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Abstract Background Chronic kidney disease (CKD) is a growing disease that affects millions of people in the USA every year. Many CKD patients progress to end-stage renal disease (ESRD), necessitating the use of hemodialysis to alleviate symptoms and manage kidney function. Furthermore, many of these patients have lower bone quality and experience more postoperative complications. However, there is currently limited information on hospitalization information and perioperative complications in this population following procedures such as total knee arthroplasty (TKA). The purpose of this study was to assess the patient characteristics, demographics, and prevalence of postoperative problems among dialysis patients who received TKA. Methods In this retrospective study, we used the Nationwide Inpatient Sample (NIS) data from 2016 to 2019 to analyze the incidence of perioperative complications, length of stay (LOS), and the cost of care (COC) among patients undergoing TKA who were categorized as dialysis patients, compared with those who were not. Propensity matching was conducted to consider associated factors that may influence perioperative complications. Results From 2016 to 2019, 558,371 patients underwent TKAs, according to the National In-Sample (NIS) database. Of those, 418 patients (0.1%) were in the dialysis group, while the remaining 557,953 patients were included in the control group. The mean age of the dialysis group was 65.4 ± 9.8 years, and the mean age in the control group was 66.7 ± 9.5 years (p = 0.006). After propensity matching, dialysis group patients had a higher risk of receiving blood transfusions [odds ratio (OR): 2; 95% confidence interval (CI): 1.2, 3.4] and a significantly larger COC in comparison to those in the control group (91,434.3 USD versus 71,943.6 USD, p

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The majority of hallux valgus (HV) corrections have been historically performed via a two-dimensional, transverse plane-focused approach, which has demonstrated high long-term recurrence rates. Recent research demonstrates that 87% of HV deformities are three-dimensional with abnormal frontal-plane rotation of the metatarsal, which cannot be completely addressed with a two-dimensional metatarsal osteotomy alone. While correction at the 1st tarsometatarsal (TMT) joint may provide the optimal surgical approach for 3D anatomic restoration at the apex of the deformity, 1st TMT fusion historically entails an extended period of non-weightbearing. This study evaluated the clinical, radiographic, and patient-reported outcomes in patients undergoing instrumented triplanar 1st TMT arthrodesis (TMTA) with a biplanar plating system and protected near- immediate weightbearing. Methods: A prospective multicenter study that will continue for 60 months post-operatively. Patients 14-58 years old with symptomatic HV (intermetatarsal and HV angles between 10-22° and 16-40°, respectively) and no prior HV surgery on the operative foot were eligible for this study. Patients were treated with an instrumented TMTA procedure using a biplanar plating system with protected early weightbearing. The primary endpoint of this study is radiographic recurrence of HV deformity at 24 months for subjects with successful correction (defined as IMA < 9°, HVA < 15° and TSP ≤ 3 at 6 weeks post-procedure). Recurrence is defined by any two of the three conditions: IMA of ≥12°, HVA ≥20° and TSP ≥4. Secondary outcomes (return to weightbearing and activities, pain measured by visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOxFQ), and Patient Reported Outcomes Measurement Information System (PROMIS)) were evaluated post-operatively. Two independent fellowship trained musculoskeletal radiologists reviewed all radiographic data. Results: 173 patients underwent TMTA with mean age of 41.0 (range:14-58) years; 92% females. Median (range) time-to-follow-up is 25 (1.5-49.2) months. Eighteen (10.4%) patients have discontinued. Mean (SD) days to protected weightbearing in CAM boot and return to full work were 8.4 (7.4) and 57.9 (46.2), respectively. At 24 months post-procedure, 99.3% (134/135) of patients were recurrence-free. Statistically significant improvements from baseline in HVA, IMA, and TSP (Table 1), VAS score, MOxFQ and PROMIS domains were observed as early as 6 weeks post-operatively and maintained over time. In 143 patients, mean (95% CI) 24-month improvements were VAS: 3.9 (3.5, 4.2); Walking/Standing (MOxFQ): 39.2 (34.9, 43.4); Physical Function (PROMIS): 9.7 (8.3, 11.2). Nineteen (11.0%) patients experienced hardware complications yet maintained radiographic correction. Conclusion: The results of this study’s primary and secondary endpoints provide supporting evidence that TMTA with biplanar plating is successful in correcting the 3D hallux valgus deformity with early return to weightbearing and low recurrence while demonstrating favorable clinical and patient-reported outcomes. Patients exhibited meaningful pain reduction after surgery and were able to return to full, unrestricted work and activities in less than two months, on average. Statistically significant improvements in patients’ health-related quality-of-life were observed through 36 months, post-operatively. Patients will continue to be followed for up to 60 months with additional evaluations for complications, recurrence, and patient satisfaction.

Diabetic foot ulcers and infections are common complications of diabetic foot disease. Additionally, these complications are a common cause of morbidity and impose a substantial burden to the patient and society. It is imperative to understand the major contributing factors, namely, diabetic neuropathy, peripheral arterial disease, and immune system dysfunction in order to guide treatment. Management of diabetic foot disease begins with a detailed history and thorough physical examination. This examination should focus on the manifestations of diabetic neuropathy and peripheral arterial disease, and, in particular, any evidence of diabetic foot ulcers or infection. Prevention strategies should include a multi-disciplinary approach centered on patient education.

Diabetes (DM) increases fracture risk, and bone quality depends on type diabetes type, duration, and other comorbidities. Diabetes is associated with a 32% increased relative risk (RR) of total fractures and 24% increased RR of ankle fractures compared with patients without DM. Type 2 DM is associated with a 37% increased RR of foot fractures compared with patients without DM. The incidence of ankle fractures in the general population is 169/100,000 per year, while foot fractures occur less frequently, with an incidence of 142/100,000 per year. Biomechanical properties of bone are negatively impacted by stiff collagen, contributing to the increased risk of fragility fractures in patients with DM. Systemic elevation of proinflammatory cytokines, such as tumor necrosis factor-alpha (TNFα), interleukin-1β (IL-1β), and interleukin 6 (IL-6), impact bone healing in patients with DM. Fractures in patients with DM, can be associated with poorly regulated levels of RANKL (receptor activator of nuclear transcription factor kappa-b ligand) leading to prolonged osteoclastogenesis, and net bone resorption. One of the most salient factors in treating fractures and dislocations of the foot and ankle is to recognize the difference between patients with uncomplicated and complicated DM. Complicated diabetes is defined as ‘end organ damage’, and for the purposes of this review, includes patients with neuropathy, peripheral artery disease (PAD) and/or chronic renal disease. Uncomplicated diabetes is not associated with ‘end organ damage’. Foot and ankle fractures in patients with complicated DM pose challenges, and surgery is associated with increased risks of impaired wound healing, delayed fracture healing, malunion, infection, surgical site infection, and revision surgery. While patients with uncomplicated DM can be treated like patients without DM, patients with complicated DM require close follow-up and robust fixation methods should be considered to withstand the anticipated prolonged healing period. The aims of this review are as follows: (1) to review pertinent aspects of DM bone physiology and fracture healing, (2) to review the recent literature on treatment of foot and ankle fractures in patients with complicated DM, and (3) to provide treatment protocols based on the recent published evidence.

Background Nonagenarians are a rapidly expanding population in the United States. These patients are met with increasing rates of hip arthritis, necessitating the need for total hip arthroplasty (THA). However, there is currently limited information on hospitalization information and perioperative complications in this population. Methods: In this retrospective study, we used the Nationwide Inpatient Sample (NIS) database from 2016-2019 to analyze the incidence of perioperative complications, length of stay (LOS), and the cost of care (COC) among patients undergoing THAs who were categorized as nonagenarians, and those who were not. Results The NIS database identified 309 100 patients who underwent THAs from 2016-2019. Of those, 1864 patients (.6%) were nonagenarian, while the remaining 307 236 patients were included under the non-nonagenarian category (control). The mean age in the nonagenarian group was 90 years compared to the control group which had a mean age of 65.8 years. There was an increased incidence of mortality rate (nonagenarian group .2%, control group .03%, P < .001), myocardial infarction (MI) (nonagenarian group .1%, control group .02%, P = .01), acute renal failure (ARF) (nonagenarian group 5.4%, control group 1.6%, P < .001), blood anemia post-operatively (nonagenarian group 28.9%, control group 17.2%, P < .001), and deep vein thrombosis (DVT) (nonagenarian group .48%, control group .07%, P < .001) in the nonagenarian group. The COC for the nonagenarian group was higher than that in the control group ( P < .001). The mean LOS was longer in the nonagenarian group (3.1 days) in comparison to the control group (1.96 days) ( P < .001). Conclusions Nonagenarians had significantly higher rates of both orthopedics and medical complications than the younger patients undergoing THAs. In addition, the nonagenarian group incurred higher COC. This information is useful for the providers to make informed decisions regarding patient care and resource utilization for nonagenarian patients undergoing THAs.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The majority of hallux valgus corrections are performed via a two dimensional approach with 1st metatarsal osteotomy and translation in the transverse plane. This approach has demonstrated high long-term recurrence rates. Recent research demonstrates that 87% of hallux valgus deformities are three-dimensional with abnormal frontal-plane rotation of the metatarsal, which cannot be completely addressed with a two dimensional metatarsal osteotomy alone. While correction at the 1st tarsometatarsal (TMT) joint may provide the optimal surgical approach for 3D anatomic restoration at the apex of the deformity, 1st TMT fusion historically entails an extended period of non-weightbearing. This study evaluated the clinical, radiographic, and patient-reported outcomes in patients undergoing instrumented triplanar 1st TMT arthrodesis (TMTA) with a biplanar plating system and protected near-immediate weightbearing. Methods: This is a prospective multicenter study that will continue for 60 months post-operatively. Patients between 14-58 years old with symptomatic hallux valgus (intermetatarsal and hallux valgus angles between 10.0-22.0° and 16.0-40.0°, respectively) and no prior hallux valgus surgery on the operative foot were eligible for this study. Patients were treated with an instrumented TMTA procedure using a biplanar plating system with protected near-immediate weightbearing. Several outcomes (radiographic, return to weightbearing and activities, pain measured by visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOxFQ), and Patient Reported Outcomes Measurement Information System (PROMIS)) were evaluated post-operatively. Two independent fellowship trained musculoskeletal radiologists reviewed all radiographic data. These interim results are limited to patients completing at least 6 months of follow-up. Results: 165 patients underwent TMTA with at least 6 months follow-up (mean (SD): 17.8 (7.7); min, max: 5.8, 37.3). Mean age was 41.0 (range:14-58) years; 91.5% of patients were female. Mean (SD) days to protected weightbearing in CAM boot and return to full work were 8.4 (7.7) and 56.8 (45.6), respectively. Significant improvements from baseline in HVA, IMA, and TSP (Table 1), VAS score, MOxFQ and PROMIS domains were observed as early as 6 weeks post-procedure. At 12 months, mean (95% CI) change in VAS was -3.7(-4.0, -3.3); Walking/Standing (MOxFQ) change was -35.2 (-39.6, -30.8); and Physical Function (PROMIS) change was 8.7 (7.1, 10.3). Fifteen (9.1%) patients experienced hardware complications, yet maintained radiographic correction to date. No patients (0/58) with 24 months follow-up have experienced recurrence. Conclusion: These interim findings support that TMTA with biplanar plating is successful in correcting the 3D hallux valgus deformity with early return to weightbearing while demonstrating favorable clinical and patient-reported outcomes. Patients exhibited meaningful pain reduction after surgery and were able to return to full, unrestricted work and activities in less than two months, on average. Statistically significant improvements in patients' health-related quality of life were observed at 6 and 12 months, post-operatively. Patients will continue to be followed for up to 60 months with additional evaluations for complications, 24-month recurrence, and patient satisfaction.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: There is a paucity of literature attempting to characterize risk factors for nonunion of the modified Lapidus procedure for correction of hallux valgus. The purpose of this study was to evaluate several patient factors to determine which may contribute to increased odds of nonunion. Methods: Patients who underwent modified Lapidus procedure between 2009 to 2018 were retrospectively reviewed. Patient age, sex, body mass index (BMI), history of previous bunionectomy, history of tobacco use, fixation method, presence of diabetes mellitus (DM), and presence of hypothyroidism were recorded along with changes in radiographic parameters. A multiple logistic regression analysis was implemented to estimate the odds of nonunion. Results: Of the 222 patients who met inclusion criteria, nonunion with modified Lapidus procedure was observed in 20 patients (9.01%). Odds of nonunion with modified Lapidus procedure were greater for patients as BMI increased (OR=1.101, 95% CI: 1.029 to 1.177), tobacco users (OR=3.511, 95% CI: 1.182 to 10.425), had a change in intermetatarsal angle (IMA) (OR=1.313, 95% CI: 1.099 to 1.569), a change in Meary's angle (OR=1.133, 95% CI: 1.024 to 1.255), and a change in calcaneal pitch (OR=1.192, 95% CI: 0.997 to 1.426), but lower for patients who had a change in hallux valgus angle (OR=0.912, 95% CI: 0.846 to 0.983). Compared with the union group, patients with nonunion had lesser mean degrees correction of IMA (4.25° vs. 7.02°) and greater mean degrees correction of Meary's angle (1.62° vs. 0.46°) and calcaneal pitch (1.09° vs. 0.38°). No increased odds of nonunion were found between fixation methods. Conclusion: Predicted odds of nonunion with modified Lapidus procedure increased in patients with high BMI, smokers, and increased change in intermetatarsal angle, calcaneal pitch, and Meary's angle pre and postoperatively.

Category: Diabetes; Midfoot/Forefoot Introduction/Purpose: Below knee amputation (BKA) and Foot amputation (AA) are two commonly performed procedures for diabetic foot conditions. Aim of this study was to analyze the characteristics of the complications and reoperations at 30 days and 1 year in a matched sample of BKA and FA in diabetic patients in a large database population. Methods: Commercially available patient database record (PearlDiver) was used for this study. Diabetic Patient undergoing BKA and FA were identified using CPT code. After matching two groups for smoking, obesity and comorbidities scores, the differences in the risk of complications at 30 days, 90 days and 1 year and the risk of reoperation at 1 year were noted in both groups. Results: There were 8555 patients in each matched group. Most patients were male (71.6%) and 6891 patients were smokers and 5292 patients were obese. More than 50% of general and systemic complications happened after 30 days. Incidence of 30 days, 90 days and 1 year general complications including Acute kidney injury, cardiac arrest, Cerebrovascular event, myocardial infarction, Pulmonary embolism, Pneumonia, sepsis and transfusion were higher in the BKA group. AKI was the most common general complication and PE was the least common general complication observed at 30 days, 90 days and 1 year. The risk of wound dehiscence, surgical site infection and overall wound complications were higher in FA group. One year reoperation for infection and dehiscence were higher in the FA group and reoperation for hematoma formation was higher in BKA group. The risk of revision to a BKA in the FA group at 1 year was 16.4% (1410 patients). Conclusion: FA is associated with higher risk of local complications at 30 days, 90 days and 1 years and higher reoperation rate at 1 year for local complications. However, BKA is associated with higher systemic major complications and higher risk of reoperation for hematoma formation. Most complications in the FA and BKA group happened after 30 days which highlights the fact that studies reporting 30 days complications after FA and BKA may underestimate the complications.

Category: Ankle; Ankle Arthritis Introduction/Purpose: Total ankle replacement (TAR) and Ankle arthrodesis (AA) are two commonly performed procedures for end stage arthritis of ankle joint. Aim of this study was to analyze the characteristics of the complications and reoperations at 30 days and 1 year in a matched sample of TAR and AA in a large database population Methods: Commercially available patient database record (PearlDiver) was used for this study. Patient undergoing TAR and AA were identified using CPT code. After matching two groups for diabetes, smoking, obesity and comorbidities scores, the differences in the risk of complications at 30 days and 1 year and the risk of reoperation at 1 year were noted in both groups. Results: There were 1287 patients in each matched group. Four hundred and thirty patients were diabetic, 102 patients were smokers and 543 patients were obese. The risk of surgical site infection and wound dehiscence were higher at 30 days in the AA group. Vast majority of observed complications (More than 50% of complications) happened after 30 days. AA group showed higher risk of SSI, wound dehiscence, mechanical complications and pneumonia at 1 year. The risk of reoperation was also higher in the AA group at 1 year. Conclusion: Ankle arthrodesis is associated with higher risk of local and systemic complications at 30 days and 1 years and higher reoperation rate at 1 year. Most complications happened after 30 days which highlights the fact that studies reporting 30 days complications after AA and TAR may underestimate the complications.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The pathogenesis of the hallux valgus deformity is still poorly understood. Consistent observations of the 1st tarsometatarsal (TMT) joint as the CORA of hallux valgus raises questions about pathology associated with that joint. Mason and Tanaka studied the 1st TMT joint in cadaveric specimens in 2012, observing three morphological subtypes to the 1st cuneiform articular surface. They noted that specimens with hallux valgus had either a unifacet (37%) or bifacet (63%) appearance, where normal feet had a trifacet appearance. This observation suggests that these bony differences may be responsible for 'instability' that generates the metatarsal deviation into varus, and thus the development of hallux valgus. If true, surgical corrections for hallux valgus deformity should address this TMT joint pathology. Methods: This study was designed to correlate the morphological differences of the TMT joint with symptomatic hallux valgus patients who are seeking surgery. The hypothesis was that the hallux valgus patients would show a majority unifacet and bifacet morphology and have an inclination towards unifacet in younger patients and patients with a larger deformity. The cohort of patients who are in the registered longitudinal study Align3D had their TMT joints harvested in a standard fashion as part of their surgical treatment. These specimens were analyzed for the number of facets by the surgeon at the time of their surgical procedure. This cohort therefore only includes symptomatic hallux valgus patients and eliminates hallux valgus associated with metatarsus adductus. Standard weight-bearing x-rays taken pre-operatively were analyzed for severity of deformities. Functional and Patient Reported Outcome measures were obtained pre-operatively and post-operatively. Results: In this study we observed 143 specimens. Unifacet was observed in 116 specimens (81.1%), bifacet was observed in 26 specimens (18.2%), and trifacet was observed in 1 specimen. Neither X-Ray findings, age, nor Functional Scores suggested a trend in severity in relation to morphological type. Mason & Tanaka's cadaveric study was limited in some respects because of the hardening effect of formaldehyde preservations. Their study represented an elderly population, mean age 86 years, whereas this study represented a much younger population, mean age 40.6, in which patients were able to participate in both X-Ray and clinical scoring. To the best of our knowledge, this is the first time that morphology of the TMT joint has been studied in symptomatic hallux valgus patients who underwent surgery. Conclusion: Symptomatic hallux valgus deformities are associated with a higher likelihood of having a unifacet morphology than previously reported in cadavers (81.1% vs 37%). This morphology may predispose patients to decreased stability resulting in more symptomatic deformity. The number of facets does not seem to correlate with severity of deformity on X-Ray evaluation, nor does it correlate with age. However, the younger age group in our study as compared to Mason and Tanaks's study suggests that morphological differences may even be congenital, leading to later development of deformity.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The majority of hallux valgus corrections are performed via a two dimensional approach with 1st metatarsal osteotomy and translation in the transverse plane. This approach has demonstrated high long-term recurrence rates. Recent research demonstrates that 87% of hallux valgus deformities are three-dimensional with abnormal frontal-plane rotation of the metatarsal, which cannot be completely addressed with a two dimensional metatarsal osteotomy alone. While correction at the 1st tarsometatarsal (TMT) joint may provide the optimal surgical approach for 3D anatomic restoration at the apex of the deformity, 1st TMT fusion entails an extended period of non-weightbearing. This study evaluated the clinical, radiographic, and patient-reported outcomes in patients undergoing instrumented triplanar 1st TMT arthrodesis (TMTA) with a biplanar plating system and protected near-immediate weightbearing. Methods: This is a prospective multicenter study that will continue for 60 months post-operatively. Patients between 14-58 years old with symptomatic hallux valgus (intermetatarsal and hallux valgus angles between 10.0-22.0° and 16.0-40.0°, respectively) and no prior hallux valgus surgery on the operative foot are eligible for this study. Patients are treated with an instrumented TMTA procedure using a biplanar plating system with protected near-immediate weightbearing. Several outcomes (radiographic, range of motion (ROM), return to weightbearing and activities, pain measured by visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOxFQ), and Patient Reported Outcomes Measurement Information System (PROMIS)) are evaluated post- operatively. Two independent fellowship trained musculoskeletal radiologists reviewed all radiographic data. These interim results are limited to patients completing at least 6 months of follow-up. Results: At time of analysis, 121 patients had undergone TMTA with at least 6 months of follow-up. Mean age was 40.6 (range:15- 58) years, and 91% of patients were female. Mean (SD) days to protected weightbearing in CAM boot, return to work, and return to full work were 8.2 (6.8), 24.0 (29.5), and 51.2 (44.0), respectively. Significant improvements (p

Category: Other Introduction/Purpose: Both the incidence of childhood obesity and the number of obese children undergoing surgical procedures are increasing in pediatrics. As such, pediatric orthopaedic surgeons will likely encounter obese patients more frequently in their practice and a better understanding of the unique risks associated with obesity is valuable to maximize patient safety. The purpose of this study is, therefore, to retrospectively evaluate the relationship between obesity and post-operative outcomes in pediatric orthopaedic surgery patients across multiple institutions using a large national database. Methods: Pediatric patients who had undergone foot surgery were retrospectively identified by cross-referencing reconstructive foot-specific CPT codes with ICD-9/ICD-10 diagnosis codes using the American College of Surgeons 2012-2017 Pediatric National Surgical Quality Improvement (ACS-NSQIP-Pediatric) database. Patients were stratified into normal weight and obese cohorts based upon Center for Disease Control BMI-to-age growth charts. Patient demographics, comorbidities, intra-operative, and post- operative factors were compared between these two cohorts via univariate analysis with false discovery rate adjustment. Multivariable logistic regression models were then generated to assess for obesity as an independent predictor of post-operative complications. Results: Of the 3,924 patients identified, 1,063 (27.1%) were obese. Obese patients were more often male (64.7% vs 58.7%; p=0.001) and taller (56.3in vs 51.3in; p

Category: Arthroscopy; Midfoot/Forefoot Introduction/Purpose: Refractory pain to the fourth and fifth tarsometatarsal (TMT) joint is a source of disability and functional impairment. The etiology of fourth and fifth TMT joint pain may be attributed to injury, post-traumatic arthritis, or arthrofibrosis, however, the principal pathologies associated with pain in the absence of arthritis are not well elucidated. The purpose of this study is to characterize arthroscopic pathology associated with chronic refractory pain to the fourth and fifth TMT joints with and without arthritis. Methods: We retrospectively examined 25 patients that underwent arthroscopic surgery of the fourth and fifth TMT joints for refractory pain at our academic institution between 2015 - 2020. Patients were placed in supine position, thigh tourniquet placed, prepped and draped in standard sterile fashion. The fourth and fifth TMT joints were accessed medially through a portal between the third and fourth TMT joint and laterally through a portal lateral to the fifth TMT joint. A 30° 2.5mm arthroscope was used as well as 2.5mm aggressive soft tissue shaver. Intraoperative fluoroscopy was use to confirm location of the arthroscope and shaver. The intraoperative findings were recorded into the medical record. We used the Outerbridge classification for chondral lesions, the Kellgren Lawrence (KL) radiographic classification for osteoarthritis, and described intraarticular pathologies as acute hypertrophic synovitis, chronic synovial fibrosis, hyaline bands, meniscoid bodies, loose joint bodies, arthrofibrosis. Results: Twenty-three fourth TMT joints and 26 fifth TMT joints, in 25 patients, underwent arthroscopic surgery for refractory pain. Average age was 62.6+-8.3 years. Average body mass index was 31.0+-5.0 kg/m 2 . All patients had pain with piano-key test. Twelve patients with arthritis to first through third TMT joints and eight patients to second through third TMT joints required arthrodesis. Approximately, 71.4% of TMT joints presented with radiographic evidence of arthritis and 28.6% of TMT joints were absent of radiographic signs of arthritis. The soft tissue pathology observed in patients without radiographic evidence of arthritis was arthrofibrosis (87.5%), chronic synovial fibrosis (75.0%), and acute hypertrophic synovitis (62.5%). Frequency plot of soft tissue pathologies, Outerbridge classification and KL radiographic classification for arthritis are shown in Figure 1. Conclusion: This is the first study to report arthroscopic findings associated with refractory pain of the fourth and fifth TMT joints with and without arthritis. These findings provide information regarding pathologies associated with fourth and fifth TMT joints pain and subsequent treatment.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The majority of hallux valgus corrections are performed via a uniplanar metatarsal osteotomy approach in which the metatarsal is cut and shifted over in the transverse plane. This approach has demonstrated high long-term recurrence rates. Recent research demonstrates that 87% of hallux valgus deformities are three-dimensional with abnormal frontal-plane rotation of the metatarsal, which cannot be fully addressed with a uniplanar metatarsal osteotomy. While correction at the 1st tarsometatarsal (TMT) joint may provide the optimal surgical approach for 3D anatomic restoration at the apex of the deformity, 1st TMT fusion has historically involved an extended period of non-weightbearing. This study evaluates the clinical, radiographic, and patient-reported outcomes in patients undergoing instrumented triplanar 1st TMT arthrodesis (TTA) with a biplanar plating system and protected near-immediate weightbearing. Methods: This is a prospective multicenter study that will continue for 60 months post-operatively. Patients between 14-58 years old with symptomatic hallux valgus (intermetatarsal and hallux valgus angles between 10.0-22.0° and 16.0-40.0°, respectively) and no prior hallux valgus surgery on the operative foot are eligible for this study. Patients are treated with an TTA procedure using a biplanar plating system with protected near-immediate weightbearing. Outcomes (radiographic, range of motion (ROM), pain measured by visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOxFQ), return to weightbearing and activities) are evaluated post-operatively. Two independent musculoskeletal radiologists reviewed radiographic data. These interim results are limited to patients completing at least 6 weeks of follow-up. Results: At time of data cut-off, 74 patients had undergone TTA with at least 6 weeks follow-up. The majority of patients were women (95%) with mean age 41.7 years. The mean (95% confidence interval) time to protected weightbearing in CAM boot was 8.0 (6.4, 9.7) days, return to work was 19.0 (13.6, 24.4) days, and return to full work was 31.5 (22.7, 40.2) days. There was a significant change in radiographic measures pre vs. post procedure and changes were maintained over time (Table). VAS pain score decreased 4 and 6 months post-procedure by 3.9 (3.2, 4.6) and 4.2 (3.5, 5.0), respectively. The mean MOxFQ Index Score pre-procedure was 53.3 (49.5, 57.1) and at month 6 had decreased to 18.6 (12.9, 24.2). Conclusion: These interim findings support that TTA with biplanar plating is successful in correcting the 3D hallux valgus deformity with early return to weightbearing and demonstrated favorable clinical and patient-reported outcomes. Patients were able to return to full, unrestricted work and activities within just a few months and had meaningful pain reduction after surgery. Patients will continue to be followed for up to 60 months. Clinical/radiographic healing at 12 months and recurrence rates at 24 months, as well as complications and patient satisfaction, will be evaluated.

Category: Trauma; Hindfoot Introduction/Purpose: Fractures of the calcaneus are life-changing events with a major socioeconomic impact from lost productivity. Traditional operative treatment with the extensile lateral approach has shown relatively high rates of wound complications. Less invasive approaches can improve fracture alignment and decrease wound healing complications. The purpose of this study is to report our experience with the sinus tarsi approach in treating calcaneus fractures. Methods: We retrospectively identified patients at our institution treated with a limited sinus tarsi approach for calcaneus fractures from 2009-2018. Demographic and radiographic data were collected including: age, sex, mechanism of injury, occupation, presence of diabetes, smoking status, Sanders classification, Bohler and Gissane angles. Postoperatively, we recorded the presence of complications, return-to-work time, and radiographic measurements. Results: Our analysis included 105 fractures in 100 patients: 86% males, 42% smokers, 4% diabetics, with an average body mass index of 26.5. The fractures were: Sanders type 2 (32%), type 3 (48%), type 4 (18%), and 2% were a tongue-type variant. Preoperatively 38% of fractures displayed a negative angle, 50% had an angle 0-20 degrees, and 12% over 20 degrees; postoperatively 13% had an angle 0-20 degrees, and 87% had an angle over 20 degrees. Of patients working prior to the injury, 72% had returned to work by 6 months, and 89% by 12 months. The wound complication rate was 12% (12/100), with only 2% (2/100) requiring additional procedures. There was no significant difference in wound complication rates in smokers versus nonsmokers (11.9% vs 12.2%, p=0.55). Conclusion: The limited sinus tarsi approach for depressed calcaneus fractures allows radiographic restoration of calcaneal height with a low rate of wound complications, even amongst active smokers. To the authors’ best knowledge, this is the largest published case series of calcaneus fractures treated with the sinus tarsi approach. Further follow up is needed to determine the success of this approach in mitigating long term complications.

Diabetic foot infection is the leading cause of non-traumatic lower limb amputations worldwide. In addition, diabetes mellitus and sequela of the disease are increasing in prevalence. In 2017, 9.4% of Americans were diagnosed with diabetes mellitus (DM). The growing pervasiveness and financial implications of diabetic foot infection (DFI) indicate an acute need for improved clinical assessment and treatment. Complex pathophysiology and suboptimal specificity of current non-invasive imaging modalities have made diagnosis and treatment response challenging. Current anatomical and molecular clinical imaging strategies have mainly targeted the host’s immune responses rather than the unique metabolism of the invading microorganism. Advances in imaging have the potential to reduce the impact of these problems and improve the assessment of DFI, particularly in distinguishing infection of soft tissue alone from osteomyelitis (OM). This review presents a summary of the known pathophysiology of DFI, the molecular basis of current and emerging diagnostic imaging techniques, and the mechanistic links of these imaging techniques to the pathophysiology of diabetic foot infections.

Category: Ankle, Ankle Arthritis Introduction/Purpose: During the last twenty years, studies comparing total ankle replacement (TAR) and ankle arthrodesis (AA) appear to demonstrate lower complication rates with TAR than with AA. However, advances in implant technology and surgical techniques have dramatically reduced complication rates. As a result, studies comparing TAR and AA require more patients to detect differences in rare events. Despite this, few epidemiologic studies have been performed examining short-term outcomes after TAR and AA using a contemporary patient population. The purpose of the current study was to compare perioperative outcomes after TAR and AA using patient data from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database between 2012 and 2017. Methods: We reviewed patient data from ACS-NSQIP database collected between 2012 and 2017 using Current Procedural Terminology (CPT) codes 27700 (TAR), 27702 (TAR), 29899 (AA) and 27870 (AA). Patients were then excluded if they were treated for fractures, infections, non-foot or ankle-related conditions or had revision procedures. Patients were also excluded if they were older than 90 years as ACS-NSQIP does not report age above 90 years. The study population included those treated in inpatient and outpatient settings. The main outcomes of interest were readmission and reoperation related to initial surgery, surgical site complications and hospital length of stay (LOS). Predictors of adverse outcomes were evaluated through multivariate regression of patient demographics, comorbidities and treatment characteristics. Results: Out of 1214 patients included in the study, 187 (15.4%) patients were treated with AA, and 1027 (84.6%) underwent TAR. Patients with AA were younger, had higher body-mass index, higher white blood cell count, more often had diabetes mellitus (DM) treated with insulin, received more dialysis treatment, had higher anesthesia risk classification and were treated in the outpatient setting more often than patients with TAR. Among outcomes, AA patients had longer hospital LOS, more deep surgical site infections and more reoperations than TAR patients. Post-operative readmissions were not significant but were higher in AA patients (2.7% vs. 0.9%, p=0.101). Combining these adverse outcomes, multivariate regression revealed that higher anesthesia risk category (p=0.0007), DM (p=0.029) and AA (p=0.049) had positive correlations with adverse outcomes. Conclusion: Ankle arthrodesis appears to be independently associated with perioperative complications compared to TAR, consistent with previous reports. Although complications were rare, patients with DM and higher anesthesia risk seem to be important factors to consider. Interestingly, patients with DM had fewer adverse outcomes with TAR than AA (3.8% vs. 7.4%). The difference was even greater in DM patients treated with insulin (4.3% vs. 13.3%) although only 38 patients had DM controlled with insulin in the cohort. Further studies are needed to identify patient populations at risk of complications, specifically those with DM.

Category: Bunion, Midfoot/Forefoot Introduction/Purpose: Hallux valgus is a complex deformity of the great toe and is a major cause of pain for patients. Despite the variety of techniques, traditional osteotomies often do not address rotational deformities. A novel biplanar plating system was used to perform correction of metatarsal rotation at our institution starting in 2017. The purpose of this study was to determine the correction of rotational deformity and of radiographic parameters, maintenance of this correction (versus recurrence of hallux valgus), complication rates and patient-reported objective survey scores. We sought to determine prognostic factors for successful correction, including age, gender, and time of surgery. Methods: By retrospective chart review, we identified all patients treated by the novel biplanar plating at our institution. We recorded patient demographics, pre-operative range of motion and maltracking, surgical details, operative complications, and any subsequent surgery. Imaging was reviewed at pre-operative and post-operative visits to approximate the hallux valgus angle (HVA), intermetatarsal angle (IMA), and tibial sesamoid position (TSP). Outcome scores (AOFAS, FAAM, SF12 PCS and MCS) pre- operatively and post-operatively at 3 months, 6 months and 12 months were also recorded. The changes in these radiographic parameters and scores were then computed and analyzed to determine if there was an improvement with surgery. Results: Fifty-seven procedures (in 55 patients) were performed and evaluated. There were 8 complications and average follow- up time was 27.1 weeks (+13.8 weeks). Older age was significantly associated with more complications (p = 0.018). Gender and time of surgery did not show any significant association with complications. Radiographic parameters including HVA, IMA, and TSP were analyzed. At 3 and 6 months post-operatively, these parameters were significantly reduced from pre-operative values. At 12 months, there was a trend towards significant reduction (p values of 0.06, 0.06, and 0.053 respectively); however, there were fewer patients who maintained follow-up during this period. The Outcome scores showed improvement post-operatively, but only the AOFAS score showed statistical significance at 3 and 6 months. Conclusion: Although statistical analysis was limited due to our population size and the retrospective nature of the study, there was an overall improvement in both radiographic parameters and clinical outcome scores. Older patients are also at higher risk of complications. Malrotation correction with this biplanar plating system is a novel technique and does require meticulous training. With continued expansion of our patient database and further longitudinal analysis, we hope to determine not only if correction is maintained over time, but also if the steepness of the learning curve affects the number of complications earlier versus later in each individual surgeon’s experience.

Category: Diabetes, Midfoot/Forefoot Introduction/Purpose: Charcot neuroarthropathy (CN) is a complication of neuropathy secondary to diabetes mellitus (DM) and may involve multiple joints of the foot, in particular the midfoot. Patients with CN deformity associated with infection, ulceration or pre-ulceration are at risk of losing their limb. In these patients, reconstruction of the foot structure through beaming arthrodesis screws for stabilization is often required. In addition to midfoot beaming, previous reports have advocated for subtalar arthrodesis. Fixation of the subtalar joint restricts motion of the hindfoot. This rigid fixation has been hypothesized to offer greater stability and fewer hardware failures. The aim of this study was to describe failure of midfoot beaming screws after midfoot reconstruction of CN with and without subtalar arthrodesis. Methods: We retrospectively reviewed patients with DM diagnosed with CN. Patient radiographs were evaluated for type of midfoot Charcot reconstruction and hardware failure. Patients included in the study had follow up of 3 months or more. The main outcome variable of interest was hardware breakage. Results: Eighteen patients who underwent midfoot reconstruction for CN were included. The average age was 52.7 years (±8.4 years), 10 (55.6%) were male, and the average body-mass index (BMI) was 35.8 kg/m2 (±10.3 kg/m2). The average follow-up time was 6.5 months (±3.7 months). In the current series, thirteen out of 18 (72.2%) patients underwent subtalar fusion along with midfoot fusion. Screw breakage occurred in two patients, one at the 1st tarsometarsal joint and 2nd-4th tarsometarsal screws in another patient at 9 and 6 months respectively. Both patients with screw breakage had subtalar fusion. A third patient who had subtalar fusion subsequently developed collapse of their talus leading to subtalar screw removal 3 months after initial surgery. Patients without subtalar fusion did not experience screw breakage. Conclusion: An extended medial column fixation with subtalar arthrodesis has been previously proposed to provide better fixation after midfoot CN reconstruction with beaming screws as it restricts motion of the hindfoot. However, little to no evidence has been reported in favor of this technique. Our findings suggest that subtalar arthrodesis may result in fixation that is too rigid, which may place the beaming screws at higher risk of breakage. However, the number of observations is a limitation of our study, and further investigation comparing these techniques is needed to fully evaluate the effect of subtalar arthrodesis on midfoot beaming outcomes.

Diabetic foot ulcers and infections are common complications of diabetic foot disease. Additionally, these complications are a common cause of morbidity and impose a substantial burden to the patient and society. It is imperative to understand the major contributing factors, namely, diabetic neuropathy, peripheral arterial disease, and immune system dysfunction in order to guide treatment. Management of diabetic foot disease begins with a detailed history and thorough physical examination. This examination should focus on the manifestations of diabetic neuropathy and peripheral arterial disease, and, in particular, any evidence of diabetic foot ulcers or infection. Prevention strategies should include a multi-disciplinary approach centered on patient education.

Introduction: This study investigated the impact of race/ethnicity on post-operative complications, revisions, costs, and time to admission among patients with hip fracture surgically managed with hip plating, nailing, hemiarthroplasty, total hip arthroplasty, and screw fixation. We hypothesize that patients from racial/ethnic minority backgrounds will have higher post-operative complications, revisions, and costs. Methods: Patient data was collected from PearlDiver, a large commercial insurance database, from 2014 to 2017. Patients from racial/ethnic minority backgrounds were matched to White patients according to age and gender, as well as comorbid tobacco use, diabetes, and obesity. Patients were also matched by Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI). Post-operative complications, revisions, and costs at 30, 90, and 365 days were evaluated among the racial/ethnic groups. Results: Data from 9,494 White (93.34 %), 500 Black (4.92 %), 94 Asian (0.92 %), and 82 Hispanic (0.81 %) patients with hip fracture who underwent hip surgery was analyzed. Patients from every minority group had statistically significant increased CCI and ECI. Unmatched Black patients experienced more complications. Unmatched Black patients also had higher costs at all time points (p

Category: Lesser Toes Introduction/Purpose: Instability at the MTPJ of the lessor toes is challenging to treat, particularly when both transverse and sagittal plane deformity coexist. Previous studies have utilized a subligamentous transfer of the EDB for crossover toes. The purpose of this pilot study was to evaluate a transosseous transfer of the EBD to correct multiplanar instability of the lessor toe. Routine exposure of the MTP was performed through a dorsal approach and a Z lengthening of the EDL was performed. The median number of concomitant produres performed was 4 and included hallux valgus repair, neuroma excision, metatarsal osteotomy, hammertoe correction and capsulotomies of other toes as needed. 27 tendon transfers were performed in 25 patients (2nd MTPJ: 20, 3 rd MTPJ: 5, 4th MTPJ: 2) Methods: A capsular release was performed on the concave side (contracted) and the convex side (lax) of the proximal phalanx and metatarsal head were exposed. A tenotomy of the EDB was performed at the musculotendinous junction and its insertion remained intact. The EDB was then transferred through a 2.5 mm drill hole in the base of the proximal phalanx. The drill hole began on the concave side and exited on the convex side with a similar hole from the convex side of the metatarsal neck to the concave side. To correct sagittal deformity the drill hole was oriented from dorsal to plantar. A low profile 1.5 mm polyethylene suture tape augmented the EDB transfer in both the proximal phalanx and metatarsal neck. A 3.0 mm interference screw is placed distally and the tape and EDB were appropriately tensioned and proximal fixation was achieved with another interference screw. Results: Results Median age in years (25-75th interquartile range) Females (N,%) 24, 96% 64(58-85) BMI (25-75th interquartile range) Previous surgery (N,%) Smoking history (N,%) Inflammatory arthritis (N,%) 27.8(21-32) 8, 32% 7, 28% 5, 25% Median number of concomitant procedures (25-75th IQR) Preop AP MTPJangle in degrees (25-75th IQR) Postop AP MTPJ angle in degrees (25-75th IQR) % Transverse Plane Improvement Preoperative to Postoperative 4(3-6) 19(11.5-24.0) 13(4.5-20.5) 31.5% (p < 0.0001) Preop Lateral MTPJ angle in degrees (25-75th IQR) Postop Lateral MTPJ angle in degrees (25-75th IQR) 41(26-58) 29(22.5-36) % Sagittal Plane Improvement Preoperative to Postoperative 29.2%(p < 0.0001) Conclusion: At a median follow up 19 weeks (12-32 weeks), EDB transfer augmented by polyethylene tape resulted in significant improvement in the transverse (31.5%) and sagittal planes (29.2%) without using temporary K wire fixation across the MTPJ. Twenty of 25 patients (80%) were completely satisfied, 4 patients (16%) were partially satisfied and 1 patient (4%) was dissatisfied. One mild infection occurred which was treated with oral antibiotics. No fractures occurred. This study is limited by relatively short follow up and the need to confirm these findings by independent surgeons. A biomechanical study is underway to assess pull out strength of the construct

Category: Diabetes Introduction/Purpose: Charcot neuroarthropathy (CN) has been associated with premature mortality, increased morbidity and reduced health related quality of life. The primary goal of treatment in patients with CN, whether surgical or non-surgical, is to achieve successful limb salvage. Traditionally, the quality of medical evidence guiding treatment has largely been based on expert opinion and uncontrolled case series. A systematic review (FAI 2012) reported that the mean and median number of patients reported in surgical studies of CN was 27 and 14 respectively. This retrospective study was performed to assess the outcomes of a consecutive series of diabetic patients with CN from a single surgeon academic practice. The primary aim was compare the major lower extremity rate (LEA) in patients with and without a preoperative ulcer Methods: This series was comprised of 256 diabetic patients with a mean age of 58.4 years (±10.1). The majority of patients were males (57%), had type 2 DM (78.5%) and used insulin (70.4%). The anatomic areas of CN involvement were midfoot (69.1%), ankle (25.1%), hindfoot (4.7%) and forefoot (0.1%). The majority of patients presented during Eichenholtz stage 3 (61%) followed by stage 1(27%) and stage 2 (12%). At the time of presentation, 144 patients (56%) had a foot ulcer and 58% of ulcer patients (N=84) had either a soft tissue infection or osteomyelitis. When comparing CN patients with and without ulcers, there were no significant differences between the two groups with regard to age, duration of DM, BMI, insulin use, serum glucose, Hbg A1C, serum creatinine, need for dialysis or PAD. Patients with foot ulcers were significantly more likely to be males and have lower levels of hemoglobin and albumin. Results: 75% of patients underwent some type of surgery and 25% were successfully managed without surgery. Major LEA was performed in 39 of 256 patients (15.2%). Three LEA (2.7%) were performed in patients (N=112) who did not have a preoperative ulcer compared to 36 LEA (25%) in patients (N=144) with ulcers (p < 0.0001). These 3 amputations occurred after reconstructive surgery in patients with PAD. Variables associated with major LEA included the presence of a preoperative ulcer [OR 12.1(95% CI 3.6-40.5), < 0.0001], preoperative infection [OR 4.5 (95% CI 2.1-9.8), < 0.0001] and male gender [OR 4.1(95% CI 1.7-9.7), 0.0007]. PAD [OR 1.3 (95% CI 0.6-2.7), 0.48] and dialysis [OR 1.3(0.4-3.6), 0.69] were not significantly associated with LEA. Thirty-seven of 256 patients (14.8%) died during the follow up period Conclusion: This study demonstrates that once an ulcer develops in patients with CN, the need for surgery, complications of surgery (i.e. surgical site infections) and risk of LEA increases significantly. Early treatment (non-surgical or surgical) should strive to prevent ulcer formation. Approximately one in six patients died during the follow up period, indicating that CN is likely a surrogate marker for cardiovascular and renal health. A major limitation of this study is that patients in this series were from an academic practice that receives tertiary referrals. Consequently, the relatively high rates of surgery and amputation may be due to selection bias.