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Category: Ankle; Midfoot/Forefoot Introduction/Purpose: In the United States, there has been a substantial rise in podiatrists to address the increasing prevalence of foot and ankle pathologies. Although this may improve accessibility to foot and ankle care, there may be differences in the quality of care delivered by podiatrists compared to orthopedic surgeons. Some studies have found that patients treated by podiatrists have higher postoperative complication rates and length of hospital stay. With a growing emphasis on patient-centered care, there is a need for research investigating these differences so patients can make informed decisions when selecting providers. The purpose of our study is to compare postoperative complications in common foot and ankle procedures performed by orthopedic surgeons and podiatrists. Methods: A national database was queried to identify patients 18 years and older who underwent forefoot surgery (including fusion and bunionectomy), hindfoot or midfoot fusion, rotational ankle fracture fixation, ankle arthrodesis, or ankle arthroplasty from 2009-2022. Provider variable codes were then utilized to identify patients who underwent the corresponding procedures by orthopedic surgeons and podiatrists. Univariate analyses and multivariate logistic regressions were performed to compare 90-day rates of medical and surgical complications between the two provider categories for each procedure while controlling for age, sex, diabetes, smoking, and obesity. Results: Overall, 34,807 patients underwent foot and ankle (F&A) procedures by an orthopedic surgeon and 43,787 patients by a podiatric surgeon. Orthopedic patients were older (51.77 versus 50.79; p< 0.001), had a higher comorbidity index (Charlson Comorbidity Score 1.13 versus 0.97; p< 0.001), and were more likely to undergo surgery from an inpatient facility (16.18% versus 2.18%; p< 0.001). Comparing 90-day complication rates, podiatry patients exhibited higher rates of complications, including neuritis, nonunion, prosthetic complications, and wound debridement across various procedures when compared to orthopedic surgeons. Conclusion: Common foot and ankle procedures performed by podiatrists may be associated with higher postoperative complications affecting quality of care which could be attributed to differences in training, case volume and variety, and surgical techniques between orthopedic surgeons and podiatrists. Although access to foot and ankle procedures has improved, these data raise questions about the safety of procedures performed by podiatrists. Thus, additional highly powered studies are needed to investigate these postoperative differences to ensure that patients have all the information necessary to make informed decisions regarding their care.

Category: Hindfoot; Other Introduction/Purpose: There are few comparative studies between the traditional triple arthrodesis and the commonly performed modified procedure in which the calcaneocuboid joint is spared. Earlier investigations proposed that stiffening the lateral column of the hindfoot can increase lateral plantar pressures, potentially precipitating lateral column pain. We used a cadaver model to quantify the potential for reduced lateral column overload achieved by sparing the calcaneocuboid joint in a cadaveric model of triple arthrodesis simulating standing on both a neutral and sloping surface. Methods: Nine fresh-frozen, thawed cadaver legs were tested in 2 positions of the loaded surface: neutral and 10 degrees of eversion. Tendon loading and axial pressure was applied according to standard cadaveric models. Medial and lateral forefoot pressures were recorded using a pressure-sensitive plate (F-scan). The data were normalized as a percentage of the native state. Results: In neutral loading, the mean contact pressures under the fifth metatarsal head increased dramatically compared to the native state in both the standard (76.3%, p

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Minimally invasive surgery (MIS) techniques have largely focused on first metatarsal osteotomies in hallux valgus correction, but have also been used for joint preparation in foot and ankle surgery. Concurrently, new fixation methods allow early weightbearing protocols with the open Lapidus procedure, with nonunion rates comparable to those of more traditional protocols requiring prolonged nonweightbearing. We aimed to assess the nonunion rate and clinical results of a percutaneous modified Lapidus (PML) technique with axial nail fixation (Phantom Lapidus Intramedullary Nail: Paragon28, Englewood, CO USA) and early weightbearing. Methods: A retrospective chart review was performed for a consecutive series of 88 feet in 70 patients who underwent the PML technique from June 2018 to January 2023 by two fellowship-trained orthopedic foot and ankle surgeons. Indications for surgery included moderate to severe hallux valgus deformity with or without first tarsometatarsal joint (TMT) instability, first TMT arthritis, adolescent bunion, and failed prior surgery. All patients initiated weightbearing in a controlled ankle motion (CAM) boot within 12 days from surgery. Nonunion rate was defined as a symptomatic nonunion (confirmed with CT scan) that underwent revision surgery. Patients were also sent follow-up questionnaires to obtain postoperative visual analog scale (VAS) pain scores, Patient-Reported Measurement Information System (PROMIS) Physical Function scores, PROMIS Pain Interference scores, and ability to return to work. Results: Overall nonunion rate was 9.1%. All nonunions were successfully treated with nail retention, medial plate augmentation and bone grafting. There was a 15.9% all-cause reoperation rate on the 1st ray. There were 3 minor wound complications (3.4%). Average tourniquet time for the PML technique (cases performed in isolation) was 65 minutes. Survey response rate was 50%. Average follow-up time from surgery to survey response was 3.4 years (SD 1.3, range 1.2 - 5.7). VAS scores improved from 3.5 (SD 2.6) preoperatively to 0.7 (SD 1.1, range 0 – 5). Mean postoperative PROMIS Physical Function and Pain Interference scores were 56.1 (SD 6.8) and 43.6 (SD 6.6), respectively. All patients who were employed within 6 months prior to surgery were able to return to work. Conclusion: The PML technique combined with early weightbearing yields low rate of wound complications and nonunion rates comparable to historical cohorts using prolonged weightbearing protocols. For the patient, this technique additionally provides improved cosmesis and accelerated rehabilitation.

Category: Hindfoot; Other Introduction/Purpose: The Evans osteotomy is a lateral column lengthening procedure of the calcaneus that is commonly used in the correction of flexible flatfoot deformities. Currently, there is no consensus on whether fixation is necessary when performing this osteotomy. The primary aim of this study was to determine the nonunion rate of an unfixed Evans osteotomy with use of an allograft wedge performed in patients undergoing flexible flatfoot reconstruction. The secondary aim was to report on the incidence and magnitude of calcaneocuboid (CC) joint subluxation. Methods: a retrospective chart review was done for a consecutive series of 145 feet in 137 patients who underwent Evans osteotomy as part of a flatfoot reconstruction with allogenic bone graft between January 2013 and October 2017, by a single fellowship-trained foot and ankle surgeon. Of those, 118 cases were available for analysis at a mean follow up of 62.5 weeks (SD 56.9). No fixation was used in any case. Time to union, estimated by clinical and plane radiographic evaluation was recorded, along with standard measures of deformity correction and CC joint subluxation. Results: There was only one nonunion 1/118 (0.84%) at final follow up. The mean time to union was 10.9 weeks (SD 1.56). Postoperative calcaneocuboid joint subluxation occurred in 50.8% of feet, with a mean of 1.51 mm, SD 2.3 mm and no correlation with wedge size (r=0.05, p=0.55). The mean wedge size was 7.1 mm , SD 1.4 mm (range, 5-12 mm). There was no correlation between wedge size and change in lateral column length (r=0.13, p=0.16). There was significant change between pre and postoperative calcaneal pitch, talonavicular uncoverage percentage, anteroposterior and lateral talo-first metatarsal angle, medial and lateral column height, and lateral column length (p < 0.05). Conclusion: Evans osteotomy without fixation for symptomatic flatfoot deformity resulted in an exceptionally low nonunion rate. CC joint subluxation occurred frequently but was small in magnitude, a finding that may be related to the relatively small size of the wedges used.

Category: Midfoot/Forefoot; Other Introduction/Purpose: The development of adjacent joint arthritis following arthrodesis is a universal concern in orthopaedic surgery. Arthrodesis of the hallux metatarsophalangeal (MTP) joint is an effective and commonly performed treatment for first MTP arthritis and other conditions. Despite its widespread use, the risk of symptomatic degeneration at the interphalangeal joint remains undetermined and is a common question from patients considering the procedure. This study investigated the rate of subsequent hallux interphalangeal joint (IPJ) fusion following arthrodesis of the first MTP joint using a large commercial database. Methods: Patients who underwent hallux interphalangeal arthrodesis after hallux metatarsophalangeal arthrodesis were identified from a large national commercial insurance database using CPT code identification (PearlDiver). The Kaplan-Meier curve for survivorship free of subsequent interphalangeal fusion was generated covering 10 years from the index operation. Results: Of 87,890 patients who had first metatarsophalangeal arthrodesis, 808 patients (0.91%) subsequently underwent subsequent hallux interphalangeal joint arthrodesis within 10 years. Because CPT codes were reported without laterality, it is possible that a small subset of patients may have undergone a subsequent contralateral IP fusion, and therefore this result should be regarded as an upper limit of the possible rate. Conclusion: This is the first large-scale data to address the common patient concern of subsequent degeneration of the interphalangeal joint following metatarsophalangeal fusion. The rate of subsequent fusion is less than 1%, a result that highlights the durability of the clinical result of the first MTP fusion and should reassure patients and surgeons considering the procedure relative to motion-sparing alternatives.

Category: Sports; Trauma Introduction/Purpose: Randomized controlled trials of surgery versus nonoperative management of Achilles ruptures have been numerous but relatively small. A recent large RCT, published in the New England Journal of Medicine by Myhrvold and coauthors, addressed this with 554 patients enrolled in 3 arms: nonoperative, open surgery, and minimally invasive surgery. The authors found no difference between groups in the primary outcome, the validated Achilles Tendon Rupture Score (ATRS), but a significantly higher rate of rerupture in the nonoperative group (6.2% vs. 0.6% vs 0.6%). The online trial protocol indicates that patients who suffered a rerupture were excluded from further data collection and analysis, but those who had surgical infections and nerve injuries were not. This selective data censoring may have biased the trial outcome against surgery. Methods: To determine if the potential effect from excluding reruptures from final analysis was numerically sufficient to alter the trial results, data models were generated by Monte Carlo analysis using the pre- and post-intervention ATRS score means and standard deviations as ground truths. A model was created of all three groups at their original size. The previously excluded rerupture patients were then added back in at an assumed ATRS score. The original statistical methods of the RCT were used to determine any between-group differences. The analysis was repeated 100,000 times for each possible ATRS score for the rerupture patients. Results: The MCID for the ATRS score is 10 points. Repeated trials analysis found that when rerupture patients were added back into the groups at an assumed ATRS score equal to the reported final mean for nonoperatively treated patients (76), the percentage of model trials that had outcomes favoring a surgical group over nonoperative treatment was 7.9%. This baseline model inherently assumes there is no dysfunction associated with a rerupture. When rerupture was assumed to have associated dysfunction, the percentage of model trials that had outcomes favoring surgery to statistical significance increased as the assumed degree of dysfunction was increased: Rerupture ATRS scores at 1 MCID below nonoperative mean (66): 13.7% Rerupture ATRS scores at 2 MCID’s below nonoperative mean (56): 22.0% Conclusion: Rerupture is almost exclusively a complication of nonoperative treatment. By excluding rerupture patients from further data collection and analysis, the protocol eliminated the likely worst outcomes from the nonoperative treatment while retaining the likely worst outcomes from surgery. While the RCT reported no difference between groups at p

Category: Hindfoot; Basic Sciences/Biologics Introduction/Purpose: Primary repair of mid-substance Achilles tendon rupture may be performed using an open or a percutaneous technique. Previous meta-analyses of clinical data comparing the two techniques have demonstrated mostly equivalent functional outcomes and re-rupture rates. Individual cadaveric studies have also compared the biomechanical properties of the two approaches. However, the results of these studies have been heterogeneous, and there is currently no consensus as to whether one technique may be biomechanically superior. The purpose of this meta-analysis was to evaluate the biomechanical properties of open versus percutaneous Achilles tendon repair. Methods: A systematic review of original research articles was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. To qualify for study inclusion, articles were required to be published in English, utilized a cadaveric laboratory design, and had to directly compare the biomechanical properties of open Achilles repair using a Krackow or Kessler technique versus percutaneous repair using either the PARS (Arthrex) or Achillon (Integra) tendon repair systems. Evaluated outcomes included displacement (mm), load to failure (N), and stiffness (N/m). Results: Nine studies met inclusion criteria, including 190 cadaveric specimens (open: 83, PARS: 56; Achillon: 51) that underwent primary mid-substance Achilles tendon repair. Pooled analysis demonstrated no statistically significant difference in displacement (p = 0.418; Figure 1), load to failure (p = 0.923; Figure 2), or stiffness (p = 0.195; Figure 3) between the open and percutaneous techniques. Among the percutaneous approaches, there was no difference in displacement (p = 0.109; Figure 4) between the PARS and Achillon tendon repair systems. Conclusion: The results of this study suggest that both open and percutaneous techniques are biomechanically viable approaches for primary mid-substance Achilles tendon repair. These biomechanical findings must be interpreted in the context of clinical outcomes data as well as the differing complication profiles of the two techniques to best inform the surgical decision-making process for primary mid-substance Achilles tendon repair.

Category: Hindfoot; Other Introduction/Purpose: The Evans osteotomy is a calcaneal lateral column lengthening procedure commonly used to correct flatfoot deformities. Currently, there is no consensus on whether fixation is needed when performing this osteotomy. Also, large sized grafts have been found to lead to degeneration of the calcaneocuboid joint. The aim of this study was to determine the nonunion rate of an unfixed Evans osteotomy with use of an allograft wedge performed in patients undergoing flexible flatfoot reconstruction and if addition of a medial calcaneal slide osteotomy will help limit graft size. Methods: We retrospectively reviewed 39 pediatric patients with idiopathic symptomatic flatfoot deformity who underwent 46 unfixed Evans osteotomies with allogenic bone graft for flatfoot reconstruction between March 2013 and September 2017, with a mean follow-up of 49 (range 9.9- 243.9) weeks. Hospital record, preoperative, follow-up radiographs and complications were reviewed. Results: Of the 46 feet, 42(91.3%) underwent an associated medial displacement calcaneal osteotomy. Mean graft wedge size was 7.2mm(SD 1.6). Mean time to union was 10.3weeks (range, 6.7-13.9)(Table 1). There were no nonunions. There was significant improvement in all radiographic parameters at final follow-up (Table 2). Postoperative calcaneocuboid subluxation occurred in 70% of feet, with no correlation with wedge size(r=0.01,p=0.53). Magnitude of calcaneocuboid subluxation was small and only significant at 6-months (p=0.02), with regression to no significance by 1-year(p=0.3). Mean change in calcaneocuboid subluxation at final follow-up was 1.07mm(SD 2.18), with postoperative subluxation diminishing over time(Table 3). No correlation was observed between wedge size and change in lateral column length (r=0.01,p=0.45). One patient had persistent sinus tarsi pain requiring arthroscopic debridement of fibrosis and graft prominence. Conclusion: An unfixed Evans osteotomy for symptomatic pediatric flatfoot deformity resulted in a significant improvement in the radiographic alignment and achieved 100% union rate with minimal calcaneocuboid subluxation at final follow-up. Performing adjunctive procedures allowed the Evans procedure to be routinely limited to less than 10 mm of lengthening. Mean graft size in our cohort was smaller than that reported by other studies. While calcaneocuboid subluxation was detectable in 70% of feet, it was small in magnitude and diminished with longer postoperative follow-up.

Category: Hindfoot; Basic Sciences/Biologics Introduction/Purpose: There are few comparative studies investigating differences between the modified double and triple arthrodesis of the hindfoot. Previous studies have suggested that stiffening the lateral column of the hindfoot can increase lateral plantar pressures, potentially precipitating lateral column pain. We sought to characterize the difference in forefoot plantar pressures between the native state, after talonavicular (TN)/subtalar (ST) arthrodesis and triple arthrodesis. Methods: Ten fresh-frozen cadaver legs were tested in 4 positions: neutral, dorsiflexion, inversion and eversion. Testing was done in a native state, after TN/ST arthrodesis then after triple arthrodesis for all 4 positions. Forefoot plantar pressures were recorded. Results: Peak pressures increased from the native state laterally underneath the 5th metatarsal (MT) head after TN/ST arthrodesis and triple arthrodesis respectively by 247% and 164% and fell medially underneath the 1st MT head to 38% and 41% in axially loaded legs at neutral (p < 0.025) without a difference between arthrodesis groups. Similarly, 5th MT head pressures were significantly increased from the native state after TN/ST and triple arthrodesis in the legs mounted in eversion by 129% and 109% respectively (p < 0.025), without differences between the two arthrodesis groups. Conclusion: In our cadaveric model of native, non-deformed legs, both a modified double (TN/ST) and triple arthrodesis led to increased lateral forefoot plantar pressures compared to the native state without a difference between the arthrodesis groups.

Category: Ankle; Other Introduction/Purpose: Peroneus brevis (PB) tendon tears are an important cause of lateral ankle pain. When PB tears are irreparable, allograft reconstruction maintains native anatomy and avoids the morbidity of tenodesis and tendon transfer procedures. Current data on allograft PB reconstruction is limited to small case series. We sought to retrospectively determine the clinical outcomes and complications in a large series of patients who underwent PB tendon reconstruction with semitendinosus allograft. Methods: After institutional review board approval, patients with PB tears who underwent tendon reconstruction with semitendinosus allograft at a single tertiary center between March 2010 and January 2020 were retrospectively reviewed. Hospital records, preoperative and postoperative visual analog pain scale (VAS), and complications were evaluated. A phone survey was conducted to assess postoperative work status, use of assistive devices, satisfaction, and patient-reported outcomes (PROMIS scores). Results: Sixty-eight patients (69 feet) (24 men,44 women) were identified. Mean age at surgery was 51.7 years (range, 23.0-74.0) and mean follow-up was 20.4 months (range, 3.4-71.4). VAS pain scale improved postoperatively (4.0±2.7 vs 2.4±2.8, p=0.0012). Most common complication was sural neuralgia in 18 (26.1%) feet, but only 2 (11%) required surgery. The allograft failed in 7 (10.1%) feet (Table 1).Of 29 (42.6%) patients available for survey, 25 (86.2%) were employed preoperatively, of whom 23 (92.0%) returned to work. Of the 29 survey patients, 25 (86.2%) did not use an assistive device, 20 (69.0%) reported being satisfied, and average T-scores for physical function and pain interference were 49.5±9.7 and 50.8±9.7, respectively. Revision PB surgery (30 [43%] feet) was not associated with sural neuralgia or patient satisfaction. Conclusion: This study demonstrated a relatively high rate of postoperative transient sural neuralgia after PB reconstruction with semitendinosus allograft, but the rate of reoperation for this complication was low. Among the subgroup of patients who completed a phone survey, there was a high rate of return to work, low rate of assistive device use, and good patient satisfaction after the procedure. These findings suggest that allograft reconstruction is a clinically effective treatment for irreparable PB tendon tears when few other options exist.

Category: Other Introduction/Purpose: Determining the success of a clinical intervention can be challenging even with modern patient-reported outcomes. Traditionally studies have used the Minimum Clinically Important Difference (MCID), the smallest difference in an outcome that is felt to have clinical significance. More recently some authors have emphasized the alternative model of the Patient Acceptable Symptomatic State (PASS), the threshold of a PRO defining where patients consider their overall status to be acceptable. PASS scores have not yet seen wide use in the foot and ankle literature, but may add insight to surgical outcomes beyond simply measuring the minimal changes implied by the MCID. Methods: The most universal patient-reported outcome in the foot and ankle literature is the simple Visual Analog Pain Scale (VAS), in which a patient rates their pain along an analog scale between 0 to 10 cm. Articles in Foot and Ankle International from December 2020 to August 2022 that reported VAS pain scores and variance following an intervention were included. Although specific PASS thresholds for VAS scores in many conditions in the foot and ankle have not been determined analytically, values ranging from 2.0 to 3.0 are typical for orthopaedic conditions, corresponding to the intuitive statement “I would like my pain to be less than 2 or 3 out of 10.” A PASS threshold of 2.0 has been used previously in the foot and ankle literature. The studies were therefore analyzed against PASS thresholds for the VAS of 2.0, 2.5, and 3.0. Results: Twenty-one studies were included. Five had multiple internal groups, yielding a total of 27 total sets of VAS scores.All 27 (100%) showed improvements well beyond the MCID and were considered successful. 17 (81%) of the 21 studies subjectively described their intervention as “reliable”, “good”, “effective” or “satisfactory”. Despite this, 8 (38%) of the 21 studies reported final mean VAS scores for all internal groups above a PASS threshold of 2.0. An analytically calculated weighted average final VAS pain score for all studies was 1.78 +/-1.89. Based upon this, the expected percentages of patients included in FAI studies whose results failed to meet VAS PASS thresholds were 45% for a threshold of 2.0, 35% for a threshold of 2.5, and 26% for a threshold of 3.0. Conclusion: Studies in the foot and ankle literature almost universally report positive results, both subjectively in their discussions and by statistically demonstrating improvement of patient-reported outcomes beyond the MCID. PASS threshold analysis yields a much less positive interpretation and emphasizes the number of negative outliers in the population who do not find their outcome acceptable. A fuller picture of the outcome of foot and ankle procedures and overall patient satisfaction can be gained from reporting both changes in the mean and comparing final outcomes to PASS thresholds.

Category: Basic Sciences/Biologics; Hindfoot; Other Introduction/Purpose: Flexor digitorum longus (FDL) transfer, in conjunction with osseous procedures, is used routinely for the treatment of posterior tibial tendon dysfunction (PTTD). It is well established however that the relative power of the FDL tendon is significantly inferior than that of the native posterior tibial tendon. The purpose of this study is to systematically evaluate the evidence that supports or refutes the use of an FDL transfer in the surgical treatment of PTTD. Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta- Analysis. Using the terms 'flexor digitorum longus OR FDL AND posterior tibial tendon dysfunction OR PTTD OR adult acquired flatfoot OR AAFD' we searched the PubMed/Medline database. Both clinical and biomechanical studies were eligible for inclusion. Results: Forty-one studies met the inclusion criteria, including 31 clinical studies and 10 biomechanical in vitro studies. All 31 clinical studies consisted of Level IV evidence, and support the use of an FDL transfer. There was significant heterogeneity of the clinical evidence due to the variety of concomitant procedures. Of the 10 biomechanical in vitro studies, 2 support the use of an FDL transfer, although these did not assess the procedure in isolation. 8 biomechanical in vitro studies specifically assessing the effect on of an FDL transfer contradict its use for PTTD. Conclusion: There is poor quality clinical evidence to support the use of an FDL transfer for PTTD and the biomechanical literature refutes the use of the procedure. It remains unknown if the clinical improvement reported in the literature can be attributed to the FDL transfer or the concomitant osseous procedures. Additional studies are needed to assess the validity of the FDL transfer and whether alternatives are available to preserve the PTT muscle.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Minimally invasive techniques (MIS) have focused on first metatarsal osteotomies in hallux valgus correction. Concurrently, new fixation methods allow early weightbearing protocols with the open Lapidus procedure, with nonunion rates comparable to those of more traditional protocols requiring nonweightbearing. We aimed to assess clinical and radiographic results of an MIS-modified Lapidus technique with axial nail fixation (Phantom Lapidus Intramedullary Nail: Paragon28, Englewood, CO USA) and early weightbearing. Methods: After institutional review board approval, the first 30 consecutive percutaneous MIS-modified Lapidus procedures by a single surgeon were retrospectively reviewed. Indications for surgery included moderate to severe hallux valgus deformity with or without first tarsometatarsal joint (TMT) instability, first TMT arthritis, adolescent bunion, and failed prior surgery. All patients initiated weightbearing within 12 days and returned to regular footwear by 6 weeks postoperatively. Patients had a minimum follow-up period of 3 months (average 8.3 months). The pre- and postoperative visual analog scale (VAS) pain scores, intra- and postoperative complications, and need for revision surgery were recorded. Pre- and postoperative radiographs were used to evaluate the hallux valgus angle (HVA), 1-2 intermetatarsal angle (IMA), and sesamoid station. Postoperative radiographs were evaluated for signs of hardware loosening and union of the first TMT arthrodesis site. A postoperative CT scan was obtained if nonunion was suspected. Results: Thirty consecutive percutaneous modified Lapidus procedures were performed in 28 patients. VAS scores improved from 4.1 preoperatively to 1.8 at final follow-up. The IMA decreased 8.3 degrees to an average of 5.9 degrees. The HVA decreased 19.2 degrees to 11.7 degrees. The medial column was shortened by 0.6%. There were no intraoperative complications. There were two reoperations, including one nonunion requiring revision first TMT fusion with autograft and one hallux valgus recurrence requiring a distal chevron osteotomy. There were no wound complications, surgical site infections, hardware complications, postoperative transfer metatarsalgia, or nerve-related problems. Conclusion: The current study provides clinical evidence that the intramedullary nail is a biomechanically stable construct evidenced by the high union rate, lack of hardware failure, and tolerance for early weightbearing. This percutaneous modified Lapidus technique may allow for a low rate of wound complications, accelerated rehabilitaion, and improved cosmesis.

Category: Sports Introduction/Purpose: Artificial turf (AT) playing surfaces have emerged as a common alternative to natural grass (NG) at all levels of athletic competition from youth to professional. While several prior articles have compared the lower extremity injury rates on AT and NG, the heterogeneity of these studies in terms of design and methodology has led to widely variable results. The purpose of this systematic review was to determine whether any definitive conclusions can be drawn with regard to the risk of lower extremity injury on AT and NG playing surfaces. Methods: A systematic review of the English-language literature was performed according to the PRISMA guidelines. All included studies presented a direct comparison of injury rates on AT versus NG playing surfaces. No restrictions were made with regard to sport, level of competition, level of evidence, or year of publication. Studies that examined only head injury rates (e.g. concussions) without any comparison of overall injury rates or lower extremity injury rates were excluded. Systematic reviews and meta-analyses were also excluded. The following data elements were extracted from each article: publication year, study design, level of evidence, industry funding, cohort selection process (ad-hoc vs. systematic), sport, level of competition, number of athletic seasons, injury setting, AT type, overall injury rate, knee rate, and foot & ankle injury rate. AT types were classified into Old Generation (1st or 2nd generation) or New Generation (3rd generation or higher). Results: 53 articles met inclusion criteria. 31 articles compared overall injury rates on AT versus NG. Roughly one-half of these studies (51.6%) found no significant difference between NG and AT, while roughly one-third (35.5%) found a higher overall injury rate on AT and just 4 studies (12.9%) found a higher overall injury rate on NG. Similarly, of the 26 articles comparing knee injury rates, 14 studies (53.8%) reported no difference between AT and NG, 8 studies (30.8%) reported a higher injury rate on AT, and 4 studies (15.4%) reported a higher injury rate on NG. With regard to foot & ankle injuries, however, a majority of articles (14/24, 58.3%) reported a higher injury rate on AT. Comparatively few articles (3/24, 12.5%) reported a higher foot & ankle injury rate on NG, while the remaining articles (7/24, 29.2%) reported no difference in foot & ankle injury rate between AT and NG. Conclusion: The present study is a systematic review of 53 articles in the English-language literature that compared injury rates on AT and NG. Our findings suggest that the rates of overall injury and knee injury are similar between these two playing surfaces, though AT may be associated with a higher rate of foot & ankle injuries compared to NG.

Category: Hindfoot Introduction/Purpose: Several minimally invasive medial displacement calcaneal osteotomy (MIS MDCO) techniques have been described utilizing differing methods for creating the osteotomy. However, there are few clinical reports of the safety profile and outcomes after percutaneous MDCO procedures. The purpose of this study was to describe short-term outcomes and complications associated with MIS MDCO for the correction of hindfoot valgus deformities. Methods: A retrospective study was conducted of all patients who underwent consecutive minimally invasive MDCO for the treatment of a hindfoot valgus deformity by a single fellowship-trained foot and ankle orthopaedic surgeon from September 2013 to August 2018. Demographic data, treatment data, and complications were recorded from the electronic medical record for the duration of the patient's follow-up. Univariate statistics were used to determine the relationship between complications and demographic/treatment variables. A p

Background: Digital media is an effective tool to enhance brand recognition and is currently referenced by more than 40% of orthopedic patients when selecting a physician. The purpose of this study was to evaluate the use of social media among foot and ankle (F&A) orthopedic surgeons, and the impact of that social media presence on scores of a physician-rated website (PRW). Methods: Randomly selected F&A orthopedic surgeons from all major geographical locations across the United States were identified using the AAOS.org website. Internet searches were then performed using the physician’s name and the respective social media platform. A comprehensive social media use index (SMI) was created for each surgeon using a scoring system based on social media platform use. The use of individual platforms and SMI was compared to the F&A surgeon’s Healthgrades scores. Descriptive statistics, unpaired Student t tests, and linear regression were used to assess the effect of social media on the PRW scores. Results: A total of 123 board-certified F&A orthopedic surgeons were included in our study demonstrating varying social media use: Facebook (48.8%), Twitter (15.4%), YouTube (23.6%), LinkedIn (47.9%), personal website (24.4%), group website (52.9%), and Instagram (0%). The mean SMI was 2.4 ± 1.6 (range 0-7). Surgeons who used a Facebook page were older, whereas those using a group website were younger ( P < .05). F&A orthopedic surgeons with a YouTube page had statistically higher Healthgrades scores compared to those without ( P < .05). Conclusion: F&A orthopedic surgeons underused social media platforms in their clinical practice. Among all the platforms studied, a YouTube page was the most impactful social media platform on Healthgrades scores for F&A orthopedic surgeons. Given these findings, we recommend that physicians closely monitor their digital identity and maintain a diverse social media presence including a YouTube page to promote their clinical practice. Level of Evidence: Level IV.

Category: Hindfoot; Other Introduction/Purpose: The Evans osteotomy is a lateral column lengthening procedure of the calcaneus that is commonly used to correct flexible flatfoot deformities. There is no consensus on whether fixation is needed to avoid nonunion and calcaneocuboid subluxation when performing this osteotomy. We assessed the nonunion rate and correlated extent of subluxation with graft size in an unfixed Evans osteotomy with an allograft wedge and no pinning of the calcaneocuboid joint at any point in the largest series of the procedure to date. Surgeries were performed in patients undergoing flexible flatfoot reconstruction. Methods: We retrospectively reviewed 120 consecutive patients who had undergone 145 unfixed Evans osteotomies by a single surgeon with allogenic bone graft for flatfoot reconstruction between January 2013 and October 2017, with a mean follow-up of 62.5 (range 9.4-266.7) weeks. The calcaneocuboid joint was not pinned during the procedure. Data were collected using clinical and radiographical examination during regular follow-up. Results: A total of 137 feet (94.5%) underwent a double calcaneal osteotomy with an associated medial displacement calcaneal osteotomy (MDCO). There was one nonunion (0.69%). The mean time to union was 10.8 (range, 6.7-17.9) weeks. There was significant improvement in all radiographic parameters postoperatively, including calcaneal pitch, talonavicular uncoverage, anteroposterior and lateral talo-first metatarsal angle, lateral column length, and naviculocuboid overlap (p

Category: Midfoot/Forefoot; Other Introduction/Purpose: Arthritis of the 1st metatarsophalangeal (MTP) joint is a common condition. Traditionally, advanced disease has been treated with arthrodesis. In 2016, Cartiva, a cylindrical polyvinyl 1st MTP implant, was approved for use in this condition by the FDA upon the basis of a company-sponsored, nonblinded, randomized controlled trial (MOTION) that reported noninferiority to arthrodesis at a -15% difference of proportions margin using a multipart ad hoc definition of surgical success. A subsequent independent level IV case series reported poor PROMIS score outcomes for the procedure but lacked any preoperative data. We report the short-term reoperation rate and pre- and postoperative VAS pain score outcomes for Cartiva in an independent multicenter series. Methods: A retrospective, multicenter review was performed of patients who had a Cartiva hemiarthroplasty placed from 2016- 18 and who had at least 6 months of follow-up. Demographic information, surgical data, and prospectively collected VAS pain scores on a 0-100 point scale on were reviewed. The primary endpoint was reoperation of the implant, defined as removal or revision during the follow-up period. Implant subsidence was measured by comparing early postoperative radiographs with final radiographs. Subgroup analysis was performed comparing Cartiva failures to the remainder of the group. Results: Fifty-three patients with 56 operated toes were included. Forty-seven (88.7%) females and 6 (11.3%) males had a mean age of 57.7 +- 7.14 years (range 43-73). At an average follow-up of 11.1 +- 4.24 months, there were 6 (10.7%) reoperations. Younger age was the only factor found to be associated with failure of the implant (p=.043). Radiographic subsidence >1 mm was identified in 26.6% of patients but did not correlate with failure. VAS pain scores improved from a preoperative average of 49.7 +/- 24.8 to a postoperative average of 33.1 +- 23.3 at final follow-up. Despite this improvement, 40.4% of patients failed to show a 30% improvement, the MCID, in their VAS pain score, and 42.6% of patients had residual pain scores above 30. Conclusion: Our cohort had a 10.7% reoperation rate for the Cartiva implant which is comparable to the results of the MOTION trial. Although aggregate results demonstrated a statistically significant improvement in VAS pain scores, many patients failed to have a satisfactory outcome as demonstrated by the large standard deviation and low achievement of the MCID. Compared to the 1-year results of the MOTION study, our final VAS pain scores were slightly worse, but the very high variance mirrored that reported in the company-sponsored trail (17.8 +- 23.0). This suggests that use of Cartiva does not reliably produce satisfactory pain outcomes.