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O experimento foi conduzido na Epagri, Estação Experimental de Ituporanga, SC, com o objetivo de determinar a época e a densidade de semeadura de Avena strigosa Schreb. (aveia preta) e Lolium multiflorum Lam. (azevém). Os tratamentos foram avaliados por três anos, dispostos num delineamento de blocos casualizados, em parcelas subdivididas com três repetições. As épocas de semeadura para as duas espécies foram: Época 1 - meados de março; Época 2 - meados de abril; Época 3 - meados de maio; Época 4 - meados de junho. As densidades de sementes puras viáveis foram: aveia preta, 60, 80 e 100 kg/ha; azevém, 15, 25 e 35 kg/ha. A aveia preta foi menos produtiva e mais precoce que o azevém. Para as duas espécies, não houve diferença significativa entre as densidades de semeaduras. A melhor época de implantação das espécies foi em meados de abril.

Introduction: Next-generation DNA sequencing (NGS) technologies have increased the sensitivity for detecting the bacterial presence and have been used in other areas of orthopaedics to better understand the native microbiome of various joints. This study uses NGS to determine whether (1) a unique microbiome exists in human ankle tissues, (2) if components of the ankle microbiome affect patient outcomes, and (3) whether microbes found on the skin are a normal part of the ankle microbiome., Methods: A prospective study recruited 32 patients undergoing total ankle arthroplasty (n = 23) or ankle arthrodesis (n = 9) via direct anterior approach between November 2020 and October 2021. During surgery, five layers of the ankle were swabbed: skin (n = 32), retinaculum (n = 31), tibialis anterior tendon (n = 31), joint capsule (n = 31), and distal tibia (n = 32). These swabs (N = 157) were sent to MicroGen Diagnostics (Lubbock) for NGS. Demographics, medical comorbidities, surgical indication, postoperative complications, readmission, and revision surgery rates were collected from patient records., Results: The mean age was 60.7 (range, 19 to 85) years, and the mean follow-up duration was 10.2 (range, 4.8 to 20.6) months. Of 157 swabs sent for NGS, 19 (12.1%) indicated that bacteria were present (positive), whereas the remaining 138 (87.9%) had no bacteria present (negative). The most common organisms were Cutibacterium acnes in eight ankles (25.0%) and Staphylococcus epidermidis in two ankles (6.25%). Most bacteria were found in the retinaculum (29.6%). Complications, nonunions, infections, 90-day readmission, and revision surgery rates did not differ by NGS profile., Discussion: This study found that C acnes and S epidermidis were the most common bacteria in the ankle microbiome, with C acnes being present in 25% of ankles. Complication rates did not differ between patients with or without positive bacterial DNA remnants. Thus, we concluded that a unique ankle microbiome is present in some patients, which is unique from that of the skin of the ankle., Level of Evidence: Level II, Prospective cohort study., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Periprosthetic joint infection (PJI) after total ankle arthroplasty (TAA) is a dreaded complication that may lead to catastrophic outcomes. Risk factors include a history of surgery on the operated ankle, low preoperative function scores, diabetes, extended surgical time, and postoperative wound-healing problems. Clinical presentation varies and may include increasing ankle pain and swelling, high temperature, local erythema, wound drainage, and dehiscence. The initial diagnostic evaluation should include plain radiographs, erythrocyte sedimentation rate, C-reactive protein levels, and leukocyte count. In suspected cases with elevated erythrocyte sedimentation rate and C-reactive protein, aspiration of the ankle joint for synovial fluid analysis, Gram staining, and culture should be performed. Antibiotic therapy should be based on the pathogen identified, and the surgical strategy should be determined based on the time lines of PJI. Early PJI can be treated with irrigation and débridement with polyethylene exchange. The surgical treatment of choice for late PJI is two-stage revision arthroplasty, which includes removal of the implant, insertion of an antibiotic spacer, and reimplantation of a TAA. In certain chronic PJI cases, permanent articulating antibiotic spacers can be left in place or an ankle arthrodesis can be performed. Below-knee amputation is considered as the final option after limb-sparing procedures have failed., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Background: This study seeks to evaluate the relationship between American Society of Anesthesiologist (ASA) score and postoperative outcomes following TAA., Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried from 2007 to 2020 to identify 2210 TAA patients. Patients were stratified into low (n = 1328; healthy/mild systemic disease) or high (n = 881; severe/life-threatening systemic disease) ASA score cohorts., Results: There was no statistically significant difference in complications, readmission, or reoperation rate based on ASA score. Increased ASA score was significantly associated with longer length of stay (low = 1.69 days, high = 1.98 days; p < .001) and higher rate of adverse discharge (low = 95.3 %, high = 87.4 %; p < .001)., Conclusion: Higher ASA scores (3 and 4) were statically significantly associated with increased length of stay and non-home discharge disposition. These findings are valuable for physicians and patients to consider prior to TAA given the increased utilization of resources and cost associated with higher ASA scores., Level of Evidence: Level III, Retrospective cohort study., Competing Interests: Conflict of interest The authors declare that there is no conflict of interest., (Copyright © 2024 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Osteochondral lesions of the talus are being recognized as an increasingly common injury. Large osteochondral lesions have significant biomechanical consequences and often require resurfacing with both boney and cartilaginous graft. The current treatment options include osteochondral autograft transfer, mosaicplasty, autologous chondrocyte implantation, or osteochondral allograft transplantation. Allograft procedures have the advantage of no donor site morbidity and ability to match the defect line to line. Careful transportation, storage, and handling of the allograft are critical to success. The failure of nonoperative management, failure of arthroscopic treatment, or large defects are an indication for resurfacing., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Previous studies have demonstrated a positive correlation between case volume and outcomes in foot and ankle surgery. This study elucidates surgical case volume benchmarks for Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic foot and ankle fellowship training in the United States., Methods: The ACGME provided case logs for orthopaedic residents and foot and ankle fellows (2018-2021). Variabilities in reported fellowship case volumes were defined as the fold-difference between 90th and 10th percentiles. Reported case volumes were compared between training cohorts with parametric tests., Results: Case logs from 65 orthopaedic foot and ankle fellows and 3146 orthopaedic residents were included. Fellows reported 1.3- to 1.5-fold more foot and ankle cases during fellowship training than during residency training (P < .001). On average, orthopaedic foot and ankle fellows reported 405.4 cases and most were arthrodesis (17%), forefoot reconstruction (17%), mid/hindfoot reconstruction (13%), tendon repair/transfer (12%), and trauma ankle hindfoot (11%). Case categories with the highest variabilities were amputation (14.8-fold difference), infection/tumor (11.6-fold difference), arthroscopy (9.2-fold difference), and calcaneus (8.7-fold difference)., Discussion: Case volume benchmarks can assist trainees and faculty during orthopaedic foot and ankle training. More research is needed to determine case minimum requirements needed for autonomous practice in foot and ankle surgery., Level of Evidence: Level III ., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Level of Evidence: Level V., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Justin Haghverdian, MD, has no conflicts; Christopher E. Gross, MD, is a paid consultant for Additive Orthopaedics and MedShape; Andrew R. Hsu, MD, is a paid consultant for Arthrex, Inc.

Major extremity fractures are serious limb injuries often including notable soft-tissue injury with possible injuries to the head, chest, or abdomen. High-energy traumatic fractures carry a high risk of surgical site infections even with use of systemic antibiotics and techniques in risk reduction. The American Academy of Orthopaedic Surgeons released a clinical practice guideline in 2023 based on current literature on the prevention of surgical site infections after major extremity trauma. The case presented in this article is an example to demonstrate the clinical application of these guidelines., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Introduction: This study analyzes the incidence rate and median workdays missed due to foot and ankle injuries across age groups, sexes, and industries., Methods: Workplace injury data from 2003 to 2019 were obtained using the Nonfatal Cases Involving Day Away from Work: Selected Characteristics database provided by the Bureau of Labor Statistics (BLS). The data were grouped by injury location (ie, foot, ankle), injury type (ie, fracture, sprain), and industry, and reported with injury incidence rates and median workdays missed., Results: The incidence rate of foot and ankle injuries significantly decreased from 2003 to 2019 (P < .001). With increasing age, the incidence rate of foot and ankle injuries decreased (P < .001) and median workdays missed increased (P < .001). Men had significantly higher rates of foot and ankle injuries (P < .001). Agriculture, forestry, fishing, and hunting (foot=10.23%, ankle=10.41%); construction (foot=8.14%, ankle=8.68%); and transportation and warehousing (foot=11.06%, ankle=13.80%) industries had the highest injury incidence rates. Transportation and warehousing (foot=16.8 days, ankle=16.3 days), mining (foot=44.9 days, ankle=17.1 days), and utilities (foot=26.7 days, ankle=24.4 days) industries had the highest median workdays missed., Conclusion: Increased incidence and severity of workplace foot and ankle injuries are associated with male sex and heavy labor industries. Age was positively associated with severity and negatively associated with incidence of workplace ankle injuries., Levels of Evidence: Level III, Retrospective cohort study., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: DJS receives research support from Arthrex and Paragon 28. CEG receives research support from Wright Medical Technology and is a paid consultant for Medshape, Novastep, and Paragon 28.

Background: The INFINITY total ankle implant is a widely and successfully used option for total ankle arthroplasty. The purpose of this study is to assess the 2-year survivorship, complication rates, patient-reported outcomes, and radiologic findings of prospectively enrolled patients undergoing a fixed-bearing total ankle arthroplasty (TAA). This study sought to determine if factors such as traditional vs patient-specific instrumentation, preoperative degree of arthritis, deformity, or etiology of arthritis impact surgical or clinical outcomes., Methods: A total of 143 prospectively enrolled patients (148 ankles) underwent TAA with a fixed-bearing total ankle implant between 2017 and 2019 at 9 different institutions by 9 different surgeons. A total of 116 completed 2-year follow-up. Patients were stratified by instrumentation used, degree of preoperative deformity, the Canadian Orthopaedic Foot and Ankle Society (COFAS) grading system, and etiology of arthritis. Outcomes used included implant survivorship and adverse events within 2 years of surgery. Additionally, patient-reported outcomes and radiographs were collected at 6-month, 1-year, and 2-year postoperatively. PROMs used included Ankle Osteoarthritis Score (AOS), Patient-Reported Outcomes Measurement Information System (PROMIS) global health score, the Foot and Ankle Outcome Score (FAOS), and patient satisfaction (rated from excellent to poor)., Results: Implant survivorship at 2 years was 97.79%. There were 17 reoperations (11.5%), with 4 of the implants requiring revision (2.7%). Significant improvements in all PROMs were observed among all subgroups at all postoperative time points without significant variation between subgroups. Patients classified as COFAS type 2 arthritis preoperatively demonstrated significantly more improvement in FAOS Total Symptom Score at the 1- and 2-year measurements than COFAS type 3 patients at both time points., Conclusion: Total ankle arthroplasty with a fixed-bearing implant system is a safe and reliable treatment option for patients with end-stage arthritis regardless of degree of deformity or COFAS grading., Level of Evidence: Level II, prospective cohort study., Competing Interests: Ethical ApprovalEthical approval for this study was obtained from Medical University of South Carolina institutional review board Pro00080181. Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Jesse Doty, MD, reports grants or contracts from any entity; royalties or licenses; consulting fees; and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Stryker. Donald R. Bohay, MD, FACS, reports consulting fees; and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Stryker. G. Andrew Murphy, MD, Paul T. Fortin, MD, and Anand Vora, MD, report support for the present manuscript from Wright Medical. David A. Friscia, MD, reports support for the present manuscript; consulting fees; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events; and support for attending meetings and/or travel from Stryker. ICMJE forms for all authors are available online.

Intraoperative complications during total ankle replacement (TAR) can be devastating. As surgeons' experience with total ankles grow and surgical techniques are refined, intraoperative complications, such as fractures, can still occur. Surgeons must be able to recognize a problem, identify the options to remediate, and then execute a solution readily. Unfortunately, given the heterogeneity of TAR outcome studies, it is difficult to garner the true incidence of complications in the peri-operative period following ankle replacements. The purpose of this review is to focus on perioperative fractures during TAR. Fractures can occur intraoperatively and postoperatively as stress fractures or post-operative trauma., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The purpose of this study is to evaluate the effect of the different surgical treatments for hallux valgus on various radiographic measures of bunion correction., Methods: A retrospective cohort study was conducted at a single academic medical center involving 2 fellowship-trained foot and ankle surgeons. One hundred and nineteen feet (110 patients) were included. Procedures included first metatarsophalangeal (MTP) arthrodesis (n = 88), Chevron and/or Scarf osteotomy (n = 23), and Lapidus (n = 8). Overall, 78.2% of patients were female, mean age was 60.49 (range, 16-81) years, and mean follow-up was 1.20 (range, 0.25-3.92) years., Results: Hallux valgus angle (HVA) significantly differed preoperatively (MTP = 33.33°, Chevron/Scarf = 27.03°, Lapidus = 32.56°; P = .026). There was no difference in distal metatarsal articular angle (DMAA) preoperatively (MTP = 18.87°, Chevron/Scarf = 17.80°, Lapidus = 14.39°; P = .629). At final follow-up, DMAA was significantly greatest among the Lapidus bunionectomy cohort (MTP = 9.63°, Chevron/Scarf = 13.51°, Lapidus = 17.45°; P = .005). There was no difference in infection (MTP = 6.8%, Chevron/Scarf = 4.4%, Lapidus = 0.0%; P = 1.00) or reoperation (MTP = 19.3%, Chevron/Scarf = 21.7%, Lapidus = 12.5%; P = .921) rates between cohorts, although both rates were highest in the first MTP arthrodesis group., Conclusion: Among the 3 hallux valgus corrections studied, Lapidus bunionectomy fared the worst regarding DMAA correction at first follow-up and final follow-up, compared with MTP fusion and distal metatarsal osteotomies. Other radiographic measures showed no significant difference among the groups., Level of Evidence: Level III: Retrospective cohort study., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: This study aimed to determine the impact of preoperative opioid use on outcomes of patients undergoing ankle or hindfoot arthrodesis, or total ankle arthroplasty (TAA)., Methods: We conducted a retrospective review of 190 patients undergoing an ankle or hindfoot arthrodesis (n=122) or TAA (n=68) between December 2015 and September 2020 with a single fellowship-trained orthopaedic foot and ankle surgeon at an academic medical center. Data collected included demographics, medical comorbidities, treatment history, complications and reoperation rates, patient-reported outcome measures (PROMs) (eg, Foot and Ankle Outcome Score [FAOS]), and opioid use., Results: Patients with preoperative opioid use were more likely to continue usage at 90 (r = 0.931, P < .001) and 180 (r = 0.940, P < .001) days postoperatively. For the entire cohort, complication and reoperation rates were 48.9% and 13.2%, respectively. While preoperative opioid use groups did not differ in the overall complication rate, users had significantly more infections (user = 12.5%, nonuser = 3.3%; P = .036) and reoperations (user = 22.5%, nonuser = 10.7%; P = .049). When analyzing postoperative opioid prescriptions, there were many significant correlations with preoperative PROMs, mainly FAOS, such that increased postoperative opioid use was associated with worse subjective outcomes., Conclusion: Preoperative opioid users are more likely to continue postoperative opioid use, experience infections, and undergo reoperations., Level of Evidence: Level III: Retrospective cohort study., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Daniel J. Scott receives research support from Arthrex and Paragon 28. Dr Christopher E. Gross is a paid consultant for Medshape, Novastep, and Paragon 28 and receives research support from Wright Medical Technology.

The use of subtalar arthrodesis procedures has been widely implemented to relieve hindfoot issues after failure of conservative treatments; however, fusion failures persist in some patients with certain risk factors. Currently, surgeons utilize cannulated screws in these arthrodesis procedures to immobilize the subtalar joint. Recent clinical studies have demonstrated improved fusion outcomes in at-risk patients using sustained dynamic compression devices in the tibiotalocalcaneal complex. These devices utilize pseudoelastic nitinol which enables sustained dynamic compression when faced with postoperative bone resorption, joint settling, and bone relaxation. While the clinical success of these devices has been established in the tibiotalocalcaneal complex, the ability of sustained dynamic compression devices to apply joint compression in the subtalar joint has not been quantified. As such, the goals of this study were to (1) compare the ability of static compression devices and sustained dynamic compression devices to apply joint compression and (2) assess the impact of device trajectory on joint compression. A custom mechanical testing fixture was utilized to test the compression applied across the subtalar joint by one sustained dynamic compression device (in anterior and posterior trajectories) as compared to 2 cannulated screws (in both parallel and diverging trajectories). Testing revealed the sustained dynamic compression devices generated 53% greater compression as compared to the static compression devices, despite single versus dual device usage, respectively. Additionally, both types of devices applied joint compression forces in an insertion trajectory-independent manner. These data illustrate the ability of a single SDC device to maintain significantly improved joint compressive forces as compared to 2 static cannulated screws, regardless of insertion trajectory. These SDC devices may be of particular interest for at-risk patients or in revision cases., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: While many patients benefit from nonoperative treatment of insertional Achilles tendinopathy (IAT), some elect for surgical debridement and reconstruction. The purpose of this study is to determine the relationship of patient demographic characteristics, comorbidity profiles, and radiological parameters with failure of conservative management of IAT., Methods: A retrospective chart review was performed to identify patients who received either surgical or nonsurgical treatment of IAT at an academic institution from September 2015 to June 2019 (N = 226). Demographic and comorbidity data, and the presence and magnitude of relevant radiological parameters were collected and compared between the surgically (n = 48) and nonsurgically (n = 178) treated groups., Results: No significant differences could be detected between groups regarding demographic factors or previous procedures. The surgery group was significantly more likely to have evidence of Haglund's deformity on clinical exam (83% vs 69%, P = .005), lower SF-12 physical scores (25.5 vs 35.5, P < .001), higher VAS pain scores (6.3 vs 5.3, P = .033), any mental illness (33% vs 20%, P = .044), and depression (27% vs 12%, P = .012)., Discussion: Patients who received surgery for IAT were significantly more likely to have evidence of Haglund's deformity on clinical exam, depression, higher VAS pain scores, and lower SF-12 physical scores. Both patients and surgeons should be aware of the higher rates of failure of conservative treatment in these patients., Level of Evidence: Level III.

Background: The purpose of this study is to determine whether patients with a history of preoperative opioid use will have an increased likelihood of postoperative opioid use and complications after undergoing forefoot, hindfoot, or ankle surgery., Methods: A retrospective review was conducted on forefoot, hindfoot, and ankle surgeries between 2015 and 2020 with a single fellowship-trained orthopaedic foot and ankle surgeon at an academic medical center. A total of 326 patients (356 feet) were included with a mean follow-up up of 2.12 (range, 1.00-4.98) years. Data collected included demographics, medical comorbidities, treatment history, complications and reoperation rates, patient-reported outcome measures (eg, Foot and Ankle Outcome Score), and opioid exposure., Results: There were significantly more complications among opioid exposed patients than opioid naïve ones (exposed = 29.41%, naïve = 9.62%; P = .044). Preoperative opioid exposure significantly correlated with postoperative opioid exposure (90-day: r = .903, p < .001; 180-day: r = .805, p < .001), and increased hospital length of stay (r = .263, p = .029). Furthermore, body mass index was a significant predictor of postoperative opioid exposure (90-day: r = .262, p = .013; 180-day: r = .217, p = .021), as was concomitant mental illness (90-day: r = .225, p = .035)., Conclusion: Patients with preoperative opioid exposure have significantly more complications and increased postoperative opioid exposure after foot and ankle surgery., Levels of Evidence: Level III: Retrospective cohort study.

Background: As the popularity of total ankle arthroplasty (TAA) increases, there is a growing need to examine the effects of sex on postoperative outcomes. This study compares patient-reported outcome measures and ankle range of motion (ROM) in the postoperative period, as stratified by sex., Methods: Patients who underwent TAA during 2013 to 2018 with a minimum follow-up of 2 years were included (N = 133). American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, Visual Analog Scale (VAS), and 12-Item Short-Form Survey (SF-12) were administered preoperatively and at 6 months, 1 year, and 2 years postoperatively. ROM was recorded at these same time points., Results: Preoperatively and at 6 months postoperatively, the cohorts did not differ in any of the measured outcomes. At 1 year postoperatively, females had lower SF-12 Physical Composite Scores (female = 44.1, male = 47.1, P = .019) and less plantarflexion (female = 20.5 degrees, male = 23.5 degrees, P = .029). By 2 years postoperative, females had lower AOFAS scores (female = 80.3, male = 85.4, P = .040). A greater complication rate amongst the female cohort approached significance at 18.6% versus 9% for males (P = .124)., Discussion: These results support TAA as a reliable means of treating ankle arthritis in both sexes, despite important differences. Understanding these outcome differences is critical for effectively managing expectations and treating both female and male populations., Levels of Evidence: Level III: Retrospective cohort study.

Background: This study evaluates the effect of surgical construct on postoperative outcomes in patients undergoing isolated talonavicular (TN) or double (TN and subtalar ST) arthrodesis. TN constructs included plate and screw, screw and staple, and isolated staple constructs. Subtalar constructs included 1- and 2-screw constructs., Methods: Retrospective chart review identified 52 patients who underwent double or isolated TN arthrodesis between 2016 and 2021 by a single fellowship-trained foot and ankle surgeon with minimum 6 months of follow-up (mean = 1.62 years, range = 0.50-4.39 years). Data collected included demographics, medical history, surgical indication, surgical constructs used, complications, reoperations, patient-reported outcome measures, and radiographic measures., Results: Overall complication and reoperation rates were 26.3% and 12.3%, respectively. Among TN constructs, time to ST (P = .026) and TN (P = .018) fusion was significantly slower among patients receiving a plate and screw construct. Complication rate did not differ, but reoperation rate was significantly higher for plate and screw TN constructs (P = .039). Postoperative Foot and Ankle Outcome Score (FAOS) Quality of Life (P = .028) and Total (P = .016) scores were significantly better among plate and screw TN constructs., Conclusion: Utilization of screw and staple or isolated staple construct have significantly quicker time to fusion and lower reoperation rates than plate and screw constructs for the TN joint., Level of Evidence: Level III: Retrospective cohort study.

Background: This study aims to investigate the effect of hypoalbuminemia on the rates of 30-day complication, readmission, and reoperation following total ankle arthroplasty (TAA)., Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2007 to 2019 to identify 710 TAA patients. Patients were then stratified into normal (n = 673) or low (n = 37) albumin groups. Demographics, medical comorbidities, concomitant procedures, hospital length of stay, and 30-day complication, readmission, and reoperation rates were compared between groups. Preoperative serum albumin level was also used as a continuous variable when analyzing postoperative outcomes., Results: The overall cohort was predominantly male (51.5%), and the mean age was 65.02 (range, 45-87) years. We found there to be no statistically significant difference in demographics between cohorts. However, hypoalbuminemia patients were significantly more likely to use long-term steroids for a chronic condition (normal = 6.1%, low = 18.9%; P = .009). Additionally, there was no difference in 30-day complication (normal = 3.0%, low = 0.0%; P = .618), readmission (normal = 2.4%, low = 0.0%; P = .632), and reoperation (normal = 1.0%, low = 0.0%; P = 1.000) rates between groups., Conclusion: The results of this study show that malnourished patients are not at an increased risk of 30-day complication, readmission, or reoperation following TAA despite having a worse preoperative comorbidity profile., Level of Evidence: Level III, Retrospective cohort study.

Background: This study investigates the effect of malnutrition, defined by hypoalbuminemia, on rates of complication, readmission, reoperation, and mortality following midfoot, hindfoot, or ankle fusion., Methods: The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2019 to identify 500 patients who underwent midfoot (n = 233), hindfoot (n = 261), or ankle (n = 117) fusion. Patients were stratified into normal (n = 452) or low (n = 48) albumin group, which was defined by preoperative serum albumin level <3.5 g/dL. Demographics, medical comorbidities, hospital length of stay (LOS), and 30-day complication, readmission, and reoperation rates were compared between groups. The mean age of the cohort was 58.7 (range, 21-89) years., Results: Hypoalbuminemia patients were significantly more likely to have diabetes (P < .001), be on dialysis (P < .001), and be functionally dependent (P < .001). The LOS was significantly greater among the low albumin group (P < .001). The hypoalbuminemia cohort also exhibited a significantly increased likelihood of superficial infection (P = .048). Readmission (P = .389) and reoperation (P = .611) rates did not differ between the groups., Conclusion: This study shows that malnourished patients have an increased risk of superficial infection following foot and ankle fusions but are not at an increased risk of readmission or reoperation, suggesting that low albumin confers an elevated risk of surgical site infection., Levels of Evidence: Level III, Retrospective cohort study.

Background: This study compared radiographic and functional patient outcomes of 1st MTP arthrodesis between hallux rigidus (HR) and hallux valgus (HV) cohorts., Methods: A retrospective review was conducted at an academic medical center on patients who underwent 1st MTP arthrodesis during 2009-2021. In total, 136 patients (148 feet: HR=57, HV=47, combined=44) met the inclusion criteria of minimum three-month follow-up (mean=1.25 years, range=0.25-6.14 years). Data collection included patient-reported outcome measures (PROMs), radiographic markers, and complication and reoperation rates., Results: PROMs improved overall, with HV patients significantly improving the least. The HR group had a significantly smaller improvement in HV angle (HR=-3.6, HV=-17, Combined=-15 p < .001), intermetatarsal angle (H=-0.16, HV=-2.8, Combined=-2.6 p < .001), and 1st-5th metatarsal width (HR=-0.98, HV=-4.6, Combined=-4.6, p < .001). Complication and reoperation rates did not differ by group., Conclusion: Outcomes of 1st MTP arthrodesis does not appear to differ between diagnostic indications of hallux rigidus, hallux valgus, or both., Level of Evidence: Level III, Retrospective cohort study., Competing Interests: Declaration of Competing Interest The authors declare that there is no conflict of interest., (Copyright © 2022 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Tibiotalocalcaneal (TTC) arthrodesis is a commonly performed operation for complex hindfoot pathology, but the effect of preoperative ulceration on TTC outcomes has been debated. This study aims to examine infection rates in patients undergoing TTC arthrodesis with internal fixation with and without concomitant hindfoot ulceration., Methods: We conducted a retrospective review of 31 patients who underwent a TTC arthrodesis between June 2016 and February 2021 with a fellowship-trained foot and ankle surgeon at an academic medical center. Nine (29.0%) patients had preoperative ulceration. Mean follow-up duration was 1.49 (range, 0.51-4.28) years. Other data collected included demographics, comorbidities, surgical approach, fixation method, and complication and reoperation rates., Results: There was no difference in overall complication (ulcer [U]=66.7%, no ulcer [NU]=50.0%; p = .397), infection (U=33.3%, NU=31.8%; p = .935), or reoperation (U=55.6%, NU=27.3%; p = .135) rates between groups., Conclusions: TTC arthrodesis with internal fixation appears to be a reasonable treatment method for patients with a preoperative ulcer., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: The Pain Catastrophizing Scale (PCS) is a measure of how patients emotionally respond to pain. It is composed of 3 subscales-rumination, magnification, and helplessness-which address intrusive thoughts of pain, expectations of negative outcomes, and inability to cope with pain. Our purpose is to compare baseline PCS scores with other baseline patient-reported outcome measures (PROMs) in patients with plantar fasciitis (PF) or chronic ankle instability (CAI)., Methods: We retrospectively reviewed 201 patients who reported at least 1 pretreatment PCS subscore and were diagnosed with PF or CAI between 2015 and 2020 in a single fellowship-trained foot and ankle surgeon's clinic. Demographics, comorbidities, treatments, other baseline PROMs (i.e., visual analog scale [VAS], Pain Disability Index [PDI], 12-Item Short Form Survey [SF-12], 8-Item Somatic Symptom Scale [SSS-8]), and postoperative outcomes were recorded., Results: The PCS total score and its subscores significantly correlated with the total score and/or subscores of each PROM. Higher PCS total score significantly correlated with worse VAS (P<.001), SF-12 mental (P=.007), PDI total (P<.001), and SSS-8 (P<.001) scores. Only the PCS magnification subscore was significantly greater among patients who did (n=41) undergo surgery (P=.043). Those who had previously undergone foot and/or ankle surgery had significantly higher PCS rumination ( P =.012), magnification ( P =.006), helplessness ( P =.008), and total ( P =.003) scores. Likewise, those with a history of substance abuse also had significantly higher PCS scores ( P =.005; P =.003; P =.006; P =.003)., Conclusion: The correlations between PCS scores and other baseline PROMs indicate that strong pain catastrophizers with PF or CAI may be at risk for poor treatment outcomes. PCS scores could be used to help with treatment for such high-risk patients.

Purpose: Our goal was to determine whether state Medicaid expansion and patient insurance statuses affected access to care for ankle sprain patients., Methods: Four pairs of Medicaid expanded (Kentucky, Louisiana, Iowa, and Arizona) and unexpanded (North Carolina, Alabama, Wisconsin, and Texas) states were chosen. Twelve practices from each state (N = 96) were randomly selected from the American Orthopaedic Foot and Ankle Society (AOFAS) directory and called twice to request an appointment for a fictitious 16-year-old with a first-time ankle sprain using either Medicaid insurance or Blue Cross Blue Shield (BCBS) private insurance., Results: An appointment was obtained at 65.6% clinics when calling with BCBS and at 45.8% with Medicaid (P =.006). There was a significant difference in successful scheduling based on insurance status in Medicaid unexpanded states (P = .007). In all states except Iowa, there were more appointments scheduled using BCBS than with Medicaid. The 3 main reasons for appointment denial were inability to provide an insurance identification number (47.1%), insurance status (23.5%), and whether the patient was referred (17.6%). The waiting period for an appointment did not differ by Medicaid expansion or insurance statuses., Conclusion: For patients with first-time ankle sprains, access to care is more difficult using Medicaid insurance rather than private insurance, especially in Medicaid unexpanded states., Level of Evidence: Level II prospective cohort study.

Introduction: The purpose of this study was to determine whether total ankle arthroplasty (TAA) and ankle/hindfoot fusion patients receiving tranexamic acid (TXA) exhibit fewer wound complications., Methods: A retrospective review was conducted of 212 patients (217 feet) undergoing TAA (n = 72), ankle (n = 36), tibiotalocalcaneal (n = 20), pantalar (n = 1), or hindfoot fusion (ie, subtalar = 47, double = 33, and triple = 8) between 2015 and 2020 by a fellowship-trained foot and ankle surgeon at an academic medical center. Demographics, medical history, complications, and union status were compared between TXA (n = 101) and non-TXA (n = 116) cohorts. The mean follow-up was 1.24 years (range, 0.25 to 4.68)., Results: The TXA group had significantly less postoperative infections (5.9% versus 15.5%, P = 0.025). Within a subgroup analysis of ankle/hindfoot fusions, the TXA group exhibited significantly more Charcot neuroarthropathy (20.7% versus 5.7%, P = 0.006) and shorter follow-up duration (0.96 versus 1.30 years, P = 0.030); however, TXA was associated with shorter time to fusion (146 versus 202 days, P = 0.049) and fewer revision surgeries (8.6% versus 21.8%, P = 0.036). Subgroup analysis excluding feet with Charcot also demonstrated less postoperative infections (4.5% versus 14.4%, P = 0.020). Subgroup analysis of TAAs showed fewer cases of superficial infections (2.3% versus 27.6%, P = 0.002) and delayed wound healing (25.6% versus 48.3%, P = 0.047) in the TXA cohort., Discussion: TXA use in ankle/hindfoot surgery was correlated with a reduction in superficial infections and radiographic time to union. The use of TXA in TAA correlated with fewer superficial infections and cases of delayed wound healing. Thus, in addition to other areas of orthopaedics, TXA seems to be beneficial in hindfoot and ankle surgery., Data Availability and Trial Registration Numbers: All data were obtained from our institution's medical records. This study is not associated with a clinical trial., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)

Background: Resilience is the ability to recover after stressful events and has been shown to correlate with surgical outcomes. However, there has been minimal research on the impact of patient resiliency on foot and ankle surgical outcomes. This study aims to determine the predictive value of preoperative resiliency scores on surgical outcomes and investigate how this compares with the predictive value of pain scores., Methods: We conducted a retrospective review of adult patients who completed a preoperative Brief Resilience Scale (BRS) and underwent surgery between November 2019 and November 2020 with a fellowship-trained foot and ankle surgeon (N=184). Data included demographics, comorbidities, surgical details, complication and reoperation rates, pre- and postoperative opioid and benzodiazepine use, and additional patient-reported outcome measures (ie, visual analog scale [VAS], Pain Catastrophizing Scale [PCS], Pain Disability Index [PDI], Foot and Ankle Outcome Score [FAOS] pain subscale). Mean follow-up duration was 4.49 (range, 1.10-14.17) months., Results: BRS weakly correlated with decreased postoperative benzodiazepine use ( P =.007). PCS magnification ( P =.050) and helplessness ( P =.047) subscales weakly correlated with increased follow-up duration. PDI total score and most subscores significantly correlated with an increase in at least 1 of the following: follow-up duration, or postoperative opioid or benzodiazepine use. Neither the VAS nor FAOS pain subscore correlated with any outcome. PDI total score was the strongest predictor of postoperative opioid (β=0.334) and benzodiazepine (β=0.315) use. Preoperative opioid users had significantly higher PDI total score (user=39.3, nonuser=24.9; P =.012) and subscores (ie, social activity, sexual behavior, self-care, life-support activities)., Conclusion: BRS is an unreliable tool for predicting outcomes in foot and ankle surgery, as it only weakly correlated with decreased benzodiazepine use. Rather, given the PDI's strong associations with postoperative measures in this study, physicians should consider the value of preoperative PDI completion when predicting how foot and ankle surgery recipients will fare postoperatively., Level of Evidence: Level III, retrospective cohort study., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2022.)

Background: Scientific publication and original articles remain the primary method of sharing scientific findings and advancing the knowledge base of that subject. Despite the value of these publications, little research has surveyed what topics are being published. This study aims to identify and characterize the most common topics in current foot and ankle literature., Methods: We reviewed all 1514 published articles in a 5.5-year period (January 2014-June 2019) in 2 foot and ankle-specific journals: Foot & Ankle International ( FAI ) and Foot and Ankle Surgery ( FAS ). The articles were sorted into different topic domains to identify the 3 most common categories of publication. The top 3 domains were further characterized by level of evidence (LOE) as well as citations., Results: The 3 most published topics in foot and ankle literature were hallux valgus (8.3%), total ankle arthroplasty (TAA) (8.3%), and ankle fracture (6.6%). These 3 subjects accounted for 351 articles (23.2%). Other common topics were patient-reported outcomes (5.0%), osteochondritis dissecans (3.9%), syndesmotic injury (3.8%), ankle instability (3.7%), hallux rigidus (3.0%), and anatomy (2.8%). The average LOE for articles on hallux valgus, TAA, and ankle fracture was 3.27 from FAI , and the average number of annual citations for a given article in both journals was 3.05. Based on our study, there is no correlation between LOE and number of overall citations, but there is a significant, negative linear correlation in ankle fracture data. We also found that articles on TAA had the highest impact factor and that articles from FAI were cited more often than articles from FAS., Conclusion: The 3 most published topics in foot and ankle literature comprise only 23.2% of all articles. This finding is indicative of the wide variety of cases performed by orthopaedic foot and ankle surgeons. High-quality data are still needed in all topics., Level of Evidence: Level III, retrospective cohort study., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Daniel Scott, MD, MBA, reports Grants or contracts from Arthrex ($5000). ICMJE forms for all authors are available online., (© The Author(s) 2022.)

Context: Injections are commonly used by health care practitioners to treat foot and ankle injuries in athletes despite ongoing questions regarding efficacy and safety., Evidence Acquisition: An extensive literature review was performed through MEDLINE, Google Scholar, and EBSCOhost from database inception to 2021. Keywords searched were injections , athletes , sports , foot and ankle , corticosteroids , platelet-rich plasma , and placental tissue . Search results included articles written in the English language and encompassed reviews, case series, empirical studies, and basic science articles., Study Design: Clinical review., Level of Evidence: Level 4., Results: Corticosteroids, platelet-rich plasma/autologous blood, anesthetic, and placental tissue injections are commonly used in the treatment of foot and ankle injuries. Primary indications for injections in athletes include plantar fasciitis, Achilles tendinosis, isolated syndesmotic injury, and ankle impingement with varying clinical results., Conclusions: Despite promising results from limited case series and comparative studies, the data for safety and efficacy of injections for foot and ankle injuries in athletes remain inconclusive.

Given that most ankle replacements are post-traumatic in origin, it is important to investigate if prior interventions affect a patient's functional outcomes or increase the possibility of complications. Prior ankle surgeries create scar tissue and zones of impaired vascularity which could ultimately interfere with surgical healing. The purpose of this study is to assess the pain and functional temporal outcomes of patients with and without prior surgeries in the ipsilateral ankle. We retrospectively identified a consecutive series of 100 primary total ankle replacements (TARs) who were followed for a minimum of 3 years, with follow-up time points of 0, 6, 12, and 36 months. We documented prior surgical interventions and several patient-reported outcomes. Outcomes were measured using American Orthopaedic Foot and Ankle Society (AOFAS) score, Visual Analogue Scale (VAS), 12-Item Short Form Study (SF-12), and range of motion scores. The 2 groups showed no difference on the temporal evolution of outcomes. An irrigation and debridement of previous open fractures was the only presurgical intervention that showed a statistically significant difference in temporal evolution of functional and pain outcomes between intervention and nonintervention groups. No significant correlations were found between all outcomes and the time between the last intervention and ankle replacement surgery. A preoperative discussion should center on potential complications and predicted functional outcomes. The presence, type, and timing of an intervention prior to an ankle replacement do not strongly affect the temporal outcomes of pain and functional outcome scores. Furthermore, the complication rate is not affected by prior surgeries., (Copyright © 2021 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Abstract: The relationship between orthopaedic surgeons and the internet is complicated. Social media allows surgeons to educate their patients while marketing to them at the same time. Conversely, patients are able to better communicate with their surgeons while anonymously rating their service and expertise. This study aims to look at the complex relationship between surgeons and social media use., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G610)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Chronic Achilles tendon ruptures can result in tendon lengthening and significant functional deficits including gait abnormalities and diminished push-off strength. Surgical intervention is typically required to restore Achilles tension and improve ankle plantarflexion strength. A variety of surgical reconstruction techniques exist depending on the size of the defect and amount of associated tendinosis. For smaller tendon defects 2 to 3 cm in size, primary end-to-end repair using an open incision and multiple locking sutures is an established technique. However, a longer skin incision and increased soft tissue dissection is required, and failure at the suture-tendon interface has been reported that can result in postoperative tendon elongation and persistent weakness. In this report, we describe a novel technique to reconstruct chronic midsubstance Achilles tendon ruptures using a small incision with knotless repair of the tendon secured directly to the calcaneus. This technique minimizes wound healing complications, increases construct fixation strength, and allows for early range of motion and rehabilitation. Level of Evidence: Level V, Expert Opinion., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Andrew R. Hsu, MD, reports personal fees from Arthrex, Inc, outside the submitted work. ICMJE forms for all authors are available online., (© The Author(s) 2021.)

Background: As a result of the high physical demand in sport, elite athletes are particularly prone to fifth metatarsal fractures. These injuries are typically managed surgically to avoid high rates of delayed union and allow for quicker return to play (RTP)., Purpose: To review studies showing clinical and radiographic outcomes, RTP rates, and complication rates after different surgical treatment modalities for fifth metatarsal fractures exclusively in elite-level athletes., Study Design: Systematic review; Level of evidence, 4., Methods: A systematic search was conducted within the PubMed, Scopus, and Cochrane databases from January 2000 to January 2020. Inclusion criteria consisted of clinical outcome studies after operative management of fifth metatarsal fractures in elite athletes. Exclusion criteria consisted of nonoperative management, high school or recreational-level athletic participation, nonclinical studies, expert opinions, and case series with <5 patients., Results: A total of 12 studies met inclusion and exclusion criteria, comprising 280 fifth metatarsal fractures treated surgically. Intramedullary screw fixation was the most common fixation construct (47.9%), and some form of intraoperative adjunctive treatment (calcaneal autograft, iliac crest bone graft, bone marrow aspirate concentrate, demineralized bone matrix) was used in 67% of cases. Radiographic union was achieved in 96.7% of fractures regardless of surgical construct used. The overall mean time to union was 9.19 weeks, with RTP at a mean of 11.15 weeks. The overall reported complication rate was 22.5%, with varying severity of complications. Refracture rates were comparable between the different surgical constructs used, and the overall refracture rate was 8.6%., Conclusion: Elite athletes appeared to have a high rate of union and reliably returned to the same level of competition after surgical management of fifth metatarsal fractures, irrespective of surgical construct used. Despite this, the overall complication rate was >20%. Specific recommendations for optimal surgical management could not be made based on the heterogeneity of the included studies., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.B.G. has received education payments from Medical Device Business Services and Peerless Surgical. W.M.C. has received hospitality payments from Medical Device Business Services. C.E.G. has received research support from Wright Medical; education payments from Arthrex and Peerless Surgical; consulting fees from Medshape; and hospitality payments from Exactech, Integra LifeSciences, Sonoma Orthopedics, and Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)

Adult acquired flatfoot deformity is a complex pathologic condition that requires considerate and thoughtful surgical solutions. Medial column procedures are often supplemented by a medializing calcaneal osteotomy and/or a lateral column lengthening because of the complex nature of progressive collapsing foot deformity and its resultant peritalar instability. Other osteotomies and fusions include a Cotton osteotomy and first tarsometatarsal fusion., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Periprosthetic joint infection (PJI) is one of the most feared complications of total joint arthroplasty (TJA). Although commonly the result of colonization by Staphylococcal species, a growing number of cases of PJI with fungal pathogens have been reported within the last decade. Although standard treatment with two-stage exchange mirrors that of bacterial PJI, the variability in virulence between fungal species makes for an unpredictable and challenging treatment course., Methods: A review of Pubmed and Scopus from years 2009 to 2019 was conducted with the search terms fungal, infection, Candida, arthroplasty, periprosthetic, and prosthesis. Publications were reviewed and screened, yielding data for 286 patients with fungal PJI in the hip, knee, shoulder, and elbow prosthetics., Results: Patient comorbidities generally included conditions impairing wound healing and immune response such as diabetes mellitus. Candida species were the most common fungal pathogens identified (85%); 30% had a concomitant bacterial infection. A two-stage exchange was most utilized, with a mean success rate of 65%. Antifungal impregnated spacers were utilized in 82 cases, with a comparatively high success rate (81%). Attempts at debridement with implant retention had substantially lower cure rates (15%)., Conclusions: Two-stage exchange is the favored approach to treating fungal PJI. Debridement with implant retention does not appear adequate to control infection, and retrieval of implanted materials should be prioritized. The use of antifungal impregnated spacers is an important area of ongoing research, with uncertainty regarding the type and quantity of antifungal agent to incorporate, although recent reports support the use of these agents., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: The association between obesity and the need for open reduction and surgical fixation of the syndesmosis in the setting of malleolar ankle fractures remains to be elucidated. Therefore, the primary objective of this study was to assess the relationship between obesity, ankle fracture complexity, and the need for open reduction and fixation of the syndesmosis., Methods: A retrospective analysis of the NSQIP database was performed for patients undergoing surgical fixation of isolated, closed ankle fractures. Patients were grouped by fracture pattern into 6 cohorts (uni-, bi- and trimalleolar ankle fractures with or without syndesmotic injury). Demographic data was collected and compared between groups and logistic regression analyses were used to assess the relationship between body mass index (BMI) and ankle fracture pattern., Results: A total of 15,841 patients (mean age 48.9 years) were identified for inclusion. Regression analyses revealed that BMI had a significant association with the incidence of open reduction and internal fixation of the ankle syndesmosis, but there was no association between BMI and malleolar fracture pattern., Conclusions: This study demonstrates that elevated BMI is associated with an increased risk for open reduction and internal fixation of the syndesmosis in malleolar ankle fractures. However, obesity was not associated with ankle fracture pattern itself, whereas older age, female sex, and white race were more significant predictors of fracture complexity. This data provides a framework for further evaluation of the effect that both modifiable and non-modifiable risk factors have on fracture complexity and operative management of patients with such injuries., Level of Evidence: Case-control study. Level III., Competing Interests: None., (© 2020 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation.)

Introduction: The purpose of this study is to investigate the current disparities for major lower extremity amputation in patients with critical limb ischemia (CLI) and infection., Methods: A retrospective analysis of the National Surgical Quality Improvement Program's database for the years 2011 to 2017 was conducted. Multivariate models were used to isolate the effect of race and ethnicity on the likelihood of a below-knee or above-knee amputation (BKA and AKA, respectively) for CLI secondary to type 2 diabetes mellitus, atherosclerosis, peripheral vascular disease, chronic osteomyelitis, and deep soft-tissue infections., Results: For all diagnoses, blacks were 93.3%, and Hispanics were 61.9% more likely to undergo a BKA than white patients (P < 0.001). In addition, black patients had a 133.0% higher risk of an AKA than white patients (P < 0.001). Disparities were greatest with blacks undergoing surgery for CLI secondary to atherosclerosis (BKA odds ratio 2.093; AKA: odds ratio 2.625). Black patients also had an elevated risk of amputation secondary to diabetes, peripheral vascular disease, and deep soft-tissue infections (P < 0.001)., Discussion: This nationally representative, cohort-based study demonstrates that notable racial and ethnic disparities for lower extremity amputations persist, with a higher proportion of black and Hispanic patients undergoing amputation compared with limb salvage procedures for atraumatic CLI and infection., Level of Evidence: Level III prognostic.

Background: There has been little-to-no evidence to support the use of opioid analgesia as a treatment modality for osteoarthritis (OA). Chronic opioid use has been associated with peri-operative and post-operative complications with joint reconstruction. The purpose of this study is to compare opioid-prescribing habits for OA between orthopedic and non-orthopedic physicians to identify encounters that increase opioid exposure., Methods: A retrospective chart review was performed on opioid-naive adult patients with outpatient opioid prescriptions for OA at a single academic institution between 2013 and 2018. Patients with prior surgery or opioid prescriptions were excluded. Independent t-tests and analysis of variance were used to compare prescription characteristics among providers., Results: A total of 9625 opioid prescriptions were identified. Non-orthopedic providers account for 92% of prescriptions vs 8% by orthopedic surgeons. The greatest number of prescriptions is written by Internal Medicine (37.1%) and Family Medicine physicians (36.0%). Non-orthopedic physicians prescribe a greater number of prescriptions per patient, dosages, and refills (P < .001 for all). Non-orthopedic encounters are associated with increased risk for prescription dosages ≥50 MME/d (odds ratio 5.81, 95% confidence interval 4.35-7.81, P < .001) and 90 MME/d (odds ratio 18.2, 95% confidence interval 4.43-35.70, P < .001)., Conclusion: The majority of opioid prescriptions for OA are written by non-orthopedic providers, with higher prescription rates, dosages, and more refills than orthopedic surgeons. OA is a common condition that will benefit from multi-disciplinary awareness to minimize unnecessary opioid exposure and reduce potential complications with joint arthroplasty., (Published by Elsevier Inc.)

Calcaneal fractures are the most common fracture of the tarsal bones and represent 1% to 2% of all fractures. Roughly 75% of these fractures include intra-articular involvement of the posterior facet of the calcaneus. Intra-articular calcaneal fractures are challenging injuries to manage for both patients and surgeons given their association with both early and late complications. This article aims to review the management, classification systems, surgical approaches, and care regarding intra-articular calcaneal fractures. A review of the current literature yielded treatment strategies that aim to reduce complications such as soft tissue injury or loss of articular reduction while maintaining satisfactory clinical outcomes. The purpose of this article is to review these current concepts in the management of intra-articular calcaneal fractures. Level of Evidence: Level V, expert opinion., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2020.)

Background: End-stage ankle arthritis can involve malalignment of the ankle in both the coronal and sagittal planes. Up to 33% to 44% of patients who present for total ankle replacement (TAR) have greater than 10° of coronal plane deformity. Normalization of the sagittal and coronal alignment is key in improving survivorship and functional outcomes in TAR. In the present study, we analyzed how both the ankle and hindfoot alignment for both a fixed-bearing and mobile-bearing TAR system changed over time. Specifically, we measured coronal and sagittal alignment of both the ankle and hindfoot complex., Methods: A retrospective study was performed on 2 independent groups of patients undergoing 2 different systems for total ankle replacement: Zimmer (lateral approach, fixed-bearing) and Hintegra (anterior approach, mobile bearing). Specific demographic data and radiographic data were measured. Within-group comparisons were performed using 1-way repeated measures ANOVA, analyzing the temporal course of clinical data within the Hintegra and Zimmer groups., Results: At the ankle joint, as measured by the α and β angles ( P > .05), the position of the components remained relatively similar in both the fixed- and mobile-bearing TAR at 24-month follow-up. The sagittal alignment, as measured by the TT (tibiotalar) ratio, demonstrated a posterior shifting of the talus in the mobile bearing group ( P = .036). Although the fixed- and mobile-bearing TAR had both significant hindfoot alignment improvement between the preoperative radiographs and at 24 months, over time, the fixed-bearing ankle had a significant increase in both the hindfoot alignment view angle and hindfoot alignment distance ( P < .001), suggesting a possible dynamism of the hindfoot in the fixed-bearing TAR., Conclusion: The lateral-approach fixed and anterior approach mobile-bearing implants maintained coronal and sagittal alignment in the short term; the temporal course of the lateral approach fixed-bearing ankle showed an increase in the valgus positioning of the hindfoot. The anterior approach mobile-bearing implant maintained its hindfoot alignment over the course of the study., Level of Evidence: Level III, case-control study.

Background:: Third generation total talar prostheses (TTPs) are viable options for talar avascular necrosis (AVN) in the absence of neighboring joint pathology. The use of modern three-dimensional (3D) printing allows the production of custom implants that exactly mimic the patient's anatomy. The aim of this study is to determine the accuracy of 3D printing in reproducing a synthetic talus and, in doing so, restoring more normal anatomical relationships. We hypothesize that this mode of replication will restore and maintain normal radiographic alignment of the ankle, subtalar, and forefoot joints in the setting of talar AVN., Methods:: A retrospective analysis was performed on all patients undergoing TTP implantation for the treatment of talar AVN between 2016 and 2017. Radiographic measurements were taken preoperatively and postoperatively to determine native talar dimensions, TTP implant dimensions, and the corresponding radiographic alignment about the forefoot, hindfoot, and ankle., Results:: A total of 14 patients were identified in our cohort. Talar arc length and width were not found to be significantly changed; however, talar height was significantly increased with use of TTP. Five alignment dimensions were measured, of which, only talar tilt angle was significantly changed. Instances of Meary's angle correction were observed in cavus and planus foot deformity., Conclusion:: As a proof of concept, 3D-printed TTP was successful in restoring talar height and talar tilt in the setting of AVN. Additionally, the procedure maintained normal alignment in nonpathological joints. TTPs, based on our cohort, are a viable option to restore more normal anatomical alignment., Levels of Evidence:: Level IV: Case series.

Distal Chevron osteotomy is a well-established surgical procedure for mild to moderate hallux valgus deformity. Many methods have been described for fixation of osteotomy site; secure fixation, enabling large displacement of the metatarsal head, is one of the essentials of this procedure. The purpose of the present study was to evaluate the short-term radiographic outcome of a distal Chevron osteotomy using an intramedullary plate for the correction of hallux valgus deformity. The present study evaluated 37 patients (40 feet) who underwent distal Chevron osteotomy using an intramedullary plate by periodic radiographs obtained preoperatively and at 4 weeks, 8 weeks, 3 months, and 6 months postoperatively. Correction of the hallux valgus angle averaged 17.8°, intermetatarsal angle 7.4°, distal metatarsal articular angle 2.7°, and sesamoid position 1.4 stages at 3 months postoperatively. The average lateral shift of the capital fragment was 6.5 mm. All patients achieved bone union, and there were no cases of dislocation, displacement, or avascular necrosis of the metatarsal head fragment. In conclusion, a distal Chevron osteotomy using an intramedullary plate was a favorable method for the correction of mild to moderate hallux valgus deformity. Levels of Evidence: Level IV: Case series.

Combined single-photon emission computed tomography and conventional computed tomography (SPECT/CT) is a hybrid imaging modality that shows a combination of metabolic and structural information about the ankle, including arthritis. We hypothesize that uptake in specific locations within the ankle joint can be associated with both clinical outcomes and may help predict which patients will have a successful SMO. Eighty-five pre-operative SMO patients with varus (37), valgus (41), or neutral (7) alignment of the hindfoot were assessed using SPECT/CT. The level of activation on SPECT/CT scans was measured. Pre and Post-operative functional scores were recorded. Patients with medial gutter activation had significantly worse (p < 0.05) AOFAS alignment (AOFAS-A) scores pre-operatively. Patients with varus or valgus alignment did not have any difference in VAS pain scores, but those in valgus did have worse AOFAS-P (pain) scores. Those with cystic lesions had a worse FAOS score pre-operatively. Ten patients (12.5%) had a treatment failure. Pre or post-operative alignment did not correlate to a treatment failure. The only statistically significant (p = 0.036) poor prognostic indicator was a bipolar lesion. Pre-operative SPECT/CT evaluation of an ankle before a SMO can be used to clinically correlate patient-specific factors such as pain and function in the pre and post-operative period. We caution against performing a SMO in patients with bipolar activation on a pre-operative SPECT-CT scan. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2015-2021, 2018., (© 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

The design of total ankle arthroplasty systems is evolving as a result of findings from longer-term studies. Our understanding of modes of failure has increased, and surgical techniques have become more refined. Currently, five total ankle arthroplasty systems are used in the United States. The landscape has changed considerably in the decade since the latest article reviewing total ankle design was published. Some implants with acceptable intermediate results had much poorer outcomes at 7- to 10-year follow-up. As more research showing mid- to long-term outcomes is published, the design rationale and current outcomes data for each of these implants must be considered.

Surface modification with polymer grafting is a versatile tool for tuning the surface properties of a wide variety of materials. From a practical point of view, such a process should be readily scalable and transferable between different substrates and consist of as least number of steps as possible. To this end, a cross-linkable amphiphilic copolymer system that is able to bind covalently to surfaces and form permanently attached networks via a one-step procedure is reported here. This system consists of brushlike copolymers (molecular brushes) made of glycidyl methacrylate, poly(oligo(ethylene glycol) methyl ether methacrylate), and lauryl methacrylate, which provide the final product with tunable reactivity and balance between hydrophilicity and hydrophobicity. The detailed study of the copolymer synthesis and properties has been carried out to establish the most efficient pathway to design and tailor this amphiphilic molecular brush system for specific applications. As an example of the applications, we showed the ability to control the deposition of graphene oxide (GO) sheets on both hydrophilic and hydrophobic surfaces using GO modified with the molecular brushes. Also, the capability to tune the osteoblast cell adhesion with the copolymer-based coatings was demonstrated.

Background: Talar osteochondral lesions (OLT) occur frequently in ankle sprains and fractures. We hypothesize that matrix-induced autologous chondrocyte implantation (MACI) will have a low reoperation rate and high patient satisfaction rate in treating OLT less than 2.5cm 2 ., Methods: A systematic review was registered with PROSPERO and performed with PRISMA guidelines using three publicly available free databases. Clinical outcome investigations reporting OLT outcomes with levels of evidence I-IV were eligible for inclusion. All study, subject, and surgical technique demographics were analyzed and compared. Statistics were calculated using Student's t-tests, one-way ANOVA, chi-squared, and two-proportion Z-tests., Results: Nineteen articles met our inclusion criteria, which resulted in a total of 343 patients. Six studies pertained to arthroscopic MACI, 8 to open MACI, and 5 studies to open periosteal ACI (PACI). All studies were Level IV evidence. Due to study quality, imprecise and sparse data, and potential for reporting bias, the quality of evidence is low. In comparison of open and arthroscopic MACI, we found both advantages favoring open MACI. However, open MACI had higher complication rates., Conclusions: No procedure demonstrates superiority or inferiority between the combination of open or arthroscopic MACI and PACI in the management of OLT less than 2.5cm 2 . Ultimately, well-designed randomized trials are needed to address the limitation of the available literature and further our understanding of the optimal treatment options., (Copyright © 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Cost containment and bundled payments are becoming increasingly important in health care. The purpose of this study was to investigate if ambulatory surgery centers (ASCs) can deliver lower cost care and to identify sources of those cost savings in total ankle replacement (TAR). A cost identification analysis of primary TAR was performed at a single academic medical center. Multiple costs and time measures were taken from 730 consecutive patients over 5 years at either an inpatient facility or ASC. The relationships between total cost and operative time and multiple variables were examined, using multivariate analysis and regression modeling. The mean operative cost over 4 years was significantly greater at the inpatient facility than at the outpatient facility. Significant cost drivers of this difference were inpatient, physical and occupational therapy, pharmacy, and operating room costs. The most significant predictor of cost was facility type. This study supports the use of ASC facilities to achieve efficient resource use in the operative treatment of~total ankle arthroplasties (Journal of Surgical Orthopaedic Advances 27(4):321-324, 2018).

Background: Surgical resident participation in the operating room is necessary for education and progression toward safe and independent practice. However, the impact of resident involvement on patient outcomes in foot and ankle surgery is unknown., Methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2012) was used to identify common foot and ankle procedures (by Current Procedural Taxonomy (CPT) code) performed by orthopedic surgeons. Resident participation was determined using the NSQIP-collected variable 'pgy'; cases missing the pgy variable were excluded. Multivariate regression models were constructed to determine an association between resident involvement and 30-day morbidity (total, medical, and surgical complications) and 30-day mortality, when controlling for patient demographics, comorbidities, American Society for Anesthesiologist (ASA) status, body mass index (BMI), and smoking status., Results: A total of 13,685 cases were analyzed for 24 common foot and ankle operations. Overall mortality rate was 3.60%. Overall complication rate was 16.9%; 10.9% had medical and 8.3% had surgical complications. Residents were involved in 55.6% of cases. In unadjusted analyses, resident cases were less likely to be emergent, but were performed on more complicated patients (i.e. higher comorbidity burden, higher ASA scores). Resident cases had increased total morbidity (18.8% vs. 14.6%, p<0.001), medical complications (12.5% vs. 9.0%, p<0.001), and surgical complications (8.7% vs. 7.7%, p=0.03), but similar mortality frequency (3.8% vs. 3.3%, p=0.2). In multivariable analyses, resident cases did not correlate with 30-day mortality, 30-day total morbidity, or 30-day surgical complications; resident cases were, however, associated with increased medical complications [Odds Ratio (OR) 1.18 (95% Confidence Interval (CI) 1.02-1.37, p=0.03)] and longer length of stay [Coeff 2.38 (1.68-3.09), p<0.001]. Subgroup analyses of orthopedic-only cases demonstrated no statistical association between resident involvement and mortality, total morbidity, or medical complications; a decrease in surgical complications was observed for open reduction internal fixation cases [OR 0.23 (0.06-0.82), p=0.02]., Conclusions: Resident involvement in foot and ankle surgery is not associated with changes in 30-day mortality, 30-day total morbidity, or 30-day surgical complication rates. Residents operate on more medically complex patients who experience higher medical complication rates and longer postoperative length of stay; however, the cause and directionality of this relationship remains to be determined. Efforts to improve the quality of foot and ankle surgery with resident involvement should target reductions in post-operative medical complications., Level of Evidence: Prognostic study, Level II., (Copyright © 2016 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Although most astute clinicians can diagnose Achilles tendon ruptures by physical examination alone, more than 20% are not accurately diagnosed in a timely fashion. The definition of a "chronic" Achilles tendon rupture in foot and ankle literature varies widely: from 4 to 10 weeks status after injury. Neglected or chronic Achilles tendon ruptures can be significantly disabling to patients if the muscle-tendon unit is stretched beyond its normal passive limit. There are a variety of treatment options that all have valid uses but have not been proven to be superior to one another., (Copyright © 2017 Elsevier Inc. All rights reserved.)