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

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

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

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

Expanded use of nurse practitioners (NPs) and physician assistants (PAs) is a potential solution to workforce issues, but little is known about how NPs and PAs can best be used. Our study examines whether medical and social complexity of patients is associated with whether their primary care provider (PCP) type is a physician, NP, or PA. In this national retrospective cohort study, we use 2012-2013 national Veterans Administration (VA) electronic health record data from 374 223 veterans to examine whether PCP type is associated with patient, clinic, and state-level factors representing medical and social complexity, adjusting for all variables simultaneously using a generalized logit model. Results indicate that patients with physician PCPs are modestly more medically complex than those with NP or PA PCPs. For the group having a Diagnostic Cost Group (DCG) score >2.0 compared with the group having DCG