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Category: Trauma; Ankle Introduction/Purpose: The importance of the deltoid ligament in the congruency of the tibiotalar joint is well known. The current trend is to repair it in cases of acute injuries in the context of ankle fractures, however, there is no information on how it should be reconstructed. The objective of this study was to compare different deltoid ligament repair types in an ankle fracture cadaveric model. Methods: 16 cadaveric foot-ankle-distal tibia specimens were used to conduct the study. All samples were prepared as a supination external rotation ankle fracture model. An axial load and cyclic axial rotations were applied on every specimen using a specifically designed frame. This test was performed without deltoid injury, with deltoid injury and finally with the ligament reconstructed. The reconstruction was performed in 4 different ways (anterior, posterior, middle, combined) using 4 specimens per group. Medial clear space (MCS) was measured for each condition on simulated weight-bearing and gravity stress radiographs. Reflective markers were utilized in tibia and talus, registering through a motion analysis system the kinematics, to record the tibiotalar uncoupling. Statistical analysis was performed using the SPSS software. Results: In all cases, the MCS increased significantly on gravity stress radiographs after damaging the deltoid ligament. There was no increase in the MCS on load radiographs. After repair, in all cases, the MCS was normalized. Kinematically, after damage the tibiotalar uncoupling increased significantly, decreasing after repair. All repairs significantly corrected the tibiotalar uncoupling, observing a significantly increased coupling effect (increased stiffness) with the combined repair. Conclusion: Our results show that deltoid repair recovers the tibiotalar coupling mechanism in an ankle fracture model. We suggest that the ideal repair should aim to repair the middle aspect of the deltoid ligament. The combined repair may lead to postoperative stiffness. Clinical studies are needed to prove these results and show clinically improved outcomes.

Category: Bunion Introduction/Purpose: Hallux valgus (HV) is of uncertain origin. Even though a huge amount of treatment options are available, no clear cause for this deformity exist. To be able to further understand this frequent pathology, a cadaveric model should be developed. A cadaveric model was developed trying to obtain similar deformities to the ones observed in Hallux valgus (first ray varus and pronation). The objective of this research is to recreate some characteristics of a HV deformity, through sequential ligaments sectioning. Methods: 8 fresh frozen lower leg specimens were used. Markers were attached to the medial and middle foot ray bones, including talus. A constant tibial axial load of 25 kg was used. Cyclic tibial rotation (to simulate gait phases) and 5 kg pull on the extensor and flexor hallucis tendons (EHL and FHL) were applied to the specimen. Limited and sequential medial and middle column ligamentous sectioning were performed, including the, dorsal and interosseous naviculo-cuneiform, intercuneiform, metatarso-cuneiform and intermetatarsal ligaments. After each ligament damage, bony alignment was measured including frontal (bone divergence) and axial plane (bone rotation). Results: After intercuneiform, Lisfranc and naviculo-cuneiform ligaments sectioning, a significant angular increase was found in the naviculo-cuneiform, intercuneiform and naviculo-metatarsal angles (p=0.001). Specifically, for bone rotation, the biggest change was found for the intercuneiform and naviculo-cuneiform angles. Regarding bone divergence, the biggest increase was found in the talo-metatarsal angle. No additional angular change was found after adding metatarso-cuneiform ligament damage. No change in the sagittal alignment was found. Conclusion: This model was able to recreate some parameters of the hallux valgus deformity. No flatfoot deformity was produced. Surprisingly, no significant angular change was produced after metatarso-cuneiform ligament damage. Most significant changes were found after intercuneiform and naviculocuneiform damage. Our findings suggest that midfoot instability has to be present to recreate a hallux valgus deformity.

Category: Trauma; Other Introduction/Purpose: Tibial torsion has been mainly analyzed in pediatric deformities of lower limbs. Nevertheless this parameter has acquired relevancy in treatment of rotational deformities in adult population, that require axial correction. There are few articles that report normal values of tibial torsion, mostly in children, parameter that must be corrected in deformities to improve long term outcomes. Normal values in our population need to be established for preoperative planning and corrections. Our objective is to establish a normality parameter of tibial torsion in adults, that helps us in surgical planning of tibial rotational mal alignment and evaluation of the postoperative axial axis in complex tibial fractures. Methods: Descriptive study. We analyzed 18 computed tomography of 18 patients (35 tibias), through the Horos v.3.3.5 program, specifically in the 3D curved-MPR. Inclusion criteria: adult patients, without prior knee, leg or ankle deformities, without post-traumatic sequelae of the limb. Exclusion criteria: severe osteoarthritis of the knee or ankle, presence of osteosynthesis material in the limb, presence of previous osteotomies. Measurements were performed in standardized form previously defined by two foot and ankle orthopedic surgeons. We establish the comparison between both legs of each patient to determine posible variability and measurement interobserver correlations through kappa values. Results: All continuous variables are reported as means +- standard deviations. Student t-test was performed for continuous variables depending on the normality of the data distribution. We also performed de paired t-test to identify any significant differences in left and right tibial measurements. Statistical analyses were carried out by an independent statistician using Stata 16 statistical software. Measurements were performed establishing parameters in axial cuts of the tibia and overlapping two images previously determined. 18 patients (35 tibias) were measured, one limb was deleted for severe compromise the tibial plafond by osteoarthritis. 15 male and 3 female patients with an average of 65 years old (62-76 years). Mean external rotation of the distal tibial was 33° (16.1°-49.8°), difference between left and right tibias was in mean values of 1.95°, not being considered statistically significant. Interobserver correlation was reported at 97% in left tibia and 98% in the right, by intraclass correlation. Conclusion: Tibial torsion is an important component when correcting tibial axial deformities in adults. Our study shows higher normal values than the ones reported in current literature, but it is important to mention that the best parameter of evaluation is the comparison with the contralateral extremity of each patient.

Category: Bunion; Other Introduction/Purpose: Recently, minimally invasive surgery for hallux valgus correction has regained popularity. The minimally invasive Chevron and Akin (MICA), has been proved to be as satisfactory for patients as conventional open techniques. However, due to its design, it is difficult to correct the coronal plane malalignment, which could lead to the recurrence of the deformity. Instead, a Bösch-type osteotomy allows multiplanar correction, and with an upgrade in its fixation we can create a stable third- generation percutaneous osteotomy. We report our early results using the minimally invasive Bösch and Akin osteotomy (MIBA). Methods: This was a prospective case series of our first 40 patients (41 feet) undergoing MIBA procedure. Outcome measures included the Manchester-Oxford Foot Questionnaire (MOXFQ), the AOFAS Forefoot Score, and the visual analog scale (VAS) for pain assessment. Radiographic measures included the hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA) and the pronation of the metatarsal. All complications and emitted radiation dosage were reported as well. Results: At 12 months MOXFQ and AOFAS improved from 54.8 to 0.66 (p=0) and 39.1 to 99.2 (p=0), respectively. The mean preoperative VAS was 5.8, and improved during the first week to 1.3 (p

Category: Trauma; Other Introduction/Purpose: Bone transports are an alternative in the treatment of severe injuries of lower extremities. They are generally associated to axis problems, delayed bone union in the docking site and pin infection. There is no evidence in the need of having a window period between the transport system and the definite internal fixation. Objetive: Describe the complications seen in a group of 6 patients that went through a tibial bone transport with circular external fixator and posterior internal fixation without pin holiday. Methods: Restrospective and decriptive study of 6 patient that went through tibial bone transport between 2012-2019, in a level 1 trauma center. Inclusion criteria considered patients >18 years old, with intra or extramedular internal fixation systems. We registered different parameters including patients comorbilities, transport time, transport index, type of internal fixation used and complications during the time of observation and treatment. We registered our clinical evaluation and both laboratory and imagenologic exams. Results: 100% of patients were men, with an average of 35.8 years old (22-48 yo). 66% of injuries compromised distal tibia, 83% considered open fractures. Average transport length was 7.43 centimeters (3-11cms) in 3.5 months (1.3-6 months), with average follow up of 52 months (24-72months). Tibial transport index in our study was of 1,2month/cm. The main complication in our study was bone consolidation delay in the docking site (50%), and 33% presented deep infection, all of them in the open fracture group. Conclusion: Pin holiday has been justified by the reduction in pin site infection. In our series there where no pin site infection cases, and only two deep infections which were associated with an important soft tissue injury that required free flap coverage.