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Category: Other Introduction/Purpose: As the field of foot and ankle surgery grows and new innovations continue to be made it is important that the quality of research improves. This will help to lay a strong foundation for current and future surgeons in the field. Leading journals need to set the tone for all orthopedic journals by publishing quality literature. This current study will look at all foot and ankle articles published by JBJS[A] over a 15-year period and analyze authorship, article type, geographic origin of articles, and level of evidence trends. This study will give a representative view of where foot and ankle research is currently and where it can go as we enter the new decade. Methods: A foot and ankle research fellow reviewed all of the articles published in JBJS[A] from January 2004 to December of 2018. Articles that related to foot and ankle topics were then selected to analyzed. Editorials, letters to the editor, announcements, technical notes, retraction notes, events, errata, retracted manuscripts, historical papers and pediatric foot and ankle articles were excluded. After exclusions were applied 321 and information pertaining to each article was analyzed. Additionally, a Google Scholar search was conducted for each article to determine the number of times an article had been cited. For calculations relating to median number of citations for each article we excluded articles that were published less than three years ago (2017 and 2018). For level of evidence a kappa value (0.82) was calculated to measure interobserver reliability between two reviewers. Results: We found the following results to be significant. Clinical therapeutic studies were the predominant study design over 15 years. The amount of literature over ankle arthroplasty has increased more than any other article topic. The amount of level IV and V evidence has decreased and the amount of level II and III evidence has increased. The median number of authors has been increasing. This includes female authorship. There has been in an increase in MD, PhDs as last authors. There is more foot and ankle research being produced by Asian countries. A majority of high level of evidence articles (level I and II) comes from North America and Europe. Level of evidence doesn’t correlate with the amount of times an article is cited. Conclusion: As the field of foot and ankle surgery continues to grow it is important that there is a high quality of research being conducted and published to guide surgical and clinical decisions. Our study shows that research is being produced more globally and the number of individuals involved in the research process is increasing and diversifying. This has led to higher quality research being produced (more level II and III) and a decrease in lower quality research (IV and V). Overall, the standard of research has increased in JBJS[A] which benefits the foot and ankle surgery community.

Category: Ankle, Basic Sciences/Biologics Introduction/Purpose: Until recently, many regional anesthetic blocks were performed without the assistance of ultrasound, relying on methods such as anatomical landmarks and nerve stimulation. The use of ultrasound for peripheral nerve blocks has proven extremely useful for improving the efficacy of many regional anesthetic techniques. There remain a few nerve blocks which have lagged in employing the assistance of ultrasound consistently, one of which is the ankle block. This block is commonly utilized for either surgical anesthesia or post-operative analgesia for a variety of foot and ankle procedures. In this study, we compared the accuracy of traditional landmark technique with an ultrasound guided approach for ankle block by assessing the spread of injectate (dye) along the posterior tibial nerve (PTN) in cadaver models. Methods: Ten below-knee cadaver specimens were used for this study. Five were randomly chosen to undergo landmark guided PTN blocks, and five were selected for ultrasound-guided PTN blocks. The landmark technique was performed by identifying the medial malleolus and Achilles tendon and inserting the needle (4 cm long, 21G Braun® Stimuplex) at the midpoint of the two structures, aiming toward the medial malleolus and advancing until bone was contacted. 2 cc of blue acrylic dye was injected at this location. The ultrasound technique was performed with a linear probe identifying the medial malleolus and the PTN. The needle was advanced in-plane with a posterior to anterior trajectory until the tip of the needle was adjacent to the nerve. 2 cc of blue acrylic dye was injected surrounding the nerve. The extremities were then dissected to determine which nerves had been coated with dye. Results: 100% of the ultrasound guided blocks resulted in completely stained PTN with dye. In the landmark group, only 40% of the landmark technique blocks resulted in completely stained PTN with dye. Of the nerves not stained with dye, 2 were noted to have had dye injected posterior to the nerve and 1 was noted to have had dye injected into the flexor digitorum longus tendon. Conclusion: The base of evidence has dramatically increased in recent years in support of the use of ultrasound in regional anesthesia. This study substantiates the superiority of ultrasound guidance for ankle block by demonstrating a 100% success rate amongst the ultrasound guided group.

Category: Midfoot/Forefoot, Trauma Introduction/Purpose: Several controversies persist regarding fracture treatment of the fifth metatarsal base. Due to its low blood supply, Jones fracture has an inherent difficulty of consolidation, and may devolop complications such as delayed union, non- union and refracture. Usually the Jones fracture treatment is done with extended period of non-weightbearing with either nonoperative or operative treatment. The surgery is indicated particularly in athletes or in the setting of nonunion or fracture displacement. The purpose of the present retrospective case series is to assess postoperative outcomes among patients who weight bear earlier than standard practice. Methods: We performed a retrospective analysis of the medical and radiographic records from patients who had undergone operative IM fixation of an acute isolated Jones fracture from May 2013 and August 2018. Patients were permitted to weight- bear as tolerated. Demographic information, such as age, gender, body mass index, the use of tobacco, presence of medical comorbidities, and the time of radiographic union were evaluated. Standardized radiographs at 2 weeks, 6 weeks, 3 months and 6 months after surgeries were chosen for evaluation. Radiographic union was defined as bridging in 2 of 3 (medial, lateral, plantar) cortices. Results: Twenty one patients were included for analysis. Of these, 14 had at least one comorbidity present at time of operation. Average BMI was 37.6, and average age was 44.8. One patient (4.8%) was lost to follow up, and therefore did not have radiographic results available for review at any appointment. At 6 weeks, 16 of 21 patients showed signs of radiographic healing; 8 were completely healed, and 8 were incomplete. One patient (4.8%) had nonunion, which was documented at 6 week, 3 month, and 6 month readings. None of the 21 patients experienced any other postoperative complications, including infection, wound dehiscence, sepsis, DVT, implant failure, or need for revision surgery. Conclusion: Patients who were subjected to early weight-bearing after fifth metatarsal Jones fracture surgery had satisfactory fusion rates with no additional postoperative complications, even despite having high average BMI and multiple comorbidities. We believe that patients can be treated with early weightbearing as tolerated after operative fixation of an acute Jones fracture, and achieve satisfactory outcomes comparable those associated with traditional postoperative protocols.

Category: Basic Sciences/Biologics, Midfoot/Forefoot Introduction/Purpose: First tarsometatarsal (TMT) joint fusion is indicated for several underlying causes of first ray dysfunction and pain, including arthritis, traumatic injury, and recurrent hallux valgus. Preparation of the joint surface by denuding the articular cartilage is a key step for arthrodesis, as inadequate preparation may result in poor fixation and non-union. However, excessive removal of cartilage and bone may result in excessive shortening of the ray. Despite the importance of joint preparation on the outcomes of fusion, the effects of using a bone saw versus osteotome on ray length is poorly documented in the literature. The purpose of this study was to investigate whether utilization of an osteotome or saw would minimize shortening of the first ray in TMT arthrodesis. Methods: Ten fresh-frozen cadaver specimens without evidence of musculoskeletal abnormalities were used for this anatomic dissection study. A medial incision was made along the first ray from the medial aspect of the medial cuneiform to the base of the first metatarsal. The first TMT joint was exposed through transverse capsulotomy. The soft tissues surrounding the joint were not removed from the bone. The specimens were randomly assigned to undergo cartilage removal and joint preparation using either an osteotome (n=5) or saw (n=5). Care was taken to reach the plantar-most aspect of the joint. Fusion was then performed using a cross-screw construct through the dorsal aspect of the proximal phalanx and the medial cuneiform. Pre- and post-operative x- rays were taken with a radiopaque ruler in the field, and length changes were compared between osteotome and sawblade groups. Results: The average change in metatarsal length was significantly smaller in the osteotome group (1.6 mm) as compared to the saw group (4.4 mm) (p=0.031). The average percent change in metatarsal length was also significantly smaller in the osteotome group (3.0%) compared to the saw group (8.4%) (p=0.025). There was no significant difference between the two groups with respect to change in cuneiform length. The osteotome group demonstrated a significantly smaller average measured change (3.0 mm vs. 6.9 mm, p=0.001) and percent change (4.1% vs. 9.3%, p

Category: Foot & Ankle Surgery Introduction/Purpose: Prescription opioids are commonly used to control postoperative pain in foot and ankle surgery, but present potentially detrimental side effects including sedation, respiratory depression, and addiction. In foot and ankle surgery, pain is a common cause of delayed hospital discharge and decreased willingness to move, thereby slowing recovery. Gabapentin acts by decreasing lesion-induced hyperexcitability of posterior horn neurons and central sensitization, and has been explored as a potential addition to patients’ pain regimen. Although studies have previously assessed the effect of gabapentin on pain relief, to our knowledge none have evaluated whether gabapentin is effective in opioid consumption reduction beyond the immediate postoperative period. This study aims to assess whether gabapentin acts synergistically to improve postoperative pain among patients undergoing foot and ankle surgery. Methods: Patients from a single institution who underwent elective foot and ankle surgery were identified using CPT codes 27700, 27702, 27870, 28705, 28715, 28725, 28730, and 28740. Those prescribed opioids postoperatively were included. A retrospective chart review was conducted for each patient to identify prescription dose, number of pills, date in which prescription was filled, and dates of refills for oxycodone, hydrocodone, oxycodone-acetaminophen, hydrocodone-acetaminophen, tramadol, and gabapentin. Medication information was collected only for prescriptions by the operating surgeon, nurse practitioner, physician assistant, resident, or fellow which were pertinent to the foot/ankle surgery performed; prescriptions from other services or providers were not included in order to ensure that the medications prescribed were specific to postoperative pain. Opioid quantities were converted to morphine equivalents and compared at various time intervals between patients who were prescribed only opioids, and patients who were prescribed opioids and gabapentin. Results: Among patients prescribed gabapentin plus opioids, total opioids prescribed (in morphine equivalents, OME) was 68.33, 221.25, 87.50, and 400.83 at weeks 1-2, 3-6, 7-12, and greater than 12, respectively. Although not statistically significantly different, patients prescribed only opioids had greater average amounts of opioids prescribed at all time intervals, equaling 98.34 OME, 553.52 OME, 540.53 OME, and 766.25 OME at weeks 1-2, 3-6, 7-12, and greater than 12, respectively. When excluding patients taking opioids preoperatively, total morphine equivalents prescribed was significantly less among patients prescribed gabapentin (196.94 OME) in comparison to those prescribed only opioids (457.41 OME) (p=0.0255). Conclusion: The findings of this study suggest that gabapentin may be effective in reducing postoperative opioid consumption beyond the immediate postoperative period among elective foot and ankle surgery patients. Gabapentin may be particularly beneficial within the three to six week postoperative period. Prospective clinical trials are warranted to further validate these results.

Category: Foot & Ankle Introduction/Purpose: Medical coverage gap in United States refers to people who are uninsured because the state they are living has still opted-out of Medicaid expansion under Patient Protection and Affordable Care Act (PPACA) and they are too poor to be benefited from subsidies designed for middle-class Americans. A large percentage of this population lives in south. Despite increasing participation of the states in expanded Medicaid, it is still unclear that if such an expansion has led to improve the access to care. However, approximately one in three American is covered under Blue Cross Blue Shield (BCBS) private insurance. The purpose of this study is to determine the access to foot and ankle care based on medical insurance, nature of illness and Medicaid expansion of the state. Methods: Five pairs of Medicaid expended (California, New York, Ohio, Minnesota and Washington) and non-expanded (Utah, Texas, Alabama, Missouri, and North Carolina) states with different geographic location were selected for the study. Twenty providers from each state were randomly selected via American Orthopedic Foot & Ankle Society (AOFAS) directory with private or academic affiliations. Each provider’s office was contacted by fictitious call for the earliest available appointment in foot and ankle clinic. A standardized script was used by the same researcher every time for a 30 year old male patient with acute Achilles tendon rupture or chronic bunion with either Medicaid or BCBS insurances. Available appointment for physician was considered as an access to foot and ankle care. We registered time until appointment (if given) and reason for denial (if denied) on phone. We also recorded requirements for insurance details, PCP (Primary Care Physician) referral or imaging records. Results: 200 providers’ offices were contacted on phone for foot and ankle clinic appointment. Successful appointment was given by 36%(72/200) offices irrespective of condition and insurance. 29% of calls with Medicaid could successfully schedule an appointment compared to 43% when calling with BCBS(P=0.03). Success rate for appointment was same for Achilles rupture and Bunion (36% each). The mean time until earliest appointment was 10.7(range 1-37) days with Medicaid and 10.5 (range 1-45) days with BCBS. For Medicaid patients, no significant difference was found in appointment rates between expanded states (30%) and non-expanded (28%) states (P=0.82). Overall appointment success rate was highest in Utah (65%) and lowest in New York (10%). Differences were observed across geographical locations, as well as between academic and private institutes. Conclusion: In our study, access to foot and ankle care clinic seems to be significantly better with BCBS private insurance compared to Medicaid. Sample size is surely a limitation, but we have included more states than similarly-designed studies for better geographic variability. There was no significant difference for appointment wait-time between Achilles tendon rupture and Bunion as well as Medicaid and BCBS insurance. Medicaid expansion facility in the state has not been associated with higher success rate but associated with lengthening of wait-time. Inability to provide insurance details or PCP-referral is definitely an important barrier for the access to podiatric care.

Category: Midfoot/Forefoot Introduction/Purpose: Although the first metatarsophalangeal joint sesamoids have biomechanical value in the foot, pathologic conditions of these sesamoids are a source of disabling pain for patients, particularly during toe-off. Underlying causes include acute fracture, acute separation of bipartite sesamoids, sesamoiditis caused by repetitive trauma, infection, chondromalacia, osteochondritis dissecans, and osteoarthritis. Nonoperative treatment is the initial standard of care and has satisfactory outcomes overall, but operative management may be indicated in cases of pain refractory to conservative management. Surgical management includes tendo-Achilles or gastrocnemius lengthening, dorsiflexion osteotomy at the base of first metatarsal, corrective osteotomies, fusions for fixed pes cavus foot. Sesamoidectomy is a relatively uncommon procedure but should be considered if 6- 12 months of conservative managements fail or if the patient experiences ongoing debilitating symptoms. Methods: A retrospective chart review was conducted at our institution from 2009-2018. Twelve patients diagnosed with fibular sesamoiditis were treated with sesamoidectomy. Baseline patient demographics as well as postoperative outcomes were recorded. All patients were initially treated for an extended period conservatively with orthotics, anti-inflammatory medications, physical therapy, limitation of activity and a trial of non-weight bearing. Despite these measures, symptoms persisted for these twelve patients - all of who then underwent fibular sesamoidectomy for their symptoms. The fibular sesamoidectomy was performed by one of the three fellowship trained foot and ankle surgeons. All surgeons used plantar approach with a longitudinal incision on the lateral edge of the first metatarsal fat pad. Postoperatively, patients were kept non–weight bearing for 2 weeks and in a post-op walking shoe for 6 weeks. Results: Average age of the patients was 38 years. Ten of twelve patients (83%) were female. Majority of the patients (10) had no history of trauma, only two referred forefoot injury in the past. Average follow-up was 35 months. Two patients had both hallux valgus and hallux rigidus. One had preexisting rheumatoid arthritis with involvement of the first MTP. MRI showed 5 of 12 (42%) of patients had avascular necrosis of the sesamoid based on magnetic resonance imaging. None of the patients developed cock-up deformity of the lesser toes or hallux varus deformity, clinically or radiologically. Two patients experienced transient neuritis, one developed a superficial infection, and one had painful postoperative scarring. Hallux varus deformity was not observed in any patients. None underwent reoperation. Conclusion: Our study contradicts earlier studies which associate sesamoidectomy with high incidence of complications, particularly hallux varus. But, most of these earlier reports focus on combinations of medial, lateral, and paired excision, rather than lateral excision alone, unlike our study. Hence, fibular sesamoidectomy can be a safe, viable procedure for patients who fail conservative measures for sesamoiditis. The plantar lateral approach allows for adequate exposure of the fibular sesamoid, repair of the plantar plate, and preservation of flexor hallucis brevis, and is beneficial in preventing the occurrence of hallux varus deformity.

Category: Sports Introduction/Purpose: Surgical repair of the Achilles tendon is a commonly-performed procedure in cases of acute tendon rupture. Open Achilles tendon surgery with traditional extensile approach is most often performed with the patient in prone position, but this can interfere with airway access, put increased pressure on the abdomen, and subject to increase perioperative period and comorbidities. Mini-open approach in supine repair may potentially avoid the risks of the prone position, but the safety and utility of this approach have not been established. The purpose of this study is to compare perioperative outcomes between patients undergoing acute Achilles rupture repair with mini-open approach in the supine position versus traditional approach in the prone position. Methods: Patients who underwent surgical repair of acute Achilles rupture between the years 2011 and 2018 at a single institution were retrospectively identified using CPT code 27650. Patients who underwent concurrent procedures for additional injuries were excluded. Charts of included patients were retrospectively reviewed for demographic information, intraoperative characteristics, and postoperative outcomes. Statistical analysis was conducted and p-values =0.05 were considered significant. Results: A total of 81 patients were included for analysis, 26 supine and 55 prone. Baseline characteristics were statistically similar between the two groups. Average total time in the operating room was significantly greater among patients in the prone position (118.7 minutes) than those in the supine position (100 minutes) (p = 0.0011). Average surgery time, blood loss, and time in PACU were greater among the prone group than the supine group, although these differences were not statistically significant. Average postoperative pain score, infection rate, dehiscence rate, sepsis rate, and DVT rate were also similar between the two groups. Conclusion: The mini open approach in supine position may be advantageous in repair of acute Achilles rupture in that it significantly reduces total time in the operating room while maintaining positive patient outcomes. Prospective clinical studies are warranted to validate these assessments.

Category: Ankle, Arthroscopy, Basic Sciences/Biologics Introduction/Purpose: Subtalar fusion is the treatment of choice for subtalar arthritis when conservative management fails. Subtalar fusion can be done through open approach or arthroscopic technique. Arthroscopic technique is associated with rapid recovery; however, it requires adequate training and skill. Arthroscopic technique can be done through lateral or posterior portals. Sometimes it may be necessary to use accessory portal to open or distract the joint for adequate joint preparation. Use of accessory portal may result in injury to the neurovascular structure. Whatever the technique, one of the most important aspects of fusion is adequate preparation of the joint. Aim of our study is to compare the preparation of subtalar joint using sinus tarsi open approach and posterior subtalar scopy using 2 portal technique in cadaveric specimens. Methods: We used 20 below knee fresh-frozen cadaver legs for this cadaveric study. Subtalar joints of ten specimens were prepared through the lateral approach, while the remaining ten joints were prepared using sinus tarsi incisions. After the completion of preparation, all ankles were dissected open, photographic images of calcaneal and talar articular were taken. (Image)Surface areas of each articular facet and prepared area of the talus, distal tibia, and distal fibula were measured and analyzed. Results: Open technique results in better preparation of joint surface in calcaneus and overall. While open technique results in preparation of 92% joint surface (combined talus and calcaneus), arthroscopic technique results in in 80% of joint surface. Open technique results in better preparation of calcaneus (79vs 94%). The anterolateral corner of calcaneus was difficult to be reached using the scope and unprepared in most cases. There was no significant difference in the preparation of talar articular surface. (Table 1) Conclusion: Open sinus tarsi results in more joint preparation compared to 2 portal posterior arthroscopic technique. The less amount of joint preparation in arthroscopic technique is mostly due to less preparation of AL corner. Of calcaneus. When using posterior arthroscopic technique, it is advisable to use accessory portal to distract the joint to aid in adequate preparation.

Category: Ankle, Trauma Introduction/Purpose: Ankle fractures are urgent, and often emergent injuries which require immediate evaluation and treatment. Delayed access to care may subject the patient to increased risk of complications, particularly if surgical management is warranted. Medicaid is a state and federal insurance program in place for those with low income, which has previously been associated with delayed access to care among patients with ACL tears and total hip arthroplasties. Studies have also shown delayed access to care among ankle fracture patients; however these studies have used hypothetical patients rather than existing data regarding timeliness of care. The purpose of this study is to assess whether patient insurance status affects access to care using data from a single institution. Methods: Patients who underwent open reduction and internal fixation for an ankle fracture between the years 2008 and 2018 at a single institution were identified by CPT codes 27829, 27784, 27822, 27814, 27769, 27792, and 27766. Patients who had polytraumatic injuries, open injuries, Medicare, no insurance, indigent/charity insurance, self-pay, or whose insurance information was not available were excluded. Insurance status was retrospectively identified as well as date of injury, date of first visit to the institution’s hospital for the injury, and date of surgery. Time elapsed from date of injury to date of surgery, date of injury to date of first visit, and date of first visit to date of surgery was compared between patients with private insurance and Medicare. P-values of less than 0.05 were considered statistically significant. Results: Results showed statistically significant differences in mean time from injury to first appointment and mean time from injury to surgery between patients enrolled in Medicaid and those with private insurance. Average time from injury to first appointment was 3.1 days and 6.6 days for privately-insured patients and Medicaid patients, respectively (p

Category: Ankle, Arthroscopy, Basic Sciences/Biologics, Sports Introduction/Purpose: The Broström Gould procedure is the gold standard for repair of lateral ankle ligament injury and ankle instability. This procedure has demonstrated excellent short- and long-term outcomes in the orthopaedic literature. Arthroscopic Broström Gould techniques have become increasingly popular among some foot and ankle orthopaedic surgeons. Typically, this technique requires standard medial and lateral portals along with an accessory lateral working portal. The exact location of this portal is variable within the available described surgical techniques. The objective of this cadaveric study is to establish a standard entry point for and to assess the safety of the accessory lateral portal with respect to nearby anatomical structures. Methods: Ten fresh-frozen below-knee cadaver specimens were used. The location of the accessory portal was created 1.5 cm anterior to the distal tip of the fibula. A small vertical incision was made at this point, followed by insertion of a Kirschner wire into the joint. The wire was then gently impacted into the fibula. Superficial dissection was subsequently carried out around the entry point to identify the peroneal tendons, superficial peroneal nerve branches, and sural nerve branches. Structures were marked with colored push pins, and distance was measured between the nearest edge of the Kirschner wire and each of the three anatomic structures listed. Any instances of structural contact or damage were documented. Results: The average distance from the Kirschner wire to the peroneal tendon was 16.1 (±4.41) mm. The average distance from the wire to the superficial peroneal nerve and sural nerve was 13.11 (±6.79) mm and 12.33 (±4.08) mm, respectively. There were no instances of injury to any of the studied structures. However, there was a notable amount of variability in the proximity of structures in question for each cadaver. A branch of the superficial peroneal nerve was measured as close as 2 mm and as far as 24 mm in separate cadaver specimens. Conclusion: Arthroscopic Broström Gould procedures are a safe and effective method for lateral ankle ligamentous repair but are not without risk. Accessory lateral portal placement is relatively safe but should be meticulously executed to avoid damage to nearby anatomical structures.

Category: Ankle, Trauma Introduction/Purpose: Ankle fractures are among the most common orthopedic injuries. While open reduction and internal fixation (ORIF) is the standard treatment for displaced ankle fractures in younger patients, there is controversy regarding the optimal management of these injuries among geriatric patients due to the high prevalence of comorbidities. Closed manipulation leads to poor long-term functional outcomes, with high rates of malunion and non-union in all populations as well as higher mortality in patients over 65 years of age. However, surgical management in the elderly carries rates of complications as high as 20-40%. The purpose of this study was to investigate risk factors for healing complications following ORIF of ankle fractures in patients greater than 75 years of age. Methods: All patients 75 years of age and older undergoing open reduction and internal fixation of ankle fractures at a single institution from 2008 to 2018 were identified. Patients with polytrauma and/or pilon fractures were excluded. Patient medical records were reviewed to obtain information regarding details about the injury, surgery, and follow-up as well as patient demographics and comorbidities. Radiographs from post-operative clinic visits were examined by a foot and ankle certified orthopedic fellow for each patient and the time for complete union was recorded as well as any delayed union or malunion. Fisher’s exact tests were used to compare post-operative complications (wound infection, wound dehiscence, sepsis, deep vein thrombosis, revision surgery, and malunion/nonunion) among those with and without specific comorbidities. Results: Patients with other comorbidities had a statistically significant increased risk of revision surgery (p

Category: Ankle, Trauma Introduction/Purpose: Ankle fractures are commonly-seen orthopaedic injuries across all age groups, and often warrant operative management. Postoperative complications are particularly common among elderly patients, and can lead to a progressive culmination of negative outcomes. Although several studies have focused on the risk factors for and prevention of such complications in elderly patients, a paucity of literature exists addressing risk of postoperative complications in younger patient populations. The purpose of this study was to compare the incidence of and risk factors for various postoperative complications between younger and older patient populations. Methods: Patients who underwent open reduction and internal fixation for an ankle fracture at a single institution between the years 2008 and 2018 were retrospectively identified based on seven different Current Procedural Terminology (CPT) codes: 27829, 27784, 27822, 27814, 27769, 27792, and 27766. Patient charts were reviewed for demographic data and comorbid conditions. Patients with open fractures, pilon fractures, and polytraumatic injuries were excluded. The sample was stratified into two cohorts based on age in years: 18-49 (group 1), and 50 and older (group 2). Incidence of various postoperative complications—including infection, wound dehiscence, sepsis, DVT, implant failure, revision surgery, and non-union— was compared between groups. Secondary analysis was conducted to compare risk factors for these complications between ages 18- 49 and older than 50. Results: 881 patients were included. A significantly greater number of patients in group 2 experienced wound dehiscence (p = 0.033) and nonunion (p