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Surgical residents cite a number of reasons to pursue a fellowship training program including improving surgical skills, furthering medical research, pursuing an academic practice, or to generally become an overall better trained surgeon and clinician. The interest in foot and ankle surgery fellowships has increased among graduating residents as have the number of fellowship programs. Since the introduction of these programs, there has been no formal investigation of the scholarly activity among foot and ankle surgery fellows. Using PubMed, a systematic review was conducted from papers published by fellows participating in American College of Foot and Ankle Surgeons or American Podiatric Medical Association approved fellowships during 2013 to 2019. A total of 76 of the 128 identified fellows published research during or within one year of completing their fellowship. Fellows that published at least once prior to fellowship were more likely to publish during fellowship compared to those who had no publication history. Over this 6-year period, fellows contributed to 279 manuscripts where they maintained primary authorship of 34.41% of the publications, across 35 journals, with the most common being the Journal of Foot and Ankle Surgery. Results of this study provide a survey of the scholastic activity among foot and ankle surgery fellows and could be used by applicants and evaluators to stratify applicant aptitude. These results could also serve as a scholarly activity benchmark for current fellows and a method of gauging scholarly involvement for new and current fellowships.

For prospective applicants many variables can factor into the decision to pursue fellowship level training. The purpose of the present study was to give prospective applicants an idea of the financial implications of podiatric foot and ankle fellowship. To calculate the net present value (NPV), weighted mean income data (clinical, general, research, associated research) from podiatric foot and ankle surgeon's (FAS's) with and without fellowship training was obtained. Income from general payments, research, and associated research was collected from manual searches of Open Source Payments. Demographic and clinical income data (based on 2080 hours) for graduate fellows from 4 programs was collected using an anonymous online survey. Socioeconomic data from the 2018 American College of Foot and Ankle Surgeons (ACFAS) compensation survey was used for comparison. The NPV of podiatric FAS's with/without fellowship training was $4.2 million and $3.03 million, respectively. The comparative NPV and cumulative net income difference over 30 years was $1.2 million and $2.5 million, respectively. The mean comparative income difference for fellowship trained podiatric FAS's annually was as follows: clinical (+$69,145.00), general (+$21,797.00), research (+$1,833.00), and associated research (+$414.00). The present study is the first attempt to provide prospective applicants with an idea of the financial implications of podiatric foot and ankle fellowship. Based on the positive NPV, pursuing an ACFAS recognized podiatric foot and ankle fellowship in advanced reconstruction could be considered an "acceptable financial investment", which may positively affect career earnings. Prospective applicants should be cognizant that the NPV varies between fellowship programs. Therefore, the data presented from graduate fellows of the programs included may not be generalizable to graduate fellows from other programs.

Surgical repair of the Achilles tendon can lead to prolonged calf atrophy and functional limitations, even with early weightbearing. The use of neuromuscular electrical stimulation (NMES) has been studied in muscle rehabilitation programs following anterior cruciate ligament repair. Accelerated recovery and pain reduction were noted. The aim of the present study was to evaluate the use of electrical stimulation on maintaining calf muscle cross-sectional area volume and improving patient reported outcome measures following Achilles tendon surgery. Randomized controlled clinical trial. Forty patients were enrolled. All patients had undergone repair of the Achilles tendon. A 4 lead NMES device was applied at time of surgery with both patient and surgeon blinded to activity of the device. All patients followed a standardized postoperative protocol. Group 1 consisted of 20 patients who received protocol specific NMES. Group 2 was the "sham device" control group, receiving subtherapeutic electrical stimulation. Preoperative and postoperative calf circumference (2, 6, 12 weeks) and magnetic resonance imaging (MRI) scans (2, 6 weeks) were conducted. Patient-reported functional outcome scores were measured. Of the 40 patients, 23 (57.5%) were male and 17 (42.5%) were female. The mean age was 48.9 years (11.1 standard deviation [SD]) with a mean body mass index of 32.2 kg/m2 (5.7 SD). Calf measurements for Group 1 (39.3 cm and 39.7 cm) were slightly higher compared Group 2 (38.4 cm and 39.2 cm) at 6 and 12 weeks postoperative. Functional scores were similar between Groups 1 and 2 at final follow-up. Foot/Ankle Computer Adaptive Test scores were 55.1 (6.9 SD) versus 58.4(8.6 SD), and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scores were 82.3 (8.2 SD) and 83.9 (9.3 SD), respectively. The visual analog scale at 12-week visit for Groups 1 and 2 was 8.4 (9.3 SD) and 8.4 (9.1 SD), respectively. This prospective randomized controlled trial was undertaken to quantify and validate the effect and ability of NMES to minimize calf atrophy after acute or chronic repair. No statistically significant difference was found between active NMES and sham control group. There was a trend showing some maintenance of calf volume per MRI study.

Total ankle replacement has become a viable alternative to ankle arthrodesis in the surgical management of advanced ankle arthritis. Total ankle replacement has generally been reserved for patients who are older and for those who will have a lower demand on the replacement. The purpose of the current study is to review patient outcomes, complications, and implant survival in patients younger than 55 years who underwent total ankle replacement at a single institution. A single-center chart and radiographic review was performed of consecutive patients who underwent total ankle replacement for treatment of end-stage ankle arthritis. All surgeries were performed by 1 of 5 fellowship-trained foot and ankle surgeons at a single institution. A total of 51 patients met inclusion criteria with a mean follow-up of 31.2 months (SD = 16.2). Implant survival was 94%, There were 7 major complications (13%) requiring an unplanned return to the operating room and 8 minor complications (15%) that resolved with conservative care. The results of this study show that total ankle replacement is a viable treatment option for patients younger than 55 years. Levels of Evidence: A retrospective case series

A number of 2-component, fourth-generation total ankle arthroplasty prostheses have been introduced to the market. The purpose of the present study was to present early experience with the CADENCE total ankle prosthesis. All patients who underwent primary total ankle arthroplasty using the prosthesis between August 2016 and June 2018 at a single institution and who were at least 1 year postoperative were included. A total of 32 ankles with a mean follow-up of 24 (range, 12-33) months met the criteria. Weightbearing radiographs were assessed using coronal and sagittal alignment parameters preoperatively, at 6 weeks postoperative, and at the most recent follow-up. Medical records and charts were reviewed and revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al and Glazebrook et el, respectively. Coronal and sagittal tibiotalar alignment significantly improved after surgery (p.001, p.005), and was maintained during the latest follow-up (p = .44, p = .30). Two (6.3%) ankles underwent early revision for aseptic loosening; while 6 (18.8%) underwent a nonrevisional reoperation. Nine (28.1%) ankles presented a total of 13 (4 high grade, 2 intermediate, and 7 low) complications according to the Glazebrook classification. The most common was intraoperative periprosthetic medial malleolar fracture (5 ankles, 15.6%), a low-grade complication. The present study is the first to report early outcomes and experience with the CADENCE total ankle. Overall, survivorship was 94% at short-term follow-up of 2 years. As with all arthroplasty devices, surgeons new to the prosthesis should be cognizant of the potential learning curve. Intraoperative medial malleolar fracture was found to be the most common complication.

Background: Lesser toe metatarsophalangeal joint (MTPJ) instability, secondary to plantar plate tear, has been the focus of numerous recent publications, the majority reporting on repair through a dorsal approach. A plantar approach has been described with the advantage of direct ligamentous repair or repair to bone, which follows conventional techniques employed throughout the body. Previous clinical studies have shown success in deformity correction and the longevity of both approaches. The proponents of the dorsal approach advocate that indirect repair of the plantar plate avoids perceived risks of complications with a plantar incision without evidence of superior outcomes. The purpose of this study was to investigate the safety and efficacy of the direct plantar approach to plantar plate repairs (PPRs) by reporting the rate of specific complications in a large clinical series. Methods: This was the institutional review board (IRB) approved retrospective study of 204 PPRs in 185 patients (194 lesser MTP, 10 hallux MTP) with an average age of 56 and a mean body mass index (BMI) of 28. Surgical technique involved repair with absorbable braided suture (88%) versus suture anchor (12%) with or without MTPJ pinning (80%). Mean follow up was 53 weeks (range 5–170). Patients were screened for associated risk factors, including diabetes mellitus (8%), tobacco use (5%), neuropathy (1%), and additional concurrent procedures (96%). Complications were defined as superficial or deep infection, painful scars, and reoperation. Analysis was conducted using the Wilcoxon-Mann-Whitney test or Fisher’s exact tests for continuous and categorical variables, respectively. Risk factors were analyzed using univariate logistic analysis to produce odds ratios (OR) with a 95% confidence interval (CI) and an inclusion criterion of a P-value, P > .2 for multivariate analysis as determined by Wald tests (significance at P < .05 for final modeling). Results: Overall, there were 31 total complications (15%) demonstrated by 14 superficial infections (6.8%) and 17 painful scars (8.3%) along with three reoperations (1.4%). All reoperations were performed for deformity or instability, not scar revision. There were no deep infections. No increased odds of complications were found with suture anchor repair, MTPJ pinning, neuropathy, or diabetes. Patients that used tobacco had 7.5 (CI 1.66, 34.06) the odds of developing any wound complication compared with nonsmokers. Tobacco use was also found to significantly increase the odds of superficial infection by 9.8 (CI 2.08, 46.15). There was no increase in painful scars or reoperation in tobacco users. This study did not find an increased complication rate with additional ipsilateral procedures performed at the time of surgery. Conclusion: To our knowledge, this is the largest study evaluating the direct plantar approach to PPR as well as the evaluation of associated complications with the plantar incision. With low complication and minimal reoperation rates, the results of this study have demonstrated the clinical viability of plantar-based incisions. Previous studies have demonstrated the success of PPR and correction of deformity with a direct approach. This case series further demonstrates the safety and efficacy of plantar-based incisions, particularly for direct PPRs. Level of Evidence: IV Retrospective Case Series Category: Lesser Toes

Introduction Os trigonum can become symptomatic following acute or chronic repetitive compression of the posterior ankle. Following conservative treatment failure, removal is often warranted. Current surgical options include traditional open resection and endoscopic removal. The purpose of this article is to review a population of patients who underwent endoscopic excision of symptomatic accessory os trigonum through a posterior approach and evaluate the outcomes of the procedure. Methods From May 2009 to September 2018, all patients who underwent excision of a symptomatic os trigonum were reviewed. Outcomes of interest were major and minor complications and time to return to full weight-bearing activities. Postoperative protocol included 5 to 7 days non–weight-bearing and 1 to 2 weeks of protected weight-bearing followed by full release to weight-bearing activities. Results Twelve patients who met the inclusion criteria were studied. Mean follow-up was 10.2 (±7.4) months with no major complications and 1 minor wound complication. Average advancement to protected weight-bearing was 7.1 days. Average return to full weight-bearing activities without restriction was 24.4 days. Conclusion The current study describes the technique and results to minimally invasive os trigonum removal with favorable postoperative outcomes. Results demonstrated minimal complications and postoperative pain, also quick return to weight-bearing and full activity. Level of Evidence: Therapeutic, Level IV: Case series

Further development of total ankle replacements (TAR) has led to the latest 4th generation prostheses. The CADENCE ankle prosthesis is a primary replacement designed to match native anatomy and function as close as possible through several key design features: (1) anatomically shaped, side specific, tibial component with unique syndesmotic “cutout” to provide 3 cortices support and reduce fibular impingement, (2) anatomically shaped, side specific, bi-condylar talus with central trochlear groove for enhanced stability, (3) minimal bone resection talar component with specially targeted cut guides to avoid talar blood supply, (4) enhanced sagittal plane ankle stabilization with available anterior and posterior biased poly inserts, and (5) efficient, streamlined instrumentation designed for the ambulatory surgery environment.

End-stage ankle joint arthritis may be treated with either ankle arthrodesis or total ankle replacement. Though ankle arthrodesis offers predictable results, it also has substantial loss of motion that leads to gait changes and surrounding midfoot and hindfoot joint arthritis. In particular, a malunion or nonunion following attempted ankle arthrodesis is a serious complication with resultant pain and functional loss. In the case of a poorly functioning and painful ankle arthrodesis, takedown to total ankle replacement may be undertaken. While limited published data is available, this is a viable option in certain candidates. The authors present the available data regarding ankle arthrodesis taken down to total ankle replacement. Ankle arthrodesis takedown to total ankle replacement is a viable option for the painful ankle malunion or nonunion, although it is more demanding than primary total ankle replacement.

Treatment of degenerative joint disease of the ankle has experienced a renaissance in the past decade as total ankle replacement has become a predictable alternative to ankle fusion for end-stage disease. There are several total ankle replacement systems on the market including the INBONE Total Ankle System. The INBONE I system was US Food and Drug Administration 510-k cleared for use in 2005 and consists of a saddle-shaped, fixed-bearing, two-component design with the polyethylene-bearing surface locked into the tibial baseplate. The INBONE II Total Ankle System is an evolution of the original INBONE Total Ankle System design. The INBONE II system retained several important design characteristics of the original INBONE Total Ankle System design, including the modular tibial stems, thicker polyethylene bearings, and intramedullary guidance, while adopting a sulcus talus articular configuration, extended length tibial base components, and optimizing for use with PROPHECY patient-specific instrumentation. In conclusion, the INBONE I and INBONE II Total Ankle Systems offer the advantages of a robust technique with advanced instrumentation when managing the arthritic ankle.

The demand for total ankle replacement (TAR) has continued to increase among patients and surgeons alike, as studies have shown higher survivorship for newer prostheses, with better improvements in function, and higher patient-reported outcome measures (PROMS) compared to ankles treated with arthrodesis (Harston et al., Foot Ankle Int. 38:1295–1300, 2017; Lee et al., J Bone Joint Surg Am. 100:835–842, 2018; Pugely et al., Foot Ankle Int. 35:207–215, 2014; Valderrabano et al., Clin Orthop Relat Res. 47–56, 2004). However, more than 50% of patients undergoing TAR have coronal deformity, which is the most common reason for additional concomitant procedures (Schuberth et al., J Foot Ankle Surg. 56:618–627, 2017; Dodd and Daniels, Foot Ankle Clin. 22:277–300, 2017). In this chapter, stepwise algorithms for addressing severe incongruent coronal (varus/valgus) deformity during TAR are detailed.

Background The INFINITY total ankle prothesis remains the most widely used fourth-generation total ankle arthroplasty (TAA) system in the United States. The purpose of the present study was to assess radiographic outcomes for INFINITY at short-term follow-up. Methods All patients who underwent primary TAA with INFINITY between August 2015 and June 2018 at a single institution and who were at least 1 year postoperative were included. A total of 55 ankles with a mean follow up 22 months (range, 12-43 months) met the criteria. Weightbearing radiographs were assessed using coronal and sagittal alignment parameters preoperatively, at 6 to 8 weeks postoperatively, and at the most recent follow-up. Medical records and charts were reviewed and revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al and Glazebrook at el, respectively. Results Overall, INFINITY survivorship was 98.2%. Coronal and sagittal tibiotalar alignment improved after surgery ( P < .001, P = .09, respectively), and was maintained during the latest follow-up ( P = .62, P = .47, respectively). Only 1 ankle (1.8%) required early revision; while 5 (9.1%) indicated non-implant-related revision; 85.5% required no reoperation. In nineteen ankles (34.5%), postoperative periprosthetic lucency was observed; most were not progressive (17 ankles, 89.5%). Twelve complications (3 high grade, 3 intermediate, and 6 low grade) in 11 ankles (20%) were recorded according to the Glazebrook classification system. Conclusion INFINITY survivorship was 98.2% at a mean of 1.8 years of follow-up, and only 1 ankle required prosthetic revision. Additional studies with longer follow-up are warranted for fourth-generation TAA prostheses. Levels of Evidence: Level IV: Case series

Background: Total ankle arthroplasty is a viable option for the treatment of end stage ankle arthritis. The purpose of this study is to report on the mid-term results with a cemented total ankle prosthesis, the Inbone™ II implant over a 5 year period. Methods: A retrospective, single-center chart and radiographic review of all patients with end stage ankle arthritis treated with Inbone™ II TAR) as the primary index procedure from 12/1/2012 to 3/1/2017. Clinical data were evaluated at 3 month, 6 month, 1 year and subsequent intervals for the study period. Preoperative diagnosis, pertinent patient demographics adjunctive procedures, implant associated complications, subsequent surgeries, and revisions were recorded. Results: 121 total ankles met our inclusion criteria. Patients had an INBONE™ II TAR implant placed with bone cement with a minimum of a 12 months follow up. Average age was 62.88 (range, 32-87) years, average body mass index was 32.74 (range, 21.8-56.04) kg/m2 and average follow up was 28.51(range, 12-69) months. Using the COFAS complication classification there were 14 minor, 11 moderate, and 5 major complications. 6/121 (5.0%) revisions which included: polyethylene exchange, device explant/fusion, and antibiotic spacer in situ. No complications over the course of this study ended in amputation. Conclusion: Total Ankle Arthroplasty utilizing the cemented INBONE™ II yielded good midterm results with regards to minor, moderate, and major complications. Rate of revision 6/121 (5.0%) was within the reported range with only 5 patients converted to fusion during the study period resulting in a 95% survivability at mid-term follow up. Levels of Evidence: Level IV: Retrospective case series

Introduction: Equinus contracture of the ankle can lead to a multitude of foot and ankle pathologies. The gastrocnemius recession has been used to address equinus deformity via various methods, including either an open or an endoscopic approach. Open techniques require increased intraoperative time and complication risks of sural nerve injury, wound complications, and poor cosmesis. Resultantly, the aim of the current study is to review the complications and outcomes of the endoscopic gastrocnemius recession. Methods: A systematic review of electronic databases was performed. The authors compiled data from retrospective and prospective patient studies including general patient demographics, outcomes, qualitative scoring measures, complications, and surgical technique. Results: Eleven studies met our inclusion criteria. A total of 697 feet in 627 patients were included in the current systematic review. The weighted mean age was 45.3 years and weighted mean follow-up was 18.4 months. The most common indication for an endoscopic gastrocnemius recession was equinus contracture. The weighted mean preoperative ankle range of motion was −2.3° and the weighted postoperative ankle range of motion was 10.9°. The most common complications included plantarflexion weakness of the ankle at 3.5%, a sural nerve injury of 3.0% and wound complication rate was 1.0% with no deep infection. The overall complication rate was 7.5%. Conclusion: The endoscopic gastrocnemius recession is a valuable surgical tool in the treatment of ankle equinus. The endoscopic approach has satisfactory outcomes including low incidence of plantarflexion weakness and sural neuritis. Patients should be counseled on these risks preoperatively. Compared with previously reported systematic review of the open technique, the endoscopic approach has a lower overall incidence of complications. Prospective clinical trials comparing open and endoscopic techniques are warranted. Levels of Evidence: Level IV

Total ankle implants have evolved consistently over the past decade, and with improvement in design, the frequency of total ankle replacement (TAR) use has increased. Implant survival, ease, and accuracy of implantation have all been shown to improve with second and third generation TAR designs, but

Surgical correction of complex foot and ankle deformities secondary to Charcot neuroarthropathy remains a significant surgical challenge. New technological advancements in hardware have allowed for the use of augmented fixation techniques in midfoot deformity correction, including the use of indication-specific locking plates and beaming techniques that offer enhanced stability. Severe hindfoot deformity management can employ the use of internal fixation, including intramedullary hindfoot nails and circular external fixation frames for limb salvage.

There is a lack of consensus in the literature regarding optimal treatment methods for Lisfranc injuries, and recent literature has emphasized the need to compare open reduction and internal fixation (ORIF) with primary arthrodesis (PA). The purpose of the current study is to compare reoperation and complication rates between ORIF and PA following Lisfranc injury in a private, outpatient, orthopaedic practice. A retrospective chart review was performed on patients undergoing operative intervention for Lisfranc injury between January 2009 and September 2015. A total of 196 patients met the inclusion criteria (130 ORIF, 66 PA), with a mean follow-up of 61.3 and 81.7 weeks, respectively. The ORIF group had a higher reoperation rate than the PA group, due to hardware removal. When hardware removals were excluded, the reoperation rate was similar. Postsurgical complications were compared between the 2 groups with no significant difference. In conclusion, ORIF and PA had similar complication rates. When hardware removals were excluded, the reoperation rates were similar, although hardware removals were more common in the ORIF group compared with the PA group. Levels of Evidence: Level III

Background. Hindfoot arthritis or significant deformity involving the ankle and subtalar joint (STJ) is a disabling condition with few salvage options. Many surgeons note a decreased STJ fusion rate compared with ankle union when a retrograde nail construct is used. The purpose of this study was to report the STJ fusion rate of tibiotalocalcaneal (TTC) arthrodesis with retrograde nail. Methods. A chart and radiographic review was performed. TTC fusions performed in patients with osteoarthritis, posttraumatic arthritis, or deformity correction with retrograde nail fixation were included. Exclusion criteria included neuropathy, Charcot arthropathy, and failed total ankle replacement. Results. Ultimately, 66 retrograde TTC fusions (in 63 patients) met inclusion criteria. The average age was 57.0 years. There were 29 female and 34 male patients. Radiographic fusion of the ankle and STJ was demonstrated in 68.2% of the patients. There were 11 cases (16.7%) of ankle arthrodesis with STJ nonunion, 6 cases (9.1%) of STJ fusion but ankle nonunion, and 4 cases (6.1%) of stable radiographic nonunion of both joints. The mean time to subtalar fusion was 112.1 days. One patient required revision surgery and conversion to below-knee amputation. One patient required a CROW walker for assistance with gait. Conclusion. A 22.8% radiographic nonunion rate of the STJ was noted in retrograde TTC fusion. Despite this, patients were stable and pain free. Levels of Evidence: Level IV: Retrospective Case series

Hindfoot and ankle Charcot neuroarthropathy (CN) deformities can be devastating, limb-threatening illnesses with high rates of complications. The fragmentation and collapse of the transverse tarsal, subtalar, and ankle joints can lead to significant deformity resulting in ulceration, osteomyelitis, and angular deformities. These issues preclude the use of normal gear and cause difficulty with ambulation. Charcot of the hindfoot and particularly of the ankle often has profound instability making bracing difficult or impossible. This can lead to a below-knee amputation in 30–50% of Charcot ankle cases, which, in many cases, can be a more stable outcome rather than limb salvage.

Peroneal tendon disorders are a common cause of persistent posterolateral ankle pain. The diagnosis of peroneal tendon pathology is frequently overlooked by the referring clinician, who is often unfamiliar with this pathology. In this chapter, we discuss our nonoperative protocol as well as our surgical management of peroneal tendon repair, tenolysis, tenodesis, SPR repair/fibular groove deepening for tendon instability, excision of an os peroneum, and tendon reconstruction with autograft/allograft transfers. Also discussed is our postoperative protocol as well as pearls/pitfalls during surgery

Surgery on the foot and ankle has tremendous potential benefits. However, there are great risks as well. As with any risk-benefit situation, the risks should be minimized where possible. In the elective foot and ankle practice, there are a few risks that need a little more attention because of the uniqueness of surgery on the most distal and the most gravity-dependent portion of the body. This chapter will begin with a highlight of several optimization factors to consider in minimizing the complications of foot and ankle surgery.

Lesser toe deformities are a common pathology seen by foot and ankle surgeons. There are numerous fixation choices for these difficult deformities. Historically, Kirschner wires have been utilized in maintaining the corrected toe as it goes onto fusion or stable resection arthroplasty. K-wires have several inherent risks, documented well in the literature, which has led to the development of the intramedullary implant. The one-component metallic implant has become the mainstay treatment for complex hammertoe deformity. The purpose of this chapter is to highlight the development of the one-component metallic hammertoe fixation prosthesis and explore the advantages and disadvantages of the individual systems.

The treatment of hallux abductovalgus continues to evolve as surgeons better understand first ray biomechanical pathology. Many authors have advocated the use of the 1st tarsometatarsal joint arthrodesis for correction of moderate to severe hallux abductovalgus deformities and those with hypermobility of the 1st ray. There continues to be debate over the best surgical technique, fixation construct, and post operative protocol for the 1st tarsometatarsal joint fusion. We describe a technique with a unique hardware construct that is reproducible and allows for excellent deformity correction and pain relief while minimizing associated complications with this procedure.

Hemophilia is a congenital bleeding disorder caused by the absence or decrease of clotting factor VIII (Hemophilia A) or XI (Hemophilia B). When severe, this X-linked disease results in intra-articular bleeding which can progress to joint destruction. This is known to be the most common complication of severe uncontrolled hemophilia. We present a case of arthroscopic assisted ankle arthrodesis in a young male presenting with advanced ankle hemophilic arthritis. Our case report presents a unique pathology and the successful 1-year post-operative outcome that can be accomplished through surgical intervention and a multidisciplinary treatment approach.

Heterotopic ossification describes the aberrant formation of ectopic bone in soft tissue. Posttraumatic or acquired heterotopic ossification is a recognized complication of orthopedic trauma, surgery and burns. Heterotopic ossification can be a source of restricted range of motion when located around joints and can also cause pain. In this rare case, a massive intra-articular island of heterotopic ossification developed in the anterior ankle recess subsequent to talar neck fracture two years previously. The patient presented to clinic with a large mass protruding at the anterior ankle and dorsal talar neck, complaining of persistent pain and very limited dorsiflexion at the ankle. Advanced imaging confirmed a large floating mass of heterotopic bone superior to the prior talar neck fracture, within the ankle joint capsule. The patient underwent surgical management with complete excision of the mass which immediately relieved pain and restored motion of the ankle joint. More research is needed to increase our understanding of the pathogenesis, pathology, prevention, treatment and classification of heterotopic ossification in the foot and ankle. Heterotopic ossification should be included in the differential diagnoses for patients with progressing lesions following traumatic incidence, even within intracapsular tissue.

Total ankle replacement studies have focused on reporting complications that are directly observed clinically or radiographically, including wound problems, technical errors, implant loosening, subsidence, infection, bone fractures, and heterotopic ossification. However, patients can still experience unresolved pain even when these problems have been ruled out. We initiated a study to more clearly define the relative risk of injury to the anatomic structures in the posterior ankle during total ankle replacement using a third-generation implant system. Ten fresh-frozen adult cadaveric below-the-knee specimens were positioned in the intraoperative positioning frame of an approved total ankle replacement system and adjusted to achieve proper foot alignment using fluoroscopic imaging. The relationship between the tibial cutting guide pins and the posterior neurovascular and tendon structures was measured using digital calipers. High rates of posterior structural injury were found. Nearly all proximal-medial pins encountered a posteromedial neurovascular structure, most commonly the tibial nerve. The distal-medial pins mainly encountered posteromedial tendinous structures, in particular, the flexor digitorum longus tendon. The proximal lateral pins were highly likely to encounter the Achilles tendon and the sural nerve. Our results support our hypothesis that the tibial neurovascular structures are at the greatest risk when preparing for and completing the bony resection, particularly with the medial and proximal cuts. Posterior ankle soft tissue structure injuries can occur during implantation but currently with unknown frequency and undetermined significance. Further study of posterior structural injuries could result in a more informed approach to post-total ankle replacement complications and management.

Tibiotalocalcaneal arthrodesis is a salvage procedure for severe hindfoot/ankle deformities, arthritis, avascular necrosis of the talus, failed total ankle replacement, and Charcot neuroarthropathy. The methods for fixation include anterior and lateral plates, screws, retrograde intramedullary nails, and external fixation. The purpose of the present report was to describe the short-term radiographic outcomes and technique using a posterior approach with an anatomic-specific locking plate for tibiotalocalcaneal arthrodesis. Nine patients underwent tibiotalocalcaneal arthrodesis using a posterior locking plate. The medical records and radiographs were retrospectively reviewed for patient demographics, fusion rate, complications, and patient satisfaction. The mean patient age was 57.89 ± 10.8 years, and the follow-up period was 11.11 ± 4.74 months for the patients undergoing posterior tibiotalocalcaneal arthrodesis. The mean time to weightbearing in a shoe with a brace was 16.68 weeks. The ankle and subtalar joints had healed within a mean duration of 13.61 ± 2.96 weeks. Two patients (22%) developed nonunion, 1 at both the ankle and subtalar joint and 1 at the ankle only. The present report demonstrates an alternative posterior approach to joint preparation and fixation. Direct visualization of both joints and soft tissue coverage provide a viable option for posterior fusion in patients with compromised anterior and/or lateral skin envelopes.

In ankle arthroplasty, little attention has been given to intraoperative nerve injury and its postoperative sequelae. The aim of the present anatomic study was to determine the relationship of the superficial peroneal nerve to the standard anterior approach for total ankle arthroplasty. The superficial peroneal nerve was dissected in 10 below-the-knee cadaver specimens. The medial and intermediate dorsal cutaneous branches were identified. A needle was placed at the ankle joint. The following measurements were recorded: bifurcation into the medial and intermediate dorsal cutaneous branches, reference needle to the branches of the medial and intermediate superficial peroneal nerve, and the crossing branches of the medial dorsal cutaneous nerve. Two specimens (20%) had a medial dorsal cutaneous branch cross from medially to laterally. Eight specimens (80%) had a crossing branch of the medial dorsal cutaneous branch within 5 cm of the incision. No intermediate dorsal cutaneous branches were within the incision. The results from the present cadaver study suggest that during an anterior ankle approach, aberrant branches of the superficial peroneal nerve could require transection in 20% of patients at the joint level and ≤80% of patients with distal extension >35 mm from the ankle joint. The risk of injury to branches of the superficial peroneal nerve is substantial. The risk of nerve injury can be decreased with meticulous operative technique, smaller incisions, and the avoidance of aggressive retraction.

Summary The Cotton osteotomy is a plantarflexion osteotomy of the medial cuneiform, which is typically utilized in the reconstruction of adult acquired pes planus, posterior tibialis tendon dysfunction stage II (Johnson and Strom), and forefoot varus. The purpose of this paper is to give an estimate of the angular correction in the sagittal plane for each millimeter of bone graft used in the Cotton osteotomy using 20 cadaveric specimens. We have demonstrated that a surgeon will gain roughly 1.9 degrees of plantar flexion of the medial column for every one millimeter graft inserted into the medial cuneiform. While we have not established the amount of correction that should be done, the effect of increasing the wedge size has been demonstrated and may be helpful to surgeons when performing the Cotton osteotomy.

In the modern treatment of Charcot neuroarthropathy, beam screw fixation is an alternative to plate and screw fixation. Exposure is minimized for implantation, and this technique supports the longitudinal columns of the foot as a rigid load-sharing construct. A published data review identified a paucity of data regarding metatarsal intramedullary canal morphology relevant to beam screw fixation. The purpose of the present study was to describe metatarsal diaphyseal morphology qualitatively and quantitatively in an effort to provide data that can be used by surgeons when selecting axially based intramedullary fixation. Twenty fresh-frozen cadaveric below-the-knee specimens were obtained. The metatarsals were exposed, cleaned of soft tissue, and axially transected at the point of the narrowest external diameter. Next, a digital caliper was used to measure the size and shape of the diaphysis of the first through fourth metatarsals. The diaphyseal canal shape was categorized as round, oval, triangular, or pear. The widest distance between the endosteal cortical surfaces was measured. Triangular endosteal canals were only found in the first metatarsal, and the remainder of the metatarsal canals were largely round or oval. These data help to approximate the size of fixation needed to achieve maximal screw-endosteal purchase.

The naviculocuneiform articulation is composed of the navicular proximally and the 3 cuneiforms distally. It is not uncommon to perform surgical interventions at this joint for multiple pathologic foot etiologies. To date, no detailed anatomic measurement is available for each cuneiform articulation on the navicular. The purpose of the present study was to present an anatomic description of this complex joint to aid in better surgical understanding and improve surgical outcomes. Ten fresh, frozen, and thawed below-the-knee cadaveric specimens were used for anatomic dissection of the navicular and associated cuneiforms. The height and width were recorded across the largest span of the entire navicular–cuneiform joint complex and each facet. The mean navicular height and width was 19.9 mm and 34.7 mm, respectively. The medial cuneiform facet mean height and width was 19.9 mm and 15.8 mm, respectively. The intermediate cuneiform facet mean height and width was 20.4 mm and 16.9 mm, respectively. The lateral cuneiform facet mean height and width was 17.5 mm and 14.7 mm, respectively. A detailed description of this joint complex will aid foot and ankle surgeons in screw placement and surgical decision-making when performing complex medial column fusions. Advanced 3-dimensional weightbearing computed tomography would give us a better idea of the motion that occurs within this complex joint.

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: A number of two-component, 4th generation total ankle arthroplasty (TAA) prostheses have been introduced to the market within the past few years. The purpose of the present study was to assess early outcomes for the CADENCE total ankle prosthesis. Methods: All patients who underwent primary TAA with CADENCE between August 2016 and June 2018 at a single institution and who were at least 1 year postoperative were included. A total of 32 ankles with a mean follow up of 19 (range, 12-33) months met the criteria. Weightbearing radiographs were assessed using coronal and sagittal alignment parameters preoperatively, at 6 weeks postoperative, and at the most recent follow-up. Medical records and charts were reviewed and revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al. and Glazebrook at el., respectively. Results: Survivorship for the CADENCE prosthesis was 93.7%. Coronal and sagittal tibiotalar alignment significantly improved after surgery (p< 0.001, p< 0.005), and was maintained at the latest follow-up (p=0.44, p=0.30). Overall, two ankles (6.3%) underwent early revision for aseptic loosening; while 6 (18.8%) underwent a non-revisional reoperation. Nine ankles (28.1%) presented a total of 13 complications (4 high grade, 2 intermediate, and 7 low) according to the Glazebrook classification system. The most common was intraoperative periprosthetic medial malleolar fracture (5 ankles, 15.6%), a low-grade complication. Conclusion: Satisfactory outcomes were observed at short-term follow-up for the CADENCE prosthesis. Additional studies with longer follow-up are warranted.

Category: Other Introduction/Purpose: The most common complications in orthopaedic surgery of the foot and ankle documented in the literature are postoperative infections with a frequency between 1 and 8%. The development of an implant-associated infection can be a potentially devastating complication following foot and ankle surgery. This leads to a high number of revision surgeries after initial fracture stabilization and potential loss of function of the joint and quality of life in the long-term follow-up. Titanium, the most commonly used alloy for foot and ankle implants, has limited strength and is notch-sensitive so repetitive stress leads to fatigue failure of implants and limits design options. Better materials with both optimized mechanical and biological properties could result in the development of superior foot and ankle implants. Methods: Several studies were performed to evaluate the biological properties of MoRe®: A study was conducted to characterize the hydrophilic properties by contact angle comparisons of the MoRe alloy compared to Titanium. A cell growth study was conducted to look at the influence of MoRe alloy on osteoblast growth and differentiation as compared to Titanium. A bone implantation study was conducted based on ISO 10993: Biological Evaluation of Medical Devices, Part 6: Tests for Local Effects after Implantation to evaluate the local tissue and bone response of MoRe® alloy test coupon compared to Titanium controls, when implanted in the mid-shaft femoral bone of rabbits for 4, 13 and 26 weeks. Biofilm formation study was conducted to quantify attachment and biofilm development of S. aureus bacteria upon MoRe® alloy in comparison to CoCr alloy in a well-controlled, reproducible, ex vivo laboratory experiment. Results: MoRe®, composed purely (99.99%) of molybdenum and rhenium, is a cofactor to the enzymes xanthine and sulfite oxidase, which are essential to bone metabolism. Rhenium is an inert metal with no biological affect. MoRe® has superior hydrophilicity (CA 37°±3°) compared to Titanium (CA 58°±3°), a key factor in cell adhesion, migration and replication. Pre-osteoblast cell seeding was found to be equivalent between MoRe° and Titanium alloy (10,000 cells/cm2). The bone implantation study demonstrated continued bone maturation over time for both MoRe® and Titanium implant sites with similar osteoconduction and bone remodeling histology of the cortical and medullary bone at 4, 13 and 26 weeks. The biofilm study found that S. aureus better colonized cobalt chrome alloy in comparison to MoRe® (p = 0.009). Conclusion: The MoRe® alloy, with its advantageous biological properties and hydrophilicity, offers great promise for the design of a new generation of bio-friendly foot and ankle implants with superior cell growth, osseointegration and biofilm resistance resulting in better outcomes for patients.

Osteochondral lesions (OCLs) are injuries affecting the articular cartilage surface of a joint. OCLs are well reported in the literature to affect the knee, talus, tibia, navicular, and first metatarsal. This rare case of a bipolar osteochondral lesion of the cuboid and calcaneus presented as lateral heel pain after a traumatic injury. After an unsuccessful course of conservative therapy, the lesion was treated with curettage and application juvenile particulate cartilage allograft. Eight months postoperatively, the patient was ambulating in supportive shoe gear without pain. The mechanism of injury leading to calcaneocuboid joint osteochondral lesions is not clearly understood. It is also questionable whether anatomic variances are contributory. Regardless of causality, OCLs should be included in the differential diagnoses for patients presenting with calcaneocuboid joint or lateral hindfoot pain.

Fractures of the distal fibula secondary to rotational ankle injuries are one of the most common injuries requiring surgical intervention. The aim of this study was to describe the anatomy of the distal fibular medullary canal as a means of aiding in surgical management with an intramedullary device. Twenty fresh cadaveric below-knee specimens (group 1, 10 in 2015, group 2, 10 in 2016) were dissected to expose the distal fibular. Fifteen (10 mm each) segments were sectioned with a sagittal saw from the distal tip proximally and measured with a digital caliper. In group I, the widest and narrowest fibular diameter was at the 20-mm interval (mean 15.02 mm) and 90-mm interval (mean 3.51 mm), respectively. From 70 to 120 mm, the mean diameter was less than 4.0 mm. In group 2, the widest and narrowest diameter was at the 20-mm interval (mean 15.05 mm) and 100-mm interval (mean 4.33 mm), respectively. From 70 to 140 mm, the mean diameter was less than 5.0 mm. The combined mean diameter at the 60- to 80-mm intervals were 4.99 ± 1.70, 4.35 ± 1.63, and 4.02 ± 1.35 mm, respectively. Based on our investigation, we propose an intramedullary device diameter of 4.5 to 5.0 mm in diameter with a length of 60 to 80 mm may provide most appropriate bony purchase to achieve acceptable cortical contact for expected osseous compression. Levels of Evidence: Level IV: Cadaveric case series

Total ankle arthroplasty is an evolving treatment of ankle arthritis. One implant uses intramedullary guidance to enhance accuracy by accessing the tibial canal through the inferior aspect of the foot, potentially placing the subtalar joint articulation at risk. The purpose of the present cadaveric anatomic evaluation was to identify posterior subtalar articular facet joint involvement during intramedullary guidance to the tibial canal. Ten below-the-knee cadaveric specimens were used. After drilling into the tibial medullary canal with a 6-mm drill bit and using the standard targeting jig, the specimens were dissected, and the posterior facet was evaluated. We graded posterior facet involvement according to the location of the drill hole and, if within the facet, the percentage of the facet violated by the drill bit, with 100% representing the full circumference of the 6-mm drill bit. Of the 8 specimens in which the drill bit passed through the subtalar posterior articular facet, the encroachment was peripheral in all cases, with no specimen showing circumferential 6-mm drill bit articular penetration (no cases with 100%). Sinus tarsi penetration occurred in 20% of the cases. The dissections with articular involvement included 3 specimens with >50% of the drill bit penetrating and 5 with

The use of biologics, namely demineralized bone matrix, bone marrow aspirate (BMA), and other growth factors, has gained popularity in foot and ankle surgery for use in compromised hosts or high-risk situations. Our research has shown the concentration of these pluripotent cells was greatest in the iliac crest. A medical record and radiographic review was performed to compare the effect of BMA harvest site osteogenic progenitor cells on the incidence of fusion. Radiographs were reviewed for radiographic evidence of trabecular bridging in 2 or more views. If fusion occurred, the number of osteogenic progenitor cells found in the combined BMA at surgery was recorded. A total of 33 patients were included in the present study. Of the 33 patients, 32 (97.0%) had radiographic fusion at a mean of 13 ± 6 (range 8 to 30) weeks, and 1 (3.0%) experienced nonunion and required revision. The patient procedures were as follows: 18 (54.5%) hindfoot arthrodeses, 8 (24.2%) forefoot arthrodeses, 4 (12.1%) fractures, and 3 (9.1%) isolated ankle fusions. The mean colony-forming units for the patients with fusion was 20.3 ± 23.5 (range 0.0 to 107.0). In the patient with nonunion, it was 0.20 colony-forming unit. Our comparison of the incidence of fusion with the use of osteogenic progenitor cells from 3 anatomic sites showed a low incidence of complications and a high incidence of fusion. No association was found between the BMA concentration and the incidence of fusion, suggesting a minimum concentration and biologic potential of pluripotent cells is necessary to achieve the clinical effect of fusion.

Background: Ankle fractures are among the most common lower extremity injuries. Proper care requires evaluation for syndesmotic ligament disruption. Ankle arthroscopy has been proposed as an intraoperative tool that can evaluate stability. Our focus was to evaluate the amount of displacement produced in the coronal, sagittal, and transverse planes visualized through ankle arthroscopy in a cadaveric model. Methods: Seven below-knee specimens were mounted in a traction tower. Four groups were evaluated: no ligamentous disruption; anterior inferior tibiofibular ligament and interosseous ligament disruption; above plus anterior talofibular ligament and calcaneofibular ligament disruption; and posterior inferior tibiofibular ligament and transverse ligament disruption. Force was applied and measured using a digital scale. The amount of displacement of the fibula in relation to the center of the incisura was measured under arthroscopic evaluation using a calibrated probe. Results: An intact syndesmosis and lateral ankle ligaments provided multiplanar stability. In group 2, syndesmosis diastasis was appreciated in the transverse-external rotation plane with as little as 6 lb of force. In group 3, a greater amount of displacement was appreciated with less force. Multiplane instability was visible in every specimen with as little as 2 lb of force. Group 4 specimens were completely disrupted and so grossly unstable that testing was impossible. Conclusion: Ankle arthroscopy has the potential to evaluate even partial disruption of the syndesmotic ligament complex. Instability in the sagittal and transverse planes was encountered early in the spectrum of disruption. Traditional evaluation methods have poor sensitivity for instability in these planes. Clinical Relevance: Arthroscopic evaluation of subtle displacement in multiple planes may assist the surgeon in understanding the extent of the syndesmotic injury. Further studies are necessary to determine to what extent instability requires fixation as well as the role for arthroscopy in assessing anatomic reduction of the syndesmosis after fixation is performed.

Detachment with reattachment of the Achilles tendon is a common surgery for debridement of retrocalcaneal exostosis, bursitis, and other insertional pathologic entities. The technique involves a midline skin incision on the posterior Achilles to the tendon. The distal Achilles attachment is removed in a U-shaped manner, leaving the medial and lateral flares, but exposing the posterior spur. This midline approach provides excellent exposure and allows for rapid and efficient surgical debridement. The tendon is reapproximated and repaired with a suture anchor to facilitate fixation to the posterior calcaneus. Some surgeons have expressed concerned that the rupture risk could be increased in the postoperative period using this technique. The present study was a retrospective medical record review of 98 patients (100 feet) who had undergone a midline approach with Achilles reattachment after insertional Achilles debridement during a 3-year period. The demographic and comorbidity data were collected and analyzed. The outcome measures were postoperative rupture and the need for revision surgery. The mean age was 51.9 years, and the patients included 59 females (60.2%) and 39 males (39.8%). The complications included 4 rupture or avulsion revisions (4.0%) and 2 recurrent pain and tendinitis revisions (2.0%). The most common repeat repair procedure included hardware removal and a flexor hallucis longus transfer or augmentation. Nine patients (9.0%) had wound complications, 7 (77.8%) of which necessitated incision and drainage. The midline approach with Achilles detachment and reattachment is a safe and effective method of surgical treatment of insertional Achilles pathologic entities. The low reoperation rate of 4.0% will allow foot and ankle surgeons to safely rely on this approach.

Background: Focal damage to articular cartilage, also called an osteochondral defect (OCD), can be a cause of pain and decreased range of motion. Recent advancements have led to transplantation techniques using particulated juvenile articular cartilage allograft. This technique has been applied to the first metatarsal head to a very limited degree, with no published results to our knowledge. The aim of this study was to review the clinical results of patients who underwent particulated juvenile cartilage allograft implantation for first metatarsal head OCDs. Methods: We performed a retrospective consecutive case series study. Nine patients, at an average age of 41 years, were treated for symptomatic focal osteochondral defects of the first metatarsal head with particulate cartilage grafting from 2010 to 2016. Patients were contacted by phone to assess interest in returning to the office for follow-up, where weightbearing radiographs of the foot were obtained and a foot examination was performed. Results: At an average follow-up of 3.3 years, 7 of 9 patients reported no pain with recreational activities and no patient required further operations. This patient cohort was physically active, with 6 of 9 listing running as a regular activity. The average overall American Orthopaedic Foot & Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale questionnaire score was 85 (maximum 100), AOFAS pain 35.6 (maximum 40), and AOFAS function 40.1 (maximum 45). Patient satisfaction surveys correlated with the AOFAS scores and revealed that 7 of 9 patients were very satisfied with their results, 1 was satisfied, and 1 patient was very dissatisfied. Conclusion: Particulated juvenile cartilage allograft transplantation is a promising treatment option for symptomatic first metatarsophalangeal focal articular cartilage lesions. Further study is needed to demonstrate which lesions respond better to this type of cartilage graft versus traditional marrow-stimulating procedures. Level of Evidence: Level IV, retrospective case series.

Background: It is well known that bone marrow aspirate from the iliac crest contains osteoblastic connective tissue progenitor cells. Alternative harvest sites in foot and ankle surgery include the distal aspect of the tibia and the calcaneus. To our knowledge, no previous studies have characterized the quality of bone marrow aspirate obtained from these alternative sites and compared the results with those of aspirate from the iliac crest. The goal of this study was to determine which anatomic location yields the highest number of osteoblastic progenitor cells. Methods: Forty patients were prospectively enrolled in the study, and separate bone marrow aspirate samples were harvested from the ipsilateral anterior iliac crest, distal tibial metaphysis, and calcaneal body. The aspirate was centrifuged to obtain a concentrate of nucleated cells, which were plated and grown in cell culture. Colonies that stained positive for alkaline phosphatase were counted to estimate the number of osteoblastic progenitor cells in the initial sample. The anatomic locations were compared. Clinical parameters (including sex, age, tobacco use, body mass index, and diabetes) were assessed as possible predictors of osteoblastic progenitor cell yield. Results: Osteoblastic progenitor cells were found at each anatomic location. Bone marrow aspirate collected from the iliac crest had a higher mean concentration of osteoblastic progenitor cells compared with the distal aspect of the tibia or the calcaneus (p < 0.0001). There was no significant difference in concentration between the tibia and the calcaneus (p = 0.063). Age, sex, tobacco use, and diabetes were not predictive of osteoblastic progenitor cell yield. Conclusions: Osteoblastic progenitor cells are available in the iliac crest, proximal aspect of the tibia, and calcaneus. However, the iliac crest provided the highest yield of osteoblastic progenitor cells. Clinical Relevance: The study demonstrated that osteogenic progenitor cells are available in bone marrow aspirate harvested from the tibia or calcaneus as well as the iliac crest. All three sites are easily accessed, with a low risk of adverse events. However, larger volumes of aspirate may be needed from the tibia or calcaneus to approach the yield of cells from the iliac crest.

Circular external fixation is a useful treatment option for the correction of complex trauma, extremity deformity, osteomyelitis, and reconstruction of the foot and ankle. The goal of the present study was to determine the degrees of bolt rotation required to create enough wire tension to cause structural failure of the lateral calcaneal wall when stressed with both olive and smooth wires in a cadaveric model. Ten fresh, thawed, below-the-knee specimens were tested at the San Diego Cadaveric Academic Research Symposium. The mean bolt rotation required to pull an olive wire through the lateral wall of the calcaneus was 79.8° ± 32.81°, and the mean bolt rotation required to "walk" a skinny wire (narrow diameter) and create 1 mm of cortical bone failure was 50.5° ± 30.91°. The results of the present investigation further define and elucidate the appropriate "Russian tensioning" technique applicable for external fixation of the calcaneus using olive or skinny wires in the case of fracture repair or compression arthrodesis.

Background: Tibiotalocalcaneal (TTC) arthrodesis using a nail has been shown to be an effective salvage technique; however, there is a risk of major amputation. A better understanding of the relative risk of amputation after TTC fusion and the factors that influence this could help the preoperative consultation and guide discussion on the economics of limb salvage. Methods: One hundred seventy-nine limbs were treated with TTC fusion with an intramedullary nail. A comprehensive chart and radiographic review was pulled from our intramedullary nail database. Patients were divided into those who went on to eventual amputation and those with successful salvage of their limb. Variables from the database were used to build a statistical model with a biostatistician. Final results were presented, and a formula to determine probability of amputation was created. Results: There were 21 limbs that were eventually treated with major amputation. This represents an overall salvage rate of 88.2% (158/179 patients). Age was a factor in amputation risk, and the highest risk factor for amputation was diabetes with an odds ratio of 7.01 and 95% confidence, P = .0019. The odds of amputation were 6.2 times and 3 times greater for patients undergoing revisions and those with preoperative ulcers, respectively. The probability of amputation could be found preoperatively by using the derived equation: ex/(1 + ex) where x is a factor of age, diabetes, revision, and ulceration. Conclusion: TTC arthrodesis with a retrograde intramedullary nail has a high rate of limb salvage across a wide range of indications and medical comorbidities. In this patient cohort, diabetes was the most notable risk for amputation, followed by revision surgery, preoperative ulceration, and age. A model has been built to help predict the risk of amputation. Level of Evidence: Level II, prognostic.

Degenerative joint disease of the ankle is a debilitating etiology, in which treatment has been disputed in the literature among healthy active patients. Total ankle arthroplasty had recently gained popularity as long- term outcomes are being reported and advancement in the design of the implants themselves evolves. Multiple implants are available on today's mar- ket including the INBONE (Wright Medical technologies, Arlington, TN) Total Ankle System. The second gen- eration INBONE total ankle arthro- plasty was launched and approved for use in the United States by the FDA in 2005. The second generation INBONE implant has a talar sulcus, allow- ing for a more biomechanically stable articulation between the polyethelene insert and the talar component (Figure 1). The initial INBONE implant had a flat articulation with the poly leading to instability. This paper will help to demonstrate the advantages of INBONE II versus INBONE I Total Ankle System in management of arthrosis of the ankle joint. D egenerative joint disease of the ankle is a debilitating etiology, in which treatment has been dis- puted in the literature among healthy active patients. Total ankle arthro- plasty had recently gained popular- ity as long-term outcomes are being reported and advancement in the design of the implants them- selves evolves. Multiple implants are available on today's market, includ- ing the INBONE (Wright Medical Technology, Inc, Arlington, TN) Total Ankle System. The second- generation INBONE total ankle arthroplasty was launched and approved for use in the United States by the Food and Drug Administration (FDA) in 2005. The second-generation INBONE implant has a talar sulcus, allowing for a more biomechanically stable articulation between the polyethylene insert and the talar component (Figure 1). The initial INBONE implant had a flat articulation with the poly leading to instability. This article will help demonstrate the

Background: The “tibiofibular line” is a new axial computed tomography parameter for assessing syndesmosis reduction, which references the flat anterolateral surface of the fibula and anterolateral tibial tubercle. These same bony landmarks are easily visualized via a lateral approach to the fibula. This cadaveric study assessed the practical aspects of measuring the tibiofibular line intraoperatively. Methods: Three observers simulated the tibiofibular line using operative rulers in 3 measurement series utilizing 10 cadaveric specimens: intact syndesmosis, syndesmosis reduction, and fixation after application of lateral plate and screws to the fibula, and post syndesmosis reduction and fixation without plate and screws. Results: The majority (78%) of clinical tibiofibular line measurements were within the “normal” range (0-2 mm). However, there was a general trend toward malreduction (>2 mm) across measurement series. Intraobserver variability ranged from poor to excellent (intraclass correlation range, 0.12-0.85, Fleiss kappa range, 0.19-0.40) and interobserver reliability was only generally in the fair range (intraclass correlation range, 0.49-0.61; Fleiss kappa range, 0.19-0.40). Conclusion: Taken as a whole, these findings found that the technique was feasible but clearly indicated that further refinement of this protocol, including the use of computed tomography, would be needed to determine if better control of confounding variables would reveal better observer reliability. Clinical Relevance: The CT-based TFL technique for syndesmosis reduction assessment could not reliably be translated into an intraoperative open technique because of the confounding effects of subjectivity and operator error.

Total ankle replacement (TAR) is a viable alternative to ankle fusion in certain patients with end-stage ankle arthritis. Despite the importance of understanding alignment and movement of the prosthesis, there is no standardized radiographic method for evaluating the position and movement of the INBONE 2 prosthesis. The aims of this study were to describe a radiographic measurement protocol for INBONE 2 for clinical practice and research while determining the interobserver and intraobserver reliability using standard weightbearing radiographs. Fifteen patients were randomly selected with operative dates from January 2011 to January 2014 who underwent primary TAR using the INBONE 2 prosthesis. Most recent preoperative and first postoperative weightbearing anteroposterior and lateral radiographs were pulled and deidentified. Three foot and ankle surgeons blinded from the patient selection and deidentification, measured the described measurements on separate occasions. Intraobserver reliability: surgeon 1 had acceptable reliability for 9 of 13 continuous radiographic measurements (69.2%), surgeon 2 had acceptable reliability for 8 of 13 measurements (61.5%), and surgeon 3 had acceptable reliability for 12 of 13 measurements (92.3%). Interobserver reliability: among the first measurements, 6 of 13 continuous radiographic measurements (46.2%) had acceptable reliability. Among the second measurements, 7 of 13 measurements (53.8%) had acceptable reliability. Among the first and second measurements combined, 7 of 13 measurements (53.8%) had acceptable reliability. This study promotes the need for meticulous evaluation of annual radiographic findings following TAR in an effort to avoid catastrophic failure and represents moderate agreement can be obtained by employing the proposed measurements for surveillance of INBONE 2 TAR at annual postoperative visits. Measurements on the anteroposterior radiograph appear to demonstrate more consistent results for surveillance than lateral measurements. The intraobserver reliability results were somewhat superior to the interobserver reliability, implying more relevance for a single surgeon applying these measurements annually for postoperative surveillance. Levels of Evidence: Diagnostic, Level III

Posterior tibial tendon dysfunction is often coupled with various degrees of hindfoot valgus and equinus. Preoperative planning is essential to appropriate procedure choice and surgical efficiency. The purpose of the present study was to assess the anatomy at the harvest site for flexor digitorum longus tendon transfer, specifically at the master knot of Henry. Thirty fresh-frozen below-the-knee cadavers were used for dissection. A standard anatomic approach was performed for posterior tibial tendon debridement and flexor digitorum longus tendon transfer. The flexor digitorum longus tendon was harvested and measured at the master knot of Henry. The present anatomic study evaluated the tendon width of the flexor digitorum longus tendon at a common harvest site. Of the 30 specimens, 20 (67%) measured 5 mm and 10 (33%) measured 4 mm. A 5.0-mm interference screw would be acceptable in each specimen and therefore would be the safest choice. A 4.0-mm interference screw would be acceptable in only 33% of the specimens. Males have a slightly more robust flexor digitorum longus tendon than females at the harvest site. This information will assist surgeons in preoperative planning during stage II flatfoot correction for posterior tibial tendon dysfunction.

Lateral column lengthening is a common procedure for correction of pes planovalgus. A tricortical bone graft has been a standard among foot and ankle surgeons. The purpose of the present study was to compare the union rates and complications between the 2 forms of fixation for lateral column lengthening. The present study was a retrospective medical record and radiograph review of 52 patients divided into 2 equal groups, allograft (group A) and opening wedge plate (group B). The radiographic analyses compared the preoperative, postoperative and long-term measurements of cuboid abduction and talonavicular angles. The outcome measures included nonunion, hardware removal, and infection. The median follow-up duration for each group was 34.5 (range 6.3 to 89.5) months and 12.6 (range 6.5 to 56.8) months for groups A and B, respectively. Group A had 4 nonunions (15.4%) and group B had 2 nonunions (7.7%). The mean radiographic measurements of cuboid abduction and talonavicular articulation for each group improved significantly. The incidence of hardware removal was greater for group A than for group B (30.8% versus 15.4%), although the difference was not statistically significant. The median time to osseous healing for group A was 12.0 (range 8.0 to 80.0) weeks and for group B was 10.0 (range 6.0 to 36.0) weeks. The interposition plating techniques for lateral column lengthening procedures had a lower nonunion rate and incidence of hardware removal compared with the traditional use of tricortical bone grafting. The findings from the present study will aid surgeons in alternative fixation for lateral column lengthening procedures.

Background: Access to the medial half of the talus can be challenging even with an osteotomy. Although several techniques are presented in the literature, critical evaluation of fixation, union, and alignment is lacking. The chevron medial malleolar osteotomy provides advantages of perpendicular instrumentation access and wide exposure to the medial talus. Postoperative displacement resulting in malunion, and possibly provoking ankle osteoarthritis, is a known complication. The present study describes our experience with the osteotomy. Methods: A consecutive series cohort of 50 bi-plane chevron osteotomies performed from 2004 to 2013 were evaluated. Forty-six were secured using 2 lag screws, and 4 were secured using 2 lag screws and a medial buttress plate. Radiographic studies performed at 2, 6, and 12 weeks and at final follow-up were analyzed for postoperative displacement, malunion, non-union, and hardware-related complications. Results: At initial postoperative follow-up, 47 of 50 had adequate radiographs for review, and 18 of 47 (38.3%) showed some displacement when compared to the initial osteotomy fixation position. By final follow-up, 15 of 50 (30.0%) had measurable incongruence. Hardware removal was performed in 13 (26.0%) cases at an average of 2.4 years postoperation. Conclusion: Bi-plane medial malleolar chevron osteotomy fixed with 2 lag screws showed a 30.0% malunion rate with an average of 2 mm of incongruence on final follow-up radiographs, which is higher than what has been reported in the literature. In our practice, we now use a buttress plate and more recently have eliminated postoperative osteotomy displacement. Level of Evidence: Level IV, retrospective case series.

Direct plantar plate repair using a plantar approach has been described previously, but with few reports of the outcomes or clinical results. The purpose of the present study was to determine the outcomes of this technique. We performed a retrospective analysis of patients who had undergone direct plantar plate repair with or without concomitant Weil osteotomy and a prospective patient-reported subjective outcomes analysis. Ultimately, 131 patients (144 toes) were included, and the response rate for the mailed surveys was 53.5% (77 of 144 toes). The clinical outcomes reported a well-aligned toe in 87.1% of cases, with a recurrence rate of 7.6% (11 of 144) and a revision rate of 2.8% (4 of 144). Statistically significant improvement in the overall modified Foot Function Index (p < .001) and subscale scores for pain (p < .001), disability (p < .001), and activity limitation (p = .001) were noted postoperatively compared with the preoperative data. The median postoperative visual analog pain scale level reported at survey completion was 2.0 (range 0.0 to 10.0; mean ± standard deviation 2.3 ± 2.6). Despite the modified Foot Function Index scores, the patient satisfaction questionnaire data reported mixed results. Our modified Foot Function Index results demonstrated that this approach provides excellent postoperative pain relief, improvement of associated disability, and improvement in activity limitations. The importance of managing patient expectations is acknowledged secondary to the discrepancy with the patient satisfaction data and the modified Foot Function Index results. Further prospective study is warranted to compare this technique with alternate dorsal approaches for plantar plate repair with and without associated commercially available suture passing systems.