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Fusion of the second and third tarsometatarsal joints is utilized for various arthritic pathologies and traumatic conditions. A cadaveric study using 20 fresh-frozen transtibial specimens were used for a stimulated arthrodesis study. Half of the specimens underwent drilling via drill guide for a respective 15 mm and 20 mm dorsal bridge length staples. Each drill guide was placed equidistant from each joint at 7.5 mm for the 15 mm bridge length and 10 m for the 20 m bridge length, then drilled bicortically in parallel with the joint line. For the 15 mm bridge length on the second metatarsal, the mean depth was 22.5 mm ± 2.2, and was 26.7 mm ± 3.8 proximal on the intermediate cuneiform. For the 20 mm bridge length on the second metatarsal, the mean depth was 22.3 mm ± 2.2 and was 27.2 mm ± 2.0 proximal on the intermediate cuneiform. For the 15 mm bridge length for the third metatarsal mean depth was 21.5 mm ± 3.2, and was 24.2 mm ± 2.9 proximal on the lateral cuneiform. For the 20 mm bridge length on the third metatarsal, the mean depth was 20.3 mm ± 2.4 and was 24.6 mm ± 2.4 proximal on the lateral cuneiform. A student's two tailed homoscedastic t-Test was calculated for the 7.5 mm vs 10 mm distal and proximal distances for both second and third TMT data sets and found there was no significant differences in depth.The current study found that for both 15 mm and 20mm bridge lengths for 2nd TMT fusions a 22 mm leg length can be used appropriate and similarly for 3rd TMT fusions, a 20 m leg length appears to be appropriate fixation. Although variations will exist, advances towards indication specific fixation may allow for varied leg length for optimal boney purchase.

First tarsometatarsal (TMT) arthrodesis is a common procedure utilized by foot and ankle surgeons for the management of a variety of first TMT pathology including hallux valgus and arthritis. The present study was undertaken to determine the average staple leg depth that allows for adequate purchase within the medial cuneiform and first metatarsal base at 2 different staple bridge lengths for dorsal compression across the 1st TMT joint. A cadaveric study was performed using 20 fresh-frozen below knee specimens. After TMT dissection was performed, drill holes were then created from dorsal to plantar and parallel to the first TMT joint at the distances utilized for 20 mm and 25 mm staple bridge lengths. The depths of each drill hole were measured and recorded. The mean medial cuneiform depth corresponding to a 20 mm and 25 mm staple bridge was 31.9 mm +/- 2.8 mm and 31.1 mm +/- 2.1 mm respectively (P-value = 0.38). The mean first metatarsal depth corresponding to a 20 mm and 25 mm staple bridge was 27.9 mm +/- 2.2 mm and 25.4 mm +/- 3.4 mm respectively (P-value = 0.04), showing statistical significance. Based on our anatomic data it is suggested that a 20 mm staple leg depth is consistently a safe depth when using 20×20 and 25×20 mm dorsal compression staples. However, further studies must be conducted to compare the amount of compression between the two respective staples.

First tarsometatarsal (TMT) arthrodesis or the modified Lapidus (ML) is a common procedure utilized by foot and ankle surgeons for the management large bunion deformities, particularly in the presence of medial column instability. The purpose of the present anatomic study was to assist surgeons in preoperative planning for ML procedure utilizing the first metatarsal to second metatarsal cross-screw technique by assessing the average length of screw guidewire placed bi-cortically through the first metatarsal and second metatarsal at a location specific to the ML procedure with metatarsal to second metatarsal cross-screw technique. This was a cadaveric study utilizing 20 fresh-frozen below-the-knee specimens. After dissection, joint preparation, and stabilization, a cannulated 4.0 screw was then placed across the first and second metatarsal bases from medial to lateral starting 1 cm distal to the 1st TMT joint. Once appropriate length and orientation was achieved the guidewire was measured using a cannulated depth gage and values were then recorded on a spreadsheet and analyzed. Amongst the 20 specimens the mean guidewire length was found to be 34 mm +/- 3.2 mm. The median guidewire length was found to be 34 mm (range: 29 – 41 mm). The present anatomic study defined the mean and median lengths of a first metatarsal to second metatarsal screw utilized for medial column stabilization and spot weld arthrodesis in the ML procedure.

Potential shortening of the first ray is an important consideration when performing a first tarsometatarsal (TMTJ) fusion. However, no previous study has sought to directly quantify the resultant shortening after TMTJ fusion. The purpose of the present anatomic study was to directly assess and compare shortening of the first ray using two joint preparation techniques (curettage, planal resection) for first TMTJ fusion. Ten pairs of matched lower extremity cadaver specimens were divided into two groups. Preoperative length assessments were performed at the first TMTJ dorsally and plantarly using a digital caliper. In Group 1, joint preparation for first TMTJ fusion was performed with curettage, whereas specimens in Group 2 underwent planal resection. Post-operative length assessments were repeated. All data was analyzed using two-tailed Students t-tests. Mean shortening of the first ray following curettage was 1.1 (range, 0.3 to 2.0) mm dorsally and 1.6 (range, 0.6 to 3.7) mm plantarly; while mean shortening following planal resection was 4.5 (range, 2.7 to 7.9) mm dorsally and 4.6 (range, 2.4 to 8.9) mm plantarly. The measured differences were statistically significant (p < 0.001, p = 0.001). Both curettage and planal resection resulted in shortening of the first ray after first TMTJ fusion. Planal resection resulted in significantly more shortening, which was also more variable. Surgeons performing first TMTJ fusions may consider curettage over planal resection to mitigate the risk of painful postoperative transfer metatarsalgia.

Ankle arthrodesis (AA) represents an effective, dependable procedure for the treatment of end-stage osteoarthritis of the ankle. While AA offers the benefits of pain relief and some preservation of function, it sacrifices ankle motion which over time may lead to progressive degeneration of the adjacent joints of the hindfoot. Historically, salvage options for failed or painful AA included revisional AA, tibiotalocalcaneal arthrodesis, pantalar arthrodesis, and amputation. More recently the conversion of AA to total ankle arthroplasty (TAA) has been shown to be a viable salvage option which, unlike early salvage options, restores motion and function to the ankle and may help to avoid the need for periarticular arthrodesis. A unique challenge faced with AA conversion to TAA includes instances where fibular resection was performed during the primary procedure. Previous studies have evaluated the viability of conversion to TAA in patients with AA and prior fibular resection, with most authors stating that the absence of the lateral malleolus is an absolute contraindication to TAA. In contrast, newer studies have reported success with various techniques to restore the lateral fibular strut and perform the conversion of AA to TAA. This case report describes a unique approach of AA conversion to TAA utilizing a custom, fibular prosthesis to restore lateral stability following prior AA with fibular resection.

Category: Ankle Arthritis; Ankle; Hindfoot; Trauma Introduction/Purpose: The etiology of ankle arthritis is multifactorial and secondary osseous changes to the tibiotalar joint can be variable. The relationship of bone density within the tibia and talus with respect to type of ankle arthritis is not well understood. Improved insight of osseous characteristics amongst ankle arthritis patients is helpful in determining optimal implant selection for total ankle arthroplasty. The purpose of this study is to retrospectively analyze pre-operative total ankle arthroplasty patients' films for osseous characteristics associated traumatic ankle arthritis compared to other forms of arthritis using computed tomography (CT) generated Hounsfield units (HU) to analyze bone mineral density and rate of cyst formation. Methods: A retrospective analysis was performed of 440 patients, under a single orthopedic practice, who underwent primary TAA between 2013-2019. Pre-operative HU of tibia and talus were analyzed amongst two groups (Non-traumatic OA, Post- traumatic OA) within one year prior to TAA. Results: Forty-nine qualified patients (23 NTA, 26 PTA) with mean follow-up in months of 19.98 (SD 15.22) were analyzed. Cystic changes at level of TAA cuts or retained bone: 5 tibia (10.2%), 7 talus (14.29%), 16 combined (32.65%). Overall tibial HU mean 270.23 (SD 91.28) and talus 463.26 (103.65). HU of the tibia amongst post-traumatic and non-traumatic patients was 257.21 (SD 93.9) and 284.94 (SD 87.9) (p=0.29137) and talus 434.53 (104.7) and 495.75 (94.33) (p=0.0365). Conclusion: Our results suggest with tibiotalar arthritis HU is a useful tool to predict bone quality. Clinical results amongst the NTA and PTA groups was comparable. Significantly lower HU values were recorded for the PTA groups. Rate of cystic formation within bone of distal tibia does not necessarily correlate with overall HU measured bone mineral density.

Category: Ankle Arthritis; Ankle Introduction/Purpose: Porous coating on the osseous interface of implants has gained increased popularity in total ankle replacement surgery. With the integration of porous coating into the newer generation of implants, this theoretically increases the chances of osseous ingrowth and survivorship in total ankle replacements. Alternatively, literature in hip replacement surgery has shown increased rates of stress shielding, aseptic loosening, thigh pain, and cystic formation around stemmed femoral implants extensively coated with porous surfaces. While some ankle prostheses have integrated porous coating technology with stemmed tibial implants, there is little to no research investigating the potential negative effects this may have on longevity or aseptic loosening secondary to a stress shielding effect. Methods: Our study identified 9 patients who underwent total ankle arthroplasty via a smooth-stemmed tibial prosthesis and matched these patients based on implant age with patients who received fully porous-coated tibial implants. We reviewed radiographs and compared postoperative rates of backside loosening and cystic formation secondary to stress shielding between the two groups. We also compared rates of heterotopic ossification between the two groups. A homoscedastic t-test was used to identify any statistical significance, which was defined as P < 0.05. Results: While the smooth-stem group showed no rates of backside cystic formation or stress shielding, the follow-up matched porous-coated group showed a rate of 55% of cystic formation and potential loosening secondary to stress shielding observed on final radiographic follow up (P < 0.01). There was no statistical difference between the two groups in their rates of heterotopic bone formation (P = 0.37). Conclusion: Despite having a relatively small sample size, this data shows that there is some consistency with the hip arthroplasty literature suggesting an increased risk for stress shielding in fully porous-coated stemmed tibial implants compared to smooth- stemmed tibial implants in total ankle arthroplasty.

Category: Ankle Introduction/Purpose: The traditional modified Brostrom-Gould has long been the procedure of choice for addressing chronic lateral ankle instability. However, more robust techniques including anatomic reconstruction are favored for larger deformity, poor tissue quality and revision surgery. Given the inherent disadvantages of allograft and non-elastic synthetic materials, material science has sought to impact the graft choice providing alternative load sharing, permeable materials with high strength. Our institution has performed anatomic lateral ligament stabilization, termed the 'ATLAS' procedure, using a novel synthetic graft (Artelon, Marietta, GA) with anecdotal success in recent years. In this study, we present our surgical technique and early experience. Methods: A retrospective cohort review was performed, evaluating the failure rate, complications and radiographic changes in anatomic alignment. A review of all patients undergoing the ATLAS procedure was performed, a total of 27 patients were included. The study included only those patients with at least 1 year follow up from the procedure. Results: Only one patient had symptoms of early failure of the procedure, while none of the patients required a revision procedure. The most common complication was minor wound dehiscence (11.1%). Overall, our short-term results with this procedure were excellent. Conclusion: We conclude that the ATLAS procedure is a predictable and effective lateral ligament reconstruction technique with no donor site morbidity, no donor tissue transmission risk, low risk of over-constraint and accomplished with a predictable technique.

Category: Ankle Arthritis; Arthroscopy Introduction/Purpose: Arthritis is a debilitating condition that negatively affects an individual's ability to carry out activities of daily living. While osteoarthritis is a term many have become familiar with, as it is the most common form of arthritis encountered, hemophilic arthritis is a condition not frequently seen or discussed. Hemophilia is a congenital bleeding disorder caused by the absence or decrease of clotting factor VIII (Hemophilia A) or XI (Hemophilia B). When severe, this X-linked disease commonly results in intra-articular bleeding which, can progress to joint destruction1-4. This subsequently leads to the progressive destruction of articular cartilage and bone6-7. Methods: Arthroscopic assisted ankle arthrodesis with calcaneal autograft was performed. Calcaneal autograft was acquired through a small linear incision along the lateral wall of the calcaneus, a power graft harvester was introduced into the medullary bone to procure the graft. The left lower extremity was then placed into a non-invasive Gould Ankle distraction system and the standard anteromedial and anterolateral ankle scope portals were established. A scope and shaver were utilized to extensively debride all visualized hemorrhagic synovium. The shaver was then exchanged for a burr following debridement to remove the articular cartilage to both the talus and tibia. Following adequate preparation of the joint margins for fusion, the ankle joint was filled with the calcaneal autograft and rhPDGF-BB. Results: Various treatments have been described for patients suffering from hemophilic arthritis. While the use of clotting factor concentrations (CFCs) may reduce the risk of hemarthrosis, the risk of bleeding cannot be completely avoided2. Arthroscopic or open synovectomies has been described to remove the pathogenic synovium. Chemical or radioisotopic synoviorthesis is an option for less severe cases, but the treatment of choice is joint fusion or arthrodesis for advanced stages of arthropathy3. Conclusion: In patients with hemophilia, regular replacement therapy with clotting factor concentrates (prophylaxis) is effective in preventing recurrent bleeding episodes into joints and muscles. However, despite this success, intra-articular and intramuscular bleeding is still a major clinical manifestation of the disease. The pathogenesis of hemophilic arthropathy is multifactorial, with changes occurring in the synovium, bone, cartilage, and blood vessels. Our case report presents a unique pathology and the successful outcome that can be accomplished through surgical intervention and a multidisciplinary treatment approach.

Category: Ankle Arthritis Introduction/Purpose: Degenerative ankle joint disease is a debilitating condition that causes significant pain, adversely affects function and quality of life. Though primary arthritis of the ankle can occur without deformity, frequently soft tissue imbalances or joint deformities complicate the clinical picture. Often, additional procedures are required to balance the foot and ankle during the index total ankle replacement procedure. When large deformities exist a staged approach to first, align the ankle joint to neutral as stage one and then implantation of the TAR as stage two can be deployed. This paper will further popularize the cement spacer staged TAR technique in correction of coronal deformities, share a clinical algorithm on approach, and depict a case series demonstrating its application. Methods: A case series was performed of 7 patients and 8 ankles, who underwent staged primary TAR utilizing a cement spacer to assist with deformity correction, between the years 2016-2019. Results: Patients' mean age 58.5 yrs., preoperative varus coronal plane deformity mean 19.1 degrees, preoperative valgus coronal plane mean 10.25 degrees. Mean time from stage 1 till 2 was 163.5, +-140.2 days. Stage 1 soft tissue procedures: Chrisman-Snook procedure with synthetic ligament graft, Brostrum-Gould with synthetic graft, Brostrum-Gould without graft, FDL transfer, and isolated medial release/peel. Osteotomies performed during stage one: Dwyer, MDCO, Cotton, and MDCO with medial malleolus osteotomy. Fusions performed during stage one consisted: Subtalar joint, talonavicular joint (TNJ), and STJ with 1st Metatarsophalangeal joint (MTPJ). Seven ankles were replaced with Cadence Total Ankle System (Integra), and one with INBONE II (Wright Medical Technology). Average follow-up time for included patients was 290.75 days (9.7 months). One revision was performed following index TAR procedure. Conclusion: This paper describes a cement wedge spacer staged total ankle arthroplasty technique for correction and stabilization of deforming forces at the ankle joint. While not all ankle deformities necessitate a staged approach, the complexity of the malalignment and the extent of tissue disruption needed to achieve a neutral ankle should be considered when correcting a given deformity with a staged or non-staged approach.

Category: Ankle; Hindfoot; Other Introduction/Purpose: Short and medium term outcomes of the INBONE I and INBONE II tibial stems have been favorable. The INBONE-2 talus has been shown to have lower reoperation and failure rates compared to its predecessor, INBONE-1 at short term follow-up. The purpose of the present study was to assess mid-term outcomes for the INBONE-2 prosthesis at 5 to 9 years follow-up considering both the tibial and talar components. Methods: All patients who underwent primary total ankle arthroplasty (TAA) with INBONE-2 between July 2010 and July 2014 at a single institution and who were at least 5 years postoperative were included. A total of 15 ankles with a mean follow up 85 (range, 61-113) months met the criteria. Radiographs were assessed using coronal and sagittal alignment parameters preoperatively, at 6 weeks postoperative, and at the most recent follow-up. Medical records were reviewed and revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al. and Glazebrook at el., respectively. Results: Survivorship for the INBONE-2 at a mean of 85 months was 93.7%. Coronal and sagittal tibiotalar alignment improved after surgery (p=0.081, p=0.15), and was maintained at the most recent follow-up (p=0.684, p=0.837). One ankle (6.7%) required early component revision; while 4 (26.7%) required a non-implant related revision. Six complications (2 high grade, 1 intermediate, and 3 low) in 5 ankles (33.3%) were recorded according to the Glazebrook classification system. Conclusion: The present study is the first to report midterm follow-up after TAA with the INBONE-2. High survivorship, maintenance of correction, and a low incidence of major complications was observed. The most common complication overall was lateral gutter impingement, which accounted for the majority of the non-revisional reoperations.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The Lapidus 1st tarsometatarsal (TMT) arthrodesis has gained popularity for its ability to correct large deformities especially in cases of medial column instability. Even with solid fusion, instability between the 1st and 2nd columns can result in loss of intermetatarsal (IM) angle correction over time. Anecdotally, a 'spot weld' between the lateral 1stmetatarsal and medial 2nd metatarsal bases seems to predict long term maintenance of IM correction. The purpose of the study is to review cases of Lapidus 1st TMT arthrodesis with supplemental screw fixation from the 1stto 2nd metatarsal base for maintenance of IM correction and determine whether a 'spot weld' is predictive of maintenance and identify an optimum position of the 1st to 2nd metatarsal screw to achieve the 'spot weld. Methods: A retrospective radiographic review of cases by a single surgeon over the past five years was performed. All cases of tarsometatarsal fusion were queried and reviewed. Inclusion criteria included primary arthrodesis of the 1st TMT joint with supplemental fixation between the 1st and 2nd metatarsal bases, availability of appropriate radiographic image and at least 4 months follow up. Exclusion criteria included 1st TMT fusion without 1st-2nd metatarsal screw fixation, multiple TMT or midfoot fusion, Charcot neuroarthropathy, and revision fusion. A standard surgical technique was utilized with an in situ joint debridement, specific preparation to the medial 2ndmetatarsal base and adjacent lateral 1st metatarsal base, autogenous bone grafting and hardware construct at the 1stTMT joint consisting of compression screw from the 1st metatarsal to the 2nd cuneiform, screw fixation from 1st to 2ndmetatarsal bases and either locking plate or compression staple fixation dorsally across the 1st TMT joint. Results: 90 cases (77 patients) met the inclusion criteria with average follow up of 309 days. Fusion of the 1st TMT occurred in 87/90 (96.7%) cases with 76 dorsal plate, 10 with dorsal staple and 4 with all screws. There was no incidence of complications related to the 1-2 screw. The mean pre-operative IM 1-2 angle was 14.90 degrees, with mean correction to 6.22 degrees post operative and final maintained correction at 7.10 degrees with mean loss of 0.87 degrees. There were 'spot welds' in 65/90 (72.2%) with a mean loss of correction of 0.48 degree versus loss of 1.88 degrees in the 'no spot weld' subgroup (p

Category: Other Introduction/Purpose: Annual national society meetings for the American College of Foot and Ankle Surgeons (ACFAS) and American Orthopaedic Foot & Ankle Society (AOFAS) have long provided an important resource to disseminate the latest innovations, techniques, and research. However, unlike submitted research abstracts which are screened by a selection committee, there are scant guidelines for selected content experts to present educational content. To date, the ability to publish in a peer-reviewed journal bestows the ultimate validity of academic expertise on a particular subject matter and supports the expertise of the clinician. The purpose of this study was to evaluate for the first time, the incidence of scholarly publication in a peer reviewed journal for invited speakers from the ACFAS and AOFAS annual meetings from 2016 to 2020. Methods: Annual meeting programs for the ACFAS and AOFAS from 2016 to 2020 were compiled by two reviewers. Faculty lists and assigned lecture tract topics from each meeting were entered into password protected databases. Oral and poster abstracts, industry/society sponsored presentations, 'competitions', and 'other events' held during the annual meetings were excluded. Speaker specific variables included: gender, number of peer reviewed journal publications on the assigned subject matter (publications preceding the meetings date), study design, weighted total topic publication citations, and H-index. The weighted total topic publication citations was obtained by dividing the total citation counts for each manuscript on a particular subject by the number of years since its publication. The H-index, an author specific metric of both productivity and citation impact was obtained from searches of an online resource ( http://www.scopus.com/freelookup ). For the purposes of the present study, only foot and ankle surgeons (DPM, MD, DO) were included for assessment. Results: There were a total 1,028 invited presentations combined between AOFAS (158) and ACFAS (870) at the annual meetings fom 2016-2020. With combined data, 724 (70%) presentations were given by speakers with no publications in the subject matter while 300 (29.2%) were given by speakers with one or more publications. Lecture topics that had the highest percentage of speakers with publications in the subject matter included Wound Care/Limb Salvage (82.8%), Charcot (63.6%) and Total Ankle Replacement/Fusions (50%). Topics with the highest number of speakers without publications on the topic included Trauma (84%), Sports (80.3%) and Forefoot Elective (78.7%). Only the Trauma category of speakers had a statistically significant difference of predicted number of lectures by publication between no publications (3.7 lectures) and those with 1 or more publications (1.6 lecture) with p=0.04. Conclusion: Content expert presentations at national society specialty meetings are a crucial source of continuing education. What makes a speaker a content expert has yet to be defined but is important to consider. Perhaps factors such as peer reviewed publications in subject matter or the speaker's H-index are characteristics to consider in selecting content experts. In our survey of ACFAS and AOFAS annual meetings from 2016-2020, there were many topics were the vast majority of lectures were given by speakers without any publications and dispersed across the spectrum regardless of the speaker's H-Index ranking. Further criteria development is likely needed.

Category: Arthroscopy; Hindfoot Introduction/Purpose: The purpose of the present study was to assess the radiographic incidence, location, and classification of heterotopic ossification (HO) in patients who underwent total ankle arthroplasty (TAA) with a 4th generation prostheses at a minimum of 1-year follow up. Baseline demographic, radiographic, and operative factors between patents with and without HO were compared. Methods: Ninety ankles that underwent TAA with a 4th generation protheses, INFINITY (n = 62) or CADENCE (n = 28) were followed for an average of 23.7 (range, 12-49) months. Incidence and location of HO was assessed on weight bearing radiographs, and severity graded according to the modified Brooker classification. Data was compared between patents with and without HO to identity any predisposing factors. Results: In 90 ankles that underwent 4th generation TAA, HO incidence was 55.6% (n = 50); 56.5% (n = 35) for INFINITY, and 53.6% (n = 15) for CADENCE. Twenty-five cases of HO were observed posteriorly, 16 anteriorly, and 9 combined. Severity was as follows; class I in 19 cases (38%), class II in 20 (40%), class III in 9 (18%) and class IV in 2 (4%). A single ankle required a non- revisional reoperation for HO debridement; reoperation rate of 2%. Conclusion: The present study suggests a similarly high incidence of HO after TAA with two different 4th generation prostheses (INFINITY 56.5%, CADENCE 53.6%). A trend for differences in location and severity between the prostheses may also be present. Given the paucity of literature, additional studies with longer follow-up are warranted to discern the significance of HO following TAA with 4th generation prostheses.

Sesamoids of the first metatarsophalangeal joint can be a source of residual pain after surgical intervention for hallux rigidus. Theoretically, after fusion of the first metatarsophalangeal joint there should be little to no motion at the metatarsosesamoid articulations; however in many cases significant arthritis disease of the sesamoids may create hypertrophy and pain. Residual motion about the sesamoid articulations could result in recalcitrant pain after joint arthrodesis. Previous studies have discussed surgical sesamoidectomy for treatment of painful sesamoid bones, while frequently advocating for ancillary incisions in an attempt to obtain direct visualization. The goals of this cadaveric study were to identify any observable motion of the sesamoid bones after simulated first MTP joint fusion and assess if adequate visualization of the sesamoid bones can be obtained for proper excision through a standard dorsomedial approach. Using live fluoroscopy, no residual sesamoid range of motion was noted after fusion fixation. We were able to perform successful total sesamoidectomy in all specimens (n = 10) via the transarticular approach, with only 1 incident of minor tendon injury. Total sesamoidectomy took an average of 2:10 minutes, and average incision length was 4.9 cm. Despite the cadaveric nature of the present study, our results confirm a lack of motion to the sesamoid articulations after arthrodesis of the first MTP joint. Furthermore, using the transarticular technique discussed in this study, we exhibited that the standard dorsomedial approach can be used for safe and efficient sesamoidectomy, when indicated in conjunction with first MTP joint arthrodesis.

The treatment of hallux abductovalgus continues to evolve as surgeons better understand first ray biomechanical pathology. Many authors have advocated the use of the 1st tarsometatarsal joint arthrodesis for correction of moderate to severe hallux abductovalgus deformities and those with hypermobility of the 1st ray. There continues to be debate over the best surgical technique, fixation construct, and post operative protocol for the 1st tarsometatarsal joint fusion. We describe a technique with a unique hardware construct that is reproducible and allows for excellent deformity correction and pain relief while minimizing associated complications with this procedure.

Heterotopic ossification describes the aberrant formation of ectopic bone in soft tissue. Posttraumatic or acquired heterotopic ossification is a recognized complication of orthopedic trauma, surgery and burns. Heterotopic ossification can be a source of restricted range of motion when located around joints and can also cause pain. In this rare case, a massive intra-articular island of heterotopic ossification developed in the anterior ankle recess subsequent to talar neck fracture two years previously. The patient presented to clinic with a large mass protruding at the anterior ankle and dorsal talar neck, complaining of persistent pain and very limited dorsiflexion at the ankle. Advanced imaging confirmed a large floating mass of heterotopic bone superior to the prior talar neck fracture, within the ankle joint capsule. The patient underwent surgical management with complete excision of the mass which immediately relieved pain and restored motion of the ankle joint. More research is needed to increase our understanding of the pathogenesis, pathology, prevention, treatment and classification of heterotopic ossification in the foot and ankle. Heterotopic ossification should be included in the differential diagnoses for patients with progressing lesions following traumatic incidence, even within intracapsular tissue.

Category: Lesser Toes Introduction/Purpose: Lesser toe metatarsophalangeal joint instability, secondary to plantar plate tear, has been the focus of numerous recent publications, majority reporting on repair through a dorsal approach. A plantar approach has been described with the advantage of direct ligamentous repair or repair to bone, which follows conventional techniques employed throughout the body. Previous clinical studies have shown success in deformity correction and longevity of both approaches. The proponents of the dorsal approach advocate that indirect repair of the plantar plate avoids perceived risks of complications with a plantar incision, without evidence of superior outcomes. The purpose of this study was to investigate the safety and efficacy of direct plantar approach to plantar plate repairs by reporting the rate of specific complications in a large clinical series. Methods: This was an IRB approved retrospective study of 204 plantar plate repairs, in 185 patients, (194 lesser MTP, 10 hallux MTP) with average age of 56 and mean BMI of 28. Surgical technique involved repair with absorbable braided suture (88%) versus suture anchor (12%) with or without MTPJ pinning (80%). Mean follow up was 53 weeks (range 5-170). Patients were screened for associated risk factors including diabetes mellitus (8%), tobacco use (5%), neuropathy (1%) and additional concurrent procedures (96%). Complications were defined as superficial or deep infection, painful scar, and reoperation. Analysis was conducted by using Wilcoxon-Mann-Whitney test or Fisher’s exact tests for continuous and categorical variables, respectively. Risk factors were analyzed using univariate logistic analysis to produce odds ratios (OR) with 95% confidence interval (CI) and an inclusion criterion of a p-value > 0.2 for multivariate analysis as determined by Wald tests (significance at p

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: A number of two-component, 4th generation total ankle arthroplasty (TAA) prostheses have been introduced to the market in the past few years, as the popularity and indications for TAA have continued to expand. The purpose of the present study was to identify independent risk factors for the early failure of 4th generation TAA prostheses. Methods: A total of 97 ankles underwent TAA with a 4th generation prostheses (INFINITY, CADENCE) between August 2015 and June 2018 at a single institution and were at least 6 months postoperative (mean 18.3 months, range 6-43). The primary outcome assessed was the need for revision surgery, defined as removal of 1 or both metal components for any reason, excluding infection. Baseline patient demographics, characteristics, radiographic alignment parameters, and distal tibia cortical bone thickness (CBT) were assessed. Revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al. and Glazebrook et el., respectively. Univariate and multivariate analyses were performed. Results: Three ankles (3.1%) underwent revision surgery for aseptic loosening at a mean of 24.3 (range, 16-31) months; all had a CBT

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: The INFINITY total ankle prosthesis remains the most widely used 4th generation total ankle arthroplasty (TAA) system in the United States. The purpose of the present study was to assess outcomes for the INFINITY prosthesis at short-term follow-up. Methods: All patients who underwent primary TAA with INFINITY between August 2015 and June 2018 at a single institution and who were at least 1 year postoperative were included. A total of 55 ankles with a mean follow up 22 (range, 12-43) months met the criteria. Weightbearing radiographs were assessed using coronal and sagittal alignment parameters preoperatively, at 6- 8 weeks postoperatively, and at the most recent follow-up. Medical records and charts were reviewed and revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al. and Glazebrook at el., respectively. Results: Overall survivorship for the INFINITY prosthesis was 98.2%. Coronal and sagittal tibiotalar alignment improved after surgery (p

Category: Bunion; Midfoot/Forefoot; Other Introduction/Purpose: Potential shortening of the first ray is an important consideration when performing a first tarsometatarsal (TMTJ) fusion. However, no previous study has sought to directly quantify the resultant shortening after TMTJ fusion. The purpose of the present anatomic study was to directly assess and compare shortening of the first ray using two joint preparation techniques (curettage, planal resection) for first TMTJ fusion. Methods: Ten pairs of matched lower extremity cadaver specimens were divided into two groups. Preoperative length assessments were performed at the first TMTJ dorsally and plantarly using a digital caliper. In Group 1, joint preparation for first TMTJ fusion was performed with curettage, whereas specimens in Group 2 underwent planal resection. Post-operative length assessments were repeated. All data was analyzed using two-tailed Students t-tests. Results: Mean shortening of the first ray following curettage was 1.1 (range, 0.3 to 2.0) mm dorsally and 1.6 (range, 0.6 to 3.7) mm plantarly; while mean shortening following planal resection was 4.5 (range, 2.7 to 7.9) mm dorsally and 4.6 (range, 2.4 to 8.9) mm plantarly. The measured differences were statistically significant (p

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: A number of two-component, 4th generation total ankle arthroplasty (TAA) prostheses have been introduced to the market within the past few years. The purpose of the present study was to assess early outcomes for the CADENCE total ankle prosthesis. Methods: All patients who underwent primary TAA with CADENCE between August 2016 and June 2018 at a single institution and who were at least 1 year postoperative were included. A total of 32 ankles with a mean follow up of 19 (range, 12-33) months met the criteria. Weightbearing radiographs were assessed using coronal and sagittal alignment parameters preoperatively, at 6 weeks postoperative, and at the most recent follow-up. Medical records and charts were reviewed and revisions, reoperations, and complications were classified according to the criteria established by Vander Griend et al. and Glazebrook at el., respectively. Results: Survivorship for the CADENCE prosthesis was 93.7%. Coronal and sagittal tibiotalar alignment significantly improved after surgery (p< 0.001, p< 0.005), and was maintained at the latest follow-up (p=0.44, p=0.30). Overall, two ankles (6.3%) underwent early revision for aseptic loosening; while 6 (18.8%) underwent a non-revisional reoperation. Nine ankles (28.1%) presented a total of 13 complications (4 high grade, 2 intermediate, and 7 low) according to the Glazebrook classification system. The most common was intraoperative periprosthetic medial malleolar fracture (5 ankles, 15.6%), a low-grade complication. Conclusion: Satisfactory outcomes were observed at short-term follow-up for the CADENCE prosthesis. Additional studies with longer follow-up are warranted.

Category: Bunion Introduction/Purpose: The Lapidus procedure is common for the treatment of moderate to severe hallux abductovalgus deformity. Standard fixation consists of a combination of crossing screws and plates. Despite arthrodesis of the first tarsometatarsal joint, recurrence of the deformity remains a concern. A recently described construct adds an additional point of fixation from the plantar medial first metatarsal to the intermediate cuneiform. This construct is termed the cross screw intermediate cuneiform construct. The purpose of this study is to determine the long-term angular maintained correction of the 1st and 2nd intermetatarsal angle, hallux abductus angle, and tibial sesamoid position after undergoing a 1st tarsometatarsal joint arthrodesis utilizing the cross screw intermediate cuneiform construct to correct and maintain the hallux abductovalgus deformity. Methods: A retrospective, single-center chart and radiographic review was performed of all patients with HAV treated with a 1st tarsometatarsal joint arthrodesis with cross screw intermediate cuneiform construct fixation by the senior author. The study period was from June 1st, 2016 to June 1st, 2017. Patients who underwent 1st tarsometatarsal joint arthrodesis for a primary diagnosis of HAV were studied. Three observers independently reviewed radiographic data including preoperative weight bearing, 1st weight bearing, and final weight bearing plain films radiographs. Preoperative films were used if they were within 3 months of the surgery, and the radiographic time line for the post-operative intervals were at 12 ± 2 weeks, 18 ± 4 weeks, 26 ± 4 weeks, 52 ± 12 weeks, and the final follow-up visit. Radiographic data evaluated were initial improvement and long-term maintenance of intermetatarsal ankle, hallux abductus angle, and tibial sesamoid position. Results: Forty-five patients met inclusion criteria and were included in the study. Mean follow-up time was 9.76 months (SD ± 7.62). Bony union was achieved in 43 of 45 patients (95.6%). Two patients required revision bunionectomy as result of recurrence (4.4%). Other complications included symptomatic hardware in 2 patients requiring hardware removal and neuritis in 2 patients. Average preoperative IMA was 15.95º (±2.55), HAA was 31.14º (±6.19), and tibial sesamoid position was 4.36 (±1.07). Final average improvement of IMA was 6.26º (±2.9), HAA was 13.89º (±7.02), and tibial sesamoid position was 2.07 (±1.34) positions. Average loss of IMA correction was 1.70º (±1.64), HAA was 2.45º (±4.6), and tibial sesamoid position was 0.8 (±0.82) positions. Wilcoxon signed rank test showed statistical significance in all radiographic parameters both in initial improvements and loss of correction (p

Category: Hindfoot Introduction/Purpose: Autogenous bone graft remains the standard bone graft in foot and ankle surgery when filling a bone void or adding biology to an arthrodesis site. Harvesting autograft can have serious donor site morbidity with an average complication rate of 8% and reports as high as 25%. Complications range from persistent pain to severe infection. Most procedures in the foot and ankle require only a small volume of graft. Using a small reaming graft harvester, surgeons can harvest autograft from the ipsilateral calcaneus. This is done within the same surgical field and requires minimal additional operative time. The purpose of this article is to review a population of patients who underwent calcaneal autograft harvesting with a reaming graft harvester and evaluate the outcomes of the procedure. Methods: From August 2015 to February 2018, all patients who underwent calcaneal autograft harvesting by a single surgeon were identified and reviewed. Patients were included if they had autograft harvested from the calcaneus on the ipsilateral operative limb using a reamer bone graft harvester and if they had complete clinical follow up of at least 6 months. Patients were excluded if they had autograft from a site other than the ipsilateral calcaneus, had a previous harvest from the ipsilateral calcaneus, or if they did not have full follow up of at least 6 months. Outcomes of interest were major and minor complications, intra- operative complications, and long term radiographic findings. Patients required graft for numerous primary procedures including a variety of arthrodesis or filling of bone voids. Postoperative protocols and return to weightbearing times varied with the accepted protocols for the primary procedure. Results: 300 patients were identified and met inclusion criteria. Average follow up was 12.6 months. There was 1 major complication (0.3%) consisting of a calcaneal stress fracture that healed with a period of 4 weeks of non weightbearing followed by 4 weeks of protected weightbearing. There were 3 minor complications (1%) consisting of transient painful scar and medial heel pain that all resolved uneventfully. There were no intraoperative complications while performing the 300 procedures. There were no incidences of neurovascular damage. Of the patients with over 1 year radiographic follow up, all harvest sites were still visible on lateral plain film radiographs. Conclusion: Using a small reamer to harvest calcaneal autograft for foot and ankle surgeries that require a small to moderate amount of bone graft is safe and effective. Approximately 4 cc of graft can be harvested very quickly without needing to prepare another surgical site for harvesting. The complication rate for harvesting calcaneal autograft was found to be extremely low in this study, despite the harvest site remaining visible on radiographs past 1 year. The proposed technique can be extremely useful to the foot and ankle surgeon.

Category: Bunion Introduction/Purpose: Fusion of the first tarsometatarsal joint is common for the treatment of moderate to severe hallux abductovalgus deformity. Despite arthrodesis of the first tarsometatarsal joint, recurrence of the deformity remains a concern. The addition of a screw from the 1st metatarsal base to the 2nd metatarsal base allows for increased stability and can help create a “spot weld” between the metatarsal bases to prevent loss of deformity correction. The additional screw construct is termed the intermetatarsal screw in this study. The purpose of the current study is to determine the long-term maintenance of angular correction of the 1st and 2nd intermetatarsal angle, hallux abductus angle, and tibial sesamoid position after undergoing a 1st tarsometatarsal joint arthrodesis with the addition of the intermetatarsal screw. Methods: A retrospective, single-center chart and radiographic review was performed of 17 consecutive patients who underwent primary hallux abductovalgus correction with a 1st tarsometatarsal joint arthrodesis using the intermetatarsal screw fixation by the senior author. The study period was from January 1, 2017 to May 14, 2018. Three observers independently reviewed radiographic data including preoperative weight bearing, 1st weight bearing, and final weight bearing plain film radiographs. Preoperative films were used if they were within 3 months of the surgery and the radiographic time line for the post-operative intervals were at 12 ± 2 weeks, 18 ± 4 weeks, 26 ± 4 weeks, 52 ± 12 weeks, and the final follow-up visit. Radiographic data evaluated were initial improvement and long-term maintenance of intermetatarsal angle, hallux abductus angle, and tibial sesamoid position. Results: 17 consecutive patients were identified for review that met inclusion criterea. Mean follow up time was 8.12 months (SD ± 3.68). Bony union was achieved in all patients. There was 1 symptomatic recurrent bunion, 1 case of symptomatic hardware, and 1 case of transient neuritis. Average preoperative IMA was 16.05º (±2.34), HAA was 33.05º (±6.24), and tibial sesamoid position was 5.77 (±0.9). Average IMA improvement was 8.38º (±2.21), HAA improvement was 17.25º (±8.21), and TSP improvement was 3.29 (±1.36) positions. Average loss of IMA was 1.03º (±1.24), HAA was 4.14º (±5.34), and tibial sesamoid position was 0.65 (±0.86) positions. Wilcoxon signed rank test showed statistical significance in all radiographic parameters; both in initial improvements and loss of correction (p

Category: Midfoot/Forefoot Introduction/Purpose: In the modern treatment of Charcot neuroarthropathy, beam screw fixation is an attractive alternative to plate and screw fixation because it minimizes the required exposure for implantation and supports the longitudinal columns of the foot from the inside out as a rigid yet load-sharing construct. Oversized implants risk metatarsal fracture and undersized implants risk implant fracture or impaired healing from mechanical instability. Our review of the scientific literature identified a lack of evidence regarding the aspects of metatarsal intramedullary canal morphology relevant to beam screw fixation. The purpose of the present study was to qualitatively and quantitatively describe metatarsal diaphyseal morphology. Methods: Twenty fresh-frozen adult cadaveric below knee specimens were utilized to assess the size and shape of the diaphysis of metatarsals 1-4. There were 10 male and 10 female specimens with a mean age of 75.8 years. No limbs had outward signs of prior injury/surgery, radiographic signs of Charcot neuroarthropathy or previous fracture. Metatarsals 1-4 were excised, cleaned of all soft tissue and then axially transected at the point of most narrow external diameter. The diaphyseal canal shape was categorized as round, oval, triangular, or pear. The widest distance between two endosteal cortical surfaces was measured. Results: Triangular endosteal canals were only found in the 1st metatarsal whereas the remainder of metatarsals canals were largely round or oval. The mean diameter of the 1st metatarsal was 9.08 ± 1.26 mm. The mean diameter of the 2nd metatarsal was 4.72 ± 0.82 mm. The mean diameter of the 3rd metatarsal was 4.53 ± 0.88 mm. The mean diameter of the 4th metatarsal was 4.51 ± 1.10 mm. Conclusion: Intramedullary fixation by internal beaming of the columns of the foot can provide anatomical alignment with stabile fixation in cases of patients with Charcot arthropathy. Our study has given the smallest average diameter for metatarsals one through 4. This data is helpful when determining what size fixation to choose to achieve the maximum screw-endosteal purchase for column beaming in Charcot reconstructions.