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Background:. Few evidence-based suggestions are available to help applicants and mentors improve reapplication outcomes. We sought to provide program directors' (PDs) perspectives on actionable steps to improve reapplicants' chances for a match. Methods:. The PDs were asked to rank positions unmatched applicants can pursue, steps these applicants can take for the next application cycle, and reasons why reapplicants do not match. Results:. Responses from 66 of 123 PDs were received (53.6% response rate). Obtaining new recommendation letters and rotating with orthopaedics were the highest 20 ranked steps unmatched applicants can take. No curriculum vitae (CV) improvement, poor interview, and poor letters of recommendation were the most important reasons hindering applicants from matching when reapplying. Conclusions:. Steps reapplicants could prioritize include obtaining new recommendation letters, rotating in orthopaedics, and producing new research items. CV strengthening and improving interview skills address the 2 main reasons why unmatched applicants failed in subsequent attempts. Level of Evidence:. Level IV

In the present case report, we have described a patient with bilateral renal artery occlusion resulting in the acute onset of refractory hypertension and renal failure requiring hemodialysis. Endovascular stenting of the renal arteries was not feasible owing to extensive aortic and renal orifice calcification. After consultation with nephrology and medical optimization, the patient underwent unilateral hepatorenal bypass, with subsequent improvement in renal function and sustained freedom from dialysis. Although percutaneous revascularization has become the preferred option for surgical management of renal artery occlusion, the findings from the present case have demonstrated that hepatorenal bypass remains a viable alternative for more complex cases.

Introduction/Purpose: Minimally invasive dorsal cheilectomy (MIDC) has become a popular alternative to an open approach for treating Hallux Rigidus, although the current literature is divided on its effectiveness regarding complications and patient reported outcomes. To combat a portion of the complications related to the MIDC approach, a first metatarsophalangeal (MTP) joint arthroscopy can often be added to the procedure. The combined procedure has been demonstrated to be effective at improving patient reported outcomes without increasing the complication rate relative to an open procedure. This study looks to examine the effectiveness of the MIDC with first MTP arthroscopy procedure in patients with hallux rigidus with minimum 1 year follow up. Methods: This was a multicenter retrospective review was conducted for adult patients treated with MIDC and first MTP arthroscopy between 3/1/2020 and 8/1/2022, with at least one year of postoperative follow-up data. Patient charts were reviewed for demographic information, operative time, pre and postoperative first MTP range of motion (ROM), visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOXFQ), and EQ5DLD scores. Continuous data was expressed as a mean and standard deviation, categorical data was expressed as a percentage. Wilcoxon Rank Sum test was used to compare continuous variables. All P < 0.05 was considered significant. Results: A total of 31 patients were included in the study with an average follow-up time of 16.5 months (range: 12 to 26.2). There was 1 (3.2%) complication of an underservice EHL tendon tear, 2 (6.5%) patients were converted to a MTP fusion, and 1 (3.2%) patient underwent revision cheilectomy and capsular release for MTP joint contracture. There was a significant improvement in patient’s ROM in dorsiflexion (50 vs 89.6 degrees, P=0.002), but not in plantarflexion (11.3 vs 18.6 degrees, P=0.07). There was a significant improvement in patient’s postoperative VAS pain scores (6.4 vs 2.1, P< 0.001), MOXFQ pain scores (58.1 vs 30.7, P=0.001), MOXFQ Walking/Standing scores (56.6 vs 20.6, P=0.001), MOXFQ Social Interaction scores (47.3 vs 19.36, P=0.002), and MOXFQ Index scores (54.7 vs 22.4, P< 0.001). Conclusion: We found that MIDC with first MTP arthroscopy was effective at improving patient reported outcomes, specifically patient’s pain scores, at one year with low complication and revision rates. These results demonstrate MIDC and first MTP arthroscopy’s is an effective treatment for early-stage hallux rigidus and may be considered as an alternative to an open approach.

Introduction/Purpose: Minimally invasive surgical (MIS) treatment of hallux valgus (HV) deformity is increasing in popularity. A 2mm-diameter burr is used to create a distal first metatarsal osteotomy prior to capital fragment translation and fixation. The metatarsal will shorten by the burr’s diameter (2mm). Plantar or dorsal capital fragment displacement may also cause load transference and possibly transfer metatarsalgia. In this study, we examine the effect of MIS HV on forefoot loading mechanics with respect to metatarsal shortening and sagittal plane displacement. Methods: Four lower-limb cadaveric specimens were studied. A pedobarography pressure-sensing mat was used to record forefoot plantar pressure in a controlled weightbearing stance position.10 Control and post-osteotomy measurements were obtained with the capital fragment fixated in 3 possible positions: 0mm, 5mm dorsal, and 5mm plantar displacement. Pedobarography data yielded pressure data within measurable graphical depictions. Raw mean contact pressure measurements were taken under the first and fifth metatarsal heads to establish medial and lateral forefoot loading pressure ratios. A priori power analysis was performed based on previous peer-reviewed pedobarographic data and our study was adequately powered. Results: 40 measurements were recorded and ratios of medial-to-lateral forefoot loading were constructed. Medial forefoot pressure change control versus 0mm displacement, and control versus dorsal displacement was not found to be statistically significant (p=0.525, p=0.55 respectively). Significant medial pressure increase was identified comparing control versus plantar displacement (p=0.006). Lateral pressure increased significantly with dorsal displacement of the osteotomy (p=0.013). Conclusion: MIS hallux valgus correction does not appear to cause increase in lateral forefoot pressure loading when sagittal plane displacements are controlled. Plantar displacement increases medial loading, and dorsal displacement increases lateral loading. The clinician must consider metatarsal head position post-osteotomy, as decrease in medial loading and subsequent increase in lateral loading may lead to lateral forefoot pain and transfer metatarsalgia.

Introduction/Purpose: Many patients use the internet as a source for medical information regarding their medical condition. However, the accuracy and reliability of the information is variable. The recent release of general population facing artificial intelligence (AI) chatbot programs has created a potential alternative medical information source for patients. Our study examined the accuracy of the information provided by ChatGPT for total ankle arthroplasty (TAA), as determined by four fellowship-trained foot and ankle orthopedic surgeons. Methods: GPT-4, the latest ChatGPT model, was asked the 12 of the most common questions patients have regarding TAA. Its responses were recorded and evaluated by four fellowship-trained foot and ankle orthopedic surgeons on a scale of 1 – 4, with 1 representing an excellent response not requiring clarification and 4 representing an unsatisfactory response requiring significant clarification. Averages of scores for each question were recorded and an average of every score was used to develop an overall accuracy score. Results: The overall accuracy score of GPT-4 was 1.35. The responses by GPT-4 received a score of 1 for 32 of 48 (66.7%) responses. There was found to be no significant difference in scores for any of GPT-4’s responses. Conclusion: Our study found that GPT-4 performed well in providing accurate and near complete information to commonly questions asked to physicians by patients regarding TAA. Our results suggest that AI models, like GPT-4, may be an effective alternative source of medical information for patients. Further study with subsequent AI models and direct patient interaction may shed further light on the utility of this potential patient education modality. ChatGPT Response Accuracy Score Accuracy scores for ChatGPT, as determined by four foot and ankle fellowship-trained orthopedic surgeons

Introduction/Purpose: The modified Lapidus procedure (MLP) or a minimally invasive surgery distal transverse osteotomy (MISDTO) are acceptable surgical treatment options for hallux valgus. The current literature is evolving when comparing the effects of each procedure on patient reported outcomes and post-operative complications. The purpose of this study is to compare postoperative outcomes, time to weight bear, and patient reported outcomes using the Patient Reported Outcome Instrumentation System (PROMIS) for the MLP and MISDTO. Methods: This study retrospectively reviewed patients who underwent a MLP or MISDTO for hallux valgus correction at Prisma Health Midlands between February 2020 – February 2022. Data collected included: demographic data, postoperative outcomes, time to weight bear, and PROMIS scores, including Pain Interference (PI), Physical Function (PF), and Mobility scores. Paired Student’s T-Test and Wilcoxon Rank Sum test were used to compare continuous variables and Chi-Squared test for categorical variables. Results: A total of 81 patients undergoing MLP and 78 undergoing MISDTO were included in the study. Average follow-up for MLP and MISDTO patients was 53.7 and 43.4 weeks, respectively. MLP demonstrated significant improvement in PI (52.5 vs 56.8, P< 0.001) and Mobility (46.3 vs 43.4, P=0.044) scores, while MISDTO demonstrated a significant improvement in PI (48.8 vs 57.1, P< 0.001), PF (50.2 vs 44.9, P< 0.001), and Mobility (49 vs 42.8, P< 0.001) scores. MISDTO patients had significantly larger improvements in PI (7.6 vs 4.5, P=0.008), PF (5.3 vs 2.2, P=0.026), and Mobility (5.5 vs 2.9, P=0.02) compared to MLP patients. MISDTO patients had a significantly lower non-union rate (13.6% vs 2.6%, P=0.025), hardware failure rate (0% vs 9.9%, P=0.007), and time to weight-bear (2.2 vs 7.8 weeks, P< 0.001). Conclusion: Both MLP and MISDTO procedures are effective treatments for improving the pain and mobility issues associated with hallux valgus while maintaining patients’ function. MISDTO was found to improve patient reported outcomes significantly more than MLP, with a lower non-union rate, lower hardware failure rate, and shorter time to weight-bear. These findings suggest MISDTO is superior to MLP in improving patient reported outcomes and postoperative outcomes in the treatment of hallux valgus. Further study multicenter and long term outcome studies could be useful further evaluate these short term findings.

Background: Percutaneous Zadek osteotomy (ZO) has emerged as a surgical treatment of insertional Achilles tendinopathy (IAT) over the last decade. Existing literature is limited regarding the comparison of this approach with the more established, open ZO technique. This systematic review aims to evaluate and compare the current data on open vs percutaneous ZO approaches to help set evidence-based guidelines. Methods: A systematic literature search was performed using the keywords (Zadek osteotomy) OR (Keck and Kelly osteotomy) OR (dorsal closing wedge calcaneal osteotomy) OR (Haglund Deformity) OR (Haglund Syndrome) OR (Insertional Achilles Tendinopathy) and MeSH terms Osteotomy , Calcaneus , Syndrome , Insertional , Achilles tendon , and Tendinopathy . Our search included the following databases: PubMed, Embase, and the Cochrane Library. The PRISMA protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2009 to 2024 and included the use of open or percutaneous approaches of ZO for the treatment of IAT with at least a 12-month follow-up. The MINORS score criteria were used to evaluate the strength and quality of studies. Results: A total of 17 studies were reviewed, including 611 subjects and 625 ZO procedures. Of these procedures, 81 (11%) subjects had a percutaneous and 544 (89%) subjects had an open ZO. The mean follow-up time was 16.1 months for patients treated with percutaneous ZO and 36.1 months for patients treated with open ZO. Both open and percutaneous studies included in this review showed postoperative improvements in AOFAS, FFI, VISA-A, and VAS scores in patients with IAT. The reported complication rate was 5.8% among patients treated with percutaneous ZO and 10.2% among patients treated with open ZO. Conclusion: Percutaneous ZO is an emerging approach with substantially fewer documented cases compared with the open ZO. Both percutaneous and open ZO appear to be relatively effective treatments for insertional Achilles tendinopathy with Haglund’s deformity. The lower complication rates reported for percutaneous ZO is encouraging. Further investigation with more subjects undergoing percutaneous ZO is clearly needed.

Background: Hindfoot fusion procedures are common for the treatment of end-stage arthritis or deformity. Surgical treatments for these conditions include talonavicular joint (single) arthrodesis, talonavicular and subtalar (double) arthrodesis, or talonavicular, subtalar, and calcaneocuboid (triple) arthrodesis. This study evaluated the complication rate, revision surgery rate, and hardware removal rate for those treated with either single, double, or triple arthrodesis. Methods: A retrospective review was conducted for patients who underwent single ( Current Procedural Terminology [ CPT ] code 28740), double ( CPT 28725 and 28740), or triple ( CPT 28715) arthrodesis to treat hindfoot arthritis/deformity ( International Classification of Diseases, Ninth Revision [ ICD-9 ] code: 734, International Classification of Diseases, Tenth Revision [ ICD-10 ] codes: M76821, M76822, and M76829) from 2005 to 2022 using the South Carolina Revenue and Fiscal Affairs databank. Data collected included demographics, comorbidities, procedure data, and postoperative outcomes within 1 year of principal surgery. Student t test, chi-squared test, and multivariable logistic regression analysis were utilized during data analysis. Results: A total of 433 patients were identified, with 248 undergoing single arthrodesis, 67 undergoing double arthrodesis, and 118 undergoing triple arthrodesis. There was no significant difference between single, double, and triple arthrodesis in the rate of complications, hardware removals, revision surgeries, or 30-day readmission when controlling for confounding variables. However, a decrease in Charlson Comorbidity Index (CCI) was found to be predictive of an increase in the revision surgery rate (OR = 0.46, 95% CI 0.22-0.85, P = .02). Conclusion: We found no difference in the rate of complications, hardware removals, or revision surgeries in those undergoing single, double, or triple arthrodesis. Surprisingly we found that a lower Charlson Comorbidity Index, indicating a healthier patient had a significant relationship with a higher rate of revision surgery. Further study including radiographic indications for surgery or the impact of overall health status on revision surgery rates may further elucidate the other components of this relationship. Level of Evidence: Level III, cohort study.

Category: Midfoot/Forefoot; Basic Sciences/Biologics Introduction/Purpose: Traditional hardware for first MTP arthrodesis procedures are typically made from stainless steel or titanium. While postoperative non-weightbearing protocols have enabled successful results with these devices, they are still prone to permanent deformation and associated plantar gapping/joint misalignment following excessive prefusion loading (e.g., patient falling). By leveraging the material properties of NiTiNOL, sustained dynamic compression (SDC) staples have been designed to recover their initial shape after large loading events. As such, implementation of these SDC staples may produce first MTP arthrodesis constructs more robust to early loading events, potentially decreasing patient immobility times and reducing incidences of postoperative joint misalignment. The goal of this study was to characterize the biomechanical performance of first MTP. Methods: Solid foam MTP replicas underwent simulated arthrodesis using one of eight constructs (N=6 replicates within each group). Groups consisted of: (1) double 2-leg staple, (2) 4-leg inline staple, (3) 4-leg Y staple, (4) 4-leg inline staple & screw, (5) 4- leg Y staple & screw, (6) double screw, (7) locking plate, and (8) locking plate & screw (Figure A-C). Simulated loading was applied to the samples 23mm distal to the joint line in the dorsiflexion direction. Samples underwent 1,000 nondestructive cycles of loading between 5-15N (replicative of postoperative walking in a recovery boot), followed by simulated overloading (destructive test) that applied 10mm of displacement at the loading point. Plantar gapping was measured using photogrammetry techniques throughout the entire testing protocol. Data were analyzed using a one-way ANOVA (α=0.05) with Dunnett’s post hoc test using the ubiquitous plate and screw group as the control. Results: Plantar gapping at simulated walking revealed significantly increased plantar gapping in the locking plate (P=.001) and double 2-leg staple (P .75, Figure D). The double screw and Y staple & screw groups exhibited significantly decreased gapping at 10mm extension as compared to the locking plate & screw group (P=.030 and .049, respectively). All SDC NiTiNOL constructs (both with and without static devices) recovered plantar gapping post-failure, with plantar gaps ≤ 0.29 mm, whereas the locking plate & screw construct group had a mean post-failure plantar gap of 0.85 mm (P

Category: Hindfoot; Other Introduction/Purpose: Minimally invasive (MIS) percutaneous calcaneal osteotomy has been increasingly investigated as a potentially safe alternative to open calcaneal osteotomy due to reduced postoperative complication and decreased pain compared to an open procedure. This retrospective chart review aims to evaluate the postoperative outcomes and complication rates of patients undergoing MIS vs. open calcaneal osteotomy. Methods: IRB approval was obtained. The study was performed by 2 fellowship-trained orthopaedic foot and ankle surgeons. 20 patients underwent MIS percutaneous calcaneal osteotomy, and 33 patients underwent open calcaneal osteotomy. All cases were completed between March 2021 and February 2023. Patient charts were reviewed for outcome data including complication rate, union rate, revision rate, and Patient-Reported Outcomes Measurement Information System (PROMIS) scores. Results: Average follow up for the MIS group was 130.4 days and 258.2 days for the open group. The MIS group was found to have a lower rate of revision, infection, and sural neuritis (0%, 5%, and 10%) compared to the open group (3%, 13.3%, and 16.7%). All participants achieved union. Average preoperative PROMIS scores in the domains of physical function, pain interference, and mobility for the MIS group were 36.8 (28.6-46), 67.1 (54.3-78), and 34.6 (25-40). Average postoperative PROMIS scores for the MIS group were 35.7 (21-76), 62.3 (39-76), and 33.4 (16-75). In the open group, preoperative PROMIS scores in these same domains were 37.0 (22.4-49.8), 65.2 (54.3-77.8), and 35.0 (19-56), whereas they were 39.6 (19-56), 60.0 (39-72), and 37.4 (16-53) postoperatively. Conclusion: MIS percutaneous calcaneal osteotomy appears to be an efficacious and safe treatment with lower rates of revision, infection, and nerve injury compared to an open procedure. Early outcome measures show comparable PROMIS scores in all three domains of physical function, pain interference, and mobility following MIS percutaneous calcaneal osteotomy when compared to standard open calcaneal osteotomy. Surgeons may consider MIS percutaneous calcaneal osteotomy as an alternative to open calcaneal osteotomy when treating hindfoot deformities.

Category: Midfoot/Forefoot; Basic Sciences/Biologics Introduction/Purpose: There are normal variations in the shape of an individual’s foot. However, recent investigations involving large, heterogenous populations are scarce, complicating attempts to create a uniform definition of clinical foot arch height. The purpose of this study was to determine the distribution of plantar foot pressures from the general population. Methods: 1015 randomly sampled individuals (2030 feet) had a bipedal standing profile obtained utilizing a high sensitivity pressure mat. Data collected included: total foot length (cm), peak pressure (kPa), peak contact pressure (kPa), and total contact area (cm 2 ). Demographic information and data regarding individual comorbidities previously to be linked to pathologic arch height conditions were collected. A flatfoot was defined as Midfoot total area>Mean+1SD while a high arch was defined as Midfoot total area< Mean-1SD. Results: Our logarithmic transformation the data was representative of a normally distributed dataset and our demographic data closely reflective of the demographics United States population. Data for the right foot vs left foot were: 8.18% and 6.50% of participants had a flatfoot, 78.82% and 79.51% had normal arches, and 13.00% and 13.99% had high arches, respectively. The prevalence of normal bilateral arches was 70.54%, bilateral flat feet was 3.55%, and bilateral high-arched feet was 8.67%. Conclusion: Our data demonstrate a normalized distribution of plantar pressures and arch heights that were sampled from a population larger and more representative of the general populous than previously described. Given that our data may more accurately reflect the spectrum of normal adult foot. With these baseline characteristics defined, future research into arch height associated pathologies may proceed with a more standardized assessment when defining study populations.

Category: Ankle; Bunion Introduction/Purpose: Using patient-reported outcomes (PRO) to predict which patients may or may not improve from orthopaedic surgery could be valuable for clinical decision making. The Patient Reported Outcome Instrumentation System (PROMIS) utilizes computerized adaptive testing based on item response theory to decrease administration time while maintaining accuracy. However, the data on the relationship between pre- and post-operative PROMIS scores for elective foot and ankle surgical patients and their ultimate PROs is limited, and the literature is conflicting. The purpose of this study is to assess preoperative PROMIS mobility, physical function (PF), and pain interference (PI) scores to determine their accuracy in predicting patient reported surgery success or failure, and to estimate preoperative score domains associated with patient reported surgery success. Methods: A retrospective chart review was used to identify a cohort of adult patients who underwent operative treatment for at least one foot or ankle surgery between 05/01/2020 – 06/01/2022. Descriptive statistics were calculated to describe the study population, clinical factors, PROMIS scores, and outcomes. Bivariate analyses were performed to assess potential associations between PROMIS score differences with other factors, and PROMIS score differences within levels of other factors. Logistic regression analysis was used to assess potential associations with patient-rated surgery success or failure with patient, clinical, and outcomes data. Significance was determined by associated p-values (p < 0.05). Results: We found that preoperative PROMIS scores for mobility, PF, and PI were not significantly associated with patient-rated surgery success (p=0.092, 0.666, 0.869, respectively). Similarly, in a regression to identify individual factors that influenced patient reported surgical failure, preoperative mobility, PF, and PI scores were all not significant (p=0.095, 0.663, 0.626, respectively). However, preoperative cut-points based on 95% confidence intervals for means were estimated locally to determine the probability of optimal patient reported surgery success, and threshold scores for mobility, PF, and PI were chosen as ≥39, ≥47, and ≤55, respectively. We also found that the only preoperative patient factors that showed higher odds of patient reported surgical failure in a multivariate logistic regression model were age of 50-64 (p=0.004) and diabetes (p=0.006). Conclusion: Our study found no significant associations between preoperative PROMIS scores and patient reported success or failure for foot and ankle surgery. This may be encouraging to surgeons when considering that even patients with seemingly unfavorable preoperative scores have a similar chance as other patients for surgical success and improvement from the patient’s perspective. Additionally, identifying optimal patient PROMIS scores for surgery success can provide an ideal baseline score cutoff for surgeons for comparison when assessing an individual’s chances of surgical success for foot and ankle surgery. However, further study is needed to investigate the clinical utility of these estimates.

Category: Ankle Introduction/Purpose: The utilization of total ankle arthroplasty (TAA) continues to increase, and identifying preoperative factors that influence postoperative outcomes after TAA may be valuable. The use of post-acute care (PAC) facilities has also grown substantially, and discharge to a PAC facility can increase patient morbidity and postoperative costs. The purpose of this study is to define the effect of BMI on discharge to a PAC facility and hospital length of stay (LOS) following TAA. Methods: We performed a retrospective review to identify a large cohort of adult patients who underwent TAA between 2006 - 2020 from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Using overweight patients as the reference BMI group, we estimated a sex- and age- adjusted log-binomial regression model on BMI categories to estimate risk ratios to analyze the association between BMI and risk of being discharged to a PAC facility and/or hospital LOS. Results: Relative to overweight patients, obese patients had 1.47 times the risk (P=0.008), and morbidly obese patients had 2.26 times risk (P < 0.001) of being discharged to a PAC facility after TAA. Males had 0.47 times the risk of females (P < 0.001), and for each year older, patients had 1.07 times the risk (P < 0.001) of being discharged to a PAC facility. There was no difference in hospital LOS for underweight patients, but healthy weight patients stayed an additional 0.29 days (P=0.004), obese patients stayed an additional 0.18 days (P=0.010), and morbidly obese patients stayed an additional 0.34 days (P=0.006). Males stayed 0.30 fewer hospital days than females (P < 0.001), and for each year older, patients stayed 0.011 days longer (P < 0.001). Conclusion: This study found that women and patients who are obese and morbidly obese have a greater LOS and chance to be discharged to a PAC facility. Increasing age is also associated with an increase in LOS and discharge to a PAC. These may be important factors when discussing the postoperative plan with patients prior to TAA.

Category: Ankle Introduction/Purpose: Total ankle arthroplasty (TAA) is an effective treatment for various ankle pathologies, but some concern remains for the relatively high associated complication and failure rates relative to major joint arthroplasty of the hip and knee. Patient body mass index (BMI) is a modifiable and potentially important preoperative variable when evaluating postoperative complications. The purpose of this study is to evaluate the effect of BMI on the acute postoperative complication rate after TAA. Methods: We performed a retrospective review to identify a large cohort of adult patients who underwent TAA between 2006 - 2020 from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Using overweight patients as the reference BMI group, we estimated log-binomial models to estimate risk ratios on outcomes, while also adjusting for sex and age, in order to investigate whether there was a significant difference in complication rate between the BMI groups. Results: We found that, relative to overweight patients, there was no statistically significant difference in the risk of acute complications for underweight (p-value=0.062), healthy weight (p-value=0.800), obese (p-value=0.993), or morbidly obese (p- value=0.781) patients who underwent TAA. There was also no statistically significant difference in the risk of acute complications based on age (p-value=0.876) or sex (p-value=0.696) for TAA. Additionally, there was no significant difference between the BMI groups when comparing how many patients had a complication out of the total number of patients in their respective BMI group for either major complications (p-value=0.9835) or minor complications (p-value=0.0578). Conclusion: We found that BMI, age, and sex did not lead to a statistically significant difference in the risk of complications, even when stratified by major vs minor complications, within 30 days postoperatively for TAA.

Category: Hindfoot; Other Introduction/Purpose: A calcaneal osteotomy is often included as part of the treatment in planovalgus and cavovarus foot deformities. Often this is done through an open approach where complications of wound infection and sural nerve injury are common. More recently, this strategy has been modified using minimally invasive techniques. A percutaneous approach, in comparison to the standard open calcaneal osteotomy, allows for reduced postoperative complication and decreased pain compared to an open procedure. This retrospective chart review aims to evaluate the postoperative outcomes of patients undergoing calcaneal osteotomy via a minimally invasive percutaneous approach in foot reconstructive surgery to assess early functional outcomes, complication rate and revision rates. Methods: One fellowship-trained foot and ankle orthopaedic surgeon at one academic institution performed minimally invasive calcaneal osteotomy on 20 patients. All cases were completed between March 2021 and March 2023. Patient charts were reviewed for outcome data including complication rate, union rate, revision rate, and Patient-Reported Outcomes Measurement Information System (PROMIS) scores. Results: Participants included 15 females and 5 males, 4 of whom were smokers. Average age was 42.2 years. Average BMI was 32.3, and average follow up was 130.4 days. Complications included 1/20 patients had a postoperative wound breakdown of the screw site requiring incision and debridement with closure and 2/20 cases of sural neuritis. One resolved 6 months after treatment and the other was present but became less symptomatic. All participants achieved union, and there were no revisions. All shifts corrected hindfoot deformity either via medializing or lateralizing osteotomy. Average preoperative PROMIS scores in the domains of physical function, pain interference, and mobility were 36.8 (28.6-46), 67.1 (54.3-78), and 34.6 (25-40), respectively. Average postoperative PROMIS scores were 35.7 (21-76), 62.3 (39-76), and 33.4 (16-75), respectively. Conclusion: Minimally invasive calcaneal osteotomy appears to be an efficacious and safe treatment option for the correction of cavovarus and planovalgus hindfoot deformities with the ability to obtain appropriate hindfoot correction with low complication rates and high union rates. Early outcome measures show a favorable pain interference PROMIS score as well as a trend in improvements in PROMIS physical function scores. Longer term data will need to be done to assess long term functional outcome and revision rates.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Bunions are one of the most common pathologies treated by orthopedic foot and ankle surgeons. The usage of minimally invasive and percutaneous surgical techniques continues to rise due to evidence of less pain, improved functional outcomes and low recurrence rates. Still, concern regarding heat generation during these procedures, osteonecrosis of bone, and nonunion persists. Literature suggests cool irrigation is superior to room temperature irrigation, but the question remains if irrigation is needed at all. This study evaluates the heat generation during percutaneous bunion surgery and analyzes the use of cooled irrigation compared to no irrigation at all. This study tested the hypothesis that cool irrigation would lead to overall lower heat generation compared to no irrigation at all. Methods: 5 matched paired cadavers (10 legs) were used to simulate MIS first metatarsal distal transverse osteotomy for all trials. Prior to osteotomy, 4 temperature probes were inserted as to the border where the Shannon burr would travel along the osteotomy site (Image 1). Probes were secured by suture and temperature was recorded using K-type thermocouples. All trials were completed using a pulse technique of 20 seconds on, 5 seconds off with a Shannon Burr and fluoroscopic guidance. Trials were complete with continuous cold irrigation (N=5) and without any irrigation at all (N=4). Temperatures were evaluated at baseline, during burring, and after burring to assess total heat generation and dissipation. A two-tailed t-test was used to analyze differences in heat generation and dissipation between procedures completed with irrigation and without irrigation (P < 0.05). Results: 5 cadavers with a mean age of 86.2 were evaluated (10 total simulations, 9 analyzed). Cadavers underwent 1 trial with irrigation, and 1 without on opposite feet. 88.9% of patients showed heat generation below the level of bone necrosis (50 oC). One trial with irrigation temperature rose to 79.1oC. Matching specimen without irrigation had probe failure and no temperature was obtained. Average burr time was 51.2±2.4 seconds with irrigation, and 35±0.5 seconds without. Irrigation was associated with a significant increase in burr time (P=0.002). Average temperature change was 13.62±11.9 and 0.7±0.5 during burring, 7.1±1.8 and 5.8±0.3 after burring in procedures with and without irrigation, respectively. No significant difference was detected between heat generation in irrigated vs non-irrigated procedures (P = 0.371, 0.548). Conclusion: This study found that in a cadaveric model the use of cooled irrigation, compared to no irrigation, did not lead to a significant difference in the heat generation during MIS first metatarsal distal transverse osteotomy. However, 1 out of the 9 samples used in this study showed a heat generation above 50 oC. Additionally, to our surprise the use of irrigation led to a significant increase in burring time. This may be useful information for a surgeon when considering the usage of cooled irrigation to reduce the potential risk of osteonecrosis when performing a MIS first metatarsal distal transverse osteotomy.

Category: Midfoot/Forefoot; Other Introduction/Purpose: Hallux valgus, a common deformity treated by orthopedic foot and ankle surgeons, can frequently present with an increased distal metatarsal articular angle (DMAA), which may require correction in addition to the hallux valgus deformity. Minimally invasive (MIS) percutaneous hallux valgus surgery is becoming more popular and often used in patients with increased DMAA. Additional recent literature has shown low rates of recurrence, minimal pain and high patient functional outcomes with MIS hallux valgus correction. Thus, we investigated the efficacy of MIS percutaneous distal transverse first metatarsal osteotomy procedure, a triplanar correction, in correcting the DMAA in hallux valgus surgery. We hypothesize that give the ability to obtain a triplanar correction with this osteotomy no additional osteotomy will be needed to correct the DMAA. Methods: A retrospective chart review was performed on patients who underwent the hallux valgus reconstruction with a MIS percutaneous distal transverse first metatarsal osteotomy between September 2021 to December 2022. Exclusion criteria included patients with inadequate follow up and all patients not undergoing MIS percutaneous distal transverse first metatarsal osteotomy for hallux valgus correction. Hallux valgus angle (HVA), intermetatarsal angle (IMA) and DMAA were measured on pre- operative and 2-week post-operative radiographs to assess immediate correction of these angles. Univariate analysis was used to describe pre- and post- measurements for DMAA, HVA, and IMA. Differences in pre- and post- measurements were evaluated using paired t-test. Results: In total, 43 minimally invasive surgery (MIS) hallux valgus corrections on 39 patients were included. On average, the DMAA decreased from 9.5 degrees pre-operatively to 4.8 degrees two weeks post-operatively (decrease of 4.7 degrees, p-value < 0.001). The average HVA decreased from 29.9 degrees pre-operatively to 4.2 degrees two weeks post-operatively (decrease of 25.7 degrees, p-value of < 0.001). Lastly, the average IMA decreased from 15.1 degrees pre-operatively to 2.9 degrees 2 weeks post-operatively (decrease of 12.2 degrees, p-value < 0.001). Conclusion: Our study showed that utilizing a MIS percutaneous distal transverse first metatarsal osteotomy for hallux valgus correction was able to significant reduce the DMAA without the need for supplementary metatarsal osteotomies. Additionally significant correction of the IMA and HVA was also obtained. MIS hallux valgus correction may be considered by orthopedic foot and ankle surgeons for those patients that need surgical correction for hallux valgus deformity that also requires DMAA correction.

Category: Midfoot/Forefoot; Other Introduction/Purpose: Minimally invasive (MIS) bunion correction is growing in popularity as a treatment option of hallux valgus deformities. This technique has been shown to help with post-operative pain and improve functional outcomes. Despite these benefits there are concerns that the Shannon burr may lead to excess heat generation, thermal necrosis of bone and potentially increase the risk of nonunion. The purpose of our study was to assess the heat generation while using a Shannon burr during MIS first metatarsal osteotomies. Methods: Four below knee cadavers were utilized and osteotomies of the distal and proximal aspects of each of the first metatarsal were performed utilizing a 2mm x 20mm Shannon burr under fluoroscopic guidance. 3 K-type thermocouples were placed in each metatarsal, one distal, one in between and one proximal to the osteotomy sites. Temperatures were evaluated during the entire burring process and after to assess heat dissipation and total heat generated. Three different techniques of burring were utilized, 1. Continuous without irrigation, 2. Continuous with irrigation and 3. Pulse burring technique with irrigation (20 seconds on, 10 seconds off). Results: The pulse burring technique with irrigation showed the overall lowest max temperature and change in temperature compared to the other techniques. Average burr time, maximum heat generation and overall change in heat was 86.2 seconds, 102.4 °F and 78.9 °F for all trials. Conclusion: The pulse burr technique with irrigation generated less heat than both continuous burring with and without irrigation. There was an overall trend toward higher heat generation with longer burr times regardless of irrigation and burring technique. Utilizing a Shannon burr with pulse burring and irrigation can minimize heat generation and potentially decrease the risk of thermal necrosis of bone.

Category: Hindfoot; Ankle Introduction/Purpose: Minimally invasive percutaneous (MIS) calcaneal osteotomy has become more popular due to low risk of nerve injury and wound complications. The Shannon burr is often used to perform these osteotomies despite concern for the heat generation. Temperatures above 50oC may lead to osteonecrosis of bone. A recent MIS calcaneal cadaveric model study showed that cool irrigation led to less heat generation than room temperature irrigation. However, questions remain if irrigation is needed at all. This study evaluates heat generation during MIS calcaneal osteotomies and analyzes whether the use of cooled irrigation significantly decreases the temperature of the burring process compared to no irrigation at all. Our hypothesis was that cool irrigation would lead to overall lower heat generation compared to no irrigation. Methods: 5 matched paired cadavers (10 legs) were used to simulate a MIS calcaneal osteotomy for all trials. Prior to the osteotomy, 4 temperature probes were inserted as to the border where the Shannon burr would travel along the osteotomy site (Image 1). Probes were secured by suture and temperature was recorded using K-type thermocouples. All trials were complete using a pulse technique of 20 seconds on, 5 seconds off with a Shannon Burr and fluoroscopic guidance. Trials were complete with continuous cold irrigation (N=5) and without any irrigation at all (N=4). Temperatures were evaluated at baseline, during burring, and after burring to assess total heat generation and dissipation. A two-tailed t-test was used to analyze differences in heat generation and dissipation between procedures completed with irrigation and without irrigation (P < 0.05). Results: 5 cadavers with a mean age of 86.2 were evaluated for a total of 10 simulations, 9 analyzed. All cadavers underwent 1 trial with irrigation, and 1 without on opposite feet. Average drill time was 124±24.5 seconds with irrigation, and 118.8±43.9 seconds without (P=0.915). 77.8% of procedures showed heat generation below the level of bone necrosis (50 oC). 2 procedures without irrigation generated heat above this threshold (54.3 oC, 54.7 oC). Average change in temperature was 15.1±4.6 and 22.9±8.7 during drilling, 8.4±1.7 and 10.7±5.3 after drilling in procedures with and without irrigation, respectively. There was no significant difference detected between heat generation during or after burring in irrigated vs non-irrigated procedures (P = 0.426, 0.661). Conclusion: This cadaveric study found that the use of cooled irrigation compared to no irrigation did not lead to a significant difference in the heat generation during a MIS calcaneal osteotomy. However, 2 out of the 9 samples used in this study showed a heat generation above 50 o C, and both were done without the use of irrigation. This may be useful information for a surgeon when considering the usage of cooled irrigation to reduce the potential risk of osteonecrosis when performing a MIS calcaneal osteotomy.

Category: Hindfoot; Other Introduction/Purpose: Zadek dorsal closing wedge calcaneal osteotomy (DCWCO) has been increasingly investigated as an effective technique for the treatment of Insertional Achilles Tendinopathy and Haglund’s deformity. More recently, this strategy has been modified using minimally invasive techniques. A percutaneous approach, in comparison to the standard open DCWCO, allows for reduced postoperative complication, improved clinical function, and decreased pain. This retrospective chart review aims to evaluate the postoperative outcomes of patients undergoing Zadek osteotomy via a minimally invasive percutaneous approach to assess early functional outcomes, complication rates, and revision rates. Methods: Two fellowship-trained foot and ankle orthopaedic surgeons at one academic institution performed minimally invasive percutaneous Zadek osteotomies on 21 patients. All cases were completed between March 2021 and February 2023. Patient charts were reviewed for outcome data including complication rate, union rate, revision rate, and Patient-Reported Outcomes Measurement Information System (PROMIS) scores. Results: Average age of patients was 54 years. Average BMI was 39.4. Average follow up was 111.6 days. Complications included 1/21 (4.7%) superficial infection that resolved with oral antibiotics, 1/21 (4.7%) tibial neuritis that resolved 3 months after surgery, and 1/21 (4.7%) postoperative plantar fasciitis that resolved with home stretching by 6 months. There were no revisions to open procedures or hardware removal. All participants achieved union. 20/21 (95%) were very satisfied with their surgery. Average preoperative PROMIS scores regarding physical function, pain interference, and mobility were 38.3 (27-51), 65.1 (55-75), and 35.0 (25-46), respectively. Average postoperative PROMIS scores in these same domains were 38.5 (19-54), 58.8 (39-72), and 36.8 (22- 51). There was an average improvement in PROMIS scores in all domains (0.23, -6.35, and 1.76). Conclusion: Minimally invasive percutaneous Zadek osteotomy appears to be an efficacious and safe treatment option for insertional Achilles tendinitis and Haglund’s deformity with low complication profile, high union rate of the osteotomy and high patient satisfaction. Early functional outcome data shows trends in improvements in PROMIS scores. However, longer term data will be needed to assess long term functional outcomes and revision rates.

Background Annually there are an estimated 4.5 million sports- and recreation-related injuries among children and young adults in the United States. The most common sports-related injuries are to the lower extremities, with two-thirds occurring among children and young adults (age range 5-24 years). The objective is to describe the epidemiology of lower leg injuries across 27 high school (HS) sports over a 3-year period. Methods The Datalys Center for Sports Injury Research and Prevention provided lower leg injury data for 27 sports in 147 high schools for 2011-2012 through 2013-2014 academic years from National Athletic Treatment, Injury and Outcomes Network (NATION) HS Surveillance Program. Results The overall rate of lower leg injuries over this 3-year period was 1.70 per 10 000 acute events (AEs) (95% CI, 1.59-1.82). In men, the highest number of lower leg injuries was in football (n=181), but indoor track had the highest rate of injury at 2.80 per 10 000 AEs (95% CI, 2.14-3.58). In women, the highest number of lower leg injuries and the highest rate of injury were in cross-country (n=76) at 3.85 per 10 000 AEs (95% CI, 3.03-4.81). The practice injury rate was 0.91 times the competition injury rate (95% CI, 0.78-1.07). Conclusion An improved understanding of the most common sports in which lower leg injuries are seen may help direct appropriate resource utilization. Our data would suggest efforts toward prevention of these overuse injuries, especially in football, track, and cross-country may have the greatest impact on the health of student athletes. Level of Evidence: Level IV, case series.

Category: Ankle, Hindfoot, Imaging- Ultrasound Introduction/Purpose: Tendinopathy of the foot and ankle is common and can progress to become incapacitating. The most frequently affected tendons in the foot and ankle are the posterior tibial, peroneal, and Achilles. Studies have found a lifetime incidence of 5.9% in sedentary people and as high as 52% in athletes for Achilles tendinopathy. Previous studies demonstrated that ultrasound (US) of the soft tissues of the foot and ankle is a highly effective tool that can evaluate nearly every anatomical structure. Its lack of ionizing radiation, low cost, and painless nature make it a viable tool for foot and ankle evaluation. We sought to utilize US to determine normal values for the Achilles, peroneal, and posterior tibial tendons in patients presenting to the foot and ankle clinic. Methods: Patients were evaluated prospectively via a standardized US examination protocol from 2015-2016. Subjects who agreed to participate received a bilateral lower extremity ultrasound performed by a musculoskeletal ultrasonographer of the posterior tibial, peroneus longus, peroneus brevis, and Achilles tendons. Images were obtained in both the transverse and longitudinal axes above and below the malleoli and saved for analysis and measurement calculations. When indicated, color flow Doppler was utilized to assess for hyperemia and recorded. The imaging for each tendon was acquired with the patients in standardized positions on the examining table. Results: A total of 200 patients with 400 extremities were identified, consented, and participated in the study. Measurements for each patient were recorded above and below the malleoli for each tendon. Most tendons demonstrated a normal distribution as illustrated in the representative Figure 1 of the peroneus brevis above the lateral malleolus. Values and distributions curves were similarly calculated for each tendon at each point of measurement. Patients with suspected tendinopathy frequently had an increase of two standard deviations above the mean. Conclusion: This is the largest studies to characterize the measurements of the posterior tibial tendon, Achilles, and peroneal tendons in patients that present to a foot and ankle clinic. This baseline data can assist clinicians in their diagnostic ability with US. Given its low cost, lack of ionizing radiation and dynamic ability along with an improved understanding of normative data it will likely become an increasingly utilized diagnostic modality.

Category: Ankle, Midfoot/Forefoot, Population Health Introduction/Purpose: Numerous studies have been published on the treatment of adult acquired flatfoot deformity (AAFF). However, there has been little focus on it’s incidence, and economic burden in the general US population. This study updates and examines surgical incidence rates, demographic factors, and economic burden compared to our previous study that used data from South Carolina. Our previous study reported on data from 2004-2014 while this study reports on data from 2004-2014 using a nationwide database. Additionally, we evaluated the number and type(s) of surgeries performed for patients with a diagnosis of flatfoot who underwent surgery. Our hypothesis was that the surgical incidence of AAFF and its economic burden would increase given the aging population and improvements in surgical treatment options. Methods: The Nationwide Inpatient Sample (NIS) compiles patient data representing a 20% stratified sample of all hospital discharges nationwide. Along with demographics, diagnosis and procedural codes the NIS includes: admission type, length of stay, age, gender, race, Diagnostic Related Group, discharge status, primary expected payer, total charges, and physician specialty code. Bivariate descriptive statistics were utilized to analyze the data. Surgical incidence was calculated by assessing the number of surgical procedures compared to the number of lives covered by the Centers for Medicare and Medicaid Services (CMS). Demographics and medical comorbidities of patients who progressed to surgical treatment for AAFF were analyzed. The cost associated with the surgical care episode was calculated to determine the economic burden of the disease. Given the retrospective nature of the study, we utilized a regression analysis with multiple dependent variables to look for trends that could be analyzed in a larger cohort or prospective fashion. Results: In total, 160,795 patients underwent AAFF corrective surgery between 2004 and 2014. Patients who underwent surgery for AAFF were more likely to be white, female and in their 5th decade of life. Average surgical incidence during this time period was 5.12%. Patients were most likely to undergo a combination of soft tissue and fusion procedures, followed by soft tissue procedures alone and then fusion procedures in isolation. The total nationwide healthcare costs associated with patients who underwent surgery for AAFF exceeded 4 billion dollars. Conclusion: Our data demonstrates that there has been an increasing burden of disease for AAFF on society over the past 10 years. Patients undergoing surgery for AAFF contributed more than 4 billion dollars to national healthcare costs between 1994- 2014. Our study confirmed prior small scale studies of the population most at risk and demonstrated an increasing surgical incidence. The increase in incidence and burden parallel rising rates of diabetes and obesity seen nationwide, known risk factors for AAFF. We hope that this data will lead to increased patient education, clinical awareness and resource allocation for future study of AAFF disease prevention.

Background: Bone marrow aspirate (BMA) is used with the putative goal of enhancing healing of injured tissue. The most common sites to harvest BMA are the iliac crest, the tibia, and the calcaneus. Investigators have found that the tibia and calcaneus have fewer progenitor cells than the iliac crest. This retrospective review evaluates the efficacy and safety profile of harvesting BMA from the calcaneus bone. We hypothesized that harvesting BMA from the calcaneus will have high efficacy and safety profile with low complication rates. Methods: A retrospective chart review of patients undergoing bone marrow aspiration from the calcaneus bone from January 2019 to October 2022 was performed. The main data points evaluated were patient satisfaction and pain level, follow-up times, quantity of BMA harvested, fusion rates, and complications including nerve damage, infections, and nonunions. Results: There were 45 (34 female and 11 male) patients who underwent 45 procedures. The average age, BMI, and amount of BMA were 45.1 years (range 23-79), 33.1 (range 19.2-61.3), and 10.3 mL (range 2-40), respectively. There was no pain reported at the final follow-up in 32 patients (71.1%), and there was minimal to no pain in the area of surgery in the remaining 13 patients (28.9%). The 10 cases of fusion successfully healed with combined use of allograft and BMA. The average follow-up time was 12.3 months (range 2.4-33.7). There were no infections, wound complications, or nerve injuries. Conclusion: Harvesting BMA from the calcaneus bone is a safe procedure. In this heterogenous series where BMA augmented other surgical strategies, patients had little to no pain and there were no cases of wound complication or iatrogenic neuropraxia after undergoing bone marrow harvest from the calcaneus. Level of Evidence: Level IV, case series.

Background: The peroneus longus (PL) and peroneus brevis (PB) tendons comprise the lateral compartment of the leg and stabilize the foot during weightbearing. Peroneal tendinopathy can precipitate lateral ankle pain and induce functional disability. The progression of peroneal pathology to lateral ankle dysfunction is thought to stem from asymptomatic, subclinical peroneal tendinopathy. There may be clinical benefit to identifying asymptomatic patients with this condition before progression to disability. Various ultrasonographic characteristics have been observed in peroneal tendinopathy. The purpose of this study is to identify the frequency of subclinical tendinopathic characteristics in asymptomatic peroneal tendons. Methods: One hundred seventy participants underwent bilateral foot and ankle ultrasonographic examination. Images were assessed for abnormalities of the PL and PB tendons by a group of physicians who recorded frequencies of abnormalities. This team consisted of an orthopaedic surgeon specializing in foot and ankle surgery, a fifth-year orthopaedic surgery resident, and a family medicine physician with musculoskeletal sonographer certification. Results: A total of 340 PL and 340 PB tendons were assessed. Sixty-eight (20%) PL and 41 (12.1%) PB tendons had abnormal traits. Twenty-four PLs and 22 PBs had circumferential fluid, 16 PLs and 9 PBs had noncircumferential fluid, 27 PLs and 6 PBs had thickening, 36 PLs and 12 PBs had heterogenicity, 10 PLs and 2 PBs had hyperemia, and 1 PL had calcification. In Caucasian participants, male gender was associated with increased frequency of abnormal findings, but there were no other significant differences based on age, body mass index, or ethnicity. Conclusion: In our studied population of 170 patients who had no complaints of associated symptoms, we found that 20% of PLs and 12% of PBs displayed ultrasonographic abnormalities. When we included all unusual findings within and around the tendons, prevalence rates of ultrasonographic abnormalities were 34% for PLs and 22% for PBs. Level of Evidence: Level II, prospective cohort study.

Category: Other; Other Introduction/ Purpose: Orthopedic surgeons are one of the highest prescribing specialties of opioids in medicine. To address the ongoing opioid crisis in the United States, many surgeons have adopted multimodal regimens for post-operative pain control to decrease the need for opioids. Recent studies have demonstrated the effectiveness of opioid-sparing multimodal pain management therapies when compared to opioid inclusive therapies. However, to date there are no published studies analyzing the cost of multimodal vs opioid postoperative pain regimens for the elective foot & ankle surgical post-surgical patient. Methods: A secondary analysis of data collected from two studies that evaluated pain control after elective forefoot surgery was analyzed. The index study examined the number of opioid pills consumed post-operatively. A follow-up then examined the clinical utility of the non-opioid pain regimen for pain control post-operatively. Medications in the non-opioid multimodal regimen included cyclobenzaprine, ketorolac, meloxicam, pregabalin, and acetaminophen. Using information collected during these two studies, deidentified patient profiles were constructed using the patient’s insurance carrier and preferred pharmacy to determine the cost of each patient’s post-operative regimen (narcotics vs multimodal). All patients, 40 patients from the multimodal pain pathway study and 59 from the opioid pain control study, were included in this analysis and their prescription costs were totaled and analyzed. Results: A box plot was constructed to visualize data and identify outliers to be removed for data analysis. Prescriptions in the opioid group had an average cost of $8.92 (SD=$5.74) while the multimodal group had an average cost of $25.60 (SD=$10.49), p Conclusion: Patients whose post-operative pain was managed by an opioid-free multimodal regimen had statistically significant higher prescription costs than with opioid monotherapy regardless of health insurance type. However, the difference may not be clinically significant as on average it was $17. As more studies demonstrate the effectiveness of opioid-free post-operative pain management, it may be reassuring to surgeons that despite a greater number of medications with the multimodal protocol the average cost difference was only about $17. This information may allow surgeons to prescribe this regimen to all patients regardless of socioeconomic status and continue to decrease post-operative opioid prescriptions.

Category: Midfoot/Forefoot; Bunion Introduction/ Purpose: Recently there has been an increase in minimally invasive surgery (MIS) for the correction of hallux valgus deformity. This systematic review aims to evaluate and present the current literature on MIS hallux valgus correction in studies reporting the use of the Shannon burr with distal metatarsal osteotomies to help establish evidence-based guidelines for surgeons utilizing this technique. Methods: Two independent authors performed a systematic literature search using the following databases: PubMed, Embase, and the Cochrane library. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2008 to 2022 and included the use of the Shannon burr during distal metatarsal osteotomies minimally invasive surgery for hallux valgus and at least 12-month follow-up. The MINORS score criteria was utilized to evaluate the strength and quality of 17 studies by three authors. Statistical analysis and meta-analysis were not performed due to the heterogeneity of the included studies and the data being descriptive. Results: A total of 17 studies were reviewed. A total of 911 subjects were included, and 1088 MIS procedures were performed. The average follow-up was 23.8 (12-59.1) months. AOFAS and VAS scores improved from 52.1 (41-62.5) to 90.3 (83.3-97.1) and 4.9 (3-8.2) to 0.8 (0-1.9). Satisfaction rates were very high among the studies that reported it. The HVA, IMA and DMAA angle improved from 31.4 (23.5-44.1) to 11.1 (7-17.2).), 13.4 (8.1-18.6) to 7.3 (4.2-10.3), and 12.3 (9-16.3) to 4.1 (1-6.7). Complication rate was 16.6%. Recurrence was 2.2%. Nonunion 0.4%, infections 1.1%, nerve injury 2.2%, avascular necrosis 0%, hallux varus 0.09%, transfer metatarsalgia 0.1% and hardware removal 6.2%. Conclusion: Minimally invasive surgery for the treatment of hallux valgus utilizing the Shannon burr appears to be a safe and effective therapy with appropriate correction of the hallux valgus deformity, improvement in functional outcomes, high patient satisfaction, low recurrence, and acceptable complication rates.

Background: Recently there has been an increase in minimally invasive surgery (MIS) for the correction of hallux valgus deformity. This systematic review aims to evaluate and present the current literature on MIS hallux valgus correction in studies reporting the use of the Shannon burr with distal metatarsal osteotomies to help establish evidence-based guidelines for surgeons using this technique. Methods: Two independent authors performed a systematic literature search using the following databases: PubMed, Embase, and the Cochrane library. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2008 to 2022 and included the use of the Shannon burr during distal metatarsal osteotomies MIS for hallux valgus and at least 12-month follow-up. The MINORS score criteria was used to evaluate the strength and quality of 17 studies by 3 authors. Statistical analysis and meta-analysis were not performed because of the heterogeneity of the included studies and the data being descriptive. Results: A total of 17 studies were reviewed. A total of 911 subjects were included, and 1088 MIS procedures were performed. The average follow-up was 23.8 (12-59.1) months. American Orthopaedic Foot & Ankle Society scale and visual analog scale scores improved from 52.1 (41-62.5) to 90.3 (83.3-97.1) and 4.9 (3-8.2) to 0.8 (0-1.9). Satisfaction rates were very high among the studies that reported it. The hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle improved from 31.4 (23.5-44.1) to 11.1 (7-17.2), 13.4 (8.1-18.6) to 7.3 (4.2-10.3), and 12.3 (9-16.3) to 4.1 (1-6.7), respectively. The complication rate was 16.6%, and recurrence was 2.2%. Nonunion comprised 0.4%, infections 1.1%, nerve injury 2.2%, avascular necrosis 0%, hallux varus 0.09%, transfer metatarsalgia 0.1%, and hardware removal 6.2%. Conclusion: MIS for the treatment of hallux valgus using the Shannon burr appears to be a safe and effective therapy, with appropriate correction of the hallux valgus deformity, improvement in functional outcomes, high patient satisfaction, low recurrence, and acceptable complication rates. Level of Evidence: Level II, systematic review.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Hallux valgus is one of the most common deformities treated by orthopedic foot and ankle surgeons. Hallux valgus can frequently present with an increased distal metatarsal articular angle (DMAA), which may require correction in addition to treating the hallux valgus deformity. Many surgical procedures can correct hallux valgus with an increased DMAA with varying levels of success. Thus, we investigate the efficacy of the modified Lapidus procedure, a triplanar correction, in correcting the DMAA in hallux valgus surgery. Methods: A retrospective chart review was performed on patients who underwent the hallux valgus reconstruction with a modified Lapidus procedure between April 26th, 2018 and November 19th, 2020. Exclusion criteria included any patient undergoing hallux valgus correction not receiving a modified Lapidus procedure and patients with inadequate follow up. Hallux valgus angle (HVA), intermetatarsal angle (IMA) and DMAA were measured on pre-operative, immediate post-operative and at final follow up weight bearing radiographs. Results: The study included a total of 99 cases of modified Lapidus procedure for hallux valgus on 85 subjects with an average follow up of 5.4 months. On radiologic assessment, the average DMAA decreased from 17.72 +- 6.18 degrees pre-operatively to 9.19 +- 5.19 degrees immediately post-operatively (p < 0.0001) and 9.79 +- 4.62 degrees at the final follow up (p < 0.0001). The average HVA decreased from 31.34 +- 10.39 degrees pre-operatively to 13.34 +- 6.16 degrees immediately post-operatively (p < 0.0001) and 15.05 +- 7.43 degrees at final follow up (p < 0.0001). Lastly, the IMA decreased from 14.99 +- 3.82 pre-operatively (p < 0.0001) to 4.66 +- 2.59 immediately post-operative and 6.62 +- 3.46 degrees at final follow up (p < 0.0001). The rate of recurrence was 3.03%. Conclusion: The modified Lapidus procedure is an effective procedure in correcting the HVA, IMA, and DMAA in hallux valgus surgery without the need for additional distal or proximal metatarsal osteotomies. Surgeons should consider this technique in patients with moderate to severe hallux valgus deformity who may require correction of their DMAA.

Category: Bunion; Other Introduction/Purpose: Orthopedic surgeons frequently prescribe and overprescribe narcotic pain medications during the postoperative period, despite our increased understanding of the opioid crisis. In an effort to minimize narcotic analgesia and its potential side effects, opiate free multimodal pain pathways have been developed with promising results. However, there is a lack of published literature looking at opiate free multimodal pain protocols for elective outpatient foot and ankle surgeries. At our institution we have been implementing a novel opiate free multimodal post-operative pain protocol for elective outpatient foot and ankle surgeries. The purpose of this study was to explore the efficacy, feasibility, outcomes and satisfaction of an opioid-free, multimodal postoperative pathway in patients undergoing elective outpatient foot and ankle surgery. Methods: This study was approved by our IRB and was a prospective study. Data was collected from December 1st, 2020 through February 9th, 2022 for patients who underwent a primary elective outpatient foot and ankle surgery including bunion correction surgery with or without a lesser toe procedure(s). These patients completed a comprehensive opioid-free, multimodal pain management protocol and a follow up with one of two fellowship trained orthopedic foot and ankle surgeons. The multimodal treatment protocol included oral Lyrica, Tylenol, Toradol and flexeril to begin POD#0. Mobic was given to POD #4 once Toradol was completed. All data was collected in a prospective manner. At POD#1, #3, and #8, patients were contacted to collect VAS scores, complications, ED and Urgent care visits, and pain medication needs. At two week follow up these were again collected in addition to overall satisfaction rates. Results: 33 patients enrolled with a mean age of 55 (19-81) years old. The average follow up was 11.5 weeks. On POD#1, #3, #8, and at 2 week follow up our patients’ average VAS pain score was a 4.0, 2.5, 1.6, and 1.4 out of 10, respectively. 18% of patients required narcotics within the first 2 weeks, but by 2 weeks no patients were taking narcotics. No patients visited an ED or urgent care during the first 2 weeks post operatively. Common side effects were drowsiness/tiredness and constipation. Only 4 reported nausea or GI upset at 2 week follow up. Overall, 91% were satisfied with their pain control, 78% would follow the same protocol again, and 82% would recommend this pain management regimen to others. Conclusion: An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing elective outpatient foot and ankle surgery with a very low risk of requiring rescue opioids, having significant side effects, and/or needing an ED or urgent care evaluation within the first 2 week post operative period.

Background: Adult acquired flatfoot (AAFD) is commonly treated by foot and ankle surgeons. Despite how commonly this disease presents, its incidence and economic impact have yet to be defined. We hypothesized that the operative incidence of AAFD and its economic burden would increase over the time period 1996 to 2014. Methods: The South Carolina database was queried for data from acute care and ambulatory surgery centers. Bivariate descriptive statistics were used to analyze the data. Operative incidence was calculated and demographics and medical comorbidities of patients who progressed to operative intervention were analyzed. Costs associated with operative care episodes were calculated to determine the economic burden. Results: A total of 1299 patients underwent AAFD corrective surgery between 1996 and 2014. Patients who underwent surgery for AAFD were most likely to be white, female, and in their fourth, fifth, and sixth decade of life. Operative incidence for AAFD rose from 0.26 per 100 000 covered lives in 1996 to 3.04 in 2014. The total health care costs associated with patients who underwent surgery for AAFD increased from $57 395.33 in 1996 to $6 859 723.60 in 2014. Conclusions: This data demonstrate that patients most commonly undergoing operative intervention for AAFD were white, female, and in their fourth, fifth, or sixth decade of life. There has been a significant increase in operative incidence, which may help direct attention to further exploration of outcome data in these patient populations, associated treatment costs, and preventative treatment options. Level of Evidence: Level III, retrospective comparative study.

Background: There is a potential role for tranexamic acid (TXA) use in foot and ankle procedures; however, the benefits of this intervention have not been fully elucidated. The purpose of this study was to explore the safety, outcomes, and medical complication profile of the use of intravenous TXA in patients undergoing foot and ankle surgery. Methods: A prospective study with retrospective review of 241 patients undergoing elective and traumatic foot and ankle procedures was performed. One gram of intravenous (IV) TXA was administered prior to incision. Patients were followed and evaluated for medical comorbidities, intraoperative blood loss, wound complication, superficial and deep infections, hematoma formation, medical complications, 30-day hospital readmission rate, and return visits to the emergency department or urgent care setting prior to first postoperative visit. Descriptive statistics were used for subgroup analysis. Mean postoperative follow-up was 4.5 months. Results: Estimated blood loss in all cases was less than 20 mL. There was 1 case of superficial cellulitis (1/241, 0.4%), 1 deep infection after Achilles tendon repair (1/241, 0.4%), 4 cases of delayed wound healing (4/241, 1.6%), 1 instance of deep vein thrombosis (1/241, 0.4%), and 2 cases of postoperative pulmonary embolism (2/241, 0.8%). There were no instances of postoperative hematoma formation. There were no additional recorded thromboembolic events. There were no adverse drug reactions. There were no 30-day hospital readmissions or return visits to the emergency department or urgent care setting before the first postoperative visit. In a subgroup analysis, there was no significant difference in wound complications or infections between nondiabetics and diabetics ( P > .05) and traumatic and nontraumatic cases ( P > .05). Conclusions: The use of IV TXA in foot and ankle surgeries was associated with low risk of wound complications, infections, hematoma formation, thromboembolic events, and overall complication rates with minimal side effect profile. Perioperative tranexamic acid use may prove to be beneficial in foot and ankle surgery patients but especially in higher-risk patients such as those with diabetes, trauma, and those that are immunocompromised. Level of Evidence: Level IV, case series.