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A previous study showed that flatfoot deformity does not develop after posterior tibialis to dorsum transfer in patients with peroneal nerve palsy. Their conclusion was that it is the unopposed pull of the peroneus brevis which leads to the flatfoot deformity in posterior tibial tendon dysfunction. This case report presents a patient who developed a flatfoot deformity after posterior tibialis to dorsum transfer despite nonfunctioning peroneal muscles. [ABSTRACT FROM AUTHOR]

Background: Supination external rotation (SER) fibula fractures with abnormal medial clear space (MCS) on stress radiographs that normalizes with weightbearing radiographs, termed SER4a ankle fractures, pose a challenge in treatment decision making. This study aims to quantify differences in joint contact area, tibiotalar rotation, and translation using weightbearing computed tomography (CT) scans in SER4a ankle fractures., Methods: Between November 2022 and September 2023, patients presenting with isolated Weber B fibula fractures were evaluated for inclusion. Adult patients presenting within 10 days of injury with an SER4a ankle fracture, and no history of ankle fractures or surgery, were included. Ten patients were enrolled and underwent bilateral ankle weightbearing CT scans. Disior Bonelogic Software was used to quantify joint contact area, tibiotalar rotation, and translation, with the uninjured ankle serving as the control., Results: Ten patients (4 male, 6 female) with an average age of 51 years were included. The average MCS measured 2.5 mm (SD 0.36) on weightbearing and 5.7 mm (SD 0.67) on stress radiographs. The difference in joint contact area between injured and healthy joints was 12.2 mm 2 ( P  = .085). Axial tibiotalar joint rotation averaged 6.6 degrees of increased external rotation on the injured extremity ( P  < .001). The mediolateral distance between the center of the tibial plafond and center of the talar dome was increased 1.0 mm in the injured extremity ( P  < .05)., Conclusion: In this study evaluating 10 patients with acute SER4a ankle fractures, no difference in joint contact area was found between individuals' healthy and injured ankles. However, differences in external rotation and lateral translation of the talus were observed on the injured ankle. The clinical effects of these tibiotalar rotational and translational changes are unknown., Clinical Relevance: This study provides insight regarding in vivo changes in 3-dimensional alignment of SER4a ankle fractures that may influence future management of these fractures., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Background: Ulnar collateral ligament (UCL) reconstruction is frequently performed on Major League Baseball (MLB) pitchers. Previous studies have investigated the effects of UCL reconstruction on fastball and curveball velocity, but no study to date has evaluated its effect on fastball accuracy or curveball movement among MLB pitchers., Purpose/hypothesis: The primary purpose of this study was to determine the effects of UCL reconstruction on fastball accuracy, fastball velocity, and curveball movement in MLB pitchers. Our hypothesis was that MLB pitchers who underwent UCL reconstruction would return to their presurgery fastball velocity, fastball accuracy, and curveball movement. The secondary purpose of this study was to determine which factors, if any, were predictive of poor performance after UCL reconstruction., Study Design: Case-control study; Level of evidence, 3., Methods: MLB pitchers who underwent UCL reconstruction surgery between 2011 and 2012 were identified. Performance data including fastball velocity, fastball accuracy, and curveball movement were evaluated 1 year preoperatively and up to 3 years of play postoperatively. A repeated-measures analysis of variance with a Tukey-Kramer post hoc test was used to determine statistically significant changes in performance over time. Characteristic factors and presurgery performance statistics were compared between poor performers (>20% decrease in fastball accuracy) and non-poor performers., Results: We identified 56 pitchers with a total of 230,995 individual pitches for this study. After exclusion for lack of return to play (n = 14) and revision surgery (n = 3), 39 pitchers were included in the final analysis. The mean presurgery fastball pitch-to-target distance was 32.9 cm. There was a statistically significant decrease in fastball accuracy after reconstruction, which was present up to 3 years postoperatively ( P = .007). The mean presurgery fastball velocity of 91.82 mph did not significantly change after surgery ( P = .194). The mean presurgery curveball movement of 34.49 cm vertically and 5.89 cm horizontally also did not change significantly ( P = .937 and .161, respectively)., Conclusion: Fastball accuracy among MLB pitchers significantly decreased after UCL reconstruction for up to 3 years postoperatively. There were no statistically significant differences in characteristic factors or presurgery performance statistics between poor and non--poor performers., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: N.D.H. has received educational support from Smith & Nephew. J.R.H. has received educational support from Elite Orthopedics. R.O. has received consulting fees from Ascension Orthopedics, Integra LifeSciences, Medacta, Smith & Nephew, and Wright Medical and nonconsulting fees from Ascension Orthopedics, Integra LifeSciences, and Smith & Nephew. G.F.H. has received educational support from Arthrex and Micromed, consulting fees and nonconsulting fees from Arthrex, and honoraria from Fidia Pharma. T.P.C. has received hospitality payments from Extremity Medical. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

Background: The number of orthopaedic residency graduates pursuing additional subspecialty training has increased along with the percentage of advertised jobs requiring fellowship. As such, the implications of fellowship training on job availability and marketability may impact their choice of subspecialty. The purpose of this study was to evaluate job availability in the United States for general orthopaedics and orthopaedic subspecialties., Methods: Job advertisements in 2019 were reviewed from the career center databases of the Journal of Bone and Joint Surgery, American Academy of Orthopaedic Surgeons, as well as of individual subspecialty societies. Job listings were cross referenced to identify unique jobs within the United States, which were categorized by the orthopaedic training required, practice type, and location. To assess job availability, a ratio of fellows to job listings was calculated based on the number of matched candidates for nine subspecialty fellowships and the number of residency graduates entering general practice in 2019., Results: A total of 466 unique job listings were identified with 114 generalist and 352 subspecialist positions. The subspecialties with the lowest number of fellows per advertised job were foot and ankle (1.1), adult reconstruction (2.0), and trauma (2.1). The subspecialties with the highest number of fellows per advertised job were sports medicine (6.3), shoulder and elbow (5.8), and oncology (5.7). Job availability for general orthopaedics was higher than for any subspecialty. The highest percentage of positions advertised were hospital employed jobs compared with private practice and academic positions., Conclusions: Job availability for fellowship graduates varies notably based on orthopaedic subspecialty. At this time, generalists and subspecialists trained in foot and ankle, adult reconstruction, and trauma seem to be in greatest demand. The reason for the differences in demand is likely multifactorial. Our findings should be considered by orthopaedic residents pursuing fellowship training in addition to weighing both personal interest and financial considerations in their subspecialty choice., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: Distal chevron metatarsal osteotomy (DCO) is a common technique to address hallux valgus (HV), which involves coronal translation of the capital fragment resulting in a nonanatomic first metatarsal. The purpose of this study was to evaluate the radiographic effect of the DCO on the anatomic vs the mechanical axis of the first metatarsal. Our hypothesis was that patients undergoing DCO would have improvement in the mechanical metatarsal axis but worsening of the anatomic axis., Methods: This was a retrospective case series of consecutive patients who underwent DCO for HV. The primary outcomes were the change in anatomic first-second intermetatarsal angle (a1-2IMA) vs mechanical first-second intermetatarsal angle (m1-2IMA). Secondary outcomes included the change in hallux valgus angle (HVA) and medial sesamoid position., Results: 40 feet were analyzed with a mean follow-up of 21.2 weeks. The a1-2IMA increased significantly (mean, 4.1 degrees) whereas the m1-2IMA decreased significantly (mean, 4.6 degrees) following DCO. There was a significant improvement in HVA (mean, 12.5 degrees). Medial sesamoid position was improved in 21 feet (52.5%). Patients with no improvement in sesamoid position were found to have a larger increase in a1-2IMA (mean, 4.7 vs 3.5 degrees, P = .03) and less improvement in m1-2IMA (mean, 3.8 vs 5.2 degrees, P = .02) compared to patients with improvement in sesamoid position., Conclusion: Distal chevron osteotomy for HV was associated with worsening of the anatomic axis of the first metatarsal despite improvements in the mechanical metatarsal axis, HVA, and medial sesamoid position. Greater worsening of the anatomic axis was associated with less improvement of sesamoid position. Our findings may suggest the presence of intermetatarsal instability, which could limit the power of DCO in HV correction for more severe deformities and provide a mechanism for HV recurrence., Level of Evidence: Level IV, retrospective case series., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: David B. Thordarson, MD, reports being Editor-in-Chief of Foot & Ankle Orthopaedics. ICMJE forms for all authors are available online., (© The Author(s) 2020.)

Background: The flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendons are commonly used for tendon transfer in reconstructive foot and ankle procedures. Some patients experience great toe weakness and loss of push-off strength. The objective of this biomechanical study was to quantify plantarflexion force after FHL and FDL harvest and correlate it to variations in tendon crossover patterns at the knot of Henry to determine if specific patterns have an increased tendency toward forefoot weakness., Methods: Simulated loads through the Achilles, FHL, and FDL were applied to cadaveric specimens while plantarflexion force was measured using a pressure mapping system. Force was recorded with the FDL and FHL unloaded to simulate tendon transfer. Afterward, specimens were dissected to classify the tendinous slips between the FHL and FDL based on a previously determined system. Functional and anatomical relationships between the classification type and loading patterns were analyzed., Results: There were no statistical differences between the tendon crossover patterns in forefoot force reduction after FHL or FDL harvest. Average decrease in great toe and total forefoot pressure after FHL harvest was 31% and 22%, respectively. Average decrease in lesser toe and total forefoot push-off force after FDL harvest was 23% and 9%, respectively., Conclusion: This study quantified loss of plantarflexion force after simulated FHL and FDL harvest and correlated these losses to variations in anatomic crossover patterns at the knot of Henry. Variations at the knot of Henry do not contribute to differences in forefoot weakness., Clinical Relevance: The decrease in forefoot pressure seen here would help explain the clinical scenario where a patient does note a loss of great toe strength after FHL transfer.

Background: Synthetic Cartilage Implantation (SCI; Cartiva) is a treatment of hallux rigidus associated with mixed clinical outcomes in the United States. Patients with persistent pain typically undergo diagnostic imaging for evaluation. We aimed to characterize the radiologic findings of SCI and surrounding tissues., Methods: This is a retrospective review of patients treated using SCI who underwent magnetic resonance imaging (MRI) for persistent pain. Metatarsophalangeal (MTP) joint spaces were compared on plain radiographs of the foot immediately postoperatively and at most recent follow-up. MRI of the foot were assessed for dimensions of the implant, bony channel, and presence of peri-implant fluid. Clinical follow-up, including Patient-Reported Outcome Measures Informational System (PROMIS) scores, satisfaction rating, and revision surgery, was collected. Eighteen cases of symptomatic SCI from 16 patients (13 females, 3 males) were included. All but 1 case involved a 10-mm implant., Results: Mean satisfaction rating was 2.25 (1-5 Likert scale). PROMIS scores indicated moderate physical dysfunction (41) and moderate pain interference (63). Six of 16 patients (37.5%) underwent revision surgery at average 20.9 months of follow-up. Plain radiographs over a 13.3-month interval showed joint space narrowing of 2 mm medially and 1.6 mm laterally ( P < .001). One hundred percent of cases had radiographic evidence of osteoarthritis (OA) progression. MRI studies were obtained on average 11.5 months postoperatively. The implant diameter averaged 9.7 mm, which mismatched the bony channel diameter of 11.2 mm ( P < .001). Fourteen of 18 cases had peri-implant fluid. All cases had edema in the metatarsal, proximal phalanx, and soft tissues., Conclusion: Radiographic loss of MTP joint space and progression of arthritis were present for all cases studied. MRI revealed bony channel widening and a smaller implant, with peri-implant fluid suggesting instability at the implant-bone interface. Persistent edema was observed in soft tissues and bone. Diagnostic imaging of SCI in symptomatic patients demonstrated concerning findings that merit further correlation with patient outcomes., Level of Evidence: Level IV, case series.

Background: The aim of this study was to determine the early outcomes and complications following the implantation of a hydrogel synthetic cartilage implant (SCI, Cartiva) for the treatment of hallux rigidus by a single surgeon., Methods: A retrospective chart review was performed of consecutive patients who underwent treatment for hallux rigidus with an SCI between August 2016 and April 2018 by a single surgeon. Demographic information, radiographic assessment, and concomitant operative procedures performed were evaluated for all patients. Postoperatively, PROMIS physical function (PF) and pain interference (PI) scores, patient satisfaction, reoperation, conversion to arthrodesis, and need for further clinical treatment were collected. Sixty-four SCIs were implanted in 60 patients. Follow-up averaged 18.5 months (range 12-30 months)., Results: 14% (9/64) of patients were very satisfied, 28% (18/64) satisfied, 20% (13/64) neutral, 11% (7/64) unsatisfied, and 27% (17/64) very unsatisfied with their outcome. In addition, 45% of patients underwent additional procedures at the time of SCI, and 23% had a history of surgery on the hallux before implantation. PROMIS PF scores averaged 42 and PROMIS PI scores averaged 60. Overall, 63% completed PROMIS PI, 66% completed PROMIS PF, and 100% completed a satisfaction survey. In addition, 30% (19/64) underwent magnetic resonance imaging (MRI) postoperatively due to pain. There was a 20% reoperation rate, which included an 8% rate of conversion to arthrodesis., Conclusion: Synthetic cartilage implantation yielded neutral patient satisfaction, mild pain, and physical dysfunction at early follow-up. We believe patient selection and counseling regarding early postoperative limitations are important before proceeding with SCI., Level of Evidence: Level IV, case series.

Background: Total ankle arthroplasty (TAA) is commonly pursued for patients with painful arthritis. Outpatient TAA are increasingly common and have been shown to decrease costs compared to inpatient surgery. However, there are very few studies examining the safety of outpatient TAA. In this study, we retrospectively reviewed 65 consecutive patients who received outpatient TAA to identify complication rates., Methods: The medical records of 65 consecutive outpatient TAA from October 2012 to May 2016 with a minimum 6-month follow-up were reviewed. All patients received popliteal and saphenous blocks prior to surgery and were managed with oral pain medication postoperatively. All received a STAR total ankle. Demographics, comorbidities, American Society of Anesthesiologists (ASA) class, and perioperative complications including wound breakdown, infection, revision, and nonrevision surgeries were observed. Mean follow-up was 16.6 ± 9.1 months (range, 6-42 months)., Results: There were no readmissions for pain control and 1 patient had a wound infection. The overall complication rate was 15.4%. One ankle (1.5%) had a wound breakdown requiring debridement and flap coverage. This patient thrombosed a popliteal artery stent 1 month postop. The 1 ankle (1.5%) with a wound infection occurred in a patient with diabetes, obesity, hypertension, and rheumatoid arthritis., Conclusion: This study demonstrates the safety of outpatient TAA. The combination of regional anesthesia and oral narcotics provided a satisfactory experience with no readmissions for pain control and 1 wound infection. The 1 wound breakdown complication (1.5%) was attributed to arterial occlusion and not outpatient management., Level of Evidence: Level IV, retrospective case series.

The management of acute Achilles tendon rupture in elite athletes is a current area of clinical controversy. Recent studies have reported near-equivocal outcomes in patients who undergo either nonsurgical or surgical treatment of Achilles tendon rupture; however, similar functional outcomes may not be observed in elite athletes who are at the highest levels of athletic performance and undergo nonsurgical or surgical treatment of Achilles tendon rupture. Surgeons should understand the risks and benefits of nonsurgical and surgical management of acute Achilles tendon rupture. Surgeons also should understand the accelerated rehabilitation protocols; functional nonsurgical and postoperative rehabilitation protocols; as well as the standard open, percutaneous, and minimally invasive surgical techniques for the management of Achilles tendon rupture from the perspective of a sports medicine foot and ankle specialist.

Management strategies for symptomatic osteochondral lesions of the talus are primarily surgical. Treatment options for symptomatic osteochondral lesions of the talus most commonly include bone marrow stimulation techniques, osteochondral autograft transplantation, osteochondral allograft transplantation, autologous chondrocyte implantation, matrix-induced autologous chondrocyte implantation, and particulated juvenile articular cartilage. The selection of the most appropriate treatment option should be based on the specifics of a talar lesion, in particular, lesion size.

Surgeons should understand the anatomic, vascular, biomechanical, and predisposing factors related to lateral ankle instability and peroneal tendon injuries, including peroneal tendinitis and tenosynovitis, peroneal tendon tears and ruptures, as well as peroneal tendon subluxation and dislocation. Surgeons should understand the treatment options and recommendations for patients who have lateral ankle instability and peroneal tendon injuries from the perspective of a sports medicine foot and ankle specialist. In addition, surgeons should be aware of arthroscopic approaches and an algorithm for the treatment of patients who have lateral ankle instability and peroneal tendon injuries.

Surgeons should understand common factors that predispose high-level athletes to stress injuries as well as the importance of vitamin D and specifics related to vascular supply, location of injury, biomechanics, and susceptibility factors in high-level athletes who have stress injuries. Surgeons should be aware of diagnostic- and management-based recommendations for and the outcomes of anterior tibia, medial malleolus, tarsal navicular, and proximal fifth metatarsal stress fractures in professional athletes.

The management of sports-related Lisfranc injuries is optimized by a detailed understanding of the relevant anatomy, mechanisms of injury, clinical diagnostic maneuvers, imaging, and treatment options for patients with this disabling injury. A lower energy ligamentous variant Lisfranc injury, which was first observed in professional football players, has recently been described. The treatment options for patients with a Lisfranc injury include nonsurgical management, open reduction and internal fixation, suture-button fixation techniques, and arthrodesis.

Background: Acute complete Achilles tendon ruptures are commonly missed injuries. We propose the Realtime Achilles Ultrasound Thompson (RAUT) test, a Thompson test under ultrasound visualization, to aid in the diagnosis of these injuries. We hypothesized that RAUT testing would provide improved diagnostic characteristics compared with static ultrasound., Methods: Twenty-two consecutive patients with operatively confirmed acute Achilles tendon ruptures were prospectively evaluated with RAUT testing and static ultrasonography. RAUT video recordings and static ultrasound images from both ruptured and uninjured sides were randomized and graded by a group of novice reviewers and a group of expert attendings. From these observations, sensitivity, specificity, positive predictive value, and negative predictive value for RAUT and static ultrasound were calculated. In addition, κ interobserver coefficients were computed. Forty-seven novice reviewers and 11 foot and ankle attendings made a total of 4136 and 528 observations, respectively., Results: For static ultrasound, sensitivity and specificity were 76.8% and 74.8% for the novice reviewers and 79.6% and 86.4% for the attendings, respectively. For RAUT testing, sensitivity and specificity were 87.2% and 81.1% for the novice group and 86.4% and 91.7% for the attending group, respectively. The κ coefficient was 0.62 and 0.27 for novice and attending RAUT reviewers, indicating substantial and fair agreement, respectively, but only 0.46 and 0.12 for static ultrasonography, representing moderate and slight agreement, respectively., Conclusion: RAUT testing was a sensitive and specific test, providing a cost-effective adjunct to the clinical examination when diagnosing acute Achilles tendon ruptures. This test can be used by surgeons with minimal training in ultrasonography., Level of Evidence: Level II, diagnostic study.

Background: A previous study has shown an increased radiographic prevalence and severity of hallux valgus interphalangeus (HVIP) after surgical correction of hallux valgus (HV) due to correction of pronation deformity. The purpose of this study was to evaluate the change in pre- and postoperative HVIP deformity with correction of HV with multiple radiographic parameters., Methods: A retrospective chart review identified all bunion surgeries performed at a single center from July 1, 2009, to September 30, 2012. Exclusion criteria included prior bony surgery to the first ray, inadequate films, nonadult bunion, Akin osteotomy, or surgical treatment other than bunion correction. Pre- and postoperative films were reviewed for 2 HV angular measurements and 5 HVIP measurements, which were compared. The angles measured were hallux valgus angle (HVA), first intermetatarsal angle (IMA), hallux interphalangeus angle (HIA), distal metatarsal articular angle (DMAA), proximal phalangeal articular angle (PPAA), proximal to distal phalangeal articular angle (PDPAA), and total distal deformity (TDD). Prevalence of HVIP was analyzed in pre- and postoperative radiographs. A 1-sided Student t test was used to compare continuous data, and a chi-square test was used to compare categorical data. Ninety-two feet in 82 patients were eligible., Results: The average preoperative HV improved with surgery. Preoperative HVA improved from 27 to 11 degrees (P < .001). Preoperative IMA improved from 13.6 to 6.1 degrees (P < .001). HVIP worsened after surgery. Preoperative HIA increased from 7.2 to 13.2 degrees (P < .001). DMAA worsened from 7.3 to 9.2 degrees (P = .001). PPAA worsened from 3.2 to 6.2 degrees. PDPAA worsened from 6.7 to 8.2 degrees (P < .001). The TDD increased from 14.6 to 17.9 degrees (P < .001). The prevalence of HVIP pre- and postoperatively as defined by HIA increased from 26% to 79% (P < .001) and by PPAA from 12% to 46% (P < .001)., Conclusion: Initial assessment of preoperative radiographs underestimated HVIP. Postoperative correction of the deformity revealed HVIP that was not obvious preoperatively., Level of Evidence: Level III, retrospective comparative series., (© The Author(s) 2015.)

Background: Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been used to augment bone healing and fusion in a variety of orthopaedic conditions. However, there is a paucity of data evaluating the potential benefits of its use in foot and ankle surgery. The purpose of this study was to investigate the effectiveness and associated complications with the use of rhBMP-2 in high-risk foot and ankle fusions and fracture nonunions., Methods: A total of 51 cases in 48 patients undergoing foot and ankle fusions or fracture nonunion revisions and considered at high risk for subsequent nonunion were identified through a retrospective review in which rhBMP-2 was used as an augment for bone healing. Rate of union, time to union, and associated complications were evaluated., Results: Forty-seven of 51 high-risk cases treated with rhBMP-2 united for a per-case union rate of 92.2%. Seventy-eight of 82 individual sites treated with rhBMP-2 united for a per-site union rate of 95.1%. Of the successful unions, the mean time to union was 111 days (95% confidence interval, 101-121). There were no statistically significant differences in time to union with regard to supplementation with bone allograft or autograft or size of rhBMP-2 kit used. Complication rates were low., Conclusion: rhBMP-2 was a safe and apparently effective adjunct to bony union in high-risk foot and ankle surgeries. Further randomized controlled trials are warranted., Level of Evidence: Level IV, retrospective case series., (© The Author(s) 2014.)

Background: A floating toe deformity occurs in many patients who undergo Weil osteotomies. It is likely caused by the failure of the windlass mechanism in shortening the metatarsal. For patients who require a proximal interphalangeal (PIP) joint arthroplasty or fusion in addition to a Weil osteotomy, the transfer of the flexor digitorum brevis (FDB) tendon to the PIP joint might restore the windlass mechanism and decrease the incidence of floating toes., Methods: Fourteen cadaveric foot specimens were examined to determine the effects of changing metatarsal length as well as tensioning the FDB tendon on the angle of the metatarsophalangeal (MTP) joint as a measure of a floating toe., Results: Shortening and lengthening the second metatarsal resulted in a significant change in MTP angle (P = .03 and .02, respectively), though there was no clear relationship found between the amount of change in metatarsal length and the change in MTP angle. Transferring the FDB to a PIP arthroplasty site plantarflexed the MTP joint and corrected floating toes; the change in angle was significant compared with the control and shortening groups (P = .0001 and .002, respectively)., Conclusion: This study supports the theory that change in length of the metatarsal, possibly via the windlass mechanism, plays a role in the pathophysiology of the floating toe deformity. Tensioning and transferring the FDB tendon into the PIP joint helped prevent the floating toe deformity in this cadaveric model., Clinical Relevance: Continued research in this subject will help to refine methods of prevention and correction of the floating toe deformity.

Background: Operative treatment of calcaneal fractures has a historically high rate of wound complications, so the most optimal operative approach has been a topic of investigation. This study reviews the radiographic and clinical outcomes of the use of the sinus tarsi approach for operative fixation of these fractures with attention to the rate of infection and restoration of angular measurements., Methods: The radiographs and charts of 20 patients with 22 calcaneal fractures were reviewed to assess for restoration of angular and linear dimensions of the calcaneus as well as time to radiographic union. Secondary outcome measures included the rate of postoperative infection, osteomyelitis, revision surgeries, and nonunion., Results: We found a statistically significant restoration of Böhler's angle and calcaneal width. Three of the 22 cases had a superficial wound infection. One patient had revision surgery for symptomatic hardware removal. There were no events of osteomyelitis, deep infection, malunion, or nonunion., Conclusion: We found that the sinus tarsi approach yielded similar outcomes to those reported in the literature., Level of Evidence: Level IV, retrospective case series.

Background: Treatment of patients with Charcot midfoot destruction is a difficult and increasingly common clinical problem. The pathoanatomical features of Charcot neuropathy have been evaluated in only a few studies. This study evaluated whether medial navicular subluxation (adduction of the navicular on the talus) is a radiographic finding present in patients with Charcot neuroarthropathy., Methods: A retrospective review of 143 consecutive patients diagnosed with Charcot arthropathy of the foot from January 2004 to May 2011 was performed. Patients were identified based on a clinical diagnosis code 713.5 during an outpatient clinic visit with 2 surgeons at a single institution. After exclusion criteria were applied, a series of radiographs of 50 feet in 40 patients were compared with radiographs from an age-matched control group. Radiographic data including talonavicular coverage angle and talonavicular uncoverage percentage were collected., Results: The mean talonavicular coverage angle of the Charcot arthropathy group was 1.5 degrees and of the control group 12.1 degrees (P < .05). The talonavicular uncoverage value for the Charcot arthropathy group was 12.2% and for the control group 22.0% (P < .001)., Conclusions: Medial navicular subluxation was a radiographic finding that was more commonly present in patients with Charcot arthropathy than in a matched control group. It is theorized that this finding is attributable to an unopposed pull of the posterior tibial tendon on the destabilized navicular., Level of Evidence: Level IV, retrospective case series.

Background: The objective of this study was to determine whether there is a difference in fracture pattern and severity of comminution between tibial plafond fractures with and without associated fibular fractures using computed tomography (CT). We hypothesized that the presence of an intact fibula was predictive of increased tibial plafond fracture severity., Methods: This was a case control, radiographic review performed at a single level I university trauma center. Between November 2007 and July 2011, 104 patients with 107 operatively treated tibial pilon fractures and preoperative CT scans were identified: 70 patients with 71 tibial plafond fractures had associated fibular fractures, and 34 patients with 36 tibial plafond fractures had intact fibulas. Four criteria were compared between the 2 groups: AO/OTA classification of distal tibia fractures, Topliss coronal and sagittal fracture pattern classification, plafond region of greatest comminution, and degree of proximal extension of fracture line., Results: The intact fibula group had greater percentages of AO/OTA classification B2 type (5.5 vs 0, P = .046) and B3 type (52.8 vs 28.2, P = .013). Conversely, the percentage of AO/OTA classification C3 type was greater in the fractured fibula group (53.5 vs 30.6, P = .025). Evaluation using the Topliss sagittal and coronal classifications revealed no difference between the 2 groups (P = .226). Central and lateral regions of the plafond were the most common areas of comminution in fractured fibula pilons (32% and 31%, respectively). The lateral region of the plafond was the most common area of comminution in intact fibula pilon fractures (42%). There was no statistically significant difference (P = .71) in degree of proximal extension of fracture line between the 2 groups., Conclusions: Tibial plafond fractures with intact fibulas were more commonly associated with AO/OTA classification B-type patterns, whereas those with fractured fibulas were more commonly associated with C-type patterns. An intact fibula may be predictive of less comminution of the plafond. The lateral and central regions of the plafond were the most common areas of comminution in tibial plafond fractures, regardless of fibular status., Level of Evidence: Level III, case control study.

Introduction: In adult acquired flatfoot deformity, it is unclear whether the lateral column length shortens with progression of the deformity, whether it is short to begin with, or whether it is short at all. To our knowledge, no previous study has examined the lateral column length of patients with adult acquired flatfoot deformity compared to a control population. The purpose of our study was to compare the lateral column length in patients with and without adult acquired flatfoot deformity to see if there was a significant difference., Methods: The study was a retrospective radiographic review of 2 foot and ankle fellowship-trained orthopaedic surgeons' patients with adult flatfoot deformity. Our study population consisted of 75 patients, 85 feet (28 male, 57 female) with adult flatfoot deformity with a mean age of 64 (range, 23-93). Our control population consisted of 57 patients and 70 feet (23 male, 47 female) without flatfoot deformity with a mean age of 61 (range, 40-86 years). Weightbearing anteroposterior (AP) and lateral foot radiographs were analyzed for each patient, and the following measurements were made: medial and lateral column lengths, talonavicular uncoverage angle, talus-first metatarsal angle, calcaneal pitch angle, and medial and lateral column heights. An unpaired t test was used to analyze the measurements between the groups. Ten patients' radiographs were remeasured, and correlation coefficients were obtained to assess the reliability of the measuring techniques., Results: For the flatfoot group, the mean medial and lateral column lengths on the AP radiograph were 108.6 mm and 95.8 mm, respectively; the mean talo-navicular uncoverage angle was 26.2 degrees; and the mean talus-first metatarsal angle was 20.0 degrees. In the control group, the mean medial and lateral column lengths on the AP radiograph were 108.8 mm and 96.5 mm, respectively; the mean talo-navicular uncoverage angle was 8.2 degrees; and the mean talus-first metatarsal angle was 7.7 degrees. On the lateral radiograph in the flatfoot group, the mean medial and lateral column lengths were 167.2 mm and 166.6 mm, respectively; the mean medial and lateral column heights were 16.0 mm and 14.7 mm, respectively; the mean calcaneal pitch angle was 15.6 degrees; and the talus-first metatarsal angle was 10.3 degrees and for the control group, the mean medial and lateral column lengths were 165.3 mm and 163.5 mm, respectively; the mean medial and lateral column heights were 22.8 mm and 13.1 mm, respectively; the mean calcaneal pitch angle was 22.4 degrees; and the talus-first metatarsal angle was -3.6 degrees. None of the differences in measurements for medial and lateral column lengths between the flatfoot and control groups achieved statistical significance. However, statistically significant differences between the 2 groups were observed in the measurements for medial and lateral column heights, talo-navicular uncoverage angle, calcaneal pitch angle, and talus-first metatarsal angle., Conclusion: There is no difference in lateral column lengths between patients with and without adult flatfoot deformity. The perceived shortened lateral column is likely due to forefoot abduction and hindfoot valgus deformities that are associated with adult flatfoot deformity., Level of Evidence: Level III, comparative series.

Background: The correction of sesamoid subluxation is an important component of hallux valgus reconstruction with some surgeons feeling that the sesamoids can be pulled back under the first metatarsal head when imbricating the medial capsule during surgery. The purpose of this study was to radiographically assess the effect of an osteotomy on sesamoid location relative to the second metatarsal., Methods: This is a retrospective radiographic study review of 165 patients with hallux valgus treated with reconstructive osteotomies. Patients were included if they underwent a scarf or basilar osteotomy for hallux valgus but were excluded if they had inflammatory arthropathy or lesser metatarsal osteotomy. A modified McBride soft tissue procedure was performed in conjunction with the basilar and scarf osteotomies. Each patient's preoperative and postoperative radiographs were evaluated for hallux valgus angle, intermetatarsal 1-2 angle, tibial sesamoid classification, and lateral sesamoid location relative to the second metatarsal., Result: The greatest correction of both hallux valgus and intermetatrsal 1-2 angle was achieved in basilar osteotomies (20.6 degrees and 9.7 degrees, respectively), then scarf osteotomies (14.4 degrees and 8.7 degrees, respectively). Basilar and scarf osteotomies both corrected medial sesamoid subluxation relative to the first metatarsal head an average of 2-3 classification stages. All osteotomies had minimal lateral sesamoid location change relative to the second metatarsal., Conclusion: The majority of sesamoid correction correlated with the intermetatarsal 1-2 correction. The concept that medial capsular plication pulls the sesamoids beneath the first metatarsal (ie, changes the location of the sesamoids relative to the second metatarsal) was not supported by our results., Level of Evidence: Level III, retrospective case series.

Background: Haglund's deformity is an enlargement of the posterosuperior prominence of the calcaneus, which is frequently associated with insertional Achilles tendinitis. To our knowledge, no study has been done successfully correlating the characteristics of a Haglund's deformity with insertional Achilles tendinitis. The purpose of our study was to analyze the characteristics of a Haglund's deformity in patients with and without insertional Achilles tendinitis to see if there was a correlation., Methods: The study was a retrospective radiographic review of a single surgeon's patients with insertional Achilles tendinitis from 2005 to 2008. Our study population consisted of 44 patients, 48 heels (22 male, 22 female) with insertional Achilles tendinitis, with a mean age of 52 (range, 23 to 79) years. Our control population consisted of 50 patients (25 males, 25 females) and 50 heels without insertional Achilles tendinitis with a mean age of 55.6 (range, 18 to 89) years. We introduced two new measurements of the Haglund's deformity in this study: the Haglund's deformity height and peak angle. A standing lateral foot or ankle radiograph was analyzed for each patient and the following measurements were made: Haglund deformity height and peak angle; Bohler's angle; Fowler-Philip angle; and parallel pitch sign. We also looked for the presence of calcification in the study group and the length and width of the calcification. Unpaired t-test was used to analyze the measurements between the groups. Ten patients' radiographs were re-measured and correlation coefficients were obtained to assess the reliability of the measuring techniques., Results: For the insertional Achilles tendinitis group, the mean Haglund's deformity height was 9.6 (range, 5.3 to 15.3) mm and the mean Haglund's deformity peak angle was 105 (range, 87 to 123) degrees. Calcification was present in 35 of 48 or (73%) of patients with a mean length of 13.3 (range, 3.2 to 41.9) mm and mean width of 4.5 (range, 1.0 to 10.4) mm. In the control group, the mean Haglund's deformity height was 9.0 (range, 5.2 to 12.1) mm and the peak angle was 105 (range, 91 to 124) degrees. Bohler's angle and Fowler-Philip angle were also similar between the groups and the positive parallel pitch sign was actually more prevalent in the control group (60% versus 41.7%). None of the differences in measurements between the groups achieved statistical significance., Conclusion: A Haglund's deformity was not indicative of insertional Achilles tendinitis and was present in asymptomatic patients. Also, a majority of the insertional Achilles tendinitis patients had calcification at the tendon insertion. We believe it is possible removing the Haglund's deformity may not be necessary in the operative treatment of insertional Achilles tendinitis.

Background: Opening wedge osteotomy of the medial cuneiform has become an established intervention for correction of forefoot varus in relation to a flatfoot deformity. The purpose of this study was to use a newly described radiographic measurement to determine the effectiveness and durability of the medial column correction with a plantarflexion opening wedge osteotomy of the medial cuneiform without internal fixation using an allograft., Methods: Twenty-three feet underwent medial cuneiform opening wedge osteotomies for correction of forefoot varus associated with flatfoot deformity. The angle between the proximal and distal articular surfaces was measured on lateral radiographs preoperatively, postoperatively prior to weightbearing and at final followup visit., Results: The average angle between the proximal and distal articular surfaces of the medial cuneiform on lateral foot radiographs was 1.0 degree preoperatively (±0.8 degrees). The average angle post-osteotomy, pre-weightbearing, was 8.4 degrees (±3.6 degrees) and at final followup was 7.5 degrees (±2.9 degrees). All patients achieved bony union., Conclusion: We describe a new radiographic measurement to focus on the correction achieved by a plantarflexion osteotomy of the medial cuneiform. It was found to be stable without internal fixation and reliably proceeded to union without significant loss of correction.

Background: Hallux valgus deformities with large intermetatarsal angles require a more proximal metatarsal procedure to adequately correct the deformity. Due to the relative ease of a closing wedge osteotomy, this technique was adopted but with concern over first metatarsal shortening. In this study, we primarily evaluated angular correction and first metatarsal shortening., Materials and Methods: We evaluated 70 feet in 57 patients (average age, 54 years) with 52 female and five male. The average followup was 14 (range, 6 to 45) months. The charts were reviewed for the presence of metatarsalgia. Digital radiographic measurements were made for pre- and postoperative hallux valgus and intermetatarsal angles, dorsiflexion angle of the first metatarsal, and absolute and relative shortening of the first metatarsal., Results: The average hallux valgus angle improved from 31 to 11 degrees (p < 0.0001) and intermetatarsal angle from 13.2 to 4.4 angles (p < 0.0001). The absolute shortening of the first metatarsal was 2.2 mm and relative shortening was 0.6 mm. There was 1.3 degrees of dorsiflexion on average., Conclusion: Excellent correction of the deformity with minimal dorsiflexion or new complaints of metatarsalgia was found with this technique. The new method of assessing the relative shortening found to be less than the absolute shortening, which we feel more accurately reflects the functional length of the first metatarsal.

Background: Coronal computed tomography (CT) scans are commonly used in fracture classification systems for calcaneus fractures. However, they may not accurately reflect the amount of fracture displacement. The purpose of this paper was to determine whether lateral radiographs provide superior assessment of the displacement of the posterior facet compared to coronal CT scans., Materials and Methods: Lateral radiographs of calcaneus fractures were compared with CT coronal images of the posterior facet in 30 displaced intra-articular calcaneus fractures. The average patient age was 39 years old. Using a Picture Archiving and Communication System (PACS), measurements were obtained to quantify the amount of displacement on the lateral radiograph and compared with the amount of depression on corresponding coronal CT scans., Results: On lateral radiographs, the angle of the depressed portion of the posterior facet relative to the undersurface of the calcaneus averaged 28.2 degrees; Bohler's angle averaged 12.7 degrees. These numbers were poorly correlated (r = 0.25). In corresponding CT images from posterior to anterior, the difference in the amount of displacement of the lateral portion of the displaced articular facet versus the nondisplaced medial, constant fragment, was minimal and consistently underestimated the amount of displacement., Conclusion: Underestimation of the amount of depression and rotation of the posterior facet fragment was seen on the coronal CT scan. We attribute this finding to the combined rotation and depression of the posterior facet which may not be measured accurately with the typical semicoronal CT orientation. While sagittal reconstructed images would show this depression better, if they are unavailable we recommend using lateral radiographs to better gauge the amount of fracture displacement.

Fractures in the dance population are common. Radiography, CT, MRI, and bone scan should be used as necessary to arrive at the correct diagnosis after meticulous physical examination. Treatment should address the fracture itself and any surrounding problems such as nutritional/hormonal issues and training/performance techniques and regimens. Compliance issues in this population are a concern, so treatment strategies should be tailored accordingly. Stress fractures in particular can present difficulties to the treating physician and may require prolonged treatment periods. This article addresses stress fractures of the fibula, calcaneus, navicular, and second metatarsal; fractures of the fifth metatarsal, sesamoids, and phalanges; and dislocation of toes.