Search

Asymmetric double-crystal monochromators (aDCMs) and inclined DCMs (iDCMs) can significantly expand the X-ray beam footprint and consequently reduce the heat load density and gradient. Based on rigorous dynamical theory calculations, the major principles and properties of aDCMs and iDCMs are presented to guide their design and development, particularly for fourth-generation synchrotrons. In addition to the large beam footprint, aDCMs have very large bandwidths (up to ∼10 eV) and angular acceptance, but the narrow angular acceptance of the second crystal requires precise control of the relative orientations and strains. Based on Fourier coupled-wave diffraction theory calculations, it is rigorously proved that the iDCM has almost the same properties as the conventional symmetric DCM, including the efficiency, angular acceptance, bandwidth, tuning energy range and sensitivity to misalignment. The exception is that, for the extremely inclined geometry that can achieve very large footprint expansion, the iDCM has (beneficially) a larger bandwidth and wider angular acceptance. Inclined diffraction has the `rho-kick effect' that can be cancelled by the second reflection of the iDCM (even with misalignment), except that inhomogeneous strains may cause non-uniform rho-kick angles. At present, fabrication/mounting-induced strains pose low risk since they can be controlled to

Background: Evidence on return to sport (RTS) criteria and timelines for pediatric patients with osteochondral (OCD) lesions of the foot and ankle is limited. Methods: This systematic review evaluated RTS criteria and outcomes in this population by querying PubMed, Embase, Web of Science, CINAHL, and SPORTDiscus up to 30 May 2024. Inclusion criteria were retrospective or prospective studies that examined pediatric patients with osteochondral lesions of the foot and ankle and gave outcomes or criteria regarding RTS. Results: Five observational studies (n = 168 patients; n = 180 OCD lesions; mean age: 14.19 ± 0.47 years; mean follow-up: 42 ± 174 months) were included. Two studies (40%) used time-based criteria for RTS, two studies (40%) used mixed criteria, and the final study (20%) used milestone-based criteria. Across the mixed and milestone criteria, physical therapy (n = 3) and minimal partial weight-bearing prior to RTS (n = 4) were most frequently seen as the milestones used for assessing RTS readiness. RTS from the postoperative period ranged from 3 months to 6 months. At the final follow-up, 61.45% of patients (n = 110) were available to provide information regarding their ability to RTS. Of these patients, 80% (n = 88) achieved RTS. Conclusions: Results showed variability in RTS criteria, ranging from three to six months, with no clear patterns. Most patients returned to sport, suggesting that such individualized criteria may be effective to an extent. Future research should focus on larger, high-quality studies to develop consistent RTS protocols.

The biomechanical efficacy of nail–plate constructs (NPCs) used in the treatment of traumatic distal femur fractures (DFFs) remains understudied compared to traditional approaches. This systematic review examines the biomechanical efficacy of NPCs compared to alternative approaches for the surgical fixation of DFFs to guide surgical decision-making and improve patient outcomes. This systematic review searched the PubMed, CINAHL, MEDLINE, Web of Science, and SPORT Discus databases from inception until 24 January 2024. Inclusion criteria were biomechanical studies that involved nail–plate combination constructs for DFFs. Six observational studies were included. Of the included studies, five studies utilized synthetic bone models in testing, and one study used both synthetic and cadaveric bone models. All studies found NPCs to have significantly higher axial and torsional stiffness and resistance to loading than distal lateral femoral locking plate (DLFLP) constructs. The 11 mm NPCs were significantly stiffer than the 9 mm NPCs under torsional and axial loading. Only one of two studies found NPCs to have greater axial stiffness than dual-plate (DP) constructs. NPCs and DP constructs had greater torsional and axial stiffness than the plate-only or DP with medial distal tibial plate constructs. NPCs had less displacement and torque than the plate- or nail-only constructs under axial and torsional loads. NPCs demonstrate superior axial and torsional stiffness and resistance to mechanical loads compared to DLFLP. The varying performance between 11 mm and 9 mm NPCs suggests that construct diameter plays a role in mechanical stability. NPCs and DP constructs performed better than plate-only constructs. Future research should explore the impact of varying nail diameters and plate configurations on stability, as well as the clinical efficacy of NPCs across different patient populations, particularly those with varying bone densities, to better understand their performance in real-world scenarios.

Abstract Broadening gene therapy applications requires manufacturable vectors that efficiently transduce target cells in humans and preclinical models. Conventional selections of adeno-associated virus (AAV) capsid libraries are inefficient at searching the vast sequence space for the small fraction of vectors possessing multiple traits essential for clinical translation. Here, we present Fit4Function, a generalizable machine learning (ML) approach for systematically engineering multi-trait AAV capsids. By leveraging a capsid library that uniformly samples the manufacturable sequence space, reproducible screening data are generated to train accurate sequence-to-function models. Combining six models, we designed a multi-trait (liver-targeted, manufacturable) capsid library and validated 88% of library variants on all six predetermined criteria. Furthermore, the models, trained only on mouse in vivo and human in vitro Fit4Function data, accurately predicted AAV capsid variant biodistribution in macaque. Top candidates exhibited production yields comparable to AAV9, efficient murine liver transduction, up to 1000-fold greater human hepatocyte transduction, and increased enrichment relative to AAV9 in a screen for liver transduction in macaques. The Fit4Function strategy ultimately makes it possible to predict cross-species traits of peptide-modified AAV capsids and is a critical step toward assembling an ML atlas that predicts AAV capsid performance across dozens of traits.

Category: Other Introduction/Purpose: Despite the questionable validity of online-based physician review websites (PRWs), negative reviews can adversely affect a provider's practice. Several investigations have explored the effect of extremely negative "one-star" reviews across subspecialties such as adult reconstruction, sports medicine, and orthopaedic traumatology; however, to date, no study has explored one-star reviews in foot and ankle surgery. The goal of this study was to characterize factors that contribute to extremely negative, one-star reviews for foot and ankle surgeons on an online review website. Methods: We conducted a retrospective analysis of negative one-star reviews on Vitals.com with corresponding patient complaints for foot and ankle surgeons (both orthopaedic surgeons as well as podiatrists) in the United States. Physicians included were selected within a 10-mile radius of the top ten largest cities in the United States. Data was stratified by patient type (e.g., those receiving surgery and those not undergoing surgical intervention) and binned according to type of patient complaint, as previously described. Results: Of the 2645 foot and ankle surgeons identified in our initial query, 13.8% of surgeons contained one-star reviews eligible for analysis. Patient complaints related to bedside manner and patient experience are the causative factors accounting for 41.5% of the one-star reviews of foot and ankle surgeons for nonsurgical-related complaints. Surgical complications and other outcomes-related factors comprised roughly 50% of the complaints related to surgical patients. Conclusion: Complaints related to bedside manner and patient experience are the causative factors accounting for 41.5% of the one-star reviews of foot and ankle surgeons for nonsurgical-related complaints. Surgical complications and other outcomes-related factors comprised roughly half of the complaints related to surgery. This data serves to inform practicing foot and ankle surgeons as to the influences behind patients leaving extremely negative reviews on PRWs.

Category: Hindfoot; Other Introduction/Purpose: Middle facet subluxation (MFS) and middle facet incongruence angle (MFIA) are established indicators of peritalar subluxation (PTS) in evaluating Progressive Collapsing Foot Deformity (PCFD) using Weight-Bearing CT (WBCT). Traditionally, MFS and MFIA are assessed in the coronal plane, which is not perpendicular to the plane of the middle facet (MF). However, the angle between the plane of the medial facet and the plane of measurement changes with plantar flexion of the talus. This approach may lead over- or underestimating the MFS and MFIA as well as a over-dysplastic appearance of the middle facet. We hypothesized that measuring these parameters in a plane perpendicular to the MF would result in changes in MFS, MFIA, and the incidence of diagnosed dysplastic joints. Methods: In this retrospective case-control study, 89 patients with PCFD and 11 controls without PCFD who underwent WBCT were evaluated. Measurements of MFS, MFIA, and middle facet dysplasia were conducted using both the classical method and the new method. The classical method consisted of identifying the center point of the middle facet on sagittal view and taking measurements in the coronal plane as described in the literature. The new method comprised of taking measurements after rotation of the coronal plane around the axis defined by the center of the middle facet on sagittal view until the coronal plane was perpendicular on sagittal view. The inclination of the MF in the sagittal plane was also recorded. Additional WBCT parameters (Foot and Ankle Offset (FAO), Talo-navicular coverage angle (TNCA), Talus-first metatarsal angle axial) were also measured. The Shapiro-Wilk test assessed data normality. A p-value of < 0.05 was considered statistically significant. Results: Significant differences were observed between the two methods across all parameters for PCFD. For controls, only the MFIA was significantly different (p:0.0045) between the two methods. Regarding the PCFD the new method demonstrated lower MFS (25.4% vs. 40.3%, p< 0.0001), lower MFIA (4.7 degrees vs. 13.1 degrees, p< 0.0001), and fewer dysplastic joints (1% vs. 37%, p< 0.0001) when compared to the classical method. However, multivariate analysis did not show inclination angle as predictive of MFS. TNCA (p < 0.05) talus-first metatarsal angle axial (p < 0.05) and FAO (p < 0.05) were stronger predictors of MFS than the inclination of the talus. Conclusion: This study confirms that MFS is a complex deformity influenced by multiple parameters but not talar inclination. The new method showed lower MFS, MFIA, and dysplasia measurements compared to current classical method. Future research should compare these two measuring techniques to more comprehensive modalities (coverage mapping). When assessing MFS, surgeons should be mindful that the plane of measurement relative to the structure is critical, and any change in the inclination of the talus may influence the appearance of MFS. We suggest using a plane of measurement perpendicular to the plane of the middle facet when assessing its subluxation.

Category: Other Introduction/Purpose: Although female students comprise over half of U.S. undergraduate and medical school enrollment, representation among residents and practicing surgeons in orthopaedics remains disproportionately low at 15% and 6%, respectively. The decline in residency may stem from a lack of early exposure to female mentors. This study investigates female representation in speaker roles at American Orthopaedic Foot & Ankle Society (AOFAS) meetings over time. Methods: The annual AOFAS meeting programs for 2012, 2017, and 2022 were reviewed by three independent raters. Each speaker, moderator, and panelist was classified based on sex and role; 15% of the data was cross-checked and evaluated using Fleiss Multirater Kappa validation. Sessions discussing surgical or biomedical topics were categorized as “technical”, and all other sessions (i.e., welcome sessions) were categorized as “nontechnical.” Individual-year odds ratios (ORs) and confidence intervals (CIs) evaluating sex versus session status, as well as sex versus speaker role, are provided. Combined results controlling for year were calculated using the Cochran-Mantel-Haenszel method. Results: A total of 403 speaking sessions were analyzed; 12% of sessions were led by female speakers. On average, female speakers were significantly more likely than males to assume nontechnical speaking roles across the three years combined (OR 3.84; 95% CI, 1.43 to 10.33). Female speakers led 12.7% of the 381 technical sessions. Females also comprised 9.8% and 16.7% of moderator and panelist roles, respectively. Conclusion: Although our study reveals an increasing trend in female speakers, panelists, and moderators from 2012 to 2022, these data demonstrate a persistent lack of sex diversity at AOFAS annual meetings, especially within technical sessions and moderator roles. Increasing female representation at conferences while fostering mentorship opportunities for medical students may serve as a valuable opportunity to address disparities between males and females within orthopaedics. Female Representation in Speaker Roles at AOFAS and Session Category Odds Ratios

Category: Ankle; Ankle Arthritis Introduction/Purpose: The incidence of primary total ankle arthroplasty (TAA) is rising, with a corresponding increase in revision surgeries. Despite this, research on risk factors for revision TAA following primary TAA remains limited. Radiographic soft-tissue thickness has been explored as a potential predictor for outcomes in hip, knee, and shoulder arthroplasty, but its role in TAA has not been assessed. This study aimed to assess the predictive value of radiographic soft tissue thickness for identifying patients at risk of requiring revision surgery following primary TAA. Methods: A retrospective study was conducted on 323 patients who underwent primary TAA between 2003 and 2019. Radiographic measurements of soft tissue thickness were obtained from preoperative lateral weightbearing radiographs. Clinical variables including age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, diabetes, smoking status, primary diagnosis, and implant type were recorded. Logistic regression analysis was used to assess the predictive value of soft tissue thickness and BMI for revision TAA. Results: The rate of revision surgery was 4.3% (14 out of 323 patients). Patients requiring revision had significantly greater tibial-tissue (3.54 vs. 2.48 cm; p=0.02) and talus-tissue (2.79 vs. 2.42 cm; p=0.02) thickness compared to those who did not require revision. Both the Tibial-Tissue thickness (Odds Ratio: 1.16 [1.12-1.20]; p < 0.01) and the Talus-Tissue thickness (Odds Ratio: 1.10 [1.05-1.15]; p < 0.01) measurements were significant predictors of revision TAA in multivariable logistic regression models. In contrast, BMI was not a significant predictor of revision TAA. The two metrics demonstrated excellent interrater reliability. Conclusion: Greater soft tissue thickness, as measured radiographically, was a better predictor of revision TAA compared to BMI. These findings suggest that radiographic soft tissue thickness may be a valuable tool for assessing the risk of the need for revision TAA following primary TAA. Further research is needed to validate these findings and explore the potential impact on clinical practice. Figure 1. Radiographical Assessment of Tissue Thickness The figure illustrates the method for obtaining the radiographic measurements on weightbearing lateral radiographs. (A) A line was drawn from the posterior distal tibia to the anterior distal tibia (Red Line), and the distance of the parallel segment extending from the anterior cortex of the tibia to the end of the soft tissue shadow was measured to determine the Tibial-Tissue thickness. A line was drawn from the lateral process of the talus to the head/neck junction of the talus (Yellow Line), and the distance of the parallel segment, extending from the head/neck junction of the talus to the end of the soft tissue shadow, was measured to determine the Talus-Tissue thickness.

Category: Hindfoot; Ankle Introduction/Purpose: Collapse of the talus and peri-talar arthritis pose treatment challenges due to the anatomy and location of the talus as a keystone of the foot and ankle. Custom 3D-printed total talus replacement (TTR) and combined total ankle total talus replacement (TATTR) have emerged as treatment options for peri-talar arthritis, avascular necrosis of the talus and talus insufficiency. However, long-term data on the safety and efficacy of these implants is unknown due to the limited number of cases and short follow-up durations. Methods: This was a retrospective study to assess surgical outcomes of patients who underwent a TTR and TATTR with or without subtalar fusion. Patient demographics, intraoperative parameters, device related surgical and non-surgical events, imaging and clinical evaluations, and patient reported outcome (PRO) measures were compiled for each case. The Odds Ratio (OR) for secondary surgery was calculated for each binary outcome using univariate and multivariate logistic regression. The multivariable model included significant variables from the univariate analysis to address potential confounders. Pre- and postoperative radiographic measurements and range of motion were compared using pairwise t-tests. Pain VAS, PROMIS Pain Interference (PI), and PROMIS Physical Function (PF) scores were compared across all timepoints using one-way ANOVA (p< 0.05 significance level). Results: A total of 38 patients received a custom 3D-printed implant with mean follow-up time of 22.1 (range: 12-45) months. In this cohort, 7 (18.4%) required secondary surgery and 3 (7.9%) required removal of the implant. The mean time to secondary surgery was 19.9 (range: 11-32) months. Multivariate logistic regression revealed that patient diagnosis of depression was a significant predictor of secondary surgery with an OR 17.50 (p= 0.037). Significant postoperative improvements were observed in talocalcaneal height (p=0.005) and talar declination angle (p=0.013) for the TATTR group. VAS and PROMIS PI scores demonstrated an initial significant decrease in pain, but this improvement did not maintain significance at most recent follow-up. However, there was a significant increase in the PROMIS PF scores (p=0.037) at most recent follow-up. Conclusion: These results demonstrate that TTR and TATTR provide improvement in radiographic foot and ankle alignment and physical function. PRO findings suggest that patients are more active despite steady pain increase over time. Surgeons considering proceeding with either of these procedures should counsel patients about pain and functional outcomes as well as realistic expectations in patients with depression. Larger cohorts of patients should be studied to identify other high-risk groups and possible interventions. Future studies should investigate the association between diagnoses like depression and PROs.

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Nitinol is a metal alloy with high elastic flexibility and shape memory characteristics, making it effective in orthopedic surgery. Although nitinol staples have shown similar efficacy to traditional implants for foot and ankle surgery, the literature is limited regarding nitinol screws. The purpose of this study is to determine whether there is a difference in outcomes and complications between nitinol screws and traditional screws used for foot and ankle surgery. Methods: A multicenter retrospective cohort study was conducted for patients who underwent a foot and ankle procedure utilizing traditional compression screws or nitinol compression screws, between February 1st, 2021, and July 1st, 2023. Demographic factors, type of implant, and outcomes were recorded. Student’s t-test and Wilcoxon rank sum test were used to compare continuous variables, while the chi-squared test was used to compare categorical variables. Results: A total of 163 patients were included in the study, with 106 patients treated with traditional screws and 58 treated with nitinol screws. There was no significant difference between those treated with nitinol screws and those treated with traditional screws in complication rate (8.6% vs 11.3%, P=0.78), non-union rate (5.2% vs 8.5%, P=0.54), revision surgeries (1.7% vs 2.8%, P=1), hardware removal (3.4% vs 11.3%, P=0.14), or 90-day hospital readmissions (0% vs 2.8%, P=0.55) for foot and ankle surgery. Conclusion: Our study found no difference in terms of complications or postoperative outcomes between those treated with nitinol screws and those treated with traditional screws for elective foot and ankle procedures. Our findings suggest that nitinol screws appear to be safe and effective for foot and ankle surgery with positive postoperative outcomes and a trend in lower complication and non-union rates. However further investigation is warranted to assess if faster time to union and quicker weight bearing may be possible with this type of fixation.

Category: Ankle; Midfoot/Forefoot Introduction/Purpose: The literature demonstrating outcomes after foot and ankle surgery has traditionally focused on clinical and functional outcomes. Recent interest has increased regarding the contribution of racial and ethnic factors on outcomes after foot and ankle surgery. However, the existing research is limited. The purpose of this systematic review and meta-analysis was to evaluate outcome metrics based on race and ethnicity after foot and ankle surgery. Methods: Outcomes after foot and ankle surgery based on race and ethnicity were searched in MEDLINE, Embase, Cochrane, Web of Science, SportsDISCUS, and Scopus from the date of inception to March 23, 2023. Inclusion criteria consisted of studies that directly evaluated the outcomes of race or ethnicity on foot and ankle surgery, including the risk or need for an index procedure. Manuscripts in non-English languages and isolated abstracts were excluded. We collected Visual Analog Scale (VAS), Patient-Reported Outcomes Information System (PROMIS) pain scale, and Short Musculoskeletal Function Assessment (SMFA) from the included studies for pooled meta-analysis. Results: The literature search identified 33 relevant studies from an initial pool of 3,451 references. These studies included a diverse demographic of 557,734 patients, assessing outcomes in foot and ankle surgery across various racial and ethnic groups. Due to heterogeneity in outcome reporting, only six studies were included in the finalmeta-analysis. Functional scores from the VAS, PROMIS pain scale, and SMFA varied in their assessment of pain and functional outcomes based on ethnicity. Resource utilization studies indicated disparities in the rates of surgical fixations and arthroplasties based on race. Conclusion: Non-White and minority patients exhibited higher rates of foot and ankle fractures, lower limb surgeries, worse functional outcomes, increased pain, longer hospital stays, and a higher incidence of complications compared to their White counterparts. While consistent with existing literature in various orthopaedic specialties, some studies contradicted these findings, suggesting the need for further research to better understand these discrepancies.

Category: Ankle; Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) is a commonly performed surgical procedure to address end-stage arthritis. Previous studies have suggested that the radiographic soft tissue thickness may be a predictor of complications including periprosthetic joint infection (PJI) after orthopedic surgery. However, there has been limited studies exploring the use of radiographic soft tissue thickness in TAA. The purpose of this study was to evaluate the predictive capabilities of radiographic soft-tissue thickness for PJI following TAA. Methods: A retrospective analysis of 323 patients at a single institution who underwent primary TAA from 2003 to 2019 was conducted. Patient characteristics, including age, sex, body mass index (BMI), and comorbidities such as diabetes, smoking status, and etiology of ankle injury were recorded. Preoperative radiographic measurements, including the Tibial-Tissue and Talus-Tissue distances were recorded. Other perioperative information included prosthesis type, tourniquet time, and time to last follow-up. Logistic regression was utilized to examine the relationship between these factors and the occurrence of PJI. Results: Of the 323 patients, there were 6 patients (1.86%) who developed a PJI. The logistic regression analysis revealed that neither Tibial-Tissue (Odds Ratio: 0.975 [0.947 - 1.004]; p = 0.09) nor Talus-Tissue thickness (Odds Ratio: 0.976 [0.940 - 1.012]; p = 0.18) were significant predictors of PJI. Although not statistically significant, the infected cohort had smaller average Tibial-Tissue (2.20 vs. 2.53 cm; p=0.05) and Talus-Tissue thickness (2.19 vs. 2.44 cm; p=0.36) compared to the non-infected cohort. Conclusion: Despite an association between radiographic soft tissue thickness and infection in other orthopedic surgeries, measurements such as Tibial-Tissue length and Talus-Tissue length were not significant predictors of PJI following primary TAA. These findings underscore the necessity for additional research to identify modifiable risk factors aimed at reducing PJI rates and enhancing patient outcomes.

Category: Hindfoot; Trauma Introduction/Purpose: Calcaneal fractures are a common work-related injury that can be treated both operatively and nonoperatively. Operative management typically consists of open reduction with internal fixation via either an extensile lateral or sinus tarsi approach. Conservative treatment employs a combination of immobilization, rest, and elevation. Given that return to work is a critical milestone for many of these patients, it is crucial that the best management option is chosen. While there have been studies that compared operative versus conservative treatment, there has been no summative review on this topic. Thus, the goal of this study was to conduct a systematic review and meta-analysis on the impact of operative versus nonoperative management on return to work outcomes. Methods: MEDLINE (PubMed), Embase (Elsevier), and Cochrane Library were searched for the concepts of calcaneal fracture and return to work. Inclusion criteria consisted of studies that reported on operative or nonoperative treatment of calcaneal fractures and outcomes relating to timing of return to work. Abstract only studies, biomechanical studies, cadaveric studies, case reports, studies involving pediatric patients, and non-English texts were excluded. Factors that were extracted included fracture type, pre-injury workload, mechanism of injury, treatment, return to work, functional outcomes, and complications. Revman 5.3 software was used for meta-analysis. Studies that did not qualify for meta-analyses were described qualitatively. Results: 2462 studies were identified on initial search. 52 texts met inclusion and exclusion criteria. A total of 3338 patients were included. Operative management had significantly improved return to work outcomes compared to nonoperative treatment, with an overall mean difference of 40.79 days [95% Confidence Interval (CI), -69.55 to -12.03, p < 0.05]. Operative treatment was also associated with significantly lower pain scores [Mean difference: -1.14; 95% CI, -2.24 to -0.04, p < 0.05] and higher SF-36 scores [Mean difference: 13.89; 95% CI, 7.69 to 20.10, p < 0.0001]. Operative treatment did have expectedly higher risk of all complications compared to the nonoperative group [Risk Ratio: 1.80; 95% CI, 1.22 to 2.66, p < 0.05]. Conclusion: While operative management was associated with higher risk of complications, patients had improved return to work, pain, and functional outcomes compared to nonoperative treatment. Careful consideration should be taken when determining treatment options for calcaneal fracture patients. Further research is needed to better elucidate differences between operative treatment options.

Category: Ankle; Ankle Arthritis Introduction/Purpose: As total ankle arthroplasty (TAA) rises in popularity nationwide for the management of end-stage arthritis, patient selection and medical optimization are crucial for the mitigation of infection risk. Diabetes increases the risk of infection due to compromised immunity and impaired wound-healing mechanisms. However, there is limited research on how diabetic management, inclusive of medications and glucose control, may impact infection risks post-TAA. This study aims to demonstrate the impact of diabetic management on the occurrence of periprosthetic joint infection (PJI) following TAA. Methods: This was a retrospective study of patients who underwent a TAA at a single academic institution from March 2002 to May 2022. Patients with diabetes who developed an intraarticular infection following TAA were propensity score matched to diabetic patients who did not. Data collection included demographics, implant types, diabetic medications, and preoperative hemoglobin A1c. PJI was diagnosed based on Musculoskeletal Infection Society (MSIS) criteria. Statistical analyses assessed differences in medication use, glucose control, and infection rates between groups. Results: Of the 1,863 patients who underwent TAA, 177 patients had a diagnosis of diabetes. The infection rate in patients with diabetes (2.8%) was higher than the total cohort rate (0.8%). Five patients with diabetes developed a PJI at an average of 2.2 months postoperatively. This cohort (n=5) was compared to propensity score-matched controls (n=15). There was no significant difference in diabetic medication use. Patients who developed PJI had higher rates of uncontrolled diabetes (60.0% vs. 6.7%) and average A1c levels (7.02% vs. 6.29%) compared to controls. Conclusion: Our findings suggest that the elevated risk of PJI observed in individuals with diabetes subsequent to TAA may be attributed not solely to the presence of diabetes, but to inadequate glycemic control. Effectively managing blood glucose levels is imperative for achieving favorable outcomes following TAA.

Category: Hindfoot; Ankle Introduction/Purpose: Approximately 6% of individuals will experience Achilles tendon pain during their lifetime, with one-third of these patients having Haglund’s syndrome. The condition represents a triad of posterosuperior calcaneal bony enlargement (Haglund’s deformity), retrocalcaneal bursitis, and Achilles tendinopathy and may be bilateral or unilateral. If a prolonged course of conservative treatment fails, surgical options include utilizing a suture bridge (SB), corkscrew anchors (CS), or suture anchors (SA). The goal of this study is to investigate outcomes comparing various surgical techniques and postoperative weightbearing status. Methods: After institutional approval, retrospective data were collected from 476 patients who received surgical treatment for Haglund’s syndrome across 8 surgeons at an academic institution from January 2015 to July 2022. Demographic data and surgical repair technique data (suture bridge – SB, corkscrew – CS, suture anchors – SA) were collected. Additional data included weightbearing status (weightbearing as tolerated -WBAT, non-weightbearing – NWB, partial weightbearing – PWB, touch down weightbearing – TDWB), complications, revisions, and date of patients’ last follow-up. Post-operative complications included Achilles rupture, wound breakdown/infection, deep venous thrombosis, plantarflexion weakness, or other complications. Descriptive statistics were completed. Results: Across 390 patients, the cohort averaged 55.14 years old and was 66.4% female. The most common racial groups were Caucasian (72.8%), African American (20.8%), and Asian (1.3%). Average BMI was 34.83 (σ =7.00) and 17.4% had diabetes. Smoking status was reported as 267 (68.5%) never, 120 (30%) current or former. ASA III was the most common scoring with n=186 (47.7%). Repair type was divided among SB (58%), SA (20.8%), and CS (21.3%). Time to last follow-up had a median of 5.8 months, range [0 days-7 years]. Postoperative recommendations also varied from NWB (68.7%), TDWB (14.4%), WBAT (13.8%), and PWB (2.3%). Overall, 75 (19.2%) patients experienced a complication, including 40 (10.3%) persistent pain, 32 (8.2%) wound breakdowns, and 1 (10.3%) rupture, with 7 (1.8%) requiring revision. Conclusion: This study offers the largest single-institution series for the operative management of Haglund’s syndrome with long-term follow-up. Certain patient characteristics (increased age, Black or African American race, female sex, and diabetes) were greater in this cohort compared to national averages. The postoperative complication rate was 20% (n=78), with WBAT reporting the highest rate of pain (14.8%) and PWB reporting the lowest (0.0%). Wound breakdown was highest for NWB (9.7%), and one rupture occurred in the WBAT group. Future research should utilize multicenter institutional data with large sample sizes to analyze associations between patient characteristics, surgical technique, and complication rates.

Category: Ankle; Ankle Arthritis Introduction/Purpose: Infection is a serious complication of primary total ankle arthroplasty (TAA) and can lead to implant failure and revision surgery. While various patient demographics, comorbidities, and surgical factors have been associated with an increased risk of infection, evidence is limited, and further research is required to better understand infection in TAA. This study aims to analyze risk factors of infection and explore outcomes following infected TAA. Methods: A retrospective cohort study was conducted using data from a single institution from 2002 to 2022. Patients who underwent primary TAA and had subsequent infection were identified and matched using propensity-score matching (PSM) based on various demographic, comorbidity, and surgical factors. Demographics were compared between the matched groups using Mann-Whitney U test and Fisher's exact test. The outcomes following infection were identified and summarized using descriptive statistics. Results: A total of 1,863 patients who underwent primary TAA were identified, and 19 (1%) were diagnosed with an infection. After PSM, there were no significant differences in age, gender, BMI, and smoking status between the cohorts. There was a statistically significant increase in the rate of diabetes in the infected cohort (26.3 vs. 15.3; p =0.01). Subsequent surgical intervention resulted in limb salvage in 18 (94.7%) cases. Two-stage revision to total ankle replacement was performed in 7 cases (36.8%), while revision to arthrodesis and isolated polyethylene exchange were each carried out in 4 cases (21.1%). One patient had to undergo amputation, however, at the time of the most recent follow-up (5.3%). All patients were found to be free of infection. Conclusion: This study demonstrated significantly increased rates of smoking and diabetes in the infected TAA cohort. Two-stage revision to TAR and revision to arthrodesis with isolated polyethylene exchange were successful in eradicating infection. Overall, a high rate of limb salvage was reported.

Category: Hindfoot; Ankle Introduction/Purpose: Haglund’s deformity is a common orthopedic condition characterized by the enlargement of the posterosuperior prominence of the calcaneus, often accompanied by inflammation of the retrocalcaneal bursa and Achilles tendon. While initial management of Haglund’s deformity consists of conservative measures, surgical intervention may be indicated if symptoms fail to resolve within 6 months. Although effective, surgical management is not without complications especially for patients with diabetes and obesity. Given obesity is one of the few modifiable risk factors when considering ideal surgical candidacy, understanding its relationship to complication status is vital. This study therefore aims to compare postoperative complications between obese and nonobese patients with Haglund deformity, filling a gap in the literature and aiding decision-making in managing this condition during the burgeoning obesity epidemic. Methods: Following institutional approval, retrospective data was collected from 476 patients who underwent resection for Haglund’s deformity between January 2015 and December 2023. All procedures were performed at a single academic center by either one of six fellowship-trained foot and ankle surgeons. To evaluate the impact of BMI on postoperative outcomes the cohort was dichotomized into obese (BMI ≥ 30 kg/m^2) and nonobese. Patient demographic data and surgical repair technique data (suture bridge – SB, corkscrew – CS, suture anchors – SA), post-operative weightbearing status (weightbearing as tolerated -WBAT, non-weightbearing – NWB, partial weightbearing – PWB, touch down weightbearing – TDWB), complications, revisions, and date of patients’ last follow-up were recorded. Statistical analysis involved descriptive summaries, univariate comparisons, and multivariate regression to identify risk factors for wound complications. P values < 0.05 were considered statistically significant. Results: Demographic characteristics were similar between groups in terms of age, sex, race, and smoking status. Surgical techniques varied among surgeons, with suture-bridge being the most common (57.9%). Postoperatively, most patients were NWB (68.7%), followed by TDWB (14.4%), WBAT (13.9%), and PWB (2.3%). Repair type and postoperative weightbearing status did not significantly differ between non-obese and obese groups. Around 20.0% of patients experienced complications, with persistent pain and wound breakdown being the most common (10.3% and 8.2%). Obese patients had a significantly higher incidence of any complication compared to non-obese patients (p=0.03), PWB (10.6% vs. 1.9%, p=0.003). Multivariable logistic regression indicated that obese patients had over six times the risk of wound breakdown compared to non-obese patients (OR=6.57, 95% CI [0.57-3.76], p=0.02). Conclusion: Haglund's deformity presents a significant orthopedic challenge, often requiring surgical intervention after failed conservative management. This study highlights the importance of understanding the impact of obesity on postoperative complications in Haglund's resection. Our findings demonstrate that obese patients have a higher risk of complications, particularly wound breakdown, compared to non-obese counterparts. This underscores the necessity of careful patient selection and preoperative optimization, especially in the context of the growing obesity epidemic. By shedding light on this relationship, our study contributes valuable insights to the literature, aiding clinicians in decision-making and improving outcomes for patients undergoing surgical management of Haglund's deformity.

Category: Other Introduction/Purpose: The increasing prevalence of foot and ankle procedures in the United States has coincided with rising costs of care, exposing socioeconomic disparities within this area of orthopedics. Insurance payor status is one such factor that can affect the quality and accessibility of medical care and has been implicated in orthopedic patient outcomes. While previous studies in other fields of orthopedics have demonstrated an association between insurance status and access to treatment, length of hospital stay, postoperative outcomes and complication rates, no comprehensive review has explores this relationship in foot and ankle surgery. Thus, the goal of this study is to examine the association between insurance payor status and outcomes in foot and ankle procedures. Methods: A systematic review of five databases was conducted, focusing on the interplay between insurance coverage and foot/ankle procedures. Included studies reported on insurance payor status and patient outcomes following foot and ankle surgery. Extracted outcomes included time to be seen by a provider, complication and revision rates, post-operative Emergency Department (ED)/Urgent Care utilization, readmission rates, hospital length of stay, pain, functional scores, discharge destinations, return to work/activity, and follow-up. Meta-analyses were performed using the Revman 5.3 software. Studies that did not qualify for meta-analyses were described qualitatively. Results: Of 1401 studies identified, 24 texts met inclusion and exclusion criteria. Across the 24 studies, there were a total of 20,950 patients. Noninsured patients had a 59% higher risk of ED/urgent care utilization within 30 days of surgery compared to insured patients [Risk Ratio (RR) = 1.59, 95% Confidence Interval (CI) = 1.18 to 2.12, p < 0.05]. Privately insured patients were seen 3.65 days earlier than patients with government insurance [95% CI = 2.02 to 5.27, p < 0.0001]. Worker’s Compensation patients tended to have poorer outcomes, higher pain scores, and lower functional scores. Similarly, Medicaid patients also fared worse on functional scores and had delayed access to appointments and treatments. Conclusion: Patients without private insurance have worser pain and functional outcomes, delayed access to care, and increased utilization of emergency resources following foot and ankle procedures. It is crucial for providers to be cognizant of these discrepancies when caring for patients. Further research is needed to better understand the nuances of these insurance-related disparities within foot and ankle subspecialties.

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Progressive Collapsing Foot Deformity (PCFD) is a symptomatic, complex, three-dimensional foot deformity that can occur in feet that were previously neutrally aligned or in those with congenital/pediatric flat feet. Once collapsed, it becomes challenging to differentiate the initial foot shape. This study aims to evaluate differences in Weight-Bearing CT (WBCT) parameters among a cohort of symptomatic PCFD patients with a history of pediatric flat foot (= pediatric PCFD), without such a history (= non-pediatric PCFD), and a control group without PCFD. We hypothesized that pediatric PCFD would display distinct WBCT parameters compared to non-pediatric PCFD, particularly with less forefoot abduction and middle facet subluxation. Furthermore, we sought to identify which parameters are the most predictive of pediatric PCFD. Methods: This retrospective comparative study included adult patients with symptomatic PCFD. Pediatric PCFD was defined as patients with flat feet since childhood, and non-pediatric PCFD was defined as patients with no history of childhood flat foot. A total of 37 symptomatic pediatric PCFD patients were compared to 52 symptomatic non-pediatric PCFD patients and 11 control patients. All patients underwent foot/ankle WBCT scans. Using dedicated software, both manual and semi-automated 3D measurements were carried out for the various PCFD deformity categories (A-Hindfoot Valgus, B-Abduction, C-Arch Collapse, and D-Peritalar Subluxation). The data underwent normality testing with the Shapiro-Wilk method, and comparisons were made via Paired T-tests or Paired-Wilcoxon tests. A p-value threshold of 0.05 or below was deemed significant. To determine which factors affect the presence of rigidity in PCFD, a multivariate nominal regression analysis was conducted. A partition prediction model was employed to identify threshold values that most accurately determine “pediatric PCFD”. Results: All parameters showed significant differences compared to control, except for BMI. Compared to non-pediatric PCFD, the pediatric PCFD group showed significantly less deformity in classes A, B, C, and D (all p< 0.002) and became symptomatic at a younger age (p< 0.001). Compared to controls, pediatric PCFD measurements for HMA (p=0.053) and SF (p=0.07) were not statistically significant. Multivariate analysis indicated that axial TFM (p=0.005), MFS (p=0.013), and ST (p=0.03) were the best predictors of pediatric PCFD (R2: 0.27). The partition prediction model showed that an ST distance >0.24 mm, axial TFM >24.28, and MFS >43.7% can rule out pediatric PCFD with 95% confidence. Conclusion: This study showed that symptomatic pediatric PCFD presents with distinct WBCT parameters compared to symptomatic non-pediatric PCFD, notably exhibiting less forefoot abduction, less middle facet subluxation, and less hindfoot malalignment and seems to become symptomatic at a younger age. ST distance >0.24 mm, axial TFM >24.28, and MFS >43.7% could rule out a PCFD with “pediatric origin.” These results suggest that a different threshold should be set to assess PCFD in patients with flat feet since childhood.

Category: Ankle; Ankle Arthritis Introduction/Purpose: While the utilization of total ankle arthroplasty (TAA) for managing severe ankle osteoarthritis has become increasingly common, there has been a subsequent increase in the occurrence of revision TAA procedures due to implant failure. The INBONE II system has risen in popularity specifically for the use in revision TAA cases, however there has been limited patient performance data for this specific indication. Given the growing number of TAA revision procedures and increasing focus on motion-preserving salvage options, this study aims to comprehensively examine the clinical outcomes associated with revision TAA using the INBONE II system. Methods: A retrospective analysis was conducted on a group of 60 patients who underwent revision TAA with the INBONE II system. Detailed information was collected on patient demographics, implant characteristics, concurrent procedures, and complications. The implant survival was estimated using Kaplan-Meier analysis. Results: The study revealed high complication rates but generally fair clinical outcomes for revision TAA utilizing the INBONE II system. Complications were observed in 22 patients (36.7%), including persistent pain (n=6), nerve injury/impingement (n=5), infection (n=3), fracture (n=3), implant failure (n=3), impaired wound healing (n=2), and osteolysis (n=3). The three-year implant survivorship rate from reoperation was 92.0% [82.7%-100.0%] while the three-year survivorship rate from major complications was 90.4% [80.8%-100.0%]. Conclusion: Our study demonstrates that revision TAA is an option to preserve joint function following primary TAA failure. Although there are high complication rates associated with revision TAA, patients generally fair clinical outcomes for revision TAA using the INBONE II system. Further study with longer-term follow-up is needed to ensure that revision TAA is durable at longer time intervals and remains a favorable option for the salvage of the failed total ankle.

Category: Ankle Arthritis; Ankle Introduction/Purpose: This retrospective cohort study compared short-term complication rates following total ankle arthroplasty (TAA), either alone or with concomitant soft tissue or bony procedures. Secondary independent risk factors were also examined as they related to postoperative outcomes in these groups. Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried using current procedural terminology (CPT) codes to identify patients that underwent TAA (27702) between 2010 to 2021. Patients were then divided into cohorts consisting of patients who underwent TAA without concomitant procedures and patients who underwent TAA with one or more concomitant bony or soft tissue procedures. Procedures included in the development of cohorts are outlined in Table 1. Propensity score matching was then employed to account for any baseline demographic differences, and statistical analyses were performed to compare short-term complication rates between the matched cohorts. Results: A total of 2,225 patients undergoing TAA were identified, with 1,432 (64.4%) receiving TAA alone and 793 (35.6%) receiving TAA with ancillary procedure(s). After matching, 793 patients were included in each cohort. The ancillary cohort had longer operative times (172.8 vs. 144.1mins) and total length of hospital stay (LOS) (1.76 vs. 1.52 days). Rates for extended length of stay were significantly higher in the ancillary cohort compared to the simple cohort (21.2% vs 16.3%). No other complications varied significantly between cohorts, including the incidence of any adverse event (AAE). When controlling for all other variables, ASA classification of 4 was found to be an independent risk factor for development of AAE (odds ratio [OR] = 1.091, p = 0.04). Conclusion: Extended length of stay was the only variable found to be significantly different between simple and concomitant TAA cohorts. Additionally, in a subgroup analysis excluding tendon lengthening procedures, we observed greater morbidity probability in the additional procedures group. The only independent risk factor for postoperative complications was ASA class 4 status. Without significant difference in rates of any AAE other than extended LOS, the relative safety of ancillary TAA appears similar to that of simple TAA alone. Such knowledge can help inform surgical decision-making and assuage safety concerns for patients requiring TAA while having multiple foot and ankle pathologies.

Category: Ankle Arthritis; Ankle Introduction/Purpose: Surgical management of ankle osteoarthritis (AOA) includes Ankle Arthrodesis (AA) or Total Ankle Arthroplasty (TAA). Existing literature has been inconclusive regarding a clear standard of treatment for AOA. The purpose of this study was to analyze data from the National Surgical Quality Improvement Project (NSQIP) to elucidate differences in outcomes between TAA and AA. Methods: Patients who underwent TAA or AA from January 2010 to December 2020 in the NSQIP database were included in this analysis. All patients were followed for at least 30 days following surgery. The independent variable was procedure type: AA or TAA. The dependent variables were complications. Independent sample t-tests and chi square tests were used to determine if there was a difference between groups. A binary logistic regression was performed to determine the odds ratio (OR) and 95% confidence intervals. Results: The matched cohorts included 359 patients in the arthroplasty group (57.2±13.3 years, 56.8% male, 33.0±7.3 kg/m 2 ) and 359 patients in the arthrodesis group (57.4±13.9 years, 58.5% male, 32.7±7.9 kg/m 2 ). There was an increase in transfusions, UTI, and return to the operating room in the arthrodesis group compared to the arthroplasty group (1.95%, 0.28%, p=0.038; 1.11%, 0.00%, p=0.045, 3.90%, 1.11%, p=0.017). The multivariate regression revealed that length of hospital stay (OR = 1.157) and insulin dependent diabetes (OR = 6.043) had an increased risk of any adverse event. Conclusion: The overall rate of any adverse event for ankle arthroplasty or arthrodesis was relatively low at 4.18% in the 30-day postoperative period. There was no adverse event that reached statistical significance, that was more likely in the TAA group compared to the AA group. Identification of these complication rates after TAA and AA, along with patient risk factors for adverse events can assist surgeons and patients in their choice of treatment for AOA.

Category: Sports; Ankle Introduction/Purpose: A symptomatic os trigonum is a common cause of posterior ankle pain that has been traditionally managed with open excision. Minimally invasive surgery (MIS) has been proposed as an alternative to open excision for improved outcomes and decreased complication rates; however, no systematic review to date has examined the utilization of MIS for a symptomatic os trigonum. The purpose of this study was to examine patient outcomes, return to sport, and complications associated with MIS for a symptomatic os trigonum. Methods: A systematic review was performed on February 22, 2023, using the PubMed, CINAHL, MEDLINE, and Web of Science databases from database inception until February 22, 2023, on the topic of MIS for a symptomatic os trigonum. Results: From initial search, 17 articles (N = 435 patients) met inclusion criteria. Mean age of the cohort was 26.01 ± 4.68 years, with a mean follow-up time of 34.63 ± 18.20 months. For MIS patients, the mean preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score was 55.85 ± 12.75, the mean final postoperative AOFAS score was 94.88 ± 4.04, the mean preoperative visual analog scale pain score was 7.20 ± 0.43, and the mean final postoperative visual analog scale score was 0.71 ± 0.48. The mean time to return to sport for patients undergoing MIS was 7.76 ± 1.42 weeks. MIS had an overall complication rate of 5.0%, the majority of which consisted of transient neurapraxia of the sural or superficial peroneal nerve. Conclusion: Minimally invasive management of a symptomatic os trigonum appears to be a viable alternative to open surgery in terms of outcomes, return to sport, and complication rates. More high-quality evidence will be required to definitely recommend minimally invasive approaches as the standard of care over open surgery.

Category: Ankle Arthritis; Hindfoot Introduction/Purpose: Recently, there has been a gradual rise in the utilization of patient-specific metallic implants within foot and ankle orthopedics, with the total ankle/total ankle replacement (TATTR) serving as a prime example. A critical decision made by surgeons in conjunction with the TATTR procedure involves the potential arthrodesis of the subtalar joint. This decision hinges upon numerous factors encompassing surgeon preference, radiographic indications, and clinical evaluations. However, no study has compared surgeon decision to the true joint health. The primary aim of this study was to determine if surgeon decision correlated with true three-dimensional joint health. It was hypothesized that arthrodesis of the subtalar joint with the TATTR procedure would be correlated with measures of sinus tarsi impingement or reduced joint space evident on 3D imaging. Methods: In this retrospective study, a 172 TATTR dataset was analyzed. Each patient underwent a bilateral computed tomography (CT) scan. Cases were semi-automatically segmented, and cases involving extensive anatomical damage were excluded. To assess joint health, a semi-automated distance mapping algorithm was written in MATLAB. Specific surfaces of the subtalar joint were manually selected. This included the posterior and middle/anterior talocalcaneal facets on the talus, and the sinus tarsi, anterior, middle, and posterior facets on the calcaneus. Distance mapping was performed by projecting a vector perpendicular from one bone triangulation until it intersected with its opposing triangulation. For detailed analysis, the sinus tarsi and posterior facet were divided into four and nine regions, respectively. Statistical analysis involved calculating the difference in means and Welch's t-test to assess significance. For visual analysis, rank plots were generated to determine if there was a clear distinction in joint spacing for fused and articulating procedures. Results: A total of 46 TATTR cases were included. No significance was found between groups for the four large regions (sinus tarsi, anterior, middle, and posterior facet), but when analyzing by specific regions, significance was found on the lateral portion of the posterior sinus tarsi as well as at both the medial portion of the anterior and middle sections of the posterior facet. When analyzing on rank plots for the posterior facet (anterior/medial), a clear cutoff was found around 2mm of joint space width (Figure 2). Table 1 summaries these results, and figures 1, 2, and 3 demonstrate our findings visually. Conclusion: In this study, surgeon decision to fuse the subtalar joint along with a TATTR procedure was compared to 3D imaging data of the pre-operative joint. Our findings indicate that patients in the fused+TATTR group, there was a noticeable anterior/medial downward shift of the talus. Moreover, our initial assumption regarding sinus tarsi impingement in fused cases was validated, as there was a significant reduction in sinus tarsi JSW. Future following of individualized surgeon decision could begin to establish trends in surgeon decision. Utilizing this tool prior to surgery in conjunction with the surgeon’s clinical decision-making process could potentially enhance patient outcomes.

Category: Midfoot/Forefoot; Ankle Introduction/Purpose: Lisfranc(LF) injuries are challenging to diagnose due to the subtlety of instability and low diagnostic sensitivity of traditional imaging methods like MRI and CT. These modalities fall short in accurately identifying subtle LF injuries because they do not simulate physiological load or provide sufficient bone detail under non-weightbearing conditions. Weightbearing computed tomography (WBCT) has emerged as a superior diagnostic technique, leveraging load-bearing conditions and superior bony visualization to detect subtle joint instabilities that other methods miss. This systematic review advances previous findings by comparing WBCT to conventional CT in diagnosing LF injury, as well as the ability to detect LF injuries of differing severity. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for this study. The PubMed, CINAHL, MEDLINE, SPORTDiscus, and Web of Science databases were searched from database inception until July 5th, 2023. The search algorithm utilized keywords that pertained to computed tomography and tarsometatarsal to find relevant articles. Eligibility criteria included articles using CT or WBCT. Articles were then retrieved, duplicates removed, and screening conducted based on article title, abstract, and full text using inclusion and exclusion criteria. Data extraction included author, publication year, patient demographic, injury description, imaging modality used, measurements, and p values. Articles were graded using the Methodological Index for Non-Randomized Studies (MINORS) scale, and statistical analysis of the extracted data conducted. Results: Out of the 498 articles retrieved, 9 met inclusion criteria. Several studies reported that WBCT was able to provide a higher level of accuracy than conventional CT when measuring the Lisfranc area, with enhanced sensitivity to subtle alterations in joint structure. WBCT also demonstrated superior sensitivity when it came to distinguishing between healthy and injured Lisfranc joint, especially when it came to identifying dorsal ligament damage. WBCT was able to detect significant variation in important measurements such as the first-second (M1-M2) distance, the first cuneiform (C1)-M2 distance, and joint volumes. WBCT also demonstrated good intra- and inter-observer reliability. This enables a more comprehensive assessment of the Lisfranc joint health, especially when it came to cases of subtle joint instability. Conclusion: This systematic review demonstrates the value of WBCT over conventional CT when it comes to diagnosing LF injury. Not only was WBCT able to detect deviations in asymmetry and LF area that conventional CT was unable to identify, but it detected instability in cases of subtle injury, and was able to differentiate between injury groups at various lower levels of injury. This review is the first to include comparisons of objective image modalities, as well as Lisfranc injuries of various severities.

Category: Ankle; Hindfoot Introduction/Purpose: Surgical options to address Haglund deformity include endoscopic and open approaches. After surgery, patients receive varying degrees of weightbearing limitation (nonweightbearing, touchdown weight bearing, or partial weight bearing). Given the scarcity of large-scale literature on the topic, this study aims to evaluate the impact of postoperative weightbearing protocols on outcomes after open surgical management of Haglund Syndrome. Methods: Following institutional approval, a retrospective review of patients undergoing surgery at a single institution by *** providers for Haglund Syndrome was performed. Patients were included if the surgery was performed by a currently active, fellowship-trained Foot and Ankle orthopaedic surgeon, without simultaneous management of other foot pathologies. This cohort of patients was reviewed for the following variables: date of birth, body mass index (BMI), smoking status (never, quit, active), American Society of Anesthesiologists Physical Status Classification (ASA), date of surgery, laterality, type of repair (corkscrew, speed bridge, suture anchor), current procedural terminology codes (CPT), postoperative weightbearing recommendations, postoperative outcomes (Achilles rupture, wound breakdown, persistent pain, debilitating plantarflexion weakness, revision), and date of most recent follow up. Statistical analysis was conducted using R with statistical significance set at p < 0.05. Results: Across 390 patients, the cohort averaged 55.14 years old and was 66.4% female. Postoperative recommendations varied from NWB (68.7%), TDWB (14.4%), WBAT (13.8%), and PWB (2.3%). Overall, 75 (19.2%) patients experienced a complication, including 40 (10.3%) persistent pain, 32 (8.2%) wound breakdowns, and 1 (10.3%) rupture, with 7 (1.8%) requiring revision. There were no significant differences in characteristics including age, diabetes, gender, BMI, and smoking status between weightbearing protocol groups. There were no statistically significant differences in complication rate between weightbearing protocols (p= 0.48354). The WBAT group experienced the highest rate of pain (14.8%) and a higher rate of the need for revision surgery in the WBAT group (3.7%), though not significant. The highest rate of wound breakdown occurred in the NWB group (9.7%). Conclusion: The study suggests that postoperative weightbearing protocols do not significantly influence the outcomes of open surgical treatment for Haglund Syndrome. This indicates that surgeons may choose the most appropriate weightbearing protocol based on individual patient needs and preferences. Future research should aim to further validate these findings and explore the impact of postoperative immobilization on outcomes in more granular detail.

Background: The utilization of social media for health-related purposes has surged, especially during the COVID-19 pandemic. TikTok, a short-form video platform, has seen substantial growth, becoming a prominent medium for health information dissemination. However, the lack of regulation poses challenges in evaluating the validity of TikTok content. Methods: This cross-sectional study assesses TikTok videos related to total knee arthroplasty rehabilitation exercises. Search terms identified 84 videos, with 64 meeting the inclusion criteria. Engagement metrics and quality scores were analyzed, utilizing the DISCERN tool and the Total Knee Replacement Exercises Education Score. Results: The analyzed videos accumulated nearly 6 million views, with a median of 10,293.5 (interquartile range = 4139.3-26,100.0). Health-care professionals contributed 48% of the content. Despite higher engagement metrics for health-care professional videos, the overall quality, as indicated by DISCERN and Total Knee Replacement Exercises Education scores, remained poor. No videos achieved an “excellent” rating, with the majority categorized as “poor.” Conclusions: This study underscores TikTok’s substantial role in total knee arthroplasty rehabilitation information dissemination but reveals a critical deficit in content quality and reliability. Health-care professionals marginally outperformed general users but displayed overall inadequacy. The study emphasizes the necessity for improving the quality of health-related content on emerging social media platforms, especially within the realm of orthopaedic surgery. Level of Evidence: Level III, Cross-sectional study.

The use of high-strength concrete (HSC) in constructing high-rise reinforced concrete buildings and their deep foundations is becoming more popular because of the significant reduction in member size and, thus, self-weight in structural members. However, the higher cement content in HSC may result in increased heat of hydration and autogenous shrinkage, growing concerns about forming early-age cracks in HSC structural members. This case study assessed the early-age cracking of HSC in bored pile construction of high-rise buildings. A nonlinear transient coupled thermal-mechanical response analysis was performed to evaluate the potential of early-age cracking caused by the heat of hydration generated in the HSC using ABAQUS and two subprograms, USDFLD and UEXPAN. A 3-D finite element model was developed considering thermal effects, time-dependent evolution of early-age strength and stiffness of HSC, crack strain development, autogenous shrinkage, and stress-relaxation in the analysis. Field measurements were carried out on a 3-m diameter bored pile constructed using Grade C50/60 HSC (fck,cube = 60 MPa) for a high-rise building project in Hong Kong to evaluate the validity of the numerical model. Optical fiber sensors were used to monitor the temperature changes of the pile for approximately 380 hours after casting. The temporal and spatial temperature distributions measured in the field measurements agree well with the simulations. Large thermal gradients and high tensile stress zones were observed across the horizontal cross-sections of the pile, resulting in the formation of vertical annular cracks. Based on the results of the analysis, the maximum crack widths were predicted and compared with the durability crack width limits.

Bambara groundnut is vital for food security due to its high nutritional content and resilience to environmental stresses. The objectives of the study were to determine associations among agronomic traits and nutrients in Bambara groundnut and identify traits influencing grain production in Bambara groundnut. Field experiments were conducted at the University of KwaZulu-Natal's Ukulinga Farm and Controlled Environment Facility (CEF) to assess agronomic performance and nutritional content. Nutritional content was evaluated using standard combustion procedures and electron microscopy. Correlation, regression, and path coefficient analyses revealed varying relationships among agronomic traits, nutrient content, and grain yield. The number of seeds (NS), healthy seeds (NHS), and plant height (PH) exhibited significant associations with grain yield. Neutral detergent fiber (NDF), starch, magnesium (Mg), nitrogen (N), oxygen (O), and phosphorus (P), were the key predictors of grain yield productivity. Path coefficient analysis showed that NS, PH and magnesium, oxygen, and carbon contents positively affected grain yield. In conclusion, grain yield was influenced by multiple traits through different pathways that are complicated by the growing environment. Selecting taller genotypes with good agronomic traits and high nutrient content is recommended to develop high yielding Bambara groundnut cultivars.

Background: Randomized controlled trials (RCTs) are the gold standard for treatment efficacy, but foot and ankle RCTs are often small or inconsistent. The Fragility Index (FI) evaluates the stability of significant findings. This study assessed the fragility of RCT outcomes for Achilles tendon pathology (ATP) interventions. Methods: This systematic review queried PubMed up to May 14, 2024, for RCTs on ATP interventions. RCTs with significant binary outcomes were included. Two reviewers assessed eligibility, extracted data, calculated FIs, and evaluated risk of bias. Frequency-weighted means were used for narrative synthesis. Results: Eleven RCTs with 4506 patients (mean cohort size: 409.64 ± 160.54) and a mean age of 36.97 ± 13.51 years (n = 4356; 96.67%) were included, covering 24 binary outcomes. The median FI across all outcomes was 3 (interquartile range 1-4; mean 3.92), indicating that changing the outcome of just a few patients could shift a study’s results from statistically significant to nonsignificant. Trials having an FI ≤3 comprised 58.33%. Three outcomes (12.5%) had an FI of zero after recalculating P values using the two-sided Fisher exact test. Half of the outcomes were robust. No RCT reported FIs or adjusted significance for multiple testing. Most studies (81.82%) performed 2 or more statistical tests, with an average of 30.81 ± 41.28 P values reported per study. The overall risk of bias was low in 1 study (9.09%) and moderate in 7 (63.64%). Most studies had low risk of bias in randomization (72.73%) and missing outcome data (90.91%). Conclusion: The FI assesses the fragility of statistically significant binary results, revealing that many ATP RCTs have fragile outcomes due to small sample sizes. A median FI of 3 means that changing the outcome of 3 patients could shift a study’s results from statistically significant to nonsignificant.

Abstract Introduction Physician-review websites (PRWs) are commonly used by patients while searching for a surgeon. There is no current literature investigating the factors that contribute to online one-star reviews of musculoskeletal oncology surgeons. This retrospective study aims to identify these factors to determine areas of care affecting patient’s subjective reviews. Methods Patient ratings and comments regarding musculoskeletal oncology surgeons from the Musculoskeletal Tumor Society (MSTS) were collected from Vitals.com. One-star reviews with comments were then classified as either operative or nonoperative. These complaints were then further classified based on content including wait time, uncontrolled pain, time spent with the physician, surgical outcomes, medical staff/institutional complaints, and bedside manner. Results A total of 169 reviews (375 complaints) from 181 physicians were included. Of these complaints, 198 were from patients in the operative category while 177 were from patients in the nonoperative category. Bedside manner was the most common complaint. Operative patients reported higher instances of uncontrolled pain in their reviews, whereas nonoperative patients more frequently cited wait time. No significant difference in the complaints that mentioned the amount of time spent with the physician, bedside manner, a disagreement with the plan, or the medical staff or institution was found. Conclusion Online one-star reviews of musculoskeletal oncology surgeons on Vitals.com referenced both surgical and non-surgical aspects of patient encounters, with bedside manner being the most popular complaint overall. Surgical patients were more likely to complain of uncontrolled pain whereas non-operative patients were more likely to complain of wait time. Type of study Outcomes 2c.

The surgical management of adult spinal deformities (ASDs) involves a wide variety of complex and technically challenging operative techniques. Despite numerous publications examining the relationship between surgeon experience and outcomes in ASD, no systematic review or meta-analysis exists. This first-time systematic review and meta-analysis examines the impact of surgeon experience on the surgical parameters and complication rates for the surgical management of ASD. Four databases were used for the initial search of this study from database inception until 22 September 2023. The inclusion criteria required articles that examined the outcomes for surgery for ASD, stratified outcomes by surgeon experience and/or the learning curve as a proxy for surgeon experience, and utilized adult patients (>18 years of age). Seven articles met the criteria for final inclusion. Patients in the Experienced Surgeon group had statistically significantly lower levels of EBL with no significant difference in operative time after surgery for ASD compared to patients in the Inexperienced Surgeon group via a meta-analysis of three articles. Patients in the Experienced Surgeon group had a statistically significantly lower total complication rate compared to patients in the Inexperienced Surgeon group via a meta-analysis. Increased surgeon experience resulted in lower levels of EBL, without a significant difference in the operative time after surgery for ASD.

Abstract The value of glyphosate to growers practicing minimum or no‐till farming has been primarily a function of three factors: broad‐spectrum weed control, little to no carryover effect, and cost effectiveness. A 2‐year field study was conducted in 2021 and 2022 at the University of Idaho Research and Extension Centers at Kimberly and Aberdeen, ID, to evaluate the efficacy of alternative pre‐plant burndown herbicide treatments as compared to glyphosate treatment, the industry standard in small grain production systems. Herbicide cost comparison and crop injury observation were also conducted. Most herbicide treatments provided ≥90% control of the predominant weed species at 3 weeks after herbicide application. At least six different herbicide treatments had an equivalent cost to that of glyphosate at $26.50 ha−1. No observable damage from herbicide treatments was observed and crop yield was not affected by the treatments. These factors indicate that there are alternatives to pre‐plant burndown herbicides that are equally effective as glyphosate. With combinations of herbicides, each having a different site of action, weed control can be achieved while simultaneously reducing the risk of herbicide resistance.

This study investigates 3D extrusion bioinks for cartilage tissue engineering by characterizing the physical properties of 3D-printed scaffolds containing varying alginate and polyvinyl alcohol (PVA) concentrations. We systematically investigated the effects of increasing PVA and alginate concentrations on swelling, degradation, and the elastic modulus of printed hydrogels. Swelling decreased significantly with increased PVA concentrations, while degradation rates rose with higher PVA concentrations, underscoring the role of PVA in modulating hydrogel matrix stability. The highest elastic modulus value was achieved with a composite of 5% PVA and 20% alginate, reaching 0.22 MPa, which approaches that of native cartilage. These findings demonstrate that adjusting PVA and alginate concentrations enables the development of bioinks with tailored physical and mechanical properties, supporting their potential use in cartilage tissue engineering and other biomedical applications.

Background: The fulfilment of customer needs is dependent on the availability and accurate selection of supplier(s). In the public sector in South Africa, Central Supplier Database is used for this purpose for the procurement up to the value of R1 000 000.00. Aim: This article examines Central Supplier Database as a supplier search engine, with its impact in procurement process efficiency as well as customer needs satisfaction. Setting: The study comprised of 20 participants at the nine provinces of a public sector institution in South Africa. Methods: This article utilised simple random sampling to secure a total number of 20 participants performing a procurement function in the Department of Justice and Constitutional Development. Qualitative data were collected through interviews and later analysed through thematic analysis. Results: The study’s findings reflect that Central Supplier Database is open for manipulation, too open-ended, enabling suppliers to register for anything, everything and everywhere they deem fit, thus causing service delivery constraints. Conclusion: There is an urgent need for rethinking and reengineering of Central Supplier Database for the enhancement of process efficiency and fulfilment of customer needs. Contribution: The study contributes to the limited research on procurement utilising Central Supplier Database in South Africa. It provides insight into the history, the current state as well as the envisaged future of procurement with Central Supplier Database.

The use of midfoot wedges for the correction of flatfeet disorders, such as progressive collapsing foot disorder, has increased greatly in recent years. However, the wedge material/composition has yet to be standardized. Metallic wedges offer advantages such as comparable elasticity to bone, reduced infection risk, and minimized osseous resorption, but a comprehensive review is lacking in the literature. Therefore, the objective of this systematic review was to organize all studies pertaining to the use of metallic wedges for flatfoot correction to better understand their efficacy and safety. This systematic review adhered to PRISMA guidelines, and articles were searched in multiple databases (PubMED, SPORTDiscus, CINAHL, MEDLINE, and Web of Science) until August 2023 using a defined algorithm. Inclusion criteria encompassed midfoot surgeries using metallic wedges, observational studies, and English-language full-text articles. Data extraction, article quality assessment, and statistical analyses were performed. Among 11 included articles, a total of 444 patients were assessed. The average follow-up duration was 18 months. Radiographic outcomes demonstrated that patients who received metallic wedges experienced improvements in lateral calcaneal pitch angle and Meary’s angle, with an enhancement of up to 15.9 degrees reported in the latter. Success rates indicated superior outcomes for metallic wedges (99.3%) compared to bone allograft wedges (89.9%), while complications were generally minor, including hardware pain and misplacement. Notably, there were no infection complications due to the inert nature of the metallic elements. This review summarizes the effectiveness, success rates, and safety of metallic wedges for flatfoot correction. Radiographic improvements and high success rates highlight their efficacy. Minor complications, including pain and mispositioning, were reported, but the infection risk remained low. Our results demonstrate that metallic midfoot wedges may be a viable option over allograft wedges with proper planning. Future research should prioritize long-term studies and standardized measures.

Abstract Background This study examines how leadership is provided at the operational level of a health system in a protracted crisis context. Despite advances in medical science and technology, health systems in low- and middle-income countries struggle to deliver quality care to all their citizens. The role of leadership in fostering resilience and positive transformation of a health system is established. However, there is little literature on this issue in Democratic Republic of the Congo (DRC). This study describes leadership as experienced and perceived by health managers in crisis affected health districts in Eastern DRC. Methods A qualitative cross-sectional study was conducted in eight rural health districts (corresponding to health zones, in DRC’s health system organization), in 2021. Data were collected through in-depth interviews and non-participatory observations. Participants were key health actors in each district. The study deductively explored six themes related to leadership, using an adapted version of the Leadership Framework conceptual approach to leadership from the United Kingdom National Health Service’s Leadership Academy. From these themes, a secondary analysis extracted emerging subthemes. Results The study has revealed deficiencies regarding management and organization of the health zones, internal collaboration within their management teams as well as collaboration between these teams and the health zone’s external partners. Communication and clinical and managerial capacities were identified as key factors to be strengthened in improving leadership within the districts. The findings have also highlighted the detrimental influence of vertical interventions from external partners and hierarchical supervisors in health zones on planning, human resource management and decision-making autonomy of district leaders, weakening their leadership. Conclusions Despite their decentralized basic operating structure, which has withstood decades of crisis and insufficient government investment in healthcare, the districts still struggle to assert their leadership and autonomy. The authors suggest greater support for personal and professional development of the health workforce, coupled with increased government investment, to further strengthen health system capacities in these settings.

Objective To assess outcomes related to Lupus Therapeutics’ Patient Advocates for Lupus Studies (LT‐PALS), a peer‐to‐peer lupus clinical trial (LCT) education program designed to improve representation of diverse groups in LCTs. Patients with lupus and clinical trial participation experience were trained as peer educators (PALs) providing trial‐agnostic education to trial‐naive patients with lupus. Methods We used a two‐arm, randomized pretest/posttest study design to evaluate outcomes related to LCT participation: knowledge, attitudes, self‐efficacy, and intentions to participate in an LCT. Five academic medical centers piloted the program. The intervention group (IG) individually received peer‐to‐peer education sessions with trained PALs, primarily via telephone; the control group (CG) received a 3‐week waiting period. We conducted within/between‐group t‐tests and multiple linear regressions with posttest scores as dependent variables and participation in LT‐PALS as the exposure variable. Results The sample (n = 136) included 64 IG and 72 CG participants, with 67.7% identifying as Black. At posttest, IG participants had higher knowledge (P

Cervical disc degenerative disease (CDDD) is a common spinal pathology that is often treated with anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty (CDA), and/or hybrid cervical surgery (HCS). The purpose of this first-time systematic review is to examine the biomechanical outcomes associated with three types of non-contiguous cervical surgeries—ACDF, CDA, and HCS—to provide a greater understanding of non-contiguous cervical surgical biomechanics. A systematic review was performed using PubMed, Cumulated Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, and Web of Science from database inception until June 6th, 2023. The inclusion criteria was any article that reported biomechanical or kinematic outcomes, outcomes for any of the three non-contiguous cervical surgeries, and human-derived and/or human cadaver subjects. A total of 5 biomechanical articles were included from a total of 523 articles. Non-contiguous two-level HCS experienced less drastic range-of-motion (ROM) changes throughout the cervical spine and decreased intervertebral disc pressure (IDP) compared to non-contiguous two-level ACDF. Non-contiguous two-level CDA resulted in more cervical ROM and less non-operative segment facet contact force compared to non-contiguous two level ACDF. There was less cephalad and caudal non-operative segment ROM in non-contiguous two-level ACDF compared to contiguous three-level ACDF.

Charcot neuroarthropathy (CN) is a rare but serious sequela of diabetes and other diseases that cause peripheral neuropathy. It is most commonly characterized by degeneration of the foot and/or ankle joints leading to progressive deformity and altered weight-bearing. If left untreated, the deformities of CN lead to ulceration, infection, amputation, and even death. Because of the associated peripheral neuropathy and proprioception deficits that accompany CN, patients typically do not perceive the onset of joint destruction. Moreover, in the hands of the untrained clinician, the initial presentation of CN can easily be mistaken for infection, osteoarthritis, gout, or inflammatory arthropathy. Misdiagnosis can lead to the aforementioned serious sequelae of CN. Thus, an early accurate diagnosis and off-loading of the involved extremity, followed by prompt referral to a specialist trained in the care of CN are crucial to prevent the late-term sequelae of the disease. The purpose of this article was to create an opportunity for enhanced understanding between orthopedic surgeons and emergency physicians, to improve patient care through the optimization of diagnosis and early management of CN in the emergent setting.

Introduction Patients with a first venous thromboembolism (VTE) are at risk of recurrence. Recurrent VTE (rVTE) can be prevented by extended anticoagulant therapy, but this comes at the cost of an increased risk of bleeding. It is still uncertain whether patients with an intermediate recurrence risk or with a high recurrence and high bleeding risk will benefit from extended anticoagulant treatment, and whether a strategy where anticoagulant duration is tailored on the predicted risks of rVTE and bleeding can improve outcomes. The aim of the Leiden Thrombosis Recurrence Risk Prevention (L-TRRiP) study is to evaluate the outcomes of tailored duration of long-term anticoagulant treatment based on individualised assessment of rVTE and major bleeding risks.Methods and analysis The L-TRRiP study is a multicentre, open-label, cohort-based, randomised controlled trial, including patients with a first VTE. We classify the risk of rVTE and major bleeding using the L-TRRiP and VTE-BLEED scores, respectively. After 3 months of anticoagulant therapy, patients with a low rVTE risk will discontinue anticoagulant treatment, patients with a high rVTE and low bleeding risk will continue anticoagulant treatment, whereas all other patients will be randomised to continue or discontinue anticoagulant treatment. All patients will be followed up for at least 2 years. Inclusion will continue until the randomised group consists of 608 patients; we estimate to include 1600 patients in total. The primary outcome is the combined incidence of rVTE and major bleeding in the randomised group after 2 years of follow-up. Secondary outcomes include the incidence of rVTE and major bleeding, functional outcomes, quality of life and cost-effectiveness in all patients.Ethics and dissemination The protocol was approved by the Medical Research Ethics Committee Leiden-Den Haag-Delft. Results are expected in 2028 and will be disseminated through peer-reviewed journals and during (inter)national conferences.Trial registration number NCT06087952.

Iron deficiency anemia is widespread among the female population. Pregnant women are a particularly vulnerable group, because the existing iron reserves are inadequate, and during pregnancy the need for iron for the formation of the placenta and fetal growth increases sharply, as a result, there is an imbalance between the intake and consumption of this trace element. Anemia increases the risks of various complications of gestation and multiplies maternal mortality. Note an increase in the frequency of premature childbirth, the threat of termination of pregnancy, placental insufficiency, weakness of labor, fetal development delay, fetal hypoxia, low birth weight of the newborn, the volume of pathological blood loss during childbirth and in the early postpartum period. At the same time, the development of these pathological conditions can be prevented by following modern protocols of pre-pregnancy preparation and pregnancy management. Prevention of anemia includes the use of various iron preparations, as well as new combinations, in particular a combination of 80 mg of elemental iron and 350 mcg of folic acid. In the article, we describe clinical cases demonstrating a rational preventive approach that prevents the development of clinical anemia and promotes safe perinatal outcomes for mother and fetus.

Introduction: Launched in 2018 for revision total ankle arthroplasty (rTAA), the INVISION talar component addresses subsidence when poor talar bone stock is present. Due to the recency of the market-availability of the INVISION, studies evaluating its efficacy are lacking. This study presents the first analysis of early-term outcomes of patients undergoing rTAA with the INVISION talar component. Methods: This was a single-center, retrospective review of 28 patients undergoing rTAA with the INVISION talar component and INBONE II tibial component performed between 2018 and 2022. Data on preoperative characteristics, postoperative complications, secondary procedures, and survivorship were collected. The primary outcome measures were rates of major complications, re-operation, and implant failure. Secondary outcomes included post-operative changes in varus and valgus alignment of the tibia and talus. Results: The most common secondary procedures performed with rTAA were medial malleolus fixation (n = 22, 78.6%) and gastrocnemius recession (n = 14, 50%). Overall, 10.7% (n = 3) of patients underwent reoperation and 14.3% (n = 4) suffered major complications. Incidence of implant failure was 10.7% (n = 3). All reoperations were caused by infection. Mean varus alignment of the tibia and talus improved from 4.07 degrees and 4.83 degrees to 1.67 degrees and 1.23 degrees, respectively. Mean valgus alignment of the tibia and talus improved from 3.67 degrees and 4.22 degrees to 2.00 degrees and 2.32 degrees, respectively. Conclusions: In a series of 28 patients undergoing rTAA with the INVISION talar component, we discovered comparatively low rates of reoperation, major complication, and implant failure (10.7%, 14.3%, and 10.7%). The INVISION system appears to have a reasonable safety profile, but further studies evaluating long-term outcomes are required to assess the efficacy of the INVISION system.

Osteochondral lesions of the talus are common injuries that are most often the result of trauma. The natural progression of osteochondral lesions is not well understood. It is still unclear which lesions eventually lead to joint degeneration and osteoarthritic changes and if the treatment method affects the progression. The existing literature surrounding this topic is sparse, with inconsistent findings. The presented images are taken from a 72-year-old man with bilateral osteochondral lesions of the talus. To our knowledge, this is the first published series of images illustrating the natural progression of a patient with bilateral osteochondral lesions of the talus over a 12-year time period.

Background: Randomized controlled trials (RCTs) are crucial in comparative research, and a careful approach to randomization methodology helps minimize bias. However, confounding variables like socioeconomic status (SES) and race are often underreported in orthopaedic RCTs, potentially affecting the generalizability of results. This study aimed to analyze the reporting trends of SES and race in RCTs pertaining to Achilles tendon pathology, considering 4 decades of data from top-tier orthopaedic journals. Methods: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used PubMed to search 10 high–impact factor orthopaedic journals for RCTs related to the management of Achilles tendon pathology. The search encompassed all articles from the inception of each journal until July 11, 2023. Data extraction included year of publication, study type, reporting of SES and race, primary study location, and intervention details. Results: Of the 88 RCTs identified, 68 met the inclusion criteria. Based on decade of publication, 6 articles (8.8%) reported on SES, whereas only 2 articles (2.9%) reported on race. No RCTs reported SES in the pre-1999 period, but the frequency of reporting increased in subsequent decades. Meanwhile, all RCTs reporting race were published in the current decade (2020-2030), with a frequency of 20%. When considering the study location, RCTs conducted outside the United States were more likely to report SES compared with those within the USA. Conclusion: This review revealed a concerning underreporting of SES and race in Achilles tendon pathology RCTs. The reporting percentage remains low for both SES and race, indicating a need for comprehensive reporting practices in orthopaedic research. Understanding the impact of SES and race on treatment outcomes is critical for informed clinical decision making and ensuring equitable patient care. Future studies should prioritize the inclusion of these variables to enhance the generalizability and validity of RCT results.

This article presents a domain-specific language for writing highly structured multilevel system specifications. The language effectively bridges the gap between requirements engineering and systems architecting by enabling the direct derivation of a dependency graph from the system specifications. The dependency graph allows for the easy manipulation, visualization and analysis of the system architecture, ensuring the consistency among written system specifications and visual system architecture models. The system architecture models provide direct feedback on the completeness of the system specifications. The language and associated tooling has been made publicly available and has been applied in several industrial case studies. In this article, the fundamental concepts and way of working of the language are explained using an illustrative example.

Category: Ankle Arthritis Introduction/Purpose: End-stage ankle osteoarthritis (OA) is a debilitating condition that adversely affects quality of life and causes considerable functional impairment. Total ankle arthroplasty (TAA) is growing in popularity as a motion-preserving option for ankle OA. A previously published meta-analysis evaluated the mid-term outcomes of TAA with a minimum average follow-up of 5 years, demonstrating excellent survivorship. To our knowledge, there is no such manuscript that evaluates the outcomes of TAA at the long-term, with a minimum follow-up of ten years or greater. Due to a lack of long-term follow-up of TAA implants in the current literature, the aim of this review was to aggregate findings from the most up-to-date analyses of the long-term outcomes of TAA via meta-analysis. Methods: We conducted a systematic review and meta-analysis according to the PRISMA guidelines. Electronic databases were searched from the date of inception to September 12, 2022. These databases included Medline, Embase, and Scopus. We included all studies that 1) involved patients that underwent uncemented TAA, and 2) all patients who had an average follow-up period of at least ten years. We excluded abstracts, as well as manuscripts written in languages other than English. We collected American Orthopaedic Foot and Ankle Score (AOFAS) and Visual Analog Scale (VAS) scores from the included studies for pooled meta- analysis. Due to the varying definition of survivability between studies, this metric was not assessed in our final evaluation. Results: Our data included a total of 2,562 patients and 2,895 ankles with an average follow-up of 10 years. Of the 25 studies included in the systematic review, 7 provided pre- and post-operative AOFAS means and 5 provided pre- and post-operative VAS means with associated measures of variability and were included in our meta-analysis. The weighted mean difference between pre- and post-operative AOFAS scores was -41.98 (95% CI: -48.28 to -35.69) (Fig. 1A), indicating that patients improved by almost 42 points between pre-and post-surgery. The weighted mean difference between pre-and postoperative VAS scores was 4.52 (95% CI: 2.26-6.43) (Fig. 1B), indicating patients improved by about 4.5 points on average between pre-and post-surgery. Survivability was not assessed due to the heterogeneity in survivability definition between studies. Conclusion: Outcomes following TAA are favorable and indicate patient-reported outcomes improve over long-term follow-up. Future, prospective, randomized research should be conducted to better assess TAA, and authors should work towards standardization of survivorship and complication reporting methodologies to allow for pooled metanalysis of these important outcome metrics.

Category: Ankle Arthritis; Ankle Introduction/Purpose: Although many patients with postraumatic ankle arthritis are of a younger age, studies evaluating the impact of age on outcomes of primary total ankle arthroplasty (TAA) reveal heterogenous results. The purpose of this study is to determine the effect of age on complication rates and patient reported outcomes after TAA. Methods: This was a retrospective study of 1,185 primary TAA divided into 3 age cohorts (Age < 55, n=219; Age55-70, n=688; Age>70, n=278). Patient demographics, intraoperative variables, postoperative complications, and patient reported outcome measures were compared among groups using univariable analyses. Multivariable Cox regression was performed to assess risk for implant failure by age group. Mean follow-up was 5.7 years. Results: Compared to Age55-70 and Age>70 groups, Age < 55 patients had the lowest mean ASA score (2.2 vs 2.4 vs 2.5; p< 0.001) and highest rates of all complications (33.8% vs 23.1% vs 19.8%; p=0.001), implant failure (9.1% vs 6.0% vs 3.2%; p=0.022), and component removal (5.0% vs 2.8% vs 1.1%; p=0.030). Univariable and multivariable cox regression analysis revealed decreased risk for implant failure for Age>70 compared to Age < 55 patients (HR: 0.43 [95%CI: 0.19-0.94], p=0.034; and HR: 0.42 [95%CI: 0.18-0.95], p=0.038, respectively). Across the AOFAS Hindfoot and all FAOS subscales, Age < 55 group reported the lowest (worst) mean pre and postoperative scores (p < 0.001). The age < 55 group had the highest mean VAS score at final follow-up (22 vs 14 vs 14; p< 0.001). Conclusion: Studies involving large sample sizes with mid-to long-term follow up are critical to reveal age-related impacts on outcomes after TAA. Younger patients had higher rates of complications and implant failure and fared worse on patient reported outcome measures in the largest single-institution series to date evaluating the effect of age on outcomes in TAA.