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Introduction/Purpose: Total ankle replacement (TAR) has achieved relatively successful outcomes with respect to postoperative complications; however, mixed evidence exists regarding early complication rates, reoperation, and infection1-5. The largest study of TAR to date indicates a statistically significant risk of postoperative infection in tobacco users and diabetic patients6 . Unlike currently established anterior approaches to arthroplasty, the lateral transfibular approach potentially avoids disruption of perfusion to the skin, possibly decreasing postoperative complications7 . The lateral ankle allows surgeons to correct malunion of the fibula in post-traumatic arthritis deformity cases and achieve appropriate coronal and sagittal implant alignment to achieve similar physiological joint orientation8,9. The purpose of this study was to report 90-day reoperation and wound complication rates in lateral approach to total ankle replacement for post-traumatic arthritis (PTA). Methods: A retrospective chart review of lateral TAR cases from 2016-2022 was conducted at a single institution. Only patients undergoing TAR for post-traumatic arthritis were included in this review. A total of 49 patients (22 females and 27 males) underwent total ankle replacement with the Zimmer Biomet Trabecular MetalTM Total Ankle by a single surgeon. Patient demographics, operative data, complications, and adverse events requiring corrective surgery were recorded within 90 days of arthroplasty. Results: The patient sample included 6 active smokers, 11 diabetics, and 32 patients with hypertension with an average age of 60.7 and average BMI of 34.3 (Table 1). Three of the 49 (6.1%) patients required secondary surgery within 3 months of surgery (Table 2). Revision surgery indications included: 1 (2.0%) for removing painful hardware, 2 (4.1%) due to infection, and 1 (2.0%) for tarsal tunnel syndrome after surgery. There were 0 nonunions of the fibula at 90 days and through 1 year follow up. Of the patients requiring secondary surgery for infection, 1 was a smoker and 1 had a history of ankle fusion nonunion and avascular necrosis which was converted to a TAR (Table 4). Conclusion: This retrospective study demonstrates a comparable rate of secondary surgeries following TAR via lateral approach in the early postoperative period (6.1%) while having a slightly higher rate of infection than those previously reported (4.1%)7,8. Notwithstanding, we observed a 100% healing rate of fibula osteotomies; however, we failed to demonstrate a lower incidence of wound complications than previously reported. Surgeons should counsel patients of these risks in those with PTA undergoing lateral TAR, especially in smokers and diabetics. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: The use of chemoprophylaxis to prevent thromboembolic complications following total ankle arthroplasty (TAA) is debated in the field of orthopaedics. The incidence of thromboembolic complications has been shown to vary within the literature, and some studies suggest that the incidence may be similar to what is seen following hip and knee arthroplasty. Therefore, some surgeons will prescribe chemoprophylaxis, such as aspirin 325mg or enoxaparin 40mg following surgery, especially in high-risk patients. To our knowledge, the cost-effectiveness of chemoprophylaxis in TAA has not been investigated. This article presents a break-even analysis for chemoprophylaxis in TAA for the prevention of thromboembolic complications. Methods: The estimated cost of treating a thromboembolic complication ($9,407.00) as well as the product cost of aspirin (325 mg) and enoxaparin (40 mg) were obtained from our institution's purchasing records. The high and low rates of thromboembolic complications were obtained from the literature. A break-even analysis was then performed to determine the absolute risk reduction (ARR) in thromboembolic complication rates to make chemoprophylaxis with aspirin 325mg and enoxaparin 40mg costeffective. Results: The initial high rate of a thromboembolic complication following TAA was determined to be 9.8%. Costing $0.25, aspirin was considered cost-effective if the initial thromboembolic complication rate decreased by an ARR of 0.00266%, while enoxaparin (costing $131.73) was cost-effective if the initial rate decreased by an ARR of 1.40034%. For comparison, the initial low rate of thromboembolic complication following TAA was determined to be 0.45%. At this rate, aspirin was again considered to be costeffective if the initial rate decreased by an ARR of 0.00266%. However, at this low rate, the ARR required to achieve costeffectiveness for enoxaparin exceeds the initial thromboembolic complication rate. Conclusion: While the use of chemoprophylaxis following TAA is still being investigated, this break-even analysis demonstrates that aspirin is highly cost-effective for preventing thromboembolic complications. Furthermore, our results indicate that enoxaparin is cost-effective at the higher rates of thromboembolic complications, but cost-effectiveness is eliminated at a low rate. Not only does this break-even analysis demonstrate the cost-effectiveness of aspirin and, in some cases, enoxaparin, but the model can be easily applied to the values at any institution in order for orthopaedic surgeons to determine the cost-effectiveness of a therapeutic of their choice. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: The preferred method of fixation for ligamentous Lisfranc injuries is controversial, with the traditional method being transarticular screws. Unfortunately, screw removal is often required leading surgeons to seek alternative fixation methods including fibertape constructs. The purpose of this biomechanical study is to compare transarticular screws to a fibertape construct under a spectrum of biomechanical loads. This controlled laboratory study involved evaluating the diastasis at three joints in the Lisfranc complex in matched pairs and creating 3D models for each loading stage to evaluate at the plantar, interosseous, and dorsal aspects of each bone. Methods: Eight matched pairs of lower extremity cadaveric specimens were fixed with either a fibertape construct with a supplemental intercuneiform limb, or two transarticular cannulated crossed-screws. The diastasis between bones was measured at three midfoot joints in the Lisfranc complex; the Lisfranc articulation, the 2nd tarsometatarsal joint, and the intercuneiform joint using a 3D coordinate digitizer. Measurements were obtained for the pre-injured, injured, and fixation under static loading at 50% donor bodyweight. Specimens then underwent stepwise increases in cyclic loading performed at 1 Hz and 100 cycles, at additional 100 N ground reaction force intervals from 100 N to 2000 N to simulate postoperative loading from the partial weightbearing stage to high-energy activities. CT scans were obtained for each specimen to create 3D models that allowed for plantar and interosseous diastasis measurements. Failure of fixation was defined as diastasis greater than 2 millimeters at the Lisfranc articulation (second-metatarsal - medial-cuneiform joint). Results: There were no significant differences detected between groups in the pre-injury, injury or fixation stage and therefore no notable differences between groups prior to surgery with different constructs. Specimens fixed with the fibertape construct demonstrated failure in 1 of 8 (12.5%) specimens during a cycle with a peak force of 2000 N. In contrast, 2 of 8 (25%) specimens fixed with screws failed at peak forces of 1000 N and 1400 N. There were no significant differences in diastasis detected at the Lisfranc articulation or the intercuneiform joint throughout all loading cycles. However, the fibertape construct showed higher non-failure in statistical predictions, and significantly less motion at the adjacent 2nd tarsometatarsal joint. Conclusion: This study displayed a high level of repeatability in our injury creation under fluoroscopy with a specific criteria to avoid disrupting any adjacent ligaments and a threshold measurement of injury. The fibertape construct with a supplemental intercuneiform limb seems to provide comparable biomechanical stability to transarticular screws. There were no significant differences detected throughout our loading protocol which exceeds loads performed in previous studies. Furthermore, in combination with not requiring removal, this construct may allow for physiologic loading potentially providing accelerated postoperative protocols. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Pain control is important following TAA. Prior studies have reported that anxiety and depression are associated with worse outcomes after orthopaedic surgery. However, the association between anxiety and depression on patient reported outcomes following TAA is not well-defined. Therefore, the purpose of this study was to investigate the effects of anxiety and depression on postoperative reported pain control following TAA. Methods: Following institutional review board approval, a retrospective chart review was conducted for all patients that underwent TAA from 2018-2021 at our institution. Patients were separated into two groups. Group A consisted of patients with a documented pre-operative history of anxiety and depression and Group B consisted of patients without documented anxiety or depression. Electronic records were reviewed at 2- and 6-weeks following surgery. Statistical analysis was then run to determine the relative risk of poorly controlled pain postoperatively in patients with and anxiety and depression. Results: At our institution, from 2018-2021, 56 patients underwent TAA. The mean age of our cohort was 60.9 (Range, 56-83). In our cohort, 31 patients were male, 25 were female, the mean patient BMI was 33.8 (Range, 21-56.2), 8 patients reported poor pain control (14.3%) and 24 patients had anxiety or depression (42.9%). Of the patients with anxiety or depression, 4 reported poor pain control. There was no statistically significant increased risk of poor pain control in patients with a history of anxiety or depression (RR: 1.5; 95% CI: 0.4145 to 5.4279). Conclusion: Despite the increased risk of poor outcomes reported in patients with a history of anxiety and depression, the results from our cohort indicate that a history of anxiety or depression is not associated with going on to have poor pain control following TAA. Albeit, our sample size was small, warranting further investigation. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Venous thromboembolism (VTE) is a feared complication following orthopaedic surgery. The limited research exploring the rate of VTE following different types of foot and ankle surgery makes it difficult to establish clear guidelines for prescribing VTE prophylaxis. Therefore, the purpose of this study was to determine the rate of VTE in patients undergoing various types of foot and ankle procedures. Methods: A large online retrospective database that utilizes ICD and CTP codes was queried to determine the rate of VTE that occurred within 1-month of surgery in common foot and ankle procedures. Surgeries investigated included: Arthrodesis, Total Ankle Arthroplasty, Bunionectomy, Hammer Toe Correction, Watson-Jones, and Achilles repair. Only patients that did not receive postoperative anticoagulation or antiplatelet agents were included in the analysis. Demographic data was also collected. Results: From 2011 to 2022, 27,872 patients underwent Arthrodesis, 1,513 had a Total Ankle Arthroplasty, 31,808 had a Bunionectomy, 26,828 had Hammer Toe correction, 7,545 had a Watson-Jones procedure, and 8,770 had an Achilles repair. Of these procedures, Achilles repair had the highest rate of postoperative VTE (1.32%), followed by Watson-Jones (1.21%), Arthrodesis (0.89%), Ankle Arthroplasty (0.86%), Hammer Toe (0.76%) and Bunionectomy (0.65%). The overall rate of VTE in all procedures was found to be 0.84% (880/104,336). Conclusion: Venous thromboembolism is a serious complication following foot and ankle surgery. The unknown incidence of VTE in common foot and ankle surgeries may contribute to the lack of clear guidelines for prescribing VTE prophylaxis. This study helps to define rates of VTE in patients not receiving prophylaxis that underwent Arthrodesis, Ankle Arthroplasty, Bunionectomy, Hammer Toe, Wa [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Venous thromboembolism is a devastating and costly complication following TAA. The true incidence of VTE is unknown and the decision to prescribe chemoprophylaxis in foot and ankle surgery continues to be debated. At our institution, all patients receive a four-week course of chemoprophylaxis following TAA. The purpose of this study was to evaluate the incidence of VTE at our institution in patients receiving routine chemoprophylaxis. Methods: Following institutional board approval, a retrospective chart review was conducted for all patients that underwent TAA from 2018-2021 by a single surgeon. Patients were followed from the time of surgery to their six-week follow-up. Demographics and the type of chemoprophylaxis was recorded. For comparison, a large online database was queried using ICD and CTP codes in order to determine the incidence of VTE at 2 week and 6 weeks postoperatively for patients that underwent TAA and did not receive any form of chemoprophylaxis. Results: At our institution, from 2018-2021, 56 patients underwent TAA. The mean age of our cohort was 60.9 (Range, 56-83). In our cohort, 31 patients were male, 25 were female, and the mean patient BMI was 33.8 (Range, 21-56.2). Of the 56 patients, 12 received aspirin (81 mg), 25 received aspirin (325 mg), 16 received enoxaparin (40 mg), 2 received apixaban (5 mg), and 1 received rivaroxaban (20 mg). The total incidence of VTE at 6 weeks was 0%. For comparison, using a large online database (from 2011- 2021), 1,463 patients underwent TAA and did not receive postoperative chemoprophylaxis. Of these patients, 13 (0.89%) developed a postoperative VTE at 6-weeks following surgery. Conclusion: At our institution, the rate of VTE at 6-weeks postoperatively was 0%. This was lower than a large online database rate (0.89%) in patients that did not receive chemoprophylaxis. Further investigation is needed. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Charcot Foot is a serious and potentially limb-threatening complication of longstanding diabetes, peripheral neuropathy, and trauma. One of the many challenges that surgeons face when treating the Charcot Foot is predicting long-term outcomes. Therefore, the purpose of this study was to determine if hemoglobin A1C level was associated with an increased risk of BKA in Charcot Foot patients. Methods: Following institutional board approval, all patients from 2015-2021 with a diagnosis of Charcot Foot were queried using hospital electronic medical records. Patients were separated into two groups. Group A consisted of patients with a diagnosis of Charcot and a hemoglobin A1C³ 6.5%, while group B consisted of patients with a diagnosis of Charcot and hemoglobin A1C < 6.5%. Statistical analysis was then performed to determine the relative risk of a BKA in patients exposed to a hemoglobin A1C³ 6.5%, compared to those with a hemoglobin A1C < 6.5%. Only patients with a documented A1C around the time of diagnosis were included. Results: From 2015 to 2021, 80 patients were diagnosed with Charcot Foot. Of these patients, 59 met our inclusion criteria. Of the 59 patients, 20.3% (12/59) went on to require a BKA and 79.6% (47/59) did not. In our cohort, 54.2% of patients had a hemoglobin A1C³ 6.5% and 45.8% (27/59) had a hemoglobin A1C < 6.5%. The relative risk of BKA in patients with an A1C³ 6.5% was 2.5 (95% CI: 0.76-8.4; p=0.13). Conclusion: Charcot Foot is a debilitating and potentially limb-threatening complication. While our results suggest an associated increased risk of BKA in patients with an A1C³ 6.5%, there was no statistical significance found. As such, further investigation is needed. [ABSTRACT FROM AUTHOR]