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School reentry after inpatient psychiatric hospitalization requires careful coordination between multiple team members to ensure stability across transitions, given documented negative academic and socioemotional impacts in the post-discharge period. Existing investigations are limited by the fact that no articles examine the perspectives of multiple participant types simultaneously. We conducted a qualitative study of multiple children transitioning out of psychiatric hospitalization and their adult reentry team members, utilizing thematic analysis informed by grounded theory. Across 16 semi-structured interviews, we analyzed perspectives from 17 participants: four children, four parents, five school staff, and four hospital staff. We identified four key themes informing an overarching theory: 1) Centering the socioemotional role of school; 2) Clarifying what constitutes good communication; 3) Reconciling multiple sources of authority; and 4) Navigating limitations with creativity. Together, these themes converge into two new theoretical concepts. First, "stereovision" represents the synthesis of multiple "lines of sight," which cross to create a densely interactional system. Second, "patchworking" represents the cobbling together of case-by-case solutions to develop an adequate support plan in the face of multiple limitations or barriers. In conclusion, by incorporating the above four thematic findings into a novel theoretical framework, we argue that when navigating school reentry after psychiatric hospitalization, children and adults must use stereovision and patchworking to create a strong, flexible support fabric. These reflections increase representation of child and adult team member voices in the literature and inform future school--hospital--family partnerships for school reentry after psychiatric hospitalization.

OBJECTIVE:  This study aimed to assess factors that influence patients decisions in accepting prenatal diagnostic testing following genetic counseling for increased risk of fetal aneuploidy. METHODS:  This is a retrospective cohort study of women at increased risk of fetal aneuploidy and genetic disorders who had genetic counseling from January 2012 to December 2016 at a single academic center. Demographics, indications for genetic counseling, and rates of diagnostic testing were collected and compared between those who accepted diagnostic testing and those who chose cell free DNA. The variables were analyzed using Chi-square, Fishers exact test, and multiple logistic regression. RESULT:  Of the 2,373 pregnant women who underwent genetic counseling for increased risk of fetal aneuploidy and genetic disorders during the study period, 321 women had diagnostic testing (13.5%). Women at 35 years and older accepted diagnostic testing more than women younger than 35 years (20.7 vs. 11.5%, p

BACKGROUND: Postoperative delirium is a common problem affecting admitted patients that decreases patient satisfaction and increases the cost and complexity of care. The purpose of this study was to use the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to compare rates and risk factors of postoperative delirium for total hip arthroplasty (THA) and hemiarthroplasty patients indicated for osteoarthritis or proximal femur fracture. METHODS: The 2021 NSQIP database was queried for patients using Current Procedural Terminology (CPT) codes for THA and hemiarthroplasty and ICD-10 codes for osteoarthritis or proximal femur fracture. Demographic, past medical history, preoperative labs, and functional status data were recorded. Procedural data were also collected. Finally, postoperative outcomes and complications were reviewed. RESULTS: Overall, 16% of patients had postoperative delirium. Delirium patients were older on average (82.4 years vs. 80.7 years, p

Abstract Background Glioblastoma multiforme (GBM) is an aggressive tumor, difficult to treat pharmacologically because of the blood-brain barrier (BBB), which is rich in ATP-binding cassette (ABC) transporters and tight junction (TJ) proteins. The BBB is disrupted within GBM bulk, but it is competent in brain-adjacent-to-tumor areas, where eventual GBM foci can trigger tumor relapse. How GBM cells influence the permeability of BBB is poorly investigated. Methods To clarify this point, we co-cultured human BBB models with 3 patient-derived GBM cells, after separating from each tumor the stem cell/neurosphere (SC/NS) and the differentiated/adherent cell (AC) components. Also, we set up cultures of BBB cells with the conditioned medium of NS or AC, enriched or depleted of IL-6. Extracellular cytokines were measured by protein arrays and ELISA. The intracellular signaling in BBB cells was measured by immunoblotting, in the presence of STAT3 pharmacological inhibitor or specific PROTAC. The competence of BBB was evaluated by permeability assays and TEER measurement. Results The presence of GBM cells or their conditioned medium increased the permeability to doxorubicin, mitoxantrone and dextran-70, decreased TEER, down-regulated ABC transporters and TJ proteins at the transcriptional level. These effects were higher with AC or their medium than with NS. The secretome analysis identified IL-6 as significantly more produced by AC than by NS. Notably, AC-conditioned medium treated with an IL-6 neutralizing antibody reduced the BBB permeability to NS levels, while NS-conditioned medium enriched with IL-6 increased BBB permeability to AC levels. Mechanistically, IL-6 released by AC GBM cells activated STAT3 in BBB cells. In turn, STAT3 down-regulated ABC transporter and TJ expression, increased permeability and decreased TEER. The same effects were obtained in BBB cells treated with STA-21, a pharmacological inhibitor of STAT3, or with a PROTAC targeting STAT3. Conclusions Our work demonstrates for the first time that the degree of GBM differentiation influences BBB permeability. The crosstalk between GBM cells that release IL-6 and BBB cells that respond by activating STAT3, controls the expression of ABC transporters and TJ proteins on BBB. These results may pave the way for novel therapeutic tools to tune BBB permeability and improve drug delivery to GBM.

Abstract Current treatment strategy for managing Weber B ankle fractures is mainly governed by mortise congruency, malleolar alignment, deltoid ligament competence and fracture stability. While nonoperative treatment has yielded good functional outcomes in satisfactorily aligned stable injuries, a biomechanical rationale is not firmly established. Furthermore, current radiographic analysis is obscured by observer inaccuracy and beam rotation. This study aimed to utilize weightbearing CT and computational biomechanics to analyse 3D mortise displacement and contact mechanics in Weber-B ankle fractures and compare them with the uninjured contralateral side. 32 patients were included who sustained a Weber-B ankle fracture and underwent bilateral weightbearing CT imaging at injury. Segmentation into 3D models of bone was performed semi-automatically, and individualized cartilage layers were modeled based on a previously validated methodology. The 3D mortise congruency was evaluated by use of following parameters: alpha angle, fibular length, talocrural angle, medial gutter- and tibiofibular clear space- distance mapping. Contact mechanics were evaluated by the mean and maximum contact stress of the tibiotalar articulation. Statistical analysis revealed that there were no significant differences for all anatomical parameters. There was also no significant difference between the mean contact stress of the injured (2.10 ± 0.42 MPa) and uninjured side (2.10 ± 0.41 MPa), nor the maximum contact stress of the injured (7.67 ± 1.55 MPa) and uninjured (7.47 ± 1.67), respectively. Contact mechanics were unaffected in congruent Weber-B fractures. These findings support consideration of nonoperative management in such cases, given their presumably low risk for posttraumatic arthritic development in the long term. Level of Evidence: Level III; retrospective case-control study.

BackgroundThe purpose of this study was to investigate the relationship between preoperative aspartate aminotransferase-to-platelet ratio index (APRI) and postoperative complications following total hip arthroplasty (THA).MethodsAll THA for osteoarthritis patients from 2007 to 2020 within the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database were included in this study. Subjects were subsequently divided into cohorts based on APRI. Four groups, including normal range, some liver damage, significant fibrosis, and cirrhosis groups, were created. Comparisons between groups were made for demographics, past medical history, and rate of major and minor complications. Other outcomes included readmission, reoperation, discharge destination, mortality, periprosthetic fracture, and postoperative hip dislocation. Multivariate logistic regression analysis was performed to determine the role of preoperative APRI in predicting adverse outcomes. Statistical significance was set at p

Purpose of reviewThe role of the microbiome in prostate cancer is an emerging subject of research interest. Certain lifestyle factors, such as obesity and diet, can also impact the microbiome, which has been implicated in many diseases, such as heart disease and diabetes. However, this link has yet to be explored in detail in the context of prostate cancer. The purpose of this review is to explore the cross-talk between obesity, dietary interventions, and microbiome alterations in the development and progression of prostate cancer.Recent findingsMany possible mechanisms exist linking obesity and dietary interventions to microbiome alterations and prostate cancer. The gut microbiome produces metabolites that could play a role in prostate cancer oncogenesis, including short-chain fatty acids, cholesterol derivatives, and folic acid. The microbiome also plays a pivotal role in the prostate tumor microenvironment (TME), contributing to inflammation, local tissue hypoxia, and epithelial-mesenchymal transition. A bidirectional relationship exists between obesity and the microbiome, and certain diets can enact changes to the microbiome, its associated metabolites, and prostate cancer outcomes.SummaryCross-talk exists between obesity, dietary interventions, and the role of the microbiome in the development and progression of prostate cancer. To further our understanding, future human studies in prostate cancer should investigate microbiome changes and incorporate an assessment of microbiome-derived metabolites and cellular/immune changes in the TME.

As screening strategies employ better biomarkers and genetics to identify individuals at an increased risk of prostate cancer, there are currently no chemotherapeutic prevention strategies. With any chemoprevention strategy, the population will be younger and healthier; therefore, they will be less tolerant of side effects. This study translated findings from screening a natural product library and pre-clinical evaluation of curcumin (CURC) in combination with ursolic acid (UA) in prostate cancer models. After manufacturing capsules for each compound, 18 subjects were enrolled. The study used a 3 × 3 phase 1 clinical trial to evaluate CURC (1200 mg/day) and UA (300 mg/day) alone and in combination over a 2-week period with endpoints of safety, bioavailability, and microbiome alterations. After enrolling six subjects in each arm, we found no grade 3 or 4 events and only minor changes in the safety laboratory values. In the pooled analysis of groups, we noted a statistically significant difference between median serum levels of UA when administered alone vs administered in the combination (2.7 ng/mL vs 43.8 ng/mL, p = 0.03). Individuals receiving the combination also had a favorable impact on gut microbiome status and a reduction in “microbiome score” predictive of prostate cancer risk.

Category: Sports; Ankle Introduction/Purpose: Osteochondral Lesions of the Talus (OLT) may progress into a cascade of cartilage degeneration. While edge-loading on the surrounding tibiotalar articular surfaces has been proposed as principal determinant of cartilage degeneration, the pathophysiological pathways have not yet been clarified. The present study aims to evaluate the patient-specific influence of OLTs on the mechanical behaviour of the surrounding cartilage of the talus and tibia. More specifically, this study aims to investigate whether the location of the OLTs influences their loading characteristics during the range of motion of the ankle joint. Methods: Patient-specific 3D models from 36 patients with an OLT, derived from weightbearing CT, were used to analyse the contact stress on the tibiotalar articulation using Discrete Element Analysis (DEA). A matched, virtual healthy control group was developed for each talus. Mean- , peak contact-stress and contact area were calculated during simulated ankle flexion. Results: The mean talar contact-stress was elevated in the OLT cases, with a notable correlation between ankle flexion and OLT location. Edge loading occurred predominantly in anteromedial lesions during dorsiflexion (2.9 MPa (IQR: 1.3) for OLT versus 2.4 MPa (IQR: 0.9) for the controls), while posteromedial lesions were mostly loaded during plantarflexion (3.5 MPa (IQR: 1.7) for the OLT versus 2.9 MPa (IQR: 1.1) for the controls). Conclusion: OLTs influence the whole-joint articular contact mechanics of the ankle, leading to increased stress on both the talus and the opposing tibia. More specifically, a clear pattern of edge-loading on the surrounding OLT cartilage was found. Anterior lesions had the highest stresses in neutral and dorsiflexion, while Posterior lesions experienced higher stress during plantarflexion. OLT versus Healthy Twin Contact Stress Contact stress plot, depicting the difference between OLT (upper) and the matched, healthy twin (lower) for increasing plantarflexion

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Following Minimally Invasive Bunionectomy (MISB), removal of hardware rates are about 5% and commonly due to midfoot pain near the distal metatarsal screw site. This distal screw head site corresponds to the proximal midshaft width measurement location, which has shown to increase postoperatively. One explanation for this increased width is medial subluxation of the first metatarsal at the tarsal-metatarsal (TMT) joint. This “TMT slippage” occurs as the metatarsal base is shifted medially to accommodate the metatarsal head lateralization at the metatarsal phalangeal joint. The force across the TMT joint overcomes the ligamentous stabilizers, allowing the metatarsal to “slip.” The aim of this study was to investigate the relation between TMT slippage and removal of hardware (ROH) rates. Methods: A retrospective analysis of prospectively collected data identified 38 patients undergoing MISB for hallux valgus (HV) with subsequent distal chevron screw removal and a control group of 40 MISB cases without hardware removal. Demographic data and surgical details were obtained via chart review. Pre- and at least 6-month post-operative radiographs were measured to obtain transverse TMT slippage on anteroposterior (AP) radiographs (Figures 1). Additionally, distal foot width, midshaft foot width, hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured. Independent samples t-tests and chi-square analyses were used to compare continuous and categorical characteristics, respectively, between patients who underwent removal of hardware. Multivariable logistic regression modeling was used to identify risk factors for undergoing hardware removal. Results: Interobserver reliability, measured by intraclass correlation coefficients (ICCs), was high for all measurements (ICC > 0.70). The change in TMT slip was significantly higher in the hardware removal (ROH) group compared to the control group (+1.39 versus +0.80, p=0.004) (Table 1). A greater decrease in distal foot width (narrower distal width postoperatively) was associated with an increased likelihood of hardware removal (OR: 0.76), while smaller reductions in HVA and IMA were linked to a higher likelihood of requiring ROH (OR: 1.12 and 1.42, respectively). Notably, a larger increase in TMT slip correlated with the highest likelihood of being in the ROH cohort (OR: 2.87) (Table 2). TMT slippage did not correlate with any other measurements (all p > 0.05). Conclusion: Our study highlights the relationship between MISB outcomes and TMT slippage. Patients requiring distal chevron screw removal showed significantly higher transverse TMT slippage. Interestingly, a smaller distal foot width reduction was associated with decreased hardware removal likelihood, suggesting a potential protective mechanism. Conversely, smaller corrections of both HVA and IMA were associated with higher chances of hardware removal. Notably, for every 1-centimeter increase in TMT slippage postoperatively, there was a nearly 3-fold increase in the likelihood of distal chevron screw removal. Further research is needed to understand the mechanisms underlying TMT slippage and its impact on HV correction outcomes.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Hallux Valgus (HV) is a common foot condition often requiring surgical intervention. Minimally invasive bunionectomy (MISB) has gained popularity for HV correction. While previous research has focused on distal foot width changes following surgery, this study introduces a novel midshaft measurement to assess proximal transverse midfoot width. The study aims to provide a comprehensive evaluation of foot width changes post-MISB. Methods: A retrospective review of prospectively collected data was conducted for 44 patients who underwent MISB for HV via an institutional outcome registry. Demographic data, surgical details, radiographs, and foot width measurements were collected. Changes in hallux valgus angle (HVA) and intermetatarsal angle (IMA) were also measured. The novel midshaft bony and soft tissue foot width measurements were included. Two independent observers conducted all preoperative and postoperative measurements. Results: Intraclass correlation coefficients (ICCs) demonstrated high interobserver reliability (all ICCs >0.70) for all measurements. MISB resulted in a consistent reduction in distal foot width, both bony (8.17%) and soft tissue (5.24%)(p 0.375, p

Category: Ankle; Sports Introduction/Purpose: Syndesmotic injuries may be associated with subsequent instability, even following operative fixation of etiologic fractures. The development of advanced imaging techniques like weightbearing computed tomography (WBCT) has enabled clinicians to identify subtle syndesmotic instability under physiologic conditions that would otherwise go undetected using conventional CT scans. Moreover, the normal reference ranges for the syndesmotic interval distance, area at 1 cm above the plafond, and volume 5 cm above the plafond have been established. These measurements, however, may be cumbersome and time-consuming to perform. This validation study aims to develop and evaluate the reliability of an automated algorithm that automatically segments WBCTs of the ankle and performs dimensional measurements. Methods: Five bilateral WBCT scans of individuals with operatively confirmed syndesmotic instability were included (10 ankles). An independent observer manually performed the anterior tibiofibular distance (ATFD) at 1 cm above the plafond, posterior talofibular distance (PTFD) at 1 cm above the plafond, the syndesmotic area (SA) at 1 cm above the plafond using 2D ROI, and the syndesmotic volume (SV) at 5 cm above the plafond using 3D ROI. Visage software was used to perform the measurements manually. The same WBCT scans were fed into the automated algorithm to perform the same measurements. The time required to perform the manual and automated measurements was recorded for comparison. The intraclass correlation coefficient (ICC) was measured for repeated automated measurements to evaluate the automation's consistency Results: The manual measurements required 19 (+/-4) minutes on average to perform for each case compared to 9 (+/-1) minutes for the automated measurements (P< 0.05). The ICC between the repeated automated measurements for each case was 0.99. Conclusion: Our automated syndesmosis dimension measurement tool can efficiently perform the ATFD, PTFD, SA, and SV measurements as reliably as an expert clinician would with significantly less time. Incorporating such a tool into existing healthcare software infrastructure, particularly in foot and ankle clinics, may expand the accessibility of this tool and provide immediate data for clinicians to support their decision-making in real time.

Category: Hindfoot; Other Introduction/Purpose: In addition to peri-talar subluxation of the foot, previous studies have demonstrated that the talus is more internally rotated with respect to the trans-malleolar axis of the ankle in PCFD patients compared with normal patients. However, no studies have investigated the change in rotation of the talus in PCFD postoperatively and its association with outcomes. The primary aim of this study was to investigate the preoperative to postoperative change in rotation of the talus following reconstruction of the flexible PCFD. Secondary aims were to determine whether changes in rotation of the talus were associated with radiographic measurements of PCFD or specific reconstructive procedures and whether postoperative talar rotation was associated with two-year patient-reported outcome scores. Methods: Thirty-four consecutive patients over the age of 18 years old who underwent reconstruction of a flexible PCFD with preoperative and at least 5-month postoperative weightbearing CT (WBCT) scans and plain radiographs and had preoperative and at least two-year postoperative PROMIS scores were included in the study. Patients were excluded if they underwent a talonavicular fusion. Talar axial rotation was the angle between the transmalleolar axis and talar axis on preoperative and postoperative WBCT scans as previously described by Kim et al (2023) with smaller angles representing more internal rotation. Hindfoot moment arm, Meary’s angle, and talonavicular angle were measured on plain radiographs. Due to small sample sizes, descriptive statistics are reported as median and interquartile ranges (IQRs). Wilcoxon signed rank and Mann Whiney U tests were used to investigate differences between groups. Spearman correlation coefficients were employed to detect associations between variables and reported using 95% confidence intervals (95% CIs). Results: Median preoperative and postoperative talar axial rotation were 39.9° (IQR 36.7°, 45.3°) and 49.7° (IQR 45.9°, 57.3°, P < 0.001), respectively. The talus externally rotated by a median of 8.3° (IQR 4.1°, 13.1°) following surgery. The preoperative to postoperative change in talar rotation was not associated with changes in any plain radiographic parameter (Table 1). Increasing external rotation of the talus was associated with an increase in postoperative PROMIS Pain Intensity (rho=0.38, 95% CI 0.00, 0.67) with similar trends in the PROMIS Physical Function (rho=-0.22, 95% CI -0.55, 0.18) and Pain Interference (rho=0.19, 95% CI -0.21, 0.53) domains (Figure 1). Lateral column lengthening and subtalar fusion procedures were not associated with changes in talar rotation (both P > 0.10). Conclusion: Reconstruction of the flexible PCFD distal to the talus results in external rotation of the talus within the ankle mortise. Talar rotation was not associated with common measures of deformity or specific procedures. Kim et al. found that control patients had approximately 40°-60° of talar axial rotation, which is similar to the corrected position of the talus in our study. However, increasing talar external rotation resulted in worse postoperative PROMIS Pain Intensity scores with a similar trend seen in other PROMIS domains and raises the possibility of overcorrecting the internal rotational deformity of the talus in flexible PCFD.

Category: Sports; Trauma Introduction/Purpose: Chronic Achilles tendon ruptures (CATR) adefined as those with a diagnosis or treatment exceeding four weeks present with retracted tendon ends and adhesions, complicating treatment and prognosis. Several surgical techniques including flexor hallucis longus (FHL) transfer, turndown flaps, V-Y advancement, and hamstring tendon transfer, have been described as treatment options, each with advantages, drawbacks, and potential complications. Despite the extensive use of patient-reported outcome measurements (PROMs) such as AOFAS, ATRS, and VISA-A, there is a lack of literature concerning comparative analyses of surgical options for CATRs. This study aims to describe the clinical and functional outcomes with each technique, and to providevaluable insights for evidence-based decision-making in the management of this pathology. Methods: This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered on the International prospective register of systematic reviews (PROSPERO, registration No. CRD42023444150). The inclusion criteria encompassed studies reporting clinical outcomes of CATR patients treated with isolated FHL transfer, hamstring tendon transfer, or turndown flaps. Clinical studies reporting at least one of the following outcomes were included: American Orthopedic Foot and Ankle Society (AOFAS) score or complications (wound complications, nerve injury, postoperative deep vein thrombosis, re-rupture, etc.). To be included, the studies had to provide sufficient data for extraction and pooling, including mean value, standard deviation (SD), and the number of subjects. Exclusion criteria comprised studies not published in English, less than 12 months of follow-up, and those with fewer than ten patients. Results: Eleven studies (295 patients) were included for isolated FHL transfer, 9 studies (168 patients) for hamstring transfer, and 6 studies (246 patients) for turndown flaps. All groups demonstrated a comparable improvement in AOFAS scores. The overall weighted complication rates were 4.1% in the Hamstring group, 6.1% in the isolated FHL group, and 12.6% in the turndown flap group. The complication rate in the Hamstring transfer group was significantly lower as compared to the turndown flaps group. The turndown flap group exhibited a significantly higher incidence of wound complications (12.5%, 95% C.I.: 8.4–16.5) compared to the isolated FHL (5.7%, 95% C.I.: 3.2–8.3) and hamstring groups (3.5%, 95% C.I.: 0.9–6.2). Conclusion: While all three techniques yielded comparable improvements in AOFAS scores for CATR management, turndown flaps were associated with a higher incidence of wound complications compared to the other two techniques. Enhanced study designs, incorporating direct comparisons of these different techniques within the same study setting, are essential. This approach will contribute to a clearer path towards identifying the optimal intervention and refining the standard of care for CATR patients.

Category: Hindfoot; Other Introduction/Purpose: As progressive collapsing foot deformity (PCFD) advances, narrowing between the lateral talar process and calcaneus at the angle of Gissane often occurs. This signifies more advanced peri-talar subluxation and may result in sinus tarsi impingement. However, the clinical significance of narrowing at the angle of Gissane and its effect on patient-reported outcomes following a flatfoot reconstruction is unknown. The primary aim of this study was to investigate if there was a relationship between preoperative talocalcaneal distance between the lateral talar process and calcaneus at the angle of Gissane and two-year postoperative outcomes in patients with flexible PCFD who underwent a reconstruction of their deformity. A secondary aim was to compare this cohort of patients to those who underwent a subtalar arthrodesis. Methods: Seventy-six consecutive patients >18 years old who underwent reconstruction of a flexible PCFD with (fusion cohort, n=40) or without (non-fusion cohort, n=36) a subtalar arthrodesis, had preoperative weightbearing CT (WBCT) scans, and had preoperative and ≥two-year postoperative PROMIS scores were included. Patient were excluded if they underwent a talonavicular fusion. Patients underwent a subtalar fusion if their chief complaint was lateral sinus tarsi pain. The talocalcaneal distance was measured on preoperative WBCT scans as the closest distance between the lateral process of the talus and the superior aspect of the calcaneus (Jeng et al 2018). Spearman correlation coefficients and multivariable regression analyses controlling for subtalar fusion were calculated between preoperative talocalcaneal distance and postoperative PROMIS scores. Due to the small sample sizes, descriptive statistics were reported as median and interquartile range (IQR), and differences between the non-fusion and fusion cohorts were determined using Mann Whitney U tests. Results: The median preoperative talocalcaneal distance for the non-fusion and fusion cohorts were 1.2 mm (IQR 0.75 mm, 1.7 mm) and 0.6 mm (IQR 0.1 mm, 1.1 mm, P=0.007), respectively. For the non-fusion cohort, there was no correlation between preoperative talocalcaneal distance and two-year postoperative PROMIS Physical Function (rho=0.198, P=0.891), Pain Interference (rho=-0.0136, P=0.891), and Pain Intensity (rho=-0.038, P=0.923). Similarly, there was no correlation between preoperative talocalcaneal distance and two-year postoperative PROMIS scores for the fusion cohort (all P>0.80). At two-years postoperatively, there was no difference in PROMIS scores between the non-fusion and fusion cohorts (all P>0.10) (Table 1). When controlling for talocalcaneal distance, there was no difference in postoperative PROMIS scores between the fusion and non-fusion cohorts (all P>0.30) (Figure 1). Conclusion: In PCFD patients undergoing a flatfoot reconstruction, there was no correlation between preoperative talocalcaneal distance and two-year postoperative patient-reported outcomes. Additionally, there was no difference in outcomes between patients who underwent a subtalar arthrodesis compared with patients who underwent a reconstruction even when controlling for talocalcaneal distance. Our results suggest that preoperative talocalcaneal distance is not an indication for subtalar arthrodesis. Additionally, patients indicated for a subtalar fusion for correction of their flexible PCFD deformity do not have worse outcomes than patients who did not undergo a subtalar arthrodesis regardless of preoperative talocalcaneal distance.

Category: Other; Basic Sciences/Biologics Introduction/ Purpose: Structural allografts have long been used in foot and ankle reconstructive surgery. Pre-contoured allograft wedges, manufactured in a variety of shapes and sizes for specific uses, have gained popularity in recent years due to their ease of use and ability to decrease operative time. A high rate of resorption of such pre-contoured allograft wedges was noted anecdotally by the senior authors, particularly in 2022. There is no known literature describing this phenomenon and thus, the purpose of this study was to identify the resorption and complication rates of pre-contoured allograft wedges over time. Methods: A retrospective review of patients who had a pre-contoured allograft wedge (Paragon28, Englewood, CO) implanted during foot and ankle surgery between 2017 and 2022 at a single institution by one of 10 surgeons was performed. Chart review was used to obtain demographic and implant information and confirm the surgical procedure(s) performed. Radiographic review was completed in order to identify patients with graft resorption and/or nonunion, confirm the site of allograft implantation, and determine the method of fixation used at the allograft site. A linear regression model was utilized to determine if there was a statistically significant association between the year and the number of cases of resorption. Results: In the 320 patients that met inclusion criteria, there were 334 wedges implanted. There were 24 grafts that resorbed and an additional 10 wedges that developed a non-union without resorption. Resorption was noted as early as 5.7 weeks post-operatively and as late as 36.6 weeks post-operatively (average 12.9 weeks). Of the allografts that resorbed, the majority were Lapidus wedges (38%) and Cotton wedges (56%) (Table 1). Resorption rates were highest in the last 2 years studied (Figure 1). Of the 78 wedges used in 2022, 11 wedges resorbed and there were 3 non-unions without resorption, for an overall complication rate of 18%. There was a statistically significant association between the year and the number of patients that had graft resorption (p = 0.03). Conclusion: While complications of allograft wedges in foot and ankle surgery have previously been described, including nonunion, resorption of pre-contoured wedges has not. Over a 5-year period at a single institution, there was a wedge resorption rate of 7% and an overall radiographic complication rate of 10%. There was an increase in allograft resorption cases as well as overall resorption rate and complication rate in 2022 compared to previous years. The majority of cases in which there was a complication occurred with the use of a Cotton or Lapidus wedge; however, no concrete identifiable patient or surgical risk factors were identified.

Category: Trauma; Ankle Introduction/Purpose: Syndesmosis fixation, a common procedure, is vital for restoring ankle biomechanics, but malreduction occurs in up to 52% of cases, necessitating precise anatomic reduction. While AO guidelines recommend a 20-30 degree trajectory in the coronal plane, the proposed ideal syndesmotic alignment is the line connecting fibula and tibia centroids. Intraoperatively determining the ideal fixation angle is challenging due to non-patient-specific and surgeon-dependent angular direction decisions. This study explores the angle bisector method's potential in establishing a patient- and level-specific syndesmotic fixation angle in cadavers, aiming for reproducibility independent of the surgeon. Additionally, the research assesses the safety of this method concerning major neurovascular structures for potential surgical application. By addressing these aspects, the study contributes to enhancing the precision and reliability of syndesmotic fixation procedures. Methods: Fixations on cadaveric leg specimens were conducted utilizing the angle bisector method at two levels (2 cm and 3.5 cm proximal) parallel to the tibial plafond. Two surgeons employed an open lateral approach for the procedure. The angle bisector method involved using a drill (2.8 mm) and screw (3.5 mm) directed along the bisector of the angle formed between two percutaneously placed K-wires (1.8 mm) at the fixation level, tangent to the anterior and posterior aspects of the fibula and tibia (Figure 1a). Subsequently, CT images of the cadavers were obtained (Figure 1b). The angle between the true centroidal axis (determined by software) and the axis of the screw placed with the angle bisector method was measured. Furthermore, distances between entry points of the centroidal axis and the screw were measured. Distances in millimeters between the positioned K-wires and major neurovascular structures were measured on cadaver dissections. (Sponsored by AOFAS-grant) Results: The mean angle between the centroidal axis and the trajectory of the screw was 2.7 degrees (±2.2, range 0-9.2 degrees) at the 2 cm level and 1.8 degrees (±2.1, 0-7.8 degrees) at the 3.5 cm level. At the 2 cm level, the average distance between the fibular entry points of the centroidal axis and the screw was 1.7 mm (±1.2, range 0-3.2 mm), while at the 3.5 cm level, it was 1.2 mm (±1.3, range 0-2.5 mm). The results exhibited low inter-surgeon variability (ICC > 0.80). The distance between the placed K-wires and major neurovascular structures consistently exceeded 5 mm, ensuring the safety of the technique, as none of these structures incurred damage. Conclusion: Our findings demonstrate that the angle bisector method offers a precise trajectory for syndesmotic fixation, proving its safety and efficacy in surgical applications. It can provide a more precise and patient-specific anatomical trajectory for syndesmotic implant compared to the conventional freehand technique, without increasing fluoroscopy exposure.

Category: Ankle; Trauma Introduction/Purpose: There has been limited investigation into physician reimbursement trends in foot and ankle procedures. The objective of the present study is to query a large, national insurance claims database to assess how utilization and reimbursement has evolved for ankle arthrodesis (AA) and total ankle arthroplasty (TAR) procedures from 2010 to 2021. Methods: A large national insurance claims database was queried for ankle arthrodesis and total ankle arthroplasty from 2010 to 2021 using Current Procedural Terminology (CPT) codes. Utilization rates, hospital reimbursement rates by payor (commercial, Medicare, Medicaid, Government, cash, other) and demographic data including gender, age, region, payor type, and service location were extracted. Subsequently, physician Medicare reimbursement rates were obtained from 2010 to 2021 using the Physician Fee Look-up Tool from the Centers for Medicare and Medicaid Services. Dollar values were then adjusted using the Consumer Price Index and are reported in 2023 US dollars. Trend analysis of utilization and reimbursement rates was then performed, with a p value of < 0.05 as significant. Results: A total of 16833 TAR patients and 33109 AA patients were identified by the query. Both procedures demonstrated a significantly positive linear trend in volume over the included time period, with increase from 2010 to 2021 of 30.28% (2453 to 3196 patients; p< 0.001) for AA cases and 140.64% for TAR (994 to 2392 patients; p< 0.001). Without consideration of inflation, Medicare physician reimbursement values were stable, demonstrating a non-significant increase for both AA (+2.67%) and TAR (+3.40%) over the included time period. On the other hand, after accounting for inflation, values declined across both AA and TA, with decrease from 2010 to 2021 of 16.78% ($1194.24 to $993.81; p< 0.001) for TAR procedures and 17.37% ($1368.26 to $1130.62) for AA procedures (Figure 1). Conclusion: Despite the growing number of Medicare beneficiaries and utilization of TAR and AA, the present data has demonstrated a decrease in Medicare reimbursement. Knowledge of such trends is important for the orthopedic field in order to advocate for sustainable reimbursement that supports the consistent delivery of high-quality patient care.

Category: Bunion Introduction/ Purpose: Hallux valgus deformity affects more than 35% of people over 65 years old. Surgical correction in this population can be more complicated due to the likelihood of poor bone quality, worse deformity, and post-operative recovery challenges associated with weight bearing restrictions. There is no consensus on which surgical option is the best in this age-group. Minimally invasive bunionectomy (MIS) has gained popularity, namely due to evidence showing reduced recovery time, earlier weight-bearing, and less post-operative pain which can eliminate the need for opioids, all of which are beneficial to older surgical patients. The purpose of this study was to compare the radiographic and clinical outcomes of patients age 65 and older who underwent either open Lapidus or minimally invasive chevron akin osteotomy for bunion correction. Methods: A retrospective review of prospectively collected data within an institutional registry was performed. We identified 62 patients age 65 or older who were treated surgically for hallux valgus (open Lapidus or minimally invasive chevron akin osteotomy) between January 2017 and August 2022 with at least 1-year post-operative PROMIS scores. Chart review was performed to obtain demographic information and to confirm the surgical procedures completed. Pre- and at least 6-month post-operative radiographs were measured to obtain the hallux valgus angle (HVA) and intermetatarsal angle (IMA). PROMIS scores were obtained pre-operatively and at one and/or two years post-operatively. Differences in demographic, clinical, and radiographic outcomes between cohorts were assessed using the Mann Whitney U test and p-values were adjusted for a false discovery rate of 5%. Results: Both the MIS and open cohorts showed significant improvement in radiographic measurements between pre- and post-operative radiographs (p < 0.001), though there was no significant difference between groups (p > 0.05). There was a clinically and statistically significant improvement within the PROMIS domain of Pain Interference for the open and MIS groups and Physical Function for the MIS group at 1 and 2-years post-operatively, however, there was only a significant difference at 2-years for the PROMIS Physical Function domain in the open group. No difference was noted in Physical Function at 1-year post-operatively for the open group or between groups (Table 1). Within the MIS and open groups, there was an overall complication rate of 26% in each group (p > 0.05). Conclusion: Patients in both the MIS and open surgical groups had improvement in radiographic measurements and PROMIS scores, though there was no clinical or statistical difference found between groups. Additionally, patients in the open group may take longer to improve as there was not a significant improvement in the PROMIS Physical Function domain until the 2-year post-operative time point. Further investigation of recovery metrics between techniques in the earlier post-operative time-point is warranted. Given the results, both MIS and open surgical techniques appear to be safe and effective in correcting hallux valgus in older patients.

Category: Diabetes; Other Introduction/Purpose: Treating chronic diabetic peripheral neuropathic pain poses significant clinical challenges due to variable outcomes and failed trials, along with the difficulty in objectively evaluating improvement and accounting for confounding factors. This study aims to investigate the treatment outcomes of three drugs (pregabalin, gabapentin, duloxetine) for chronic diabetic peripheral neuropathy. Methods: From June 2019 to June 2021, 180 patients with type 2 diabetes diagnosed with diabetic peripheral neuropathic pain received treatment with pregabalin, gabapentin, or duloxetine. The study protocol was approved by the institution’s IRB. Patients were consented and enrolled in a single Korean - center, prospective, randomized cohort study with 60 participants per drug group. Treatment lasted for 3 months, and participants were randomly assigned to groups at a 1:1:1 ratio using 3-multiple block randomization. Group 1 received Gabapentin (300mg bid), Group 2 received Pregabalin (75mg bidX mg ), and Group 3 received Duloxetine (30mg bid PO daily). Efficacy and safety were assessed every 2 weeks over a 6-week period. Baseline assessments included lipidemia profile, blood viscosity tests, BUN/Cr, OT/PT, and HbA1c. Clinical evaluations were performed using the Korean version of pain DETECT, categorizing degrees of improvement. Results: All treatments significantly improved painDETECT scores at 6 weeks of medication compared to their baseline (p=0.001). The mean HbA1c of the three groups showing symptomatic improvement by more than 50% was 9.424 (95% CI, 8.17-10.68) for Group 1, 10.430 (95% CI, 8.65-12.21) for Group 2, and 7.718 (95% CI, 6.74-8.70) for Group 3. There was no significant difference in HbA1c between Groups 1 and 2 regarding symptom improvement by more than 50%. However, the HbA1c of Group 3 was significantly lower than that of Groups 1 and 2 (p=0.001). Improvement of the symptom over 50% varied with HbA1c levels among three groups (p=0.001) . Adverse effects such as dizziness and nausea were significantly higher in the duloxetine group compared to pregabalin and gabapentin groups (p=0.001). Conclusion: All three medications effectively alleviated chronic diabetic peripheral neuropathic pain compared to their baseline level with no difference between the groups. However, HbA1c levels could be considered when selecting drugs because the HbA1c level when symptoms improve is different between the gabapentin, pregabalin, and duloxetine groups. There was no significant difference in the improvement of painDETECT scores in the three treatment groups up to the second week. However, by the sixth week, the pregabalin and duloxetine groups exhibited significantly more improvement in painDETECT scores than the gabapentin group (p=0.001).

Category: Other; Hindfoot Introduction/Purpose: The current classification system of progressive collapsing foot deformity (PCFD) is comprised of 5 classes that can occur simultaneously. Classes A-E indicate various deformities: hindfoot valgus, midfoot/forefoot abduction, forefoot varus/medial column instability, and ankle joint instability/valgus tilting in the ankle mortise, respectively. While the relationship between each of the PCFD deformities in the classification system to one another has been studied, to our knowledge, the correlation between the various classes and patient-reported outcomes has not been assessed. The purpose of this study was to evaluate whether the PCFD classification system is predictive of patient-reported outcomes and overall prognosis following surgery. The hypothesis was that patients with more severe deformity would have worse patient-reported outcomes. Methods: A retrospective review of prospectively collected data within an institutional registry was performed. We identified 74 patients aged 18 or older who were treated surgically for PCFD between October 2018 and October 2021 with preoperative, 1-year, and 2-year postoperative PROMIS scores. Chart review was performed to obtain demographic information and to confirm the surgical procedures completed. Using radiographs, weight-bearing computed tomography (WBCT), and office notes, patients were classified using the PCFD classification system. Patients were divided into two groups depending on whether subclasses D and/or E were present, indicating more severe deformity. Linear mixed models were used to assess longitudinal change in PROMIS scores between groups over time. Results: Patient demographic and classification characteristics are presented in Table 1. 47 patients were allocated to the Class D/E group and 27 patients were allocated to the No Class D/E group. Patients in the Class D/E group had worse pre-operative Global Physical Health (GPH) (p=0.018) and depression scores (p=0.012); however, post-operatively, there was only a difference in the PROMIS domain of Physical Function (PF) at both 1-Year (p=0.019) and 2-Year (p=0.038) time points (Table 2). There were no statistical differences between the two groups for any other domain at any timepoint (Table 2). Conclusion: Patients with more severe PCFD had clinically significant improvement in physical function at both 1- and 2-years post-operatively, but had worse outcomes compared to those with less severe deformity. The findings regarding preoperative GPH and depression suggest that while Class D/E patients did not perform as well functionally, they may be satisfied with their overall quality of life due to the similar scores postoperatively when compared to the patients with less severe deformity. Future studies are needed to better determine if the novel PCFD classification system is predictive of overall prognosis following surgery based on the various deformities present.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Hallux valgus(HV) is a triplanar deformity that includes the pronation of the first ray. Although there is little data regarding the effect of pronation on clinical outcomes, the rotational component of HV may play an important role. One study suggested that the modified Lapidus technique effectively decreased the pronation of the first ray. However, there is no evidence for alternative procedures such as minimally invasive(MIS) bunionectomy. This study sought to assess if MIS bunionectomy can effectively correct the first ray's pronation and determine the correlation with improved PROMIS scores. In addition, the association between postoperative first-ray pronation and the sesamoid station was investigated. We hypothesized a significant decrease in first-ray pronation after MIS bunionectomy, which would be associated with improved PROMIS scores. Methods: Sixty-three consecutive patients who underwent MIS bunionectomy with available pre- and at least 5-month postoperative WBCT-scans were included. Pre- and postoperative measurements of HV deformity, including the intermetatarsal angle(IMA) and hallux valgus angle (HVA) on plain radiographs, and triplanar pronation angle (TAP – a measure of first ray pronation) and sesamoid station from WBCTs, were performed as previously described. The TAP was referenced to the dorsal aspect of the second metatarsal base. Pre- and 1-year postoperative PROMIS scores were reviewed. Sample t-tests were used to compare pre- and postoperative values. The Kruskal-Wallis test assessed statistical differences between postoperative sesamoid station groups regarding postoperative TAP or IMA. Spearman rank (rho) was used to assess correlations between pre- to postoperative change in TAP with PROMIS scores in the physical function (PF), pain interference (PIF), and pain intensity (PI) domains. Scatterplots were simultaneously presented to visualize potential trends between TAP and PROMIS scores. Results: The mean TAP significantly decreased by 8.21º(95%CI -9.62,-6.8) after MIS bunionectomy (p< 0.05). Mean(SD) pre- and postoperative TAP values were 31.57º(8.3) and 23.36º(7.6), respectively. Similarly, mean HVA and IMA values decreased by 21.98º and 11.41º, respectively. Mean preoperative sesamoid station was 1.84, which decreased to 0.95 after surgery. Forty-four patients reduced their sesamoid position by one station. There was a statistically significant difference in TAP between postoperative sesamoid station groups (p=0.038). Mean(SD) postoperative TAP according to sesamoid station was 25.93º(6.2) for group 1, 23.83º(7.9) for group 2, and 18.75º(6.6) for group 3. No significant differences between groups were observed regarding IMA (p=0.25). There was a modest correlation between TAP change and PROMIS PF (rho = 0.046), PIF ( rho = -0.30), and PI (rho = -0.03). Conclusion: Our study suggests that MIS bunionectomy is an effective tool for reducing first-ray pronation in patients with HV. Although there was a statistically significant correlation between first-ray pronation and sesamoid station, our results showed that patients with higher first-ray pronation had less reduced sesamoids. Therefore, these should be considered separate deformities, and the sesamoid station shouldn’t be used as a guide for pronation correction. It appears that correction of the first-ray pronation is poorly associated with 1-year PROMIS scores. Consequently, future studies assessing mid-to-long-term effects of first-ray pronation on clinical outcomes, such as recurrence, are still warranted.

Category: Diabetes; Midfoot/Forefoot Introduction/Purpose: Wound healing in diabetic foot ulcers (DFU) poses challenges, requiring extensive debridement and amputations. Negative pressure wound therapy (NPWT) can be utilized for DFUs with large soft tissue defects to promote granulation tissue growth. The optimal timeframe for successful NPWT lacks extensive studies. Advanced wound scanning with a three-dimensional (3D) camera can enhance DFU area and volume calculations. This study aimed to investigate the efficacy of 3D wound assessment in predicting granulation tissue filling velocity following NPWT in DFUs. Methods: After receiving IRB approval from the single Korean center, a retrospective case series study was performed for 101 DFUs (Wagner classification 3 and 4) undergoing NPWT from September 2018 to June 2019. Demographic data, vascular patency, and wound characteristics were recorded. Wound was irrigated before NPWT. An infra-red 3D camera (inSight ® , eKare, Fairfax, VA, USA) was used to capture digital photographs. Wound area and volume were measured. Measurements were taken weekly from before treatment to one month after using inSight ® cloud software. The risk factors of diabetic foot ulcers related to wound healing were evaluated. Results: NPWT resulted in significant area improvements for open diabetic foot ulcers (p = 0.001). Postoperative 1-week area change velocity was 1.35 cm2/day, peaking at 2 weeks (1.84 cm2/day). Volume also showed significant improvement over time (p = 0.001), with a 1-week peak velocity of 1.20 cm3/day. All peak area and volume changes occurred within two weeks after NPWT application. Midfoot and hindfoot exhibited higher velocity of volume than forefoot (p = 0.001). Postoperative volume change was the fastest with a patent peroneal artery. Conclusion: 3D wound assessment for velocity of granulation tissue filled in an open DFU after NPWT could be effective to predict outcomes. Most wound healing following NPWT in DFUs was completed within two weeks. Application of NPWT for an additional two weeks did not significantly impact the completion of wound healing even though midfoot and hindfoot exhibited higher velocity of volume than forefoot.

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: The diagnosis of fractures can be challenging in specific medical settings due to limited expertise or time. While deep learning has shown promising results, its use is confined to the quality of images and the hassle of importing images to the models. This study aims to develop a model to detect fifth metatarsal fractures based on cell phone photos of radiographs directly taken from a regular screen. Methods: retrospective case-control study was conducted including patients aged > 18 years with fifth metatarsal fractures (n=1240) (Fx), and healthy controls (n=1224) (NoF). Three view radiographs (anterior, posterior, and lateral) were obtained from the Electronic Health Record (EHR) in PNG format. To generate a mixed-quality dataset, Android and iOS smartphones (SP) were used to create two separate datasets for each Fx and NoF group. Two separate deep learning models on each EHR, SP, and combined datasets were developed using Inception V3 architecture (Figure 1.). The models were also tested on a separate SP dataset (SP-test) that was not included in the development process. Area Under the Receiver Operating Characteristics Curve (AUC) along with other performance metrics were calculated and reported. Continuous data were presented as median (interquartile range), and a p-value of < 0.05 was considered to be significant. Results: Baseline analysis revealed differences between the groups with a median age of 56 years (36-68) for the Fx group, and 62 years (51-72) for the NoF group (p < 0.001). Similarly, the racial composition of the groups was also different (Fx: 84.8% white; NoF: 92.2% white; p < 0.001). Initially, the SP model showed the best performance (Youden Index (YI): 0.92, AUC: 0.99) followed by the EHR (YI: 0.74, AUC: 0.96), and combined (YI: 0.52, AUC: 0.97) models. When tested on the SP-test dataset the EHR model’s performance dropped markedly showing a YI of 0.33, an AUC of 0.78, and a sensitivity of 0.49 (Table 1.). However, the SP and combined models continued to perform optimally (YI: 0.94, AUC: 0.99; YI: 0.78, AUC: 0.98, respectively). Conclusion: This study highlights the crucial role of image quality in developing deep learning models for detecting fifth metatarsal fractures. Our findings demonstrate a markedly reduced performance of the EHR model in identifying fractures within lower-quality images. This emphasizes the need for training algorithms on images of varying quality to create more generalizable models capable of operating effectively across diverse settings.

Category: Other Introduction/Purpose: Orthopedic surgery is witnessing a substantial increase in fellowship training, with a notable shift from almost 50% practicing as "generalists" to less than 15% over the least 35 years. The Orthopaedic Fellowship Match has expanded to include various subspecialties, contributing to a favorable job market for fellowship-trained surgeons. However, the surplus of fellowship positions compared to graduating residents raises considerations regarding individualized selection processes and addressing disparities in the orthopedic field. Methods: A scoping review of the literature on orthopedic surgery fellowship choices utilized a literature search following PRISMA-ScR guidelines, which were subsequently analyzed using Covidence systematic review software; inclusion criteria encompassed primary, survey-based studies from 2010-2023, involving orthopedic surgery residents, fellows, attending physicians, and plastic surgery residents pursuing hand surgery fellowships, who completed their residency training in the United States. Data extraction involved compiling an evidence table encompassing respondent training levels, target demographics, survey types, factors considered, survey distribution details, response rates, results, and study limitations. Results: Intellectual curiosity dominated all other reasons for choosing fellowship among orthopedic residents across various studies, even when considering gender discrepancies and differing response measurement forms. The choice of surgical procedures also significantly influences the fellowship preferences of medical residents; factors such as the complexity and case variety, exposure to bread-and-butter cases, and surgical experience consistently emerge as crucial considerations in determining fellowship preferences, reflecting a common trend among applicants. Mentorship plays a pivotal role in residents' choice of subspecialty, particularly for female residents facing challenges finding mentors of the same gender. Other less prevalent contributing factors influencing a resident's decision in pursuing a specific fellowship include family commitments, financial debt, lifestyle preferences, previous research, and timing of their decision. Conclusion: The surge in orthopedic surgery fellowship training is marked by a substantial increase in graduates opting for subspecialization, driven by factors like intellectual interest, the nature of procedures in a specific fellowship, and mentor influence or experience. Our study emphasizes these factors as pivotal in residents' choices. However, the need for extensive prospective studies arises to conclusively ascertain if these influences remain consistent across all residents and if additional unexplored factors might play a more significant role in determining specific fellowship paths.

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Interdigital Neuroma (IN) is a benign enlargement of tissue surrounding the common plantar digital nerve. Traditionally, neurectomy has been performed as the standard surgical treatment for IN. However, recent attention has been given to less invasive surgical decompression by intermetatarsal ligament (IML) release with neurolysis. This study aims to compare the outcomes of IML release with neurolysis to traditional interdigital neurectomy. Methods: A retrospective chart review was conducted on 350 consecutive patients who underwent surgical treatment for IN. Patients who satisfied our inclusion and exclusion criteria were categorized into two groups based on the surgical treatment received: IML release with neurolysis or interdigital neurectomy. Inclusion criteria were patients older than 18 years with symptomatic IN, having an indication for surgical treatment following at least three months of unsuccessful conservative treatment, and at least 12 months of postoperative follow-up. Patients with concurrent procedures at the time of surgery, multiple affected web spaces, trauma to the affected forefoot, or asymptomatic IN without clear indications for surgical treatment were excluded from the study. Evaluated outcomes included recurrence of symptoms, rate of revision surgery, and postoperative wound infection. Results: Out of the 350 patients screened, 127 fulfilled the inclusion and exclusion criteria. Forty (32%) patients experienced recurrence of symptoms within a 12-month follow-up period with an overall mean time-to-recurrence of 3.96 +/- 3.15 months. Patients who underwent IML release with neurolysis had a significantly higher recurrence rate (48%) and mean time-to-recurrence of 4.61 +/- 3.22 months compared to those who underwent interdigital neurectomy (24%) with a mean time-to-recurrence of 3.47 +/- 3.08 months (P< 0.01). The rate of postoperative wound infection was similar between the two groups. The rate of revision surgery among those with symptom recurrence in the IML release group (16%) and neurectomy group (4%) was not statistically significant between both groups (P=0.49). Conclusion: IML release with neurolysis appears to have a higher risk of symptom recurrence compared to interdigital neurectomy. However, patients who did experience symptom recurrence in either operative group had similar rates of revision surgery, which may be due to mild recurrent symptoms in the IML release group that did not warrant revision surgery in these patients. No patient-specific factors were identified as being associated with symptom recurrence. Future studies should consider objective symptom recurrence severity and patient satisfaction.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Third-generation minimally invasive (MIS) bunionectomy requires a lateral shift of the metatarsal head, pushing the shaft into adduction and levering off the 1st-tarsometatarsal (TMT) joint. A previous study on plain radiographs reported postoperative 1st-TMT joint slippage in the transverse plane, with a medial subluxation of the 1st metatarsal base. However, risk factors and clinical implications have yet to be determined. This study sought to assess the prevalence of postoperative 1st-TMT joint slippage in the transverse plane and to identify associated risk factors using weight-bearing CT (WBCT) scans. In addition, the effect of 1st-TMT slippage on postoperative midshaft foot width was investigated. We hypothesized that postoperative 1st-TMT slippage in the transverse plane would be associated with preoperative 1st-TMT instability and increased postoperative midshaft foot width. Methods: Sixty-three consecutive patients who underwent MIS bunionectomy with available pre- and postoperative WBCT-scans were included. Radiographic measurements included hallux valgus angle(HVA), intermetatarsal angle(IMA), and midshaft foot width, measured from the 1st metatarsal shaft to the 5th metatarsal head on AP-foot radiographs. Tri-planar rotation angle(TAP), and 1st-TMT plantar-gap and medial-middle(MM) intercuneiform distances(mm) were obtained from WBCTs. Two raters measured pre- and postoperative 1st-TMT distances between the most lateral aspect of the medial cuneiform and 1st metatarsal base at the dorsal, central, and plantar thirds on axial cuts. The average corresponds to the overall 1st-TMT lateral distance, a measure of 1st-TMT slippage. Rater agreement was assessed. Paired t-tests were used to compare pre- and postoperative values. Logistic regression models were used to investigate the association of postoperative 1st-TMT lateral distance with potential risk factors (preoperative 1st-TMT lateral distance, 1st-TMT plantar-gap distance, IMA, TAP, and MM intercuneiform distance) and postoperative midshaft foot width. Results: The interobserver reliability of the 1st-TMT lateral distance was excellent (r=0.97). Mean (SD) 1st-TMT lateral distance increased from 0.26 mm(0.4) to 1.33 mm(0.9) after surgery(P< 0.05). Postoperative 1st-TMT lateral distance was > 2 mm in 15 patients(24%), and > 1 mm in 33(52%). Mean(SD) dorsal 1st-TMT lateral distance (2.7mm[1.3]) was significantly higher than central (0.85mm[1.1]) and plantar (0.55mm[0.99]) 1st-TMT lateral distances. Mean(SD) midshaft foot width increased from 80.04mm(6.7) to 84.25mm(6.1) postoperatively (P< 0.05). Regression analysis showed that pre- and postoperative 1st-TMT lateral distances were correlated (Coef=0.64,P=0.02), and identified a 1 mm increase in postoperative 1st-TMT lateral distance with each 0.63 mm increase in preoperative 1st-TMT plantar-gap distance (Coef=0.63,P=0.008). A significant positive correlation was also observed between postoperative 1st-TMT lateral distance and postoperative midshaft foot width (Coef=1.43,P< 0.05). Conclusion: Our study suggests a possible association between postoperative 1st-TMT joint slippage and preoperative 1st-TMT multiaxial instability following MIS bunionectomy. This raises an important question as to whether alternative techniques, such as modified Lapidus, should be preferred over MIS bunionectomy in patients with 1st-TMT instability. Notably, medial slippage was significantly higher at the dorsal aspect of the 1st-TMT joint, suggesting a component of rotational instability. It appears that 1st-TMT slippage is associated with a wider midshaft foot width postoperatively, and patients should be warned about it. Future studies assessing mid-to-long-term effects of 1st-TMT slippage, like recurrence or degenerative changes, are warranted.

Category: Ankle; Sports Introduction/Purpose: Osteochondral lesions of the talus (OLT) commonly arise after chronic ankle sprains and fractures. Conservative treatment is the first step, yet surgical intervention is often warranted in patients with persistent symptoms. The effect of social determinants of health (SDOH) on treatment outcomes of this patient population has rarely been investigated to date. Methods: Patients with OLT who were 18 years of age and older and underwent operative treatment, with at least one patient-reported outcome and SDOH data available, were included. Patient-Reported Outcome Measures (PROMs) and Visual Analog Scale (VAS) pain scores were collected, and their trends were analyzed based on the patients’ SDOH, including Area DeprivationIndex(ADI)andSocialVulnerabilityIndex(SVI). Pre-operativePROMsorVAS pain scores had to have been collected within 90 days of surgery, immediate post-operative PROMs or VAS scores were recorded within 90 days of surgery were and post-operative PROMs or VAS scores within 180 days (± 30 days). Exclusion criteria were presence of concomitant pathologies such as fractures, bone lesions, cysts, foot and ankle deformities, presence of hardware, and lack of follow-up visits and lack of any patient reported outcomes in their profile. A P-value < 0.5 was considered statistically significant. Results: 109 of 551 confirmed patients with OLT met the inclusion criteria. Significant correlations were found between SDOH and PROMs, elucidating disparities in pain scores, physical function, and depression. A multitude of SVI components, but most profoundly overall SVI, and ADI rank, were found to be significantly correlated to VAS pain scores (Table 1.). Furthermore, insurance status showed a significant impact on pain intensity and depression measures. Nuanced influences of race, insurance status, and social vulnerability were observed. Conclusion: This study shows that SDOH have a significant effect on postoperative PROMs and VAS scores. Based on our results, these most prominently include overall SVI, insurance status, ethnicity, and race. Systemic interventions guided by neighborhood-level measures of disadvantage are key in advancing health equity.

Category: Diabetes; Midfoot/Forefoot Introduction/Purpose: The therapeutic efficacy of negative pressure wound therapy (NPWT) in treating skin defects in diabetic foot ulcers has been demonstrated, although the management of bacterial biofilms remains controversial. Limited clinical data exist on outcomes when utilizing polyhexamethylene biguanide (PHMB) alongside NPWT. This study aims to assess the efficacy of PHMB in diabetic foot ulcers compared to conventional methods during NPWT. Methods: After receiving IRB approval from a single center Korean institution, sixty patients with Wagner 3 or 4 diabetic foot ulcers undergoing open amputation of forefoot and midfoot were included from March 2020 to August 2021. NPWT was administered at two-day intervals post-amputation by an expert surgeon affiliated with the institution. Patients were assigned to 3 different adjuvant therapies; 1) Saline; 2) povidone iodine; and 3) hydrochloric PHMB irrigation solutions. Bacterial cultures were performed, assessing time to negative bacterial culture. Wound analysis utilized a three-dimensional infrared camera (inSight ® , eKare, Fairfax, VA, United States) to measure volume and area continuously and its correlation of risk factors. Results: Patients with hydrochloric PHMB therapy exhibited faster wound recovery rates in terms of volume and area compared to those treated with saline and povidone iodine solutions (p=0.001) (Figure 4 and 5). Hydrochloric PHMB and povidone iodine groups showed significantly shorter times to bacterial negativity compared to the saline group (p=0.001) (Figure 6). HbA1c, body mass index, dialysis status, age, smoking history, and diabetes duration did not significantly impact wound recovery rates. Conclusion: Hydrochloric PHMB with NPWT can be useful to treat open diabetic foot ulcers, with a high wound recovery rate and moderate antimicrobial efficacy, as the combination decreases wound toxicity and intermediate bactericidal effects in comparison to normal saline and povidone-iodine solutions.

Category: Ankle; Trauma Introduction/Purpose: Osteochondral lesions of the talus (OLT) impact both sedentary individuals and athletes, affecting both daily function as well as athletic performance. Purported causations include trauma, genetics, and hypovascularity. Although it is known that the talar dome’s vascularity is mainly supplied the posterior tibialis artery (PTA) and to a lesser degree the sinus tarsi artery (STA), the pathophysiological impact of talar dome hypovascularity on OLT remains poorly studied. Our first hypothesis was that the patients with OLT have a lower diameter of PTA (dPTA) and STA (dSTA), and the second hypothesis was that among the group of the patients with OLT, the patients that require surgery have a lower d PTA and dSTA. Methods: This was a retrospective study that included 77 patients with OLT, and for the control group 77 patients with peroneal tendinitis. To mitigate the effect of comorbidities the patients between 30 to 40 years of age were included and the ones with a history of smoking, diabetes, rheumatologic, and peripheral artery diseases were excluded. The dPTA measurements were done in three different levels for all groups: at the level of 1 cm above plafond, at the level of plafond and at the level of medial malleolar tip (MMT). dSTA was measured at the level of talar neck. Area, volume, depth, and localization of OLT were recorded, as well. Results: The study group had significantly lower dPTA at three levels (1.05±0.22mm, 0.99±0.18mm, 0.98±0.31mm, proximal to distal) compared to the control group (1.25±0.23mm, 1.20±0.22mm, 1.14±0.18mm, proximal to distal) (P< 0.001). The dSTA was also lower in study group as compared to control group (0.5±0.11mm vs. 0.57±0.08mm, respectively P=0.001). ROC Curve analysis revealed the cutoff values for OLT occurrence after ankle injury as; 1.115 mm for the level of 1 cm above plafond, 1.075 mm for the level of plafond,1.055 mm for the level of MMT, 1.085 mm for mean dTPA and 0.5665mm for dSTA (Table-1). A significant negative correlation was observed between OLT size area (mean: 42.24±24.76 mm 2 ) and arterial diameters (P< 0.01, P< 0.01, and P=0.014 for three different levels of dPTA and P< 0.001 for dSTA). Conclusion: Smaller dPTA and dSTA appear to be associated with the occurrence of OLT, with the defect size inversely correlated to arterial diameters. The determined cutoff values for dPTA may help clinicians identify high risk patients to develop OLT after an acute ankle injury. Further elucidation of these vascular abnormalities, particularly dPTA, could hold significant prognostic potential and be used to predict disease progression as well as the likelihood of surgical success in OLT treatment.

Category: Bunion; Other Introduction/Purpose: Hallux valgus (HV) is a prevalent forefoot deformity that leads to pain, stiffness, and difficulties with footwear. Conventional diagnosis of HV relies on clinical and radiographic examination, which can be cumbersome and expose patients to ionizing radiation. The emergence of 3D scanning technologies, such as structured light, integrated into smartphones, presents a novel approach to early detection and diagnosis of HV, potentially allowing for earlier intervention and subsequent reduction in the progression of the deformity. Methods: This prospective non-randomized clinical trial recruited patients from the foot and ankle clinic, identifying cases and controls based on the presence or lack of clinically diagnosed HV. Patients older than 18 years of age and able to consent were included. The 3D scanning of the foot utilized structured light technology integrated into smartphones, with an algorithm developing a surrogate angle for HV detection. This angle was correlated with conventional radiographic measurements, including hallux valgus angle (HVA) and intermetatarsal angle (IMA) from weightbearing radiographs. A cluster analysis assessed the algorithm’s capacity to identify deformity severity according to radiographic severity grading. The algorithm's accuracy and performance were assessed using the area under the receiver operating characteristic curve, precision-recall Curves, and the leave-one-out cross-validation method. Results: 120 patients were enrolled in this trial. Out of 240 feet examined, HV was present in 29.1% of cases. The algorithm's surrogate angle showed a robust correlation with the clinical hallux valgus angle (HVA), with a correlation coefficient of 0.91 and a specificity of 0.882. Notably, the surrogate angle's correlation with the intermetatarsal angle (IMA) was also significant, albeit lower (r = 0.65). The area under the ROC curve (AUC) was 0.947, and the precision-recall AUC scores for positive and negative classes were 0.89 and 0.92, respectively. These metrics confirmed the algorithm's potential as a reliable diagnostic tool for detecting HV and determining its severity through non-invasive, commonly available smartphone technology. Conclusion: This study validates the accuracy of a smartphone-based 3D scanning algorithm in detecting and grading HV deformity, providing a low-cost, accessible decision-support tool for physicians and patients. This approach could improve early detection, reduce the need for clinical visits, and potentially expand to remote monitoring of HV and other pathologies, aligning with the growing trend of telemedicine and personalized healthcare.

Category: Hindfoot; Trauma Introduction/Purpose: Fractures of the calcaneus are the most frequent form of fractures among the tarsal bones. The treatment plan depends on various fracture characteristics, particularly the extension of the fracture line into the subtalar joint surfaces. While X-rays are the primary diagnostic tool, Computed Tomography (CT) scans are often necessary as they provide a more detailed description of these fractures, especially if the articular surfaces are involved. Although informative, CT scans expose patients to higher doses of ionizing radiation, and they might not be readily available in certain settings. This study aims to develop a deep learning model that will first detect calcaneal fractures and then classify the type of fracture based on its extension into the subtalar joint surfaces. Methods: A retrospective case-control study was conducted. Patients aged >18 years who sustained a calcaneal fracture were included in the case group, along with the same number of healthy adults for the control group. Various X-ray views of the foot including anterior, posterior, lateral, along with the axial and lateral calcaneal views were obtained. Two experienced orthopaedic researchers screened the dataset and confirmed the type of fracture. Two models were developed using an Inception V3 architecture and a split ratio of 60:20:20 for training, validation, and testing purposes. The first model was designed for fracture detection, and the second one was designed for detecting intra-articular fracture extension, if present. Conventional model metrics including sensitivity, specificity, Youden index, area under the receiver operating characteristic curve (AUC), and F1 score were reported for each model. A p-value below 0.05 was statistically significant. Baseline values are presented in median and interquartile ranges (IQR). Results: A total of 1102 individuals (n=551 for each group) with a female-to-male ratio of 1.6:1 were included. Baseline comparisons showed a significant difference in the age of the groups [cases: 55 (IQR 42, 67) years; controls: 62 (IQR 51, 72 years), p-value < 0.001]. The first model for fracture detection demonstrated a high performance with an AUC of 0.99 and a Youden index of 0.96. The intra-articular fracture detection model showed a slightly lower performance with an AUC of 0.97 and a Youden index of 0.88 (Table 1, Figure 1). Conclusion: Our study showed promising results with the utility of deep learning methods for detecting calcaneal fractures and classifying intra- vs extra-articular fractures. This algorithm may help facilitate the diagnosis and treatment of patients with suspected calcaneal fractures, serving as a decision-support tool in settings where CT scanning is not available.

Category: Trauma; Ankle Introduction/Purpose: Syndesmosis injuries, often involving the posterior malleolus (PM), are common in rotational ankle fractures. Concomitant intra-articular involvement, along with deltoid ligament rupture and open reduction and internal fixation (ORIF) affects outcomes predisposing to postoperative complications. Our study aims to investigate the outcomes of posterior malleolar fractures with concomitant syndesmosis injuries and identify prognostic factors associated with these injuries. Methods: This retrospective study investigated posterior malleolar ankle fractures with syndesmotic injury in 71 patients between January 2004 and March 2021. Among these, there were 54 cases of trimalleolar fractures and 17 cases of trimalleolar equivalent fractures. After receiving IRB approval from a single Korean center institution, demographic data, revision surgeries, syndesmotic implant removal, deltoid ligament rupture, deltoid ligament repair, types of implants, and insurance status were evaluated by an expert surgeon affiliated with the institution. Weight-bearing plain radiographs were analyzed for various parameters including superior and medial clear space (MCS), tibiofibular overlap, tibiofibular clear space, implant height, fibular shortening, and synostosis. Radiographic parameters were recorded preoperatively, postoperatively, at 3-month follow-up, and final follow-up. CT scans were utilized to assess posterior malleolar fracture involvement and evaluated using the Haraguchi classification. The severity of ankle joint obliteration was determined. Fibular shortening and synostosis presence were assessed from follow-up radiographs. Results: All radiographic parameters showed significant improvement over time (p-=0.001). No significant differences were found between groups with and without deltoid ligament rupture, except for postoperative 3-month TFO, which showed a significantly higher value in group of the deltoid ligament rupture (p=0.001). Fixation of the posterior malleolar fracture was significantly associated with a preoperative MCS with optimal cut off value of 3.72 mm as absolute value and 84% as the percent divided by the superior clear space as in area under curve (p=0.001, AUC=0.717). Male sex was significantly associated with unexpected syndesmotic implant removal. Deltoid rupture was significantly associated with postoperative ankle osteoarthritis. Preoperative TFC and ORIF of the posterior malleolar fracture were negatively associated with postoperative ankle osteoarthritis. Conclusion: A preoperative medial clear space measurement of 3.72 mm or more in posterior malleolar fractures with syndesmotic injury may be beneficial in deciding the fixation approach for posterior malleolar fractures. Male gender is identified as a risk factor for unplanned removal of syndesmotic implants. Deltoid ligament rupture, preoperative tibiofibular clear space (TFC), and the need for posterior malleolar fixation may be regarded as risk factors for postoperative ankle osteoarthritis.