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Category: Other Introduction/Purpose: In foot and ankle surgery, the fulfillment of patients’ preoperative expectations is a unique and validated method to assess postoperative success. Expectation fulfillment is closely associated with postoperative outcomes, satisfaction, and patient-reported improvement. Ideally, foot and ankle patients should have realistic expectations of surgery so that they are appropriately prepared for their postoperative symptoms and function. Inappropriately high expectations may predispose to worse outcomes because patients have unrealistic views about what their surgery can actually accomplish. Conversely, inappropriately low expectations may represent a lack of motivation to improve or participate in rehabilitation and postoperative protocols. This study aimed to identify the relationship between preoperative expectations and postoperative fulfillment. These results may facilitate surgeon-patient communication and help patients prepare for their operation and their postoperative function. Methods: Adult patients undergoing elective foot and ankle surgery at a single center were prospectively enrolled. Demographics, diagnosis, and outcomes surveys (Short Form [SF]-12, Foot & Ankle Outcome Score, improvement, satisfaction) were collected. Preoperatively, each patient completed the Expectations Survey (range 0-100, with 100 indicating maximum expectations), which asks about anticipated improvement in domains like pain, ambulation, function, and shoewear. Two years after surgery, for each expectation cited preoperatively, patients answered how much improvement they actually achieved. Using a ratio of the postoperative and preoperative scores, a Fulfillment Proportion (FP) was calculated, along with the minimal clinically important difference (MCID). This permitted identification of patients with unfulfilled, fulfilled, and surpassed expectations. Bivariate correlations, chi-square analyses, and multivariate regressions with 95% confidence intervals (CI) were performed to identify the relationship between preoperative expectations, clinical variables, and postoperative expectation fulfillment. Results: There were 271/340 (80%) patients with 2-year follow-up, with mean age 55.4 years and 65% female. Most common diagnoses were hallux valgus (25%), flatfoot (11%), hallux rigidus (11%), ankle arthritis (10%), and chronic tendon injury (9%). Expectation fulfillment differed significantly with extent of preoperative expectations (Figure). Patients with average/high expectations had higher rates of unfulfillment compared to patients with low preoperative expectations (40-41% vs. 22%). Rates of surpassed expectations were highest in patients with low preoperative expectations (23%) compared to average (12%) or high (0%) preoperative expectations (pConclusion: Preoperative expectations were a significant predictor of expectation fulfillment after foot and ankle surgery. Lower preoperative expectations were associated with fulfilled or surpassed expectations after surgery, whereas high preoperative expectations were significantly more likely to be unmet. These findings may help guide whether patients’ expectations are realistic or inappropriate preoperatively. It is imperative for surgeons to consider and discuss patients’ expectations prior to surgery to ensure they have an appropriate understanding of their potential outcome. Further research should be directed to the extent that patients’ preoperative expectations can be modified in order to maximize postoperative satisfaction.

Category: Other Introduction/Purpose: Fulfillment of patients’ expectations following foot and ankle surgery has been previously studied and validated in assessing patient-reported outcomes (PROs). While this assessment has been shown to correlate well with patient satisfaction and PROs, the impact of postoperative complications on fulfillment of expectations is unknown. The aim of this study is to therefore investigate the impact of postoperative complications on fulfillment of patients’ expectations. Methods: Preoperatively, patients completed a validated Foot and Ankle expectations survey consisting of 23 questions encompassing domains including pain, ambulation, daily function, exercise, and shoe wear. At 2 years postoperatively, patients answered how much improvement they received for each item cited preoperatively. A fulfillment proportion (FP) was calculated as the amount of improvement received versus the amount of improvement expected. The FP ranges from 0 (no expectations fulfilled), between 0 and 1 (expectations partially fulfilled), 1 (expectations met), to greater than 1 (expectations surpassed). In addition, patient-reported outcomes (FAOS), satisfaction, and Delighted-Terrible scale (how they would feel if asked to spend the rest of their life with their current foot/ankle symptom) were collected at final follow-up. Chart review was performed to identify patient demographics, comorbidities, pain management, and postoperative complications, which were classified as minor (infection requiring antibiotics) or major (unplanned return to OR, reoperation, or revision). Results: Of the 271 patients (mean age 55.4 years, 65% female), 31 (11.4%, mean age 53.6, 58% female) had a postoperative complication; 27 major (17 revisions, 10 removal of hardware due to pain/infection) and 6 minor (6 superficial infections requiring antibiotics). Complications were associated with significantly worse FP (0.69 +- 0.45 vs 0.86 +- 0.40, p=0.02). Average time from complication to completion of fulfillment survey was 15 (+-3.6) months. Having a complication significantly correlated with worse satisfaction, Delighted-Terrible scale, and FP (pConclusion: Our data suggests that postoperative complications following foot and ankle surgery are associated with worse patient-reported fulfillment of their surgical expectations. This finding is independent of preoperative expectations, and correlates with several validated outcomes measures including patient satisfaction. Therefore, while patient fulfillment following foot and ankle surgery is multifactorial, the importance of preoperative education and counselling for potential complications should not be overlooked.

Category: Ankle, Ankle Arthritis, Arthroscopy, Bunion, Hindfoot, Midfoot/Forefoot, Sports, Trauma Introduction/Purpose: Depression and anxiety are increasingly recognized to have a dramatic impact on patients with musculoskeletal pathologies. They complicate treatment due to complex relationships between pain, function, and affective symptoms. Depression/anxiety can cause social isolation, attention towards painful symptoms, and avoidance of physical exertion, all which may affect patient outcomes in orthopaedic surgery. Prior work has demonstrated that patients with depression/anxiety have greater preoperative expectations of foot/ankle surgery. However, no study to date has investigated the effect depression/anxiety on fulfillment of expectations and patient satisfaction postoperatively. We hypothesized that patients with preoperative depression or anxiety symptoms would have lower rates of expectation fulfillment than patients without affective disorders, particularly for expectations of pain relief and going back to normal. Methods: Patients undergoing elective foot/ankle surgery at a single center were prospectively enrolled. Demographics, diagnoses, and preoperative Foot and Ankle Outcomes Scores (FAOS) were collected. Preoperatively, patients completed an expectations survey, which asks about anticipated improvement in items including pain control, ambulation, function, and more generalized items like going back to normal and preventing foot/ankle pathology from worsening. Depression and anxiety were assessed using the Patient Health Questionnaire (PHQ-8) and Generalized Anxiety Disorder screener (GAD-7) respectively; for both surveys, scores of 10 or more were used to designate depression and anxiety. Patients repeated the expectations survey 2 years postoperatively, answering how much improvement was actually attained for each item. Patients also reported satisfaction with surgery, perception of overall improvement, extent to which expectations were fulfilled, and answered the Delighted- Terrible scale. Survey responses were compared between patients with depression and/or anxiety (D/A) and no D/A patients using t-tests and Chi-square analyses (pResults: Of 271 total patients, 53 (20%) met criteria for D/A. D/A and no D/A patients were statistically similar in age (54.4 vs 55.7 yrs), gender (62% vs 66% female), comorbidities, education, ethnicity, and diagnoses. D/A patients had significantly worse preoperative FAOS scores and greater preoperative expectations. Postoperatively, both groups had similar proportions of expectations fulfilled (p=0.292) and improvements in FAOS scores (p>0.225). D/A patients had significantly less expectation fulfillment for ambulation tolerance (77% vs 90%, p=0.017), improving confidence in foot/ankle (77% vs 88%, p=0.049), and going back to normal (76% vs 87%, p=0.043). D/A patients were significantly more dissatisfied (21% vs 9%, p=0.013), had less perceived improvement, and were less likely to want to repeat surgery (p=0.019) or recommend surgery to someone else (p=0.017). Conclusion: D/A patients had significantly lower postoperative rates of overall perceived improvement and satisfaction with surgery compared to patients without affective symptoms. A majority of D/A patients did not meet their expectations for ambulation tolerance, confidence, and returning to normal. However, despite having worse baseline outcomes scores and more preoperative expectations, patients with depression/anxiety had similar improvements in FAOS and proportions of expectations fulfilled postoperatively. Therefore, despite perceived poor outcomes, D/A patients have similar improvements in outcomes and expectation fulfillment. These findings may improve surgeon/patient communication and management of expectations.

Category: Ankle, Ankle Arthritis, Arthroscopy, Bunion, Hindfoot, Lesser Toes, Midfoot/Forefoot, Sports, General Foot/Ankle, Outcomes, Satisfaction Introduction/Purpose: Success in orthopaedic surgery was traditionally defined by postoperative radiographs or legacy outcomes scores, but increasingly incorporates more patient-centered metrics. Patient expectations are one such measure, and have been described using a new validated survey for foot/ankle patients. Understanding patients’ expectations of surgery is critical in order to facilitate shared decision-making and set reasonable goals for outcomes. In other specialties, postoperative expectations surveys have also been created and shown to correlate with measures of satisfaction and traditional patient-reported outcomes scores. However, there are no such studies in the foot and ankle literature. This study aimed to validate a method of assessing expectation fulfillment in foot/ankle patients postoperatively. We hypothesized that the survey would significantly correlate with measures of improvement, satisfaction, and clinical outcomes scores. Methods: This is a single-center prospective study of patients undergoing elective foot and ankle procedures. Preoperative demographics, clinical data, and Foot & Ankle Outcomes Score (FAOS) were collected. Patients completed the expectations survey, consisting of 23 questions for domains including pain, ambulation, daily functioning, exercise/sports, shoe wear, and generalized items like “improving confidence in foot/ankle” and ”going back to normal.” Postoperatively, patients answered how much improvement they received for each item listed on the preoperative survey. Using previously validated methods, the proportion of expectations fulfilled was calculated as a ratio of the preoperative to postoperative expectations score, with values of 0 -1 indicating some expectations met, 1 indicating expectations met; and >1 indicating expectations surpassed. Receiver operator characteristic (ROC) curves and areas under the curve (AUC) with 95% confidence intervals (CI) were used to compare the expectations survey to other outcomes scales, including FAOS, perceived improvement, overall fulfillment, Delighted-Terrible scale, and satisfaction. Results: 271/340 (80%) of patients with preoperative data completed 2-year follow-up (mean age 55.4 years, mean BMI 27.5, 65% female). Most common diagnoses were hallux valgus (25%), flatfoot (11%), hallux rigidus (11%), and ankle arthritis (10%). Mean proportion of expectations fulfilled was 1.15, indicating surpassed expectations. The proportion of expectations fulfilled correlated best with perceived improvement, global expectation fulfillment, and the Delighted-Terrible scale, and to a lesser degree with satisfaction and change in FAOS (all except activity). Based on the inflection point of the ROC curves corresponding to greatest AUC (Table), a clinically important proportion of expectations fulfilled was 0.81 and correlated with feeling delighted (sensitivity 0.88, specificity 0.85), improvement (sensitivity 0.89, specificity 0.83), overall expectations (sensitivity 0.91, specificity 0.81), and satisfaction (sensitivity 0.85, specificity 0.81). Conclusion: The proportion of expectations fulfilled is a valid outcome tool for foot and ankle surgery. It is uniquely able to capture pre- and postoperative data in one value and can be tailored to each patient’s specific goals. This survey can be used by surgeons after a variety of procedures to assess if a patient’s specific expectations have been fulfilled after surgery. We can use this tool to assess which patient and surgical factors may influence the fulfillment of expectations. This, in turn, will help surgeons better indicate the appropriate procedure in the optimal patient to achieve the greatest postoperative success.

Category: Hindfoot Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) is characterized by concurrent bony deformities, tendinous and ligamentous insufficiencies. Weightbearing CT (WBCT) is a new imaging technique that allows excellent evaluation of the relative three-dimensional positioning of the tarsal bones in dynamic deformities such as AAFD. MRI, on the other hand, provides an accurate evaluation of soft tissue integrity in the unloaded foot. The objective of this study was to evaluate the correlation between bone deformity and soft tissue insufficiency in patients with stage II AAFD, using WBCT and MR images. We hypothesized that a significant correlation would be found between WBCT measurements of increased longitudinal arch collapse, hindfoot valgus, peritalar subluxation and forefoot abduction, with MRI findings demonstrating degree of involvement of ligaments and posterior tibial tendon (PTT). Methods: This retrospective comparative study included 55 patients (56 feet) with stage II AAFD, 20 men and 35 women, mean age of 52.5 (range, 20 to 78) years. Multiple WBCT and MRI variables related to the severity of the deformity were evaluated by four blinded and independent readers (two radiologists and two foot and ankle surgeons), including: arch collapse (navicular-floor distance and forefoot arch angle), hindfoot alignment angle (HAA), forefoot abduction (talonavicular uncoverage angle), subtalar joint subluxation, sinus tarsi and subfibular impingement, and soft tissue insufficiency (posterior tibial tendon, spring and talocalcaneal ligaments). Tendinous and ligamentous involvement on MRI were graded from zero (normal) to four (complete tear). Intra- and interobserver reliabilities were assessed by Pearson/Spearman’s and intraclass correlation coefficient, respectively. A multiple regression analysis was used to evaluate the relationship between bone alignment (WBCT variables) and soft tissue injury (MRI variables). P-values of less than 0.05 were considered significant. Results: We found overall good to excellent intra (range, 0.83-0.99) and interobserver reliability (range, 0.71-0.97) for WBCT measurements and MRI readings. Spring ligament superomedial component involvement was the only finding to correlate with medial column collapse and decreased navicular-floor distance (p=0.03). Superomedial spring ligament and PTT degeneration were also significantly correlated with increased HAA (pConclusion: This study is the first to evaluate correlation between bone, tendinous and ligamentous involvement in AAFD patients, using WBCT and MR images. Our results demonstrated that progressive bone deformity in WBCT is significantly correlated to MRI involvement of the PTT and other important restraints such as the spring and talocalcaneal ligaments. The implications are that WBCT can predict ligamentous injuries and that MRI can predict dynamic bone deformity in AAFD patients. Furthermore, the correlation of bone and soft tissue involvement could impact surgical planning of flatfoot patients, decreasing thresholds for additional soft tissue procedures such as a spring ligament reconstruction.

Category: Ankle, Hindfoot, Flatfoot Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) is a complex deformity characterized by hindfoot valgus, medial longitudinal arch collapse, midfoot abduction, and forefoot supination. In its most advanced stages (stage IV), the deltoid ligament is compromised, which leads to valgus talar tilt at the tibiotalar joint. This talar tilt puts patients at high risk of developing ankle arthritis necessitating ankle arthrodesis or arthroplasty. Tendon graft reconstruction of the deltoid ligament has previously demonstrated good clinical and radiographic outcomes at short to intermediate-term follow-up but controversy over efficacy of the procedure remains. The goal of the current study was to present the intermediate to long-term clinical and radiographic outcomes of the largest series to date of patients undergoing this procedure. Methods: Data from a prospectively collected Foot and Ankle Registry was reviewed. All consecutive patients undergoing deltoid ligament reconstruction with tendon allograft or autograft as part of their flatfoot surgery by the senior author prior to 1/1/2015 were eligible for inclusion. Patients with radiographic follow-up of Results: 35 feet/34 patients were eligible. Two feet/patients failed treatment (one ankle fusion, one deep infection and amputation). Three patients were deceased, two unable to follow-up due to unrelated medical problems, one missing preoperative imaging, and five unwilling to return for long-term follow-up. None of these patients failed treatment at last follow-up. 21 feet/20 patients (7/7 female) underwent radiographic analysis. Mean age at surgery was 58.4 (43.8-80.9) years. Interobserver agreement assessing change in talar tilt was excellent (ICC=.892). At mean radiographic follow-up of 10.3 (4.1-18.3) years, talar tilt improved significantly from an average of 9.71 +/- 6.22 degrees preoperatively to 3.63 +/- 3.27 degrees valgus postoperatively (pConclusion: Our findings demonstrate that deltoid ligament reconstruction with tendon graft enables radiographic correction, though not always complete, in patients with stage IV AAFD over the medium to long-term. Although limited by the sample size, our study demonstrates overall good clinical outcomes with few treatment failures. Though accessory procedures performed routinely at the time of flatfoot reconstruction present possible confounding variables, untreated ankle valgus likely leads to worsening deformity and ankle arthritis. Although the correction is not necessarily full, surgical reconstruction of the ligament may preclude patients from requiring joint sacrificing procedures such as ankle fusion or replacement over the long-term.

Category: Ankle; Ankle Arthritis; Arthroscopy; Basic Sciences/Biologics; Bunion; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports; Trauma; Other Introduction/Purpose: Patients’ expectations - and whether they are met - are an integral component of orthopaedic foot and ankle surgery. An expectations survey has been developed and validated to quantify patients’ expectations preoperatively and the fulfillment of those expectations postoperatively. The fulfillment of expectations correlates highly with perceived improvement, outcomes scores, and overall satisfaction with surgery, both in foot and ankle surgery and across orthopaedic subspecialties. Yet unlike other orthopaedic specialties, foot and ankle contains an inherently wide variety of patient diagnoses and procedures. This study sought to identify the effect of foot and ankle diagnosis on postoperative outcomes in terms of the extent to which expectations are fulfilled. We hypothesized that the fulfillment of expectations would vary with diagnosis. Methods: This is a prospective single-center study of adult patients undergoing elective foot and ankle surgery. Preoperatively, all patients completed the validated Expectations Survey (range 0-100, with 100 indicating maximum expectations), which asks about anticipated improvement in items like pain, ambulation, function, and more generalized items like ‘going back to normal.’ Two years postoperatively, patients noted how much improvement (none, a little, moderate, a lot, or complete) actually attained for each item cited preoperatively. This allowed for calculation of a ‘Fulfillment Proportion (FP),’ a numerical representation of whether each patient’s expectations were unmet (FP=0), partially met (FP 0-1), met as expected (FP=1), or surpassed (FP>1). FP was compared across diagnoses, and bivariate analysis between diagnoses and expectation fulfillment was performed using ordinal regression. Multivariate ordinal regression was then used to analyze the effect of diagnosis, clinical variables, and preoperative expectations on expectation fulfillment. Results: 271 of 340 (80%) patients had both preoperative and 2-year postoperative expectations data. Mean age was 55.4 years, mean BMI was 27.5 kg/m2, and 65% were female. Patients with diagnoses of midfoot/hindfoot arthritis (FP 0.68 +- .46) and neuroma (FP 0.69 +- .89) had the lowest proportion of expectations fulfilled (Table). Conversely, ankle arthritis patients had the highest proportion of expectations fulfilled (FP 0.94 +- .41). In multivariate regression analysis, diagnosis and preoperative expectations scores were significant independent predictors of low expectation fulfillment. Despite having lower preoperative expectations, neuroma patients were 5 times more likely (95% CI 1.5-14.6, p=.008) and midfoot/hindfoot arthritis patients were 3 times more likely (95% CI 1.3-8.5, p= .013) to have unfulfilled expectations. Conclusion: In orthopaedic foot and ankle surgery, the fulfillment of expectations varies with preoperative diagnosis. Patients with diagnoses of midfoot/hindfoot arthritis and neuroma were significantly more likely to have lower proportions of expectations fulfilled. Although the exact causes are unknown, possible explanations include the need for subsequent procedures, continued need for orthotics, progression of arthritis to adjacent joints in midfoot/hindfoot arthritis patients, and recurrent or residual symptoms in neuroma patients. Preoperatively, surgeons should emphasize the risks of surgery as well as the importance of realistic expectations in these patients in order to optimize their outcomes postoperatively. [Table: see text]

Background: Active participation in patients’ own care is essential for success after Lapidus procedure. Poor health literacy, comprehension, and retention of patient instructions may be correlated with patient participation. Currently, there is no objective measure of how well patients internalize and retain instructions before and after a Lapidus procedure. We performed this study to assess how much of the information given to patients preoperatively was able to be recalled at the first postoperative visit. Methods: All patients between ages 18 and 88 years undergoing a Lapidus procedure for hallux valgus by the senior author between June 2016 and July 2018 were considered eligible for inclusion. Patients were excluded if they had a history of previous bunion surgery or if the procedure was part of a flatfoot reconstruction. Patients were given written and verbal instructions at the preoperative visit. Demographic and comprehension surveys were administered at their first visit approximately 2 weeks postoperatively. A total of 50 patients, of which 42 (84%) were female and 43 (86%) had a bachelor’s degree or higher, were enrolled. Results: Mean overall score on the comprehension survey was 6.2/8 (±1.2), mean procedure subscore was 1.8/3 (±0.64), and mean postoperative protocol subscore was 4.4/5 (±0.8). The most frequently missed question asked patients to identify the joint fused in the procedure. Conclusion: Although comprehension and retention of instructions given preoperatively was quite high in our well-educated cohort, our findings highlight the importance of delivering clear instructions preoperatively and reinforcing these instructions often. Level of Evidence: Level II, prospective cohort study.

Category: Ankle Arthritis Introduction/Purpose: Ankle arthritis is a debilitating problem, causing significant pain and functional limitations. Previous literature suggests patients treated with ankle arthroplasty (TAA) versus ankle arthrodesis (AA) may have better function and have lower risk for adjacent joint arthritis in the foot. However, there is little research on how these interventions impact proximal joints, such as the knee. The knee adduction moment (KAM) is a surrogate measure for the force experienced at the medial tibiofemoral compartment and is linked with the onset and progression of knee osteoarthritis. We hypothesized that patients with TAA and AA will exhibit altered frontal plane kinematics and kinetics in the affected limb compared to the contralateral unaffected side, and that the AA cohort will have a significantly greater KAM compared to TAA. Methods: Instrumented 3D walking gait was recorded in 10 TAA and 10 AA patients, minimum 2-year post-operatively. Subjects were demographically matched, had unilateral ankle arthritis and lacked complications such as adjacent joint arthritis, neuropathy or significant weight-bearing pain. The TAA patients had either a Salto-Talaris or INBONE prosthesis. Lower limb kinematic and kinetic data were measured with reflective skin surface markers and floor-embedded force plates at self-selected walking speeds. Average first and second peak KAMs [N-m/kg], KAM impulse [N-m-s/kg] and range-of-motion (ROM, [°]) were calculated on both the affected and unaffected limb for each patient. Group differences in KAM, impulse and ROM between TAA and AA interventions and the affected and unaffected limb were analyzed using a 2-sample unpaired t test. P-values less than 0.05 were considered significant. Results: See Table 1 for demographic and statistical analyses summary. Between the affected and unaffected limbs in each surgical cohort there were no significant differences in the KAM’s first and second peak or impulse (p>0.135) and no difference in the knee ROM in any plane (p>0.214). When comparing AA with TAA, the average first peak KAMs generated while walking were 0.07N-m/kg greater in the TAA treatment but that difference was not significant (p=0.429). The second peak KAM was, on average, 0.1N-m/kg greater within TAA patients but was also not statistically different from AA patients (p=0.594). The KAM impulse and ROM in all 3 planes were not different between intervention types (p>0.318). Conclusion: TAA and AA may not significantly affect ipsilateral knee kinetics and KAMs in short term follow-up. This study highlights the importance of continuing to study these parameters in larger cohorts of patients with longer follow-up to determine how our treatment of end-stage ankle arthritis may affect the incidence or progression of ipsilateral knee osteoarthritis.

Category: Hindfoot Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) is characterized by concurrent bony deformities, tendinous and ligamentous insufficiencies. Weightbearing CT (WBCT) is a new imaging technique that allows excellent evaluation of the relative three-dimensional positioning of the tarsal bones in dynamic deformities such as AAFD. MRI, on the other hand, provides an accurate evaluation of soft tissue integrity in the unloaded foot. The objective of this study was to evaluate the correlation between bone deformity and soft tissue insufficiency in patients with stage II AAFD, using WBCT and MR images. We hypothesized that a significant correlation would be found between WBCT measurements of increased longitudinal arch collapse, hindfoot valgus, peritalar subluxation and forefoot abduction, with MRI findings demonstrating degree of involvement of ligaments and posterior tibial tendon (PTT). Methods: This retrospective comparative study included 55 patients (56 feet) with stage II AAFD, 20 men and 35 women, mean age of 52.5 (range, 20 to 78) years. Multiple WBCT and MRI variables related to the severity of the deformity were evaluated by four blinded and independent readers (two radiologists and two foot and ankle surgeons), including: arch collapse (navicular-floor distance and forefoot arch angle), hindfoot alignment angle (HAA), forefoot abduction (talonavicular uncoverage angle), subtalar joint subluxation, sinus tarsi and subfibular impingement, and soft tissue insufficiency (posterior tibial tendon, spring and talocalcaneal ligaments). Tendinous and ligamentous involvement on MRI were graded from zero (normal) to four (complete tear). Intra- and interobserver reliabilities were assessed by Pearson/Spearman’s and intraclass correlation coefficient, respectively. A multiple regression analysis was used to evaluate the relationship between bone alignment (WBCT variables) and soft tissue injury (MRI variables). P-values of less than 0.05 were considered significant. Results: We found overall good to excellent intra (range, 0.83-0.99) and interobserver reliability (range, 0.71-0.97) for WBCT measurements and MRI readings. Spring ligament superomedial component involvement was the only finding to correlate with medial column collapse and decreased navicular-floor distance (p=0.03). Superomedial spring ligament and PTT degeneration were also significantly correlated with increased HAA (p

Category: Bunion Introduction/Purpose: Longitudinal arch collapse and first ray instability represent landmarks for adult acquired flatfoot deformity (AAFD), and have been linked to the development and progression of hallux valgus (HV). Radiographic evaluation of first ray instability is usually marked by increased angulation between the first and second metatarsals. The 1-2 intermetatarsal angle (IMA) is also an important aspect in the staging of HV deformity. Weightbearing CT imaging (WBCT) provides three-dimensional evaluation of dynamic deformities such as AAFD and HV. The purpose of this study was to assess the correlation between hallux valgus severity and foot collapse indicators using WBCT measurements, in patients with AAFD. We hypothesized that a flattening of the longitudinal arch, increased hindfoot valgus and forefoot abduction would correlate with greater IMA and HV angles. Methods: In this retrospective comparative study, 108 patients with stage II AAFD, 36 men and 72 women, with a mean age of 54.4 (range, 20-78) years, had their WBCTs evaluated by 2 blinded and independent board-certified foot and ankle orthopedic surgeons. The readers assessed multiple variables related to the severity of the hallux valgus and flatfoot deformities including: 1-2 intermetarsal angle, hallux valgus angle, talocalcaneal angle in the axial plane, talus-first metatarsal angle in the axial and sagittal planes, hindfoot alignment angle, hindfoot moment arm, navicular- and medial cuneiform-floor distance and the talonavicular uncoverage angle. Intra- and interobserver reliability were calculated by Pearson or Spearman’s correlation and intraclass correlation coefficient, respectively. A multiple regression analysis was used to evaluate the correlation between the variables indicative of AAFD and the severity of HV. P-values less than 0.05 were considered significant. Results: The intra- and interobserver reliability ranged from (0.65-0.99). Means and standard deviations for IM and HV angles were 11.3°±3.7° and 17.6°±13.4°, respectively. These angles significantly correlated with each other (p

Category: Other Introduction/Purpose: Neuraxial anesthesia is often viewed as superior to general anesthesia (GA), but there are concerns that it may prolong length of stay (LOS). Most studies comparing the two anesthesias were performed in the absence of peripheral nerve blocks (PNBs), which when used as an analgesic adjunct may overcome the associated negative side effects of GA and allow decreased LOS. We hypothesized that patients given PNBs and GA would be discharged sooner than patients given PNBs and spinal anesthesia plus sedation, without increased incidence of adverse side effects such as pain, opioid administration and nausea. Methods: A single-center triple-blinded randomized controlled trial of 36 consecutive patients receiving elective F&A surgery predicted to take 1-3 hours under planned PNB with either spinal or GA was performed (see table 1. for demographics).The primary outcome was time to meet criteria for home discharge. The a priori clinically relevant difference with 80% power was determined to be 45 minutes. Patients were assessed after admission to the PACU and at 15-minute intervals thereafter. Once an Aldrete score=9 (scale signifying patient no longer needs intensive monitoring) was obtained, patients were transferred to Phase II and assessed until the post anesthesia discharge scoring system, a home readiness scale, was =9. Actual time to discharge was also recorded.Additional outcomes included a series of baseline characterizations which were assessed pre-and post-operatively, and again during Phase II.The primary outcome was compared using multivariable unconditional quantile regression. Various regressions were performed on secondary outcomes. Results: After adjustment for age and surgical duration, patients given GA plus PNB were ready for discharge from PACU 39 minutes prior to patients given neuraxial anesthesia plus PNB, but this difference did not reach the clinically relevant a priori selected difference of 45 minutes (Table 1). However, the adjusted median time to meet ambulation discharge criteria was 52 minutes fewer (p = 0.003) (Table 1). Patients met discharge criteria substantially sooner than their time until actual discharge which was not different between groups (Table 1). Pain scores at rest were higher among GA patients at 1 hour in the PACU (adjusted difference in means [95% CI]: 2.1 [1.0, 3.2], p < 0.001). Subsequent pain scores and all other secondary outcomes were not different. Conclusion: GA with PNB patients were ready for discharge 39 minutes earlier, but that difference may not be clinically significant. Although patients met criteria for discharge sooner due to a significantly more rapid ability to ambulate, they were not discharged sooner because PACU staff was not acclimated to the earlier readiness and so did not push for earlier discharge. These findings suggest that GA plus PNB leads to earlier discharge with similar side effects as spinal plus PNB. Therefore, the use of GA with PNB for foot and ankle surgeries could save the hospital and the patient time and resources.