syndesmotic instability, though no evidence-based requisite force has been described for the test. We hypothesize that surgeons do not apply force uniformly or consistently when performing the LFST and that substantial variation exists. Fundamentally, this could lead to inconsistent diagnosis of syndesmotic instability as surgeons may not be applying the force in a consistent manner. Methods: A biomechanical ankle model consisting of an industrial force gauge attached through a SawBones model was fashioned. Orthopaedic attending surgeons and trainees were asked to perform a series of LFSTs and to simulate the force they typically apply intraoperatively. Basic demographic data were collected on each participant. Results: Thirty-three surgeons participated in the study, including 18 trainees. The median (IQR) force applied during the LFST was 96.42 (71.42-126.33), 87.49 (69.19-117.40), 99.99 (79.91-137.49), for the pooled group, attendings, and trainees respectively. More than half (54.5%) of all trials were less than 100 N (57.8% of surgeons, 51.8% trainees). Intraobserver correlation was excellent within the overall cohort (0.92, P < .001), trainees (0.90, P < .001), and attendings (0.94, P < .001), respectively. Interobserver reliability was fair among the overall cohort (κ =0.28, P = .49), and poor between the attendings (κ = 0.11, P = .69) and the trainees (κ = 0.05, P = .82), respectively. Conclusion: Our study demonstrates that the amount of force applied by typical surgeons when performing the LFST test is highly variable. Variable force application when performing the LFST may lead to inconsistent detection of syndesmotic instability, which may portend a poorer outcome. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Minimal invasive proximal metatarsal osteotomy (PMO) offers a successful approach for addressing metatarsus adductus while avoiding exposure of all metatarsals, thereby reducing the risk of complications such as wound infections and non-unions. An important hurdle is the absence of direct visualization for precise osteotomy placement. Staying within the tarsometatarsal (TMT) capsule enhances the chances of better union due to improved blood supply, although operating outside the capsule can aid in correcting more significant deformities. Despite having a macroscopic understanding of anatomical locations through specimens, there has been a lack of prior reports on their mapping in fluoroscopic images. Developing such maps could significantly improve the navigational skills of surgeons. This study aims to present heatmaps that illustrate the positions of distal attachments of TMT capsules. Methods: A total of nine specimens below the knee, devoid of any prior bone or joint abnormalities, were thawed a day prior to the experiments. After dissecting the dorsal skin, neurovascular structures, and tendons, only the bones and capsules remained. Flexible wires were placed alongside the distal edges of TMT capsules, encompassing the 1st, 2nd, 3rd, and 4th tarsometatarsal joints. This arrangement aimed to make the paths of these capsules visible when observed through X-ray imaging. The wires were then securely attached to the structures using a soft tissue adhesive. Fluoroscopy images were captured, including a calibration marker of a known diameter, in addition to taking macroscopic photographs. The specific coordinates of these structures were marked in a three-dimensional space within specialized 3D software. Subsequently, these coordinates were imported into a custom-designed Python script crafted for the purpose of generating heatmaps. Results: The heatmaps were successfully produced encompassing all TMT capsules spanning from the 1st to the 4th, and these were overlaid onto an anteroposterior fluoroscopy image of the foot (refer to Figure 1). This gradient of colors serves as a visual representation of differing magnitudes, with red denoting the most prevalent areas of the distal attachment of the TMT capsule, while blue corresponds to lower occurrences. Conclusion: These heatmaps not only showcase the predominantly observed sites of distal TMT attachments, depicted in red, but also signify diverse deviations, identifiable by the presence of less frequent zones indicated in blue. Consequently, surgeons are advised to consider these findings while planning their osteotomies based on their preferred positions. By furnishing surgeons with an extensive heatmap that outlines potential tarsometatarsal capsule insertions, this research not only furnishes them with a dependable guiding resource but also establishes a foundation for more assured and prosperous minimally invasive midfoot fusion procedures. [ABSTRACT FROM AUTHOR]

Category: Hindfoot; Sports Introduction/Purpose: Posterior heel pain at the Achilles tendon insertion is a prevalent and debilitating condition that is not yet fully understood. It results from a combination of bony and soft tissue abnormalities, including insertional Achilles tendinopathy, retrocalcaneal bursitis, and posterosuperior bony prominence. While the most commonly used surgical technique for treatment is debridement and reattachment of the tendon, dorsal closing wedge calcaneal osteotomy (DCWCO) has recently gained popularity. In this meta-analysis, we aimed to analyze the published literature related to both surgical techniques and compare their outcomes. Our hypothesis was that DCWCO can provide similar clinical outcomes with a lower complication rate. Methods: We conducted a literature search in Medline, Embase, and Scopus databases. Clinical studies reporting at least one of the clinical outcomes among AOFAS score and complications, with an open technique and sufficient data to extract and pool, were included. The extraction was made by two users using the Covidence platform. Studies with less than 10 patients or less than 12 months follow-up were excluded. Initial search yielded 329 papers, and after excluding duplicates and irrelevant studies, 43 papers were left. After a full-text review of these 43 papers, we found 15 papers eligible for meta-analysis. We used the Modified Coleman Methodology to assess the quality of papers. Results: Out of the 15 articles, seven included reattachment patients, while eight included DCWCO patients. 171 feet underwent reattachment, while 239 feet underwent DCWCO. The average follow-up of patients was significantly higher in the DCWCO group (42.2 months) than reattachment group (23.2 months). The average AOFAS score improvement was similar between the groups. The total complication numbers were 30 (16.6%) in the reattachment group and 28 (9.2%) in the DCWCO group, but the difference did not reach significance since the confidence intervals were overlapping. However, wound complications were significantly more common in Reattachment group (10.1%) compared to DCWCO (2.5%). The number of revision surgeries and neurological complications (sural neuritis, hypersensitivity, etc.) were similar between the groups. The average AOFAS score improvement was similar between the groups. Conclusion: Both techniques yielded comparable clinical outcomes. The overall complication rate was similar, but DCWCO exhibited a lower wound complication rate than reattachment. Therefore, the study results imply that DCWCO can provide similar clinical outcomes with fewer wound complications. However, further well-designed studies are necessary to reach a definitive conclusion on this matter and compare both techniques in the same study setting. [ABSTRACT FROM AUTHOR]

Category: Trauma; Ankle Introduction/Purpose: Ankle fractures represent an increasingly common injury world-wide and the decision for operative fixation often hinges on the definition of acceptable stability. Mortise malalignment has generally been considered as the main predictive factor leading to poorer outcomes and the development of post-traumatic osteoarthritis. Following pioneering work by Ramsey & Hamilton, 1-2 mm of lateral talar displacement has commonly been regarded as a cutoff value for surgical decision making. However, isolated lateral talar translation (as studied in previous works) does not fully replicate the multidirectional joint subluxation seen in ankle fractures. Furthermore, previous studies have been limited by low fidelity methodologic techniques. Therefore, the aim of this study was to analyze the influence of multiplanar talar displacement on tibiotalar contact mechanics utilizing finite element analysis (FEA). Methods: 19 patients having undergone advanced computed tomography (CT) scanning of the ankle were included. A female patient (age 18 years, weight 60 kg) without preexisting articular ankle pathology underwent a weightbearing CT-arthrogram of the left ankle. Additionally, 18 ankles derived from the contralateral healthy side in patients who underwent bilateral weightbearing CT scans (WBCT) for evaluation of a contralateral ankle fracture were included (mean age = 38.70 years, mean weight = 80.00 kg, left/right: 9/9). Segmentation of the WBCT images into 3D models of bone and cartilage was performed semi-automatically, while on the non-arthrography WBCT images, personalized cartilage layers were modeled based on a previously validated methodology. 3D multiplanar talar displacement was simulated to investigate their respective influence on the tibiotalar contact mechanics. Tibial peak contact stress, talar peak contact stress and contact area were extracted from the FEA models for each condition. Results: The talar peak contact stress (in MPa), tibial peak contact stress (in MPa) and contact area (in mm²) for each condition are presented in Table 1. Overall, both the mean and peak contact stress for the talus and tibia incrementally increased when the talus was displaced, for all directions. Correspondingly, the contact area incrementally decreased. Contact stress maps of the talus and tibia were computed for each of the conditions, demonstrating unique patterns of pressure derangement. 1 mm of lateral translation resulted in 11% increase in peak contact pressure and a 12% decrease in contact area. External rotation exhibited the greatest influence on contact stress, reaching a peak talar stress of 510% above baseline after 20 degrees of external talar rotation. Conclusion: In this study, we were able to build on the paradigm of prior uniplanar cadaveric studies and provide a multiplanar mortise malalignment model. The use of advanced computational technologies allowed for more precise quantitative evaluation of articular contact mechanics. With lateral talar translation, our model demonstrated less dramatic increases in tibiotalar contact area compared to previous studies, whereas external rotation had the largest effect regarding pathologic joint loading. Clinically, this study provides a novel understanding of the mechanical sequelae of 3D talar displacement and the importance for adequate mortise alignment. [ABSTRACT FROM AUTHOR]

Category: Ankle; Trauma Introduction/Purpose: The term 'quadrimalleolar fracture' (QMF) describes a trimalleolar (TM) ankle fracture with an associated Chaput or Wagstaffe fracture. Optimal fixation of these injuries not only allows for bone-to-bone healing but also facilitates syndesmotic reduction. However, this is a relatively new concept, and the literature on QMFs is limited to a few case series. Hence, we conducted this study to determine the epidemiology, patterns, and clinicoradiologic correlations of QMFs. The primary objective of this study was to describe the prevalence and patterns of QMFs. The secondary objective was to determine if certain clinical or radiological parameters were associated with different types and patterns of QMFs. Methods: A retrospective analysis of ankle fractures presenting to three tertiary referral hospitals was undertaken. Adult patients (≥18 years) presenting with an acute, traumatic TM ankle fracture over 3 years (July 2018 to July 2021) were included. Isolated medial and lateral malleolar fractures, bimalleolar ankle fractures, pediatric patients, pilon fractures, pathological fractures, and those with delayed presentation or (≥3 weeks of injury) were excluded. Clinical demographic variables were obtained from the patients' medical records. AP, lateral, and mortise ankle radiographs, and CT scans, (axial, coronal, and sagittal sections along with 3D volume reconstructed models) whenever available, were evaluated in detail. Demographics and radiological parameters were compared between TM and QMF, as well as between different types of QMFs. Odds ratios with 95% confidence intervals were determined to test the strength of association. Results: A total of 876 adult patients with ankle fractures were included after the screening, of which 323 had a TM ankle fracture for which a CT scan had been performed. A total of 159 AITFL avulsions were identified, yielding a prevalence of 18.2% amongst all ankle fractures and 26.1% in ankle fractures where a CT scan had been performed. TMFs had the significantly highest proportion of CT-confirmed AITFL avulsions (44.4%) in comparison to unimalleolar (4.4%) and bimalleolar fractures (6.4%) (P < 0.0001). Age and osteoporosis were significant associations of QMFs. Avulsion of the medial malleolus, Weber B fibular fracture, and supination external rotation mechanism were significantly associated with Wagstaffe fractures. Size of the Chaput fracture was inversely related to that of the posterior malleolar fracture. Conclusion: Quadrimalleolar ankle fractures account for a significant proportion of ankle fractures. The strengths of this study include a large sample size, which was derived from three different hospitals, consecutive inclusion (or exclusion) of cases, strict adherence to the STROBE guidelines, and the fact that only CT-confirmed cases were used to determine clinic-radiological associations. Wagstaffe and Chaput fractures have distinct clinical and radiological correlations. However, further research is needed to determine the optimal fixation protocols for these injuries. [ABSTRACT FROM AUTHOR]

Category: Hindfoot; Sports Introduction/Purpose: The use of a dorsal closing wedge calcaneal osteotomy (DCWCO) in the treatment of insertional Achilles tendinopathy (IAT) has recently gained popularity. The anatomical changes imposed by the osteotomy are believed to improve both the biological and mechanical processes involved in IAT. However, the impact of shortening the Achilles leverage arm after DCWCO and the full impact of DCWCO on foot anatomy and function is not well understood. This study aimed to examine the effects of DCWCO on the 3D alignment and biomechanics of the foot and ankle in IAT patients through simulated models of DCWCO. The hypothesis was that DCWCO would significantly impact foot alignment and decrease gastrocsoleus lever arm. Methods: Six weightbearing ankle CTs of patients with IAT were identified from the clinical database. Bone segmentation was performed and DCWCOs were conducted in standardized planes with six variations, resulting in a total of 36 foot models. Two plantar osteotomy starting points were defined as 1-cm anterior (posterior osteotomy) and 2-cm anterior (anterior osteotomy) to the most plantar point of calcaneus. The osteotomies were extended to dorsal surface at 1-cm anterior to posterosuperior calcaneus with 6, 10, or 14-mm wedges anteriorly. After the osteotomies, the posterior part of the calcaneus was rotated around the plantar starting point until proper bone contact was achieved. Achilles reconstruction was also performed using pre-defined Achilles insertion points. All models were then transferred to a MATLAB-based algorithm for automated measurements. These measurements included talocalcaneal, calcaneal pitch, Böhler, and Achilles tendon sagittal angles, Achilles moment arm, Achilles- posterosuperior calcaneus distance, and difference in soleus-Achilles length. Results: Anteriorly placed osteotomy caused more significant decrease in the Böhler angle (p < 0.001). Evaluation of the posteriorly placed osteotomy separately showed no significant decrease in the Böhler angle for patients with more than 30- degrees of preoperative Böhler angle (p=0.26). However, patients with a preoperative Böhler angle less than 30-degrees showed a significant decrease, approaching values close to 5-degrees (p=0.004). Gastrocsoleus moment arm decrease was found to be 2-3% by using force/moment equation. The change in the distance between Achilles tendon and the posterosuperior calcaneus was similar between anterior and posterior osteotomies, with less than 3-mm in a 6-mm wedge and more than 5-mm in a 10-mm wedge osteotomy. The calculations showed that ankle dorsiflexion can increase by one degree for each mm of resection. Conclusion: An anteriorly placed starting point for a DCWCO can negatively affect foot alignment and offer limited benefits for Achilles decompression. If the preoperative Böhler angle is less than 30, a DCWCO can significantly decrease the Böhler angle, potentially putting the subtalar joint at risk for arthritis by increasing the load as reported by some finite element studies. The maximum decrease in gastrocsoleus power is less than 3%, which may be clinically insignificant. A posterior starting point with 10- mm wedge can be adequate to move Haglund around 5-mm anteriorly and can move Achilles insertion 10-mm superiorly to decrease tension. [ABSTRACT FROM AUTHOR]

Category: Ankle; Trauma Introduction/Purpose: The use of artificial intelligence (AI) is particularly salient to visually oriented medical professions, especially orthopedics. The most prominent use of AI in orthopedics comes in the form of medical imaging examinations. AI has a huge potential to help doctors make diagnoses by acting as a second pair of eyes. Some results suggested a very high level of agreement between AI models' and the clinician's assessments of radiographs. Furthermore, it was also suggested that the sensitivity and specificity of emergency medicine physicians for detecting some pathologies are significantly improved when aided by an AI tool. In view of these observations, our study aimed to create an AI-based ankle fracture detection tool that can be used on smart devices for X-ray interpretation. Methods: We examined 2,193 patients' charts from 2 academic and 1 community hospital in Boston. We retrieved the anteroposterior (AP), oblique, and lateral ankle X-rays of each patient. Patients with ankle fractures and adults older than 18 years met our inclusion criteria. We excluded patients younger than 18 years old and those with any artifact, such as a cast, screws, or other artifacts in their X-rays. The study comprised 352 healthy controls and a total of 579 ankle fracture patients. Other than the digital images obtained from Electronic patient records (EPR), we used two different smart devices, a cellphone, and a tablet, to capture images from the monitor screen. Using Machine Learning models, we developed a fracture detection model using all three types of imaging and named it the "combination model". We subsequently tested the combination model on digital X-rays, smart devices, and on both datasets together (Table 1). Results: We extracted the X-rays of a total of 931 patients in this study. Following the development and testing of our AI models, we noticed that all performed well with AUCs and accuracies above 0.85 and 0.86, respectively (Table1). The best performance was found when the combination model was tested on images taken from the camera of our smart devices, with an AUC of 0.88, a sensitivity of 0.86, and an accuracy of 0.89. This performance was closely followed by that of our model tested on a mix of both smart devices and original digital images with an AUC of 0.88, a sensitivity of 0.86, and an accuracy of 0.88. Conclusion: Our AI-based tool showed promising performance in the detection of ankle fractures using smart devices and images obtained from the monitor screen. We were able to reach an accuracy of diagnosis on smart device-captured images that were comparable with the original digital X-rays. The outcome of this study can be used to help providers who lack sufficient experience in detecting fractures. It can also be used for educational purposes for trainees in this field. [ABSTRACT FROM AUTHOR]

Category: Ankle; Trauma Introduction/Purpose: The Medial Clear Space (MCS) is an anatomic space between the lateral cortex of the medial malleolus and the medial cortex of the talus. Measurement of the MCS is helpful in differentiating which ankle fractures are amenable to non- operative treatment, and which may require fixation. The MCS is often evaluated on radiographic views of the ankle, and several different methods of measuring the MCS have been described in the literature. There is little information on intra-observer reliability of MCS measurement, nor validation of the various medial clear space measurement techniques. As such, the aim of this study was to better understand intra-observer reliability of MCS via several of the most popularly described techniques. Methods: Patients with matched ankle X-rays and CT scans - either weight bearing or non-weight bearing imaging pairs - were identified via electronic medical record database review of a Level-1, academic medical system after IRB approval. Measurement of the MCS on CT scan was used as the gold standard against which radiographic measurements were compared given its superior osseous definition. Four independent reviewers measured the medial clear space on 20 weight bearing, and 20 non-weight bearing x-rays via the five most commonly described methods: 5mm inferior to the talar dome (MCS #1), half way down the medial articular surface of the talus (MCS #2), obliquely at the supero-medial corner of the talus (MCS #3), and at the level of the talar dome (MCS #4). Intraclass Correlation Coefficients (ICC) were then calculated for each of the four MCS measurements methods after compilation of all independent reviewer data. Results: The ICC varied between each of the four MCS measurement techniques. For measurements 5mm below the talar dome (MCS #1) the ICC was 0.041. Measured halfway down the medial talar articular surface, the ICC was 0.466. The superior oblique MCS measurement ICC was 0.725, and the MCS measured at the level of the talar dome had an ICC of 0.419. MCS measurement 5mm below the talar dome had poor intra-observer reliability, while measurement halfway down the medial articular surface and at the level of the talar dome had fair intra-observer correlation. Overall, measurement of the MCS at the superomedial talar dome had good intra-observer reliability, ranking as the most favorable measurement method. Conclusion: The commonality of ankle fractures demands accurate radiographic interpretation for the determination of need for surgical intervention. The medial clear space measurement is the most common metric used to determine the need for surgery. There is no consensus regarding the optimal method, nor reliability of the various MCS measurement techniques. The results of this study suggest that measurement of the medial clear space at the superomedial corner of the talar dome has the highest intra- observer reliability. [ABSTRACT FROM AUTHOR]

Category: Midfoot/Forefoot; Midfoot/Forefoot Introduction/Purpose: Lisfranc injury consists of a spectrum of injuries affecting the tarsometatarsal joint. Various fixation methods are used to treat Lisfranc injuries and each show different outcomes. Metal implants have been used for open reduction and internal fixation (ORIF) of Lisfranc injuries routinely. However, other than the complications in these patients, such as non- anatomical reduction, implant loosening, breakage, and arthrosis, most of these patients will undergo a second surgery for implant removal. Using bio-degradable and bio-integrative materials in these implants reduces the need for these re-operations; however, whether other complications reported for metal implants occur by using bio-integrative materials has yet to be proven. The aim of our study is to assess patient-reported outcome measures (PROMs) and complications in patients received bio-integrative screws for Lisfranc fixation. Methods: The inclusion criteria were 1) ≥ 18 years old, and 2) had ORIF for Lisfranc injury using bio-integrative (OSSIOfiber ™) screws. The patients' charts were reviewed, and the variables were gathered, including the type of injury, pain score, and PROMs. The questionnaires used to evaluate PROMs were Patient-Reported Outcome Measurement Information System (PROMIS) surveys for physical function, pain interference, pain intensity, and depression. We also reported the average scores for these PROMs among a randomly sampled population of patients who had ORIF with metal screws for Lisfranc injuries for comparison (n=12). Results: We recruited 12 patients for this study. The minimum follow-up time of the patients in this study was three months. Out of 12 patients, 1 patient showed non-union. The mean (SD) PROMIS scores for physical function, pain interference, pain intensity, and depression were 43.9 (14.9), 56.1 (13.9), 45.9 (10.1), and 43.5 (4.9) in patients who received bio-integrative screws, respectively. In the sampled population treated with metal screws, these PROMs were 42.1 (9.5), 55 (10.1), 46.4 (8.1), and 44.4 (6.4) for physical function, pain interference, pain intensity, and depression, respectively. No significant difference was observed between the two groups regarding physical function (P=0.72), pain interference (P0.82), pain intensity (P=0.88), and depression (P=0.69). Conclusion: The current report showed promising patient-reported outcomes after Lisfranc ORIF with bio-integrative screws. However, longer term follow-ups, as well as comparison with a larger population for both types of instruments, bio-integrative and metal, will shed light on the pros and cons of both materials. Moreover, cost-effective studies are highly suggested to assess the usefulness of these implants against their costs for the healthcare system and the patients. [ABSTRACT FROM AUTHOR]

Category: Trauma; Ankle Introduction/Purpose: There is a paucity of literature regarding the effect of socioeconomic disparity on patient access to health care following surgery for acute musculoskeletal injuries. We hypothesized that lower socioeconomic status (SES) is independently associated with increased utilization of the emergency department (ED) for care, and less reliable outpatient follow up after ankle fracture surgery. Methods: A retrospective analysis was performed of 1,571 patients who underwent ankle fracture surgery between 2010 and 2020 at three large academic medical centers and one community hospital. Using 2010 United States Census data linked to place of residence, a summary measure of SES was created for each zip code. SES was divided into three percentile groups: 0-25%, 26-75% and 76-100%, wherein the 0- 25% group represented the lowest SES score. Independent patient and injury factors associated with ED visits and outpatient in-office follow up within 90 days of ankle fracture surgery were examined using multivariable Poisson regression models. Results: Patients in the lowest quintile of SES had a higher incidence of ED visits within 90 days after surgery (adjusted incidence ratio [aIR], 1.54, p< 0.001). Patients in the highest quintile of SES had a higher frequency of outpatient follow up within 90 days after surgery (aIR, 1.23, p< 0.001) compared to those in the middle SES quintile. Independent factors associated with increased ED visits following ankle fracture surgery were lower SES, lateral malleolus fracture, heightened comorbidities, increased BMI, Spanish-speaking patients, and patients with drug and/or alcohol dependence. Conclusion: Patients of lower socioeconomic status, those with substance use disorders, and those who must overcome language barriers to seek care demonstrate higher emergency resource utilization and are less likely to follow up in clinic after ankle fracture surgery. A better understanding of patient and injury factors associated with such increased ED visits may provide guidance as to which patient subpopulations may require more attention after ankle fracture surgery. [ABSTRACT FROM AUTHOR]

Category: Sports; Ankle Introduction/Purpose: Acute Achilles tendon ruptures (ATRs) can be treated surgically through either open repair or minimally invasive surgical techniques (MIS). While the relative complication rates between these techniques, including wound dehiscence, re-rupture, and sural nerve injury, have been debated, many studies demonstrate no significant difference between these two approaches. In this study, we conducted a Kaplan-Meier survival analysis to compare the incidence and timing of complications between open and MIS repair of acute ATRs and examine factors that may influence these rates. Methods: A retrospective study was conducted to evaluate the outcomes of patients (≥18 years) who underwent surgical intervention for acute ATR within a four-week period following injury, with a minimum follow-up of three months. Data on demographic variables, type of surgical procedure (MIS or open approach), and the occurrence and timing of postoperative complications were collected. Postoperative complications were classified as venous thromboembolism (VTE), re-rupture, surgical site infecti+D2on (SSI), wound dehiscence, and sural nerve injury.The Kaplan-Meier method was employed to compare the complication rates between the MIS and open repair groups. The log-rank test was used to test the equality of survivor functions. The Cox proportional hazards model was employed to determine predictors of complications. Results: In total, 417 patients were included in the final analysis. The MIS group had a higher proportion of patients with tobacco use. Fifty-two complications in 50 patients were recorded (Table 1). We found no significant difference in the complication rates between the MIS and open repair groups. However, Cox proportional hazards modeling revealed that body mass index (BMI) was a significant predictor of re-ruptures (HR 1.2, 95% CI = 1.05–1.4) and that surgical delay was found to be a significant predictor of wound dehiscence (HR 1.2, 95% CI =1.01–1.3) and sural nerve injury (HR 1.2, 95% CI =1.1–1.3). A surgical delay of more than 2 weeks was noted to have a positive likelihood ratio of 2.3 for wound dehiscence and 3.1 for sural nerve injury. Conclusion: The results of this study indicate that MIS and open repair techniques for acute ATRs demonstrate comparable complication rates. However, patients with elevated BMI exhibit an increased risk of re-rupture. Those with surgical delay beyond two weeks have an elevated likelihood of wound dehiscence and sural nerve injury, presumptively due to associated scaring and the requisite tissue manipulation. Surgeons and patients may consider these variables when formulating a surgical treatment plan. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: The lateral fibular stress test (LFST), also known as the hook or Cotton test, is commonly performed to assess syndesmotic instability intraoperatively. Several studies have determined that 100 Newtons (N) is the required force applied when performing the LFST to detect syndesmotic instability. We hypothesize that surgeons do not uniformly nor consistently apply 100N of force when performing the LFST and that substantial variation exists. Fundamentally, this could lead to under-detection of syndesmotic instability as surgeons may not be applying the requisite force in a consistent manner. Methods: A biomechanical SawBones lower leg model including simulated soft tissue envelope (SawBones inc., Vashon Island, Washington) was mounted to a board and a 1cm diameter hole was drilled across the tibia and fibula in the area of the syndesmosis. An industrial force gauge (Nidec-Shimpo, Kyoto, Japan) was then mounted. A metal extension piece was passed from the force gauge through the hole and positioned so that the tip was exposed on the lateral side of the model. A commonly utilized reduction clamp was affixed to the force gauge. Orthopaedic attending surgeons and trainees were asked to perform a series of LFSTs and to simulate the force they typically apply intra-operatively and this force was recorded in Newtons (N). Basic demographic data was collected on each participant. Results: 33 surgeons participated in the study, including 18 trainees. The median (IQR) force applied during the LFST was 96.42(71.42-126.33), 87.49 (69.19-117.40), 99.99(79.91-137.49), for the pooled group, attendings, and trainees respectively. Over half (54.5%) of all trials were less than 100N (57.8% of surgeons, 51.8% trainees). The distribution of pulls is shown in Figure 1. Intraobserver correlation was excellent within the overall cohort (0.92, p<0.001), trainees (0.90, p<0.001) and attendings (0.94, p<0.001), respectively. Inter-observer reliability was fair among the overall cohort (Kappa =0.28, p=0.49), and poor between the attendings (Kappa=0.11, p=0.69), and the trainees (Kappa=0.05, p=0.82), respectively. Conclusion: Our study demonstrates that the amount of lateral force applied by surgeons in a biomechanical ankle model when performing the LFST is variable and often less than 100N. Inadequate force application when performing the LFST may lead to under-detection of syndesmotic instability which may portend a poorer outcome. Either the intraoperative use of force gauges and/or specific practice outside of the operating theatre (to become familiarized with the proprioceptive feel of generating the requisite force) may permit surgeons to consistently apply the test in a manner that is clinically reproducible. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Diagnosing syndesmotic injuries is challenging. Avoiding intra-operative syndesmotic malreduction is even more challenging. Malreduction can be devastating to the long-term health of the ankle joint and has been shown to be more frequent and unforgiving with rigid screw fixation when compared to flexible implants. Syndesmotic position assessment postoperatively is usually performed using bilateral CT. Evaluation is frequently subjective or based on conventional distance, angular, area, and volumetric measurements. Diagnostic accuracy of these measurements is still questionable. The goal of this study was to utilize a 3D Weightbearing CT distance mapping algorithm to objectively assess syndesmotic position in a cadaveric model simulating different patterns of syndesmotic malreduction. We also aimed to evaluate the relative changes in syndesmotic position when fixation was converted from rigid to flexible. Methods: In this cadaveric experimentation, four below-knee specimens were utilized. Specimens were mounted in an external frame simulated weightbearing condition (350N of axial load). Specimens underwent sequential WBCT imaging in four different conditions: native normal ankle, syndesmotic instability, malreduced, and released conditions. In the instability condition, syndesmotic ligaments were surgically released using a conventional limited lateral approach. The malreduced position consisted of controlled 5mm anterior displacement, 5mm posterior displacement, 15o of internal rotation, and over-compressed (160N) states. Fixation was performed with a single implant 20mm proximal to the ankle joint. Implant utilized allowed initial rigid screwtype fixation, followed by implant flexibilization similar to a suture-type fixation (released position). Tibia, fibula, and talus WBCT images were segmented, and syndesmotic incisura and gutter distances were assessed using a 3D distance map algorithm. The syndesmotic position was compared between normal, unstable, malreduced, and released positions. Color-coded representations of the observed differences were presented (Figure). Results: When comparing normal to unstable condition, we observed significant widening of the syndesmotic posterior aspect (average, 13.9%; p=0.004). Overall, all four malreduced positions lead to significantly decreased tibiofibular distances when compared to the unstable state, consistent with syndesmotic over-compression (average, 19.8%; p=0.01), particularly in the posterior aspect of the joint (average, 26.9%; p=0.04). This over-compression was also more pronounced in the anterior displacement (31.5%) and internal rotation malreductions (23.1%). In the released flexible position we found a non-significant trend towards widening of the tibiofibular distances (average, 12%; p=0.08) when compared to the malreduced conditions, indicating partial restoration the syndesmotic relationship. The syndesmotic distances in the released position were also not significantly different from the normal condition. When compared to normal, the lateral gutter demonstrated significant widening in the unstable condition (average 16.7%; p=0.02), narrowing in the malreduced state (average 6.6%; p=0.04), and widening in the released position (average 3.7%; p=0.002). Conclusion: In this study we used 3D WBCT distance mapping to assess syndesmotic position in a cadaveric model simulating syndesmotic instability and multiple syndesmotic malreduction conditions (anterior and posterior displacement, internal rotation and over-compression). We observed significant widening when the syndesmotic ligaments were sectioned, followed by significant tibiofibular narrowing in the malreduced and fixed rigid states. When the implant fixation was released, we observed a trend towards restoration of normal syndesmotic alignment, with relative widening that was however not significantly different from the malreduced rigidly fixed state. Increased sample size cadaveric assessment and clinical studies are necessary to validate our results. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Acute Achilles tendon rupture repair has undergone several changes in the past decade, aiming to minimize complications while maximizing clinical outcomes. Less invasive approaches have been associated with comparable results and decreased infection risk compared with traditional open techniques. Patient positioning during surgery also influences outcomes; prone positioning is associated with increased operative times as well as risk of neuropraxia and ophthalmologic injuries as compared to supine positioning. The Medial Mini-Open Supine (MMOS) Achilles Repair technique combines the benefits of supine positioning and mini-open techniques. This study compares 1-year clinical outcomes, operative times, and complication rates of patients undergoing repair with this novel technique to those treated with an open or mini-open approach with prone positioning. Methods: Patients undergoing operative acute Achilles rupture repair at our institution after February 2015 were included in this study. Patients were grouped by technique used: 1) open repair with prone positioning, 2) mini-open repair with prone positioning, or 3) the medial mini-open repair with supine positioning. Patients were followed for a minimum of 1 year postoperatively. Primary outcome measures include Patient-Reported Outcomes Measurement Information System (PROMIS) scores (Physical Function, Pain Interference and Depression), Foot and Ankle Ability Measure (FAAM) assessments (ADLs and Sport) and Visual Analog Scale (VAS) pain scores. Secondary outcome measures include intraoperative times and complication rates. Statistical analysis to assess for significant differences between the groups was conducted using the Kruskal-Wallis test, Nemenyi test, ANOVA with posthoc Tukey test and chi-square test as was appropriate. Results: A total of 56 patients (Group 1: n=18, Group 2: n=14, Group 3: n=24) were included in this study. Average 1-year PROMIS Physical Function scores were 59.57 (+-12.9), 64.29 (+-13.96) and 63.03 (+-11.69) for Groups 1, 2 and 3 respectively. Average Pain Interference scores were 46.05 (+-17.65), 42.12 (+-8.75) and 42.48 (+-7.11). Depression score averages were 40.79 (+-7.61), 36.87 (+-9.35) and 39.81 (+-9.48) for Groups 1, 2 and 3, respectively. Differences between groups were not significant (p >0.05). Group 3 had statistically significant differences in total OR time compared to both Groups 1 and 2. The median difference was 33 min between Groups 1 and 3, and 35 min between Groups 2 and 3 (p<0.01) The majority of time savings arose from pre-incision setup and post-closure times. Differences in complication rates (5.5% (n=1), 14.3% (n=2), and 12.5% (n=3), for Groups 1, 2 and 3 respectively) were not statistically significant (p=0.73). Conclusion: The Medial Mini-Open Supine Achilles Repair technique shows promise as a viable option for acute Achilles tendon rupture repair; ease of patient positioning preoperatively translates to decreased set up, operative, and sedation time, directly benefiting patients. Patient-reported outcomes at 1-year follow-up demonstrate comparable results with both open and mini-open prone techniques, without an increase in complication rates. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: There is a lack of consensus regarding optimal management of Posterior Malleolar Fractures (PMFs). Indirect reduction and fixation with posterior-anterior (PA) screw shows promise of avoiding the risks associated with direct reduction or indirect anterior to posterior (AP) approaches. Some authors have raised concerns about potential risk to nearby structures with PA technique, including hardware prominence into the syndesmosis. This study highlights the use of a posteromedial vertical syndesmotic line as a fluoroscopic landmark, helping surgeons avoid intra-syndesmotic placement. Methods: Indirect PA screw placement was completed on ten cadaveric specimens, followed by fluoroscopy in mortise and lateral views. Dissection was performed to assess screw placement relative to the posteromedial border of the syndesmosis. The posterior border of the syndesmosis was marked with a radiopaque wire. Repeat imaging was completed to validate the fluoroscopic posteromedial vertical syndesmotic line is representative of the posteromedial border of the tibial incisura. Results: On dissection, 9 of 10 cadavers had accurate screw placement with no penetration into the syndesmosis (Figure 1, bottom left & bottom right). Corresponding imaging showed the screw head to be medial to the marker on mortise view. For the specimen with penetration into the syndesmosis, imaging confirmed that the screw head was lateral to the marker on mortise views (Figure 1, top center & top right). The radiopaque marker correlated with the posteromedial vertical syndesmotic line for all specimens when comparing anatomic to radiographic findings. A radiographic safe zone is defined for the PA screw 12 mm medial to the vertical syndesmotic line to ensure no iatrogenic injury to the FHL tendon. Conclusion: This study demonstrated that the posterior incisura tibialis fluoroscopic landmark is unambiguous in localizing the posterior syndesmotic border (Figure 1, top left) and that screws medial to this line are safely out of the syndesmosis, while screws placed lateral are either in or at risk of intra-syndesmotic placement. A safe zone is defined for screw placement. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Plantar fasciitis is the most common cause of heel pain in adults, affecting 1 out of 10 of the population at some point during their lifetime. Plantar specific stretching programs are popularity among foot and ankle surgeons consisting of passively dorsiflexing foot and using thumb to apply pressure. This technique is not without limitations. Certain patients are unable to properly perform the stretching techniques, such as limited mobility from advanced age, disability, or simply from performing stretching exercises incorrectly. The aims of this study are; first, identify what configuration of plantar-specific stretching combined with applied pressure to the plantar aponeurosis generates the greatest tensional force in the plantar fascia. And second, to construct a prototype device that could simulate these forces in a hands-free technique. Methods: Six (will be 10) fresh-frozen, morphologically normal cadaver feet (Medcure, RI) were utilized. Plantar fascia was exposed, ankle was fixed at 90-degree dorsiflexion using Calcaneo-Tibial Schanz Pin, specimen was then inverted and potted in a custom-made box (Smooth-Cast 300q, PA). Using an electromagnetic motion tracking system (Liberty, Polhemus, VT), the motion of sensors was recorded at 120 Hz. Utilizing tissue adhesive glue (Vetbond, 3M, Minnesota), the first sensor was attached to medial calcaneal tuberosity, and the second sensor was placed 5 cm distal to the first sensor on the plantar aponeurosis. Custombuilt testing apparatus was made for induction of MTP dorsiflexion application of pressure on the plantar aponeurosis to mimic current conservative treatments. Weights were added to the custom build stretcher device in 10Lb increments. Strain percentage was calculated as the change in length divided by the baseline length position (condition 1) using the formula: ([L - Lo]/Lo) × 100. Results: Dorsiflexion of 2nd-5th MTPs increases strain percentage more in comparison with 1st MTP dorsiflexion (Condition 3>4>2). This might show that dorsiflexing of 1st metatarsal is less effective at straining the plantar fascia because of the midfoot motion. By adding thumb pressure, strain percentages go higher, up to a point that in condition 7 (dorsiflexing all MTPs in combination of thumb pressure) it is significantly higher than our baseline condition (P=0.0385). It is noteworthy that, stretcher device itself (condition 8), cannot replicate conditions 4 or 7 strain percentages. When adding direct pressure and weight to the stretcher device (conditions 12 and 13), strains are even higher than condition 7 and also are significantly higher than the baseline (P= 0.0090 and 0.0291 respectively). Conclusion: The stretcher device itself is insufficient for stretching the plantar fascia, supporting the hypothesis of this study that we need a direct forceful pressure on the plantar aponeurosis as well. Our customized plantar stretcher not only can replicate the conventional stretching program, but also can produce higher strains on the plantar aponeurosis than the current manual application of plantar specific stretching. This device may impact the rehabilitation process in patients with advanced age as well as patients with spine mobility limitation who cannot perform manual stretching programs. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Current treatment of ankle fractures is predicated on 1-2 mm of talar shift leading to abnormal contact pressures. Determination of anatomic alignment has conventionally been based on plain radiographs. The ability of x-ray to detect subtle mortise displacement however is unknown. The purpose of this investigation is to determine if CT scan can detect malalignment undetectable utilizing plain radiography when assessing injuries assumed to have anatomic mortise alignment. The findings have implications for utilizing higher resolution diagnostic imaging to assess malalignment and challenging the validity of previous literature in which conclusions of anatomic mortise alignment were determined based on plain radiography. Methods: 24 patients with stress-negative, stable SER-II type ankle fractures were included. Contralateral ankle mortise radiographs were obtained in addition to static and gravity stress radiographs of the injured side. Bilateral CT scans were performed once patients were deemed to have achieved clinical/radiographic healing. Measurements of the medial clear space (MCS) and syndesmosis were performed by two blinded orthopedic surgeons at two different time points. Intraclass correlation coefficients (ICC) were calculated to evaluate the intra- and inter-rater reliability and consistency of measurements. Statistical analyses were performed to determine any differences between x-ray and CT scan measurements to detect discrepancies between the injured and normal ankle measurements. Statistical significance was defined as a two-sided alpha error of less than 0.05 (p < 0.05). Results: Despite plain radiographs demonstrating no statistical side-to-side differences and achieving apparent final anatomic alignment in the majority of the cohort, CT MCS on coronal, axial planes and syndesmosis measurements were significantly different when comparing the injured to the normal contralateral ankle by on average of about 0.5mm. There was also excellent intra and interobserver agreement achieved for the measurements. Conclusion: CT is superior to plain radiography in detecting subtle mortise/syndesmotic displacement and side-to-side differences undetectable by x-ray. These findings challenge conventional assumption of anatomic alignment for SER II injuries and reliance on x-rays to assess anatomic alignment. While injured ankles uniformly demonstrated non-anatomic alignment as compared to the uninjured side, the clinical implications of subtle malalignment are unknown. However, broad reaching implications of this preliminary study include challenging the validity of x-ray to detect possibly clinically-relevant mortise malalignment in patients presenting with isolated lateral malleolus fractures. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Three dimensional printing is an actively emerging field within the realm of medical devices. This technology expands therapeutic options and customization of implants to individual patients. The ability to create products that replicate normal bony anatomy has been a significant advancement in the setting of difficult clinical scenarios. 3-D generated, custom implants increase the potential for joint and limb salvage with the goal of improving functional outcomes. We present a technical tip for utilizing 3-D printing technology to create custom, anatomically-matched antibiotic cement spacers for limbsalvage applications. We present two illustrative cases and share our experiences, lessons learned, and a succinct review of the pertinent literature merging 3-D printing and the use of antibiotic cement as temporary and permanent reconstructive solutions. Methods: While the majority of 3-D printing is done for the purpose of generating devices for implantation, we present a technical tip for designing a 3-D printed mold from which to create an antibiotic cement spacer for implantation. Two case illustrations demonstrate comorbid patients presenting with infected implants, osteomyelitis, bone loss, deformity and wound dehiscense. We describe the process of patient selection, implant design, fabrication, and implantation of a custom molded antibiotic cement talus for the purpose of limb salvage. Results: Case illustrations present two successful limb salvage patients while giving a thorough explanation of our technique, learned tips and tricks. This applied technology builds on prior use of antibiotic cement in limb salvage of the lower extremity, most of which is joint sacrificing. 3-D printing the mold for an anatomic talus cement spacer results in a joint sparing limb salvage solution. Conclusion: Utilization of currently available 3-D printing technology as applied to production of anatomic cement spacers should be considered to enhance limb salvage. This innovative application of printing technology is merged with current, pertinent literature regarding antibiotic cement to offer surgeons expanded options for temporary or definitive reconstructive techniques in some of the most challenging patients. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Fractures of the fifth metatarsal base have been a source of confusion since their original description by Jones in 1902. The term Jones' fracture has been used indiscriminately leading to further confusion. Zone classifications have been described but never evaluated for their reliability. The most recent classification, metaphyseal versus metaphyseal-diaphyseal is unknown to most surgeons. The purpose of this study was to evaluate the inter-rater reliability of American Orthopaedic Foot & Ankle Society (AOFAS) members classifying fractures of the base of the fifth metatarsal. Methods: A survey was emailed to members of the AOFAS including radiographs of 18 fifth metatarsal base fractures. Demographic information was collected in addition to evaluation of the 18 sets of radiographs using three classification systems. Surgeons were asked if the fracture is a Jones' fracture, zone of the fracture and if the fracture was metaphyseal or metaphysealdiaphyseal. A total of 223 surgeons with an average experience of 14 years in practice (range: fellow - 50 years) completed the initial survey for inter-rater reliability. Additionally, each surgeon was asked which zones or zone junctions they consider a Jones' fracture. Reliability was tested using Fleiss' Kappa scores. Results: Inter-rater agreement for use of the term Jones' fracture was moderate (kappa 0.533, 95% confidence interval (CI) [0.530, 0.535]). The zone classification had an inter-rater agreement was moderate (kappa 0.537, 95% CI [0.535, 0.539]). Interrater agreement for metaphyseal versus metaphyseal-diaphyseal was substantial (kappa 0.705, 95% CI [0.702, 0.708]). Results of surgeon definition of a Jones' fracture is seen in Figure 1. Conclusion: This is the largest study of its kind looking at inter-rater reliability of an orthopaedic classification with 223 raters. The terminology regarding the classification of fifth metatarsal base fractures remains confusing and inconsistent. The term Jones' fracture has little meaning in terms of communicating these injuries as there is only moderate agreement when surveying surgeons and it is defined differently by most. The zone classification has similar reliability as the Jones' fracture. The terms metaphyseal and metaphyseal-diaphyseal was the most reliable means to describe these fractures. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Assessment of mortise stability is paramount in determining appropriate management of ankle fractures. While instability is readily apparent in bimalleolar or trimalleolar ankle fractures, determination of instability in the apparent isolated Weber B fibula fracture often requires further investigations such as stress radiography. While several authors have previously demonstrated poor predictive value of physical examination findings such as tenderness, ecchymosis and swelling with instability, no previous investigation has examined the ability of a translational test to determine deltoid ligament injury. The goal of this study is to test the validity of a novel clinical test, the lateral drawer test, in determining mortise instability in a cohort of patients with Weber B fibula fractures. Methods: Patients presenting with isolated fibula fractures were prospectively identified by an orthopaedic nurse practitioner or resident. Three views of the ankle as well as gravity stress views (GSV) were obtained. Prior to examining radiographs, two foot & ankle fellowship-trained orthopaedic surgeons (JYK, CPM) performed and graded the lateral drawer test. (Grade 0: no instability/symmetric to contralateral ankle, Grade I: translation < 5mm, Grade II: translation >= 5mm) While the surgeons were made aware of the presence of a Weber B fibula fracture, radiographs were not visualized prior to conducting the drawer test. Medial clear space (MCS) was measured. VAS pain scores were obtained before and after testing. The results of the lateral drawer test results were compared with radiographic measurements of MCS. Results: The study enrolled 57 consecutive patients with Weber B ankle fractures. Twenty-nine (51%) patients demonstrated radiographic instability with widening of the medial clear space >= 5 mm on GSV. When correlated with MCS measurement, the lateral drawer test demonstrated a sensitivity of 83.3%, specificity of 96%, positive predictive value (PPV) of 96% and negative predictive value (NPV) of 84% for determining instability. There was a strong correlation between the lateral drawer test grade and amount of MCS widening (ρ=0.82, p<0.001). Patients tolerated the lateral drawer test well with an average increase of 0.8 points on the VAS pain scale after testing. Conclusion: The lateral drawer test demonstrates high sensitivity, specificity, PPV and NPV for detecting instability in patients presenting with Weber B fibula fractures. While further validation is required in a larger cohort of patients, the lateral drawer test may offer an adjunct tool via physical examination to predict mortise stability. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Early revision rates within 12 months after ankle fracture open reduction internal fixation (ORIF) are fairly low, however remain relevant given the sheer volume of ankle fractures which occur each year. Understanding these rates is complex because reoperation due to technical or mechanical complications - such as malunion, inadequate reduction or fixation failure - are typically reported alongside returns to the operating room for soft-tissue related problems like wound dehiscence or infection. There is limited data identifying risk factors specifically for revision of ankle fracture fixation in the absence of soft-tissue complications. Understanding variables which predispose to aseptic technical and mechanical failure without this confounder may provide insight and improve patient care. Methods: The purpose was to identify risk factors for aseptic revision of ankle fracture within ORIF 1 year of primary operation. A retrospective cohort study was performed at two large academic medical centers. Research Patient Data Registry (RPDR) data available from 2002-2019 was used to identify patients who underwent aseptic revision of ankle fracture ORIF within 12mo of their primary ORIF. Patients were excluded if <18yo at primary surgery, or if indications for return to the operating room included surgical management of a dehisced wound or deep infection. A control group was selected by identifying sequential patients who underwent ankle fracture ORIF which did not require revision within 12mo. Primary and revision surgeon characteristics, patient demographics, comorbidities, fracture characteristics, surgical techniques and post-operative events were recorded and compared in univariate analysis. Variables which achieved significance in univariate comparisons were included as candidates for multivariable analysis. Results: 33 patients were identified for the Revision group. 100 patients were identified for the Control group (Power = 80% for detecting moderate differences). Groups did not differ in age or gender. Final multivariable logistic regression modeling, adjusting for all other variables within the multivariable analysis, demonstrated the following factors to be independently associated with an increased risk of revision surgery: Documented falls in the early post-operative period (aOR: 298; 95% CI: 15.4, 5759; P<0.001), Movement-altering disorders (aOR≥81.7; 95% CI: 4.12, 1620; P=0.004), a non-anatomic mortise (MCS > SCS) on immediate postoperative imaging (aOR=28.4; 95% CI: 5.53, 267; P<0.001), more severe initial fracture displacement (ARCS Type C) (aOR vs Type A =25.8; 95% CI: 2.81, 237; P=0.004), Substance abuse (aOR=15.7; 95% CI: 2.66, 92.8; P=0.002), and polytrauma (aOR=12.3; 95% CI: 2.02, 74.8; P=0.006). Conclusion: Six factors were found to be predictive of the need for aseptic revision: Documented falls in the early postoperative period (aOR: 298), movement-altering disorders (aOR≥81.7), a non-anatomic mortise (MCS > SCS) on immediate postoperative imaging (aOR=28.4), more severe initial fracture displacement (ARCS Type C) (aOR=25.8), substance abuse (aOR=15.7) and polytrauma (aOR=12.3). Identifying these factors may allow surgeons to better counsel their patients and discuss risk during the informed consent process. These may also serve as future targets for intervention aimed at improving patient safety and outcomes follow ankle fracture ORIF. [ABSTRACT FROM AUTHOR]