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Congenital dislocation of the fifth metatarsophalangeal (MTP) joint can cause significant limitations in a patient’s ability to wear a closed shoe. Historic treatment has involved amputation of the digit or attempts at reconstruction. These techniques have had limited success with unreliable correction and/or unacceptable cosmesis. The authors present a detailed, methodical approach to reconstruction of this deformity with a stepwise algorithm that addresses both the bony and soft tissue components of the deformity. With this modern technique, reliable and satisfactory results can be expected.

This first of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey the state of scientific knowledge related to incidence, diagnosis, pathologic mechanisms, and injection treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 3, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Part 1 overviews areas of epidemiology and pathophysiology, current approaches in imaging, diagnostic and therapeutic injections, and genetics. Opportunities for future research are discussed. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the needs of patients that suffer from arthritis of foot and ankle. The foot and ankle contain a myriad of interrelated joints and tissues that together provide a critical functionality. When this functionality is compromised by OA, significant disability results, yet the foot and ankle are generally understudied by the research community. Level of Evidence: Level V - Review Article/Expert Opinion.

This second of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey current treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 10, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Topics were chosen by meeting organizers, who then identified and invited the expert speakers. Part 2 overviews the current treatment options, including orthotics, non–joint destructive procedures, as well as arthroscopies and arthroplasties in ankles and feet. Opportunities for future research are also discussed, such as developments in surgical options for ankle and the first metatarsophalangeal joint. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the importance to patients of addressing the foot and ankle with improved basic, translational, and clinical research. Level of Evidence: Level V, review article/expert opinion.

Category: Ankle; Hindfoot; Sports Introduction/Purpose: Surgical reconstruction for the complete loss of both peroneal tendons is challenging, with no established standard. This is true both for concomitant tears that extend superior to the superior peroneal retinaculum, and for nonfunctioning, unsalvageable peroneal tendons after prior repair or reconstruction, which have recurrent tears, tendon degeneration, scarring, and stretching. These cases have in common that there is no option for retention of the native tendons. Allograft reconstruction can bridge long defects, reestablishing the insertion of the proximal musculo-tendinous unit to the lateral foot. However, there are limited published data on allograft reconstruction, and series are small and heterogenous. This study reports the results of allograft reconstruction at a mean of 4.1 years follow-up (range 1.5-7.3 years). Methods: A retrospective study reviewed patients who had allograft reconstruction for unsalvageable or recurrent tears of both the peroneus brevis and peroneus longus tendons. In all cases, the unsalvageable segments of both peroneal tendons were excised. A hamstring allograft tendon with width of >6mm was pre-stretched, then anchored to the proximal 5thmetatarsal, and also sutured to itself and the adjacent brevis stump, if viable. The peroneal retinaculae were reconstructed over the allograft tendon. The peroneal muscle-proximal tendon units were extensively stretched inferiorly using suture loops in the tendons. They were maximally tensioned and anastomosed to the maximally tensioned allograft while holding the hindfoot in maximum eversion. Of the 14 eligible patients, 13 had minimum one-year follow-up and constituted the study population. Mean age was 50.7 years (range 26.3-68.6 years). Ten patients had at least one prior peroneal tendon surgery; four patients had at least two. Results: At mean follow-up of 4.1-years, seven patients were 'very satisfied,' one 'satisfied,' one 'neutral,' and two 'dissatisfied.' Ten stated they would have the procedure again, one would not. Two could not be reached to answer these questions. Visual analogue scale pain score decreased from 4.6 to 3.4 (p=0.150), ankle osteoarthritis scale (AOS) pain subscale decreased from 36.2 to 13.8 (p=0.013), AOS disability subscale decreased from 42.8 to 21.9 (p=0.032), and AOS total score decreased from 39.5 to 17.8 (p=0.014). No statistical change in SF-36 physical function score (p=0.547) or PROMIS physical function score (p=0.580) was detected. At last examination, 12 of 13 patients had active eversion and a palpable, tensioned graft. The patient without active eversion underwent triple arthrodesis; no other patient had additional peroneal or hindfoot surgery. Conclusion: Allograft interposition is effective to reconstruct unsalvageable concomitant tears of both peroneal tendons as well as the most difficult revision cases of nonfunctioning, unsalvageable peroneal tendons after prior repair or reconstruction, which have recurrent tears, tendon degeneration, scarring, and stretching. There is a high rate of restoration of peroneal function, a reasonable rate of patient satisfaction, and statistically significant improvements in ankle-specific patient-reported outcomes.

Category: Ankle; Ankle Arthritis; Basic Sciences/Biologics; Hindfoot Introduction/Purpose: Preoperative factors influencing functional disability imparted on the patient by ankle arthritis have not previously been assessed with gait analysis. The purpose of this study was to assess the influence of ankle arthritis etiology and deformity, measured radiographically, on gait performance in a dedicated gait lab utilizing a multisegment foot model. With three calcaneal and four metatarsal markers in addition to standard lower extremity markers, the modified Helen Haynes model allows for the evaluation of range of motion (ROM) within the 'ankle-hindfoot segment.' The primary hypothesis was that three- dimensional ankle-hindfoot segment ROM would be more restricted in patients with post-traumatic ankle arthritis than other etiologies. The secondary hypothesis was that temporospatial and kinetic measures would not vary by etiology. Methods: A longitudinal cohort of 183 patients with end-stage ankle arthritis were prospectively enrolled from 2008-2018. Mean age was 61, BMI 29, and 56% were male. Four etiologic groups were defined: Post-fracture (100), arthritis caused by planovalgus foot deformity (23), chronic instability associated with cavovarus (32), and miscellaneous (28), comprised of inflammatory (7), idiopathic (6), instability without deformity (5), septic (2), and avascular necrosis (3) as causes. The four-segment Milwaukee foot model was used in a dedicated gait lab with a 12-camera motion capture system. Gait data was collected over a minimum 20 gait cycles across a 10-meter walkway. Kinetic data was simultaneously collected with two force plates embedded in the walkway operating at 1 MHz. AP and lateral tibiotalar angles, lateral talus-first metatarsal angles, calcaneal pitch, and tibiotalar ratio were measured. Multivariate regression analyzed the effect of etiology and radiographic measures on gait function, controlling for age, gender, and BMI. Results: The primary hypothesis was confirmed. Sagittal plane ankle-hindfoot segment ROM was lower in post-traumatic and higher in valgus patients compared to other etiological groups (P

Category: Ankle; Ankle Arthritis; Hindfoot Introduction/Purpose: Despite substantial advancements in Total Ankle Arthroplasty (TAA), catastrophic failure due to implant subsidence remains a common and serious problem. While there are many studies of short and some of intermediate term follow- up of TAA, the number of long-term studies, especially with prospectively collected data, is much fewer, and the data on the incidence and impact of talar subsidence on those results is even more limited. Talar subsidence can be especially challenging to manage, given the limited talar bone stock and revision options as compared to the larger tibial bone stock. The purpose of this study was to evaluate the long-term incidence and characteristics of TAA implant failure. Methods: A prospectively collected database of TAAs performed in a tertiary referral center began enrolling in 1999. Medical records/radiographs were reviewed to evaluate outcomes of TAA and final radiographs were reviewed to identify implant failure from 1999-2016. Minimum radiographic follow-up was two years. Pre-operative and post-operative radiographs were measured for ankle, foot, and implant coronal and sagittal alignment Failure and reoperation rates of two different implants, the mobile bearing Scandinavian Total Ankle Replacement (STAR) and the fixed bearing Salto Talaris (Salto) were analyzed. Paired Student t- tests were performed between groups. TAA revision surgeries were excluded if the primary TAA was performed at another institution. Reoperations were recorded according to the Reoperations Coding System (CROCS) classification of the Canadian Orthopaedic Foot and Ankle Society (COFAS). There were 149 TAAs reviewed in 146 patients (136 STARs and 13 Saltos), with an average follow-up of 7.03 years (range 2-20 years). Results: Implant survival was 85.8% at mean 7 years. 25 TAAs demonstrated radiographic catastrophic failures, 21 underwent re- operation, and 4 declined revision surgery (Table 1). One failure was due to infection (CROCS 10), others were aseptic (CROCS 9). 13/25 failures were related to talar subsidence, all STARs (9.6% of all STARs in the series). Nine STARs (6.4%) had less severe talar subsidence but were asymptomatic, The STAR talar component, in total, subsided in 17.6% (24/136) of STARs, requiring revision in 13 (9.6%) of cases at mean 3.8 years post-op. There was no difference in pre-operative/post-operative radiographic alignment between the TAAs that did and did not fail. Twenty-six ankles (17.4%) underwent additional surgery with retention of metal components, bringing the total reoperation rate to 47/149 (31.5%). Conclusion: At long-term follow-up, TAA demonstrates reasonable implant survival rates, especially given the learning curve that includes STARs implanted prior to the Food and Drug approval study. We describe a unique mode of failure in STARs that highlights one of the risk factors for failure in total ankle arthroplasty. This represents the highest reported rate of talar subsidence in the literature with almost 10% of STARs demonstrating talar-sided failure at mean 7-year follow-up. Surgeons who utilize the STAR total ankle should be vigilant for talar subsidence given the high rates reported in this series.

Background: Arthrodesis of the ipsilateral hallux metatarsophalangeal (MTP) and interphalangeal (IP) joints may be required for severe arthritis or deformity at both joints. The purpose of this study was to review outcomes of ipsilateral first MTP and IP joint arthrodesis. Methods: Twenty feet were identified, for which the diagnosis was rheumatoid arthritis in 14, failed hallux valgus surgery in 5, and hallux rigidus in 1. The IP arthrodesis was performed first in 6 feet; MTP first in 8 feet; and both joints simultaneously in 6 feet. Median follow-up was 28 months (range 12-94). Medical records and radiographs were reviewed. American Orthopaedic Foot & Ankle Society (AOFAS) score and patient satisfaction were determined. Results: Although all of the MTP arthrodeses healed, 8 of 20 feet (40%) failed to heal at the IP arthrodesis. The rate of IP nonunion was 17% (1/6) with IP arthrodesis first, 50% (4/8) with MTP arthrodesis first, and 50% (3/6) with simultaneous arthrodesis. Four of 8 IP nonunions were symptomatic. Subsequent surgery was required in 11 feet (55%), including repair of IP nonunion in 3 feet, hardware removal in 4, revision MTP malunion in 2, wound debridement in 1, and soft tissue reconstruction in 1. Median hallux AOFAS score for the cohort increased from 25 to 68. Eighteen feet resulted in patients who were very satisfied or satisfied with minor reservations. Neither AOFAS score nor satisfaction trended toward association with IP union. Conclusion: Ipsilateral arthrodesis of the hallux MTP and IP joints was challenging because of high rates of reoperation and IP nonunion, the latter of which was likely related to increased mechanical stress on the IP joint with immobilization of the MTP joint. Despite the high IP nonunion rate, IP nonunion did not predict patient-reported outcome. Fibrous ankylosis was an acceptable clinical outcome in many cases. Level of Evidence: Level IV, case series.

Category: Other; Sports Introduction/Purpose: While it is a commonly accepted principle peroneal tendon (PT) tears are associated with cavovarus deformity, this is the first study that both quantifies deformity in patients with surgically proven tears using sophisticated and reproducible methods to compare radiographic measurements to a matched control group. Understanding of the anatomy and mechanism of injury affecting the PTs has led to greater recognition of PT tears as an important cause of lateral sided foot and ankle pain. The literature reports a presumed correlation between the cavus foot and PT tears. Little data exist quantifying the correlation between PT tears and the alignment of the foot. We hypothesize the cavovarus foot applies stress over the lateral border of the foot leading to degenerative changes in PTs. Methods: A cohort of 252 consecutive patients operatively treated for peroneal tendon tears (PT) were compared to an age- and sex- matched control (C) group of 104 outpatients treated for isolated forefoot problems. Calcaneal pitch, calcaneal - first metatarsal, talometatarsal, and talocalcaneal angles were compared on standing lateral radiographs. Talometatarsal and talocalcaneal angles, and talonavicular coverage, were compared on standing anteroposterior radiographs. Published radiographic criteria were used to determine cavovarus. ANOVA analysis detected statistically significant differences between patients and controls and a subsequent Tukey-Kramer test compared the control group with each type of PT tear. An a prioripower analysis was performed to calculate the minimum sample size in each cohort to detect a 90% effect size for a significance level of p

Category: Midfoot/Forefoot; Other Introduction/Purpose: Cheilectomy and arthrodesis are the primary surgical treatments of hallux rigidus. While cheilectomy preserves limited motion, that motion can be the source of persistent pain that later requires arthrodesis. Cheilectomy with interposition arthroplasty using a synthetic hydrogel implant (Cartiva) has been proposed as an alternative to arthrodesis. Previous studies compared Cartiva to arthrodesis, but Cartiva is really a modification of cheilectomy, meant to improve its results by distracting the bony surfaces of the first MTP joint. This study compared outcomes of cheilectomy with Cartiva to cheilectomy alone. Methods: A retrospective cohort study assessed the results at 1-year minimum follow-up, identifying patients by CPT code for cheilectomy with (28291) and without (28289) Cartiva interposition. There were forty-five patients: 26 in the Cartiva group and 19 in the cheilectomy group. Tabulated data included: age, gender; preoperative, 6-month, and final postoperative total first MTP ranges of motion (ROM); preoperative and final postoperative VAS and SF-36 scores; and reoperation information. Hallux rigidus grade was assessed by Coughlin and Shurnas criteria. First MTP joint space was measured at the medial, midline, and lateral portions of the joint on both AP and lateral radiographs before, immediately following, and at maximum postoperative follow-up (16 month mean). For analysis, medial, midline, and lateral joint measurements were averaged to generate a composite measure of radiographic joint space. Follow-up means were 23 months for all patients, 18 for Cartiva and 28 for cheilectomy. Results: Mean age was 54. Mean preoperative grade was 2.6 for Cartiva and 2.1 for cheilectomy (p=0.037). Mean preoperative ROM was 44°. At 1 year follow-up, ROM was 39° for Cartiva and 47° for cheilectomy (p=0.95). Mean VAS improved from 5.8 to 2.0 and 3.0 for Cartiva and cheilectomy, respectively, at final follow-up (p=0.002, p=0.004). Following Cartiva, two week postoperative joint space means increased: AP midline 1.4 to 2.6 mm, AP composite 1.4 to 2.2 mm, and lateral midline 1.3 to 2.7 mm (p0.3). Five patients in each group (22%) underwent revision. Conclusion:: Cartiva offers similar intermediate-term ROM preservation and pain relief as cheilectomy in a cohort with higher grade hallux rigidus. Joint distraction gained by synthetic hydrogel interposition subsides with time to levels similar to cheilectomy. Revision surgery for persistent pain is common in both groups.

Category: Bunion Introduction/Purpose: Compared to women, hallux valgus in men is less common, more severe, and has higher rates of undercorrection, recurrence and greater distal metatarsal articular angle (DMAA). Bunionectomies that correct metatarsus primus varus (MPV) by valgus rotation paradoxically increase 1stMTP valgus in high DMAA, contributing to recurrence and undercorrection. While proximal valgus osteotomy or arthrodesis plus distal varus-producing metatarsal osteotomy can correct both components, there is a simpler solution. A modified Scarf osteotomy technique was developed in which the osteotomy is simultaneously translated laterally to correct MPV, while rotating the distal metatarsal in varus to correct DMAA. While previous literature on male hallux valgus is comprised of many studies using a combination of surgical techniques, all patients in this series had the same procedure. Methods: A retrospective review of prospectively collected data was performed in male patients treated with modified scarf osteotomy and soft tissue realignment for symptomatic hallux valgus, who failed conservative treatment. Preop and postop range of motion (ROM), radiographs, and validated patient reported outcome (PROM) scores including Pain VAS and SF-36, were tabulated, as well as complications, and AOFAS Hallux scores for historical comparison. There were 22 patients (26 feet), mean age 53 (17-79). Mean clinical and radiographic follow up was 24 months, and mean postop PROM’s follow up was 4.7 years. Six of 26 feet (23%) required a modified Akin osteotomy for a congruent 1stMTP joint. A subset of patients with minimum 4-year and mean 7.6 -year follow up (9 patients, 10 feet), was also analyzed. Weightbearing radiographs were evaluated for DMAA, hallux valgus angle (HVA) and 1st-2ndintermetatarsal angles (IMA). Results: Statistically significant improvements were found in VAS scores (5.8 to 1, p

Category: Ankle; Ankle Arthritis; Hindfoot Introduction/Purpose: In vivo gait analysis is the objective functional measurement compared to subjective patient-reported outcomes. Intermediate-term gait studies showed positive results of Total Ankle Arthroplasty (TAA). To date, there are no published Long-Term functional outcomes of TAA. Methods: Three-dimensional gait analysis with twelve-camera digital-motion capture system and double force plates recorded temporal-spatial (TS), kinematic (KM), and kinetic (KN) measures, in 33 patients who had STAR (28) or Salto Talaris (5) TAA, done pre-operatively and at intervals post-operatively, with last testing at a mean of 7.6 years. Almost half the patients had 8-13 year follow up. Results: Improvements were found in multiple gait parameters, with TS increases in cadence, (+9.5 steps/min; P

Peroneal tendon tears are a common but under-recognized source of ankle pain and dysfunction. Recognition of the characteristic symptoms, physical findings, and imaging results of peroneal tendon tears is essential for accurate diagnosis and appropriate treatment. Acute, limited tears of a single peroneal tendon may be debrided and repaired. However, by the time operative treatment is undertaken, many tears of a single tendon are sufficiently advanced that the surgeon may need to consider excision of the nonviable segment and tenodesis of the damged tendon to the to the adjacent peroneal tendon. Irreparable tearing of both peroneal tendons may be treated with flexor tendon transfer and/or allograft reconstruction. This review article focuses on diagnosis and operative treatment of peroneal tendon tears, including the treatment algorithms, operative technique, and published outcomes.

Category: Ankle, Ankle Arthritis Introduction/Purpose: Operative treatment of end-stage ankle arthritis involves either ankle arthrodesis (AA) or total ankle arthroplasty (TAA). The theoretical benefit of TAA is the ability to preserve range of motion (ROM) at the tibiotalar joint. Previous studies have questioned whether it is justified to perform TAA over AA in stiff, arthritic ankles. However, a recent study showed that patients who underwent TAA with stiff ankles preoperatively experienced significant clinical improvement in range of motion and gait function compared to more flexible groups at 1-year follow-up. We retrospectively assessed these same gait and functional parameters to see if these improvements held up in long-term follow-up. Methods: A retrospective study of long-term, prospectively collected functional gait data in 33 TAA patients at a mean of 7.6 years postoperatively (range 4.8-13.3) used a multivariate regression model to determine the effect of ankle stiffness on the long- term, objective outcomes of TAA. Data was analyzed by quartiles (Q1, Q2+Q3, Q4) of preoperative sagittal ROM using one-way analysis of variance (ANOVA) to compare both preop and postop gait parameters. The two middle quartiles were combined to conform to distribution of the data. The multivariate analysis determined the independent effect of age, gender, BMI, years post- surgery, and preop ROM on every preop and postop parameter of gait. Results: Statistically significant differences were found in all three gait parameter categories, including temporal-spatial (step length and walking speed), kinematic (total sagittal ROM and maximum plantarflexion), and kinetic (peak ankle power). The stiffest ankles preoperatively (Q1) had the greatest absolute increase in total sagittal ROM postoperatively, +5.3o, compared to -1.3o (p

Category: Midfoot/Forefoot Introduction/Purpose: Cartiva (Wright Medical Group N.V.) was developed as an implantable interposition device for the treatment of hallux rigidus. It is performed along with a limited cheilectomy and serves as a joint preserving alternative to arthrodesis. In some patients, we have noticed gradual decreases in the joint space after surgery with Cartiva, presumably representing subsidence of the implant. The aim of this study is to report a radiographic analysis of visible joint space in surgical cases of hallux rigidus where dorsal cheilectomy and Cartiva were used. Methods: A prospectively collected patient database was queried for CPT code 28291 and those patients in which Cartiva was implanted were determined. The pre-operative and post-operative radiographs were analyzed for hallux rigidus grade, and measurements of visible joint space prior to and after Cartiva was implanted were performed at two weeks, one month, three months, and six months post-operatively. The percentage of visible joint space increase or decrease after implantation of Cartiva was calculated for each post-operative time point. Results: A total of 79 Cartiva were implanted in 74 patients between April 2017 and Sept 2018. The procedure was performed for Grade I hallux rigidus in 11% of patients (n=9), 66% grade II (n=52), 23% grade III (n=18). Mean pre-operative visible joint space measured 1.1 mm (n=79). Visible joint space measured at two weeks post-surgery was 2.2 mm (n=74); one month, 1.6 mm (n=65); three months, 1.2 mm (n=64); six months, 1.0 mm (n=30). Implantation of Cartiva resulted in 100% increase in visible joint space compared to pre-operative measurements at two weeks post-surgery, 45% increase at one month, 9% at three months, and a 9% decrease in visible joint space at six months. Conclusion: Cartiva implantation and limited cheilectomy for patients with symptomatic hallux rigidus provided a 100% increase in visible joint space on radiographs taken two weeks post operatively. However at six months post-surgery there was an overall 9% decrease in visible joint space presumably representing a subsidence of the Cartiva implant with time.

Congenital dislocation of the fifth metatarsophalangeal (MTP) joint can cause significant limitations in a patient’s ability to wear a closed shoe. Historic treatment has involved amputation of the digit or attempts at reconstruction. These techniques have had limited success with unreliable correction and/or unacceptable cosmesis. The authors present a detailed, methodical approach to reconstruction of this deformity with a stepwise algorithm that addresses both the bony and soft tissue components of the deformity. With this modern technique, reliable and satisfactory results can be expected.

Category: Diabetes Introduction/Purpose: When non-operative treatment of very severe Charcot neuroarthropathy (CN) of the ankle and hindfoot fails, surgical options for limb salvage are limited. Some patients have insufficient bone stock or medical and psychosocial factors that make arthrodesis untenable. Resection arthroplasty can create a braceable, plantigrade ankle and foot, preserving the limb and maintaining ambulatory independence. This study evaluated the results of resection arthroplasty and bracing as an alternative technique of limb salvage in the subset of patients who would otherwise require amputation for unreconstructable Charcot deformity. Methods: The medical records and radiographs of 16 patients who underwent resection arthroplasty for unreconstructable Charcot deformity from 2000-2014 were retrospectively reviewed. All had diabetic peripheral neuropathy. The average follow-up was 46.75 months (range 9-111 months). Data included demographics, medical history, ambulatory status, and soft tissue lesions. Radiographs were categorized according to the Brodsky Charcot classification. Pre-operatively, 2 patients were community ambulators without assistive device. Four patients were wheelchair bound. Ten patients (62.5%) had limited ambulatory independence, as either home ambulators or reliant on assistive devices, such as crutches and walkers. At the time of surgery, 87% had presence of persistent and recalcitrant ulceration as a result of their deformity. Fifteen patients (93%) had Brodsky Type 2 (Hindfoot) or Type 3 (ankle) Charcot joints. Primary outcomes assessed were limb survivorship and ambulatory status at last follow-up. Secondary outcomes included wound complications, infection, and need for subsequent surgical procedures following index procedure. Results: Kaplan-Meier survivorship probability estimate for limb salvage at 5 years following resection arthroplasty was 93% (95% CI 66%-99%). A total of 4 resection arthroplasties ultimately failed, requiring BKA. Three out of 4 amputations occurred after 5 years of successful function. Of the 12 patients who retained their limb at final follow-up, all had braceable deformity without evidence of skin breakdown or infection at the time of final follow-up. Eleven of the 12 were independent community ambulators with bivalved AFO (BAFO). With regard to overall changes in ambulatory status following resection arthroplasty, all patients who were independent community ambulators pre-operatively maintained their ambulatory independence post-operatively with use of BAFO. For patients who were either non-ambulatory or dependent ambulators pre-operatively, 10/14 (71%) achieved ambulatory independence. Conclusion: Resection arthroplasty with long-term post-operative bracing is an effective alternative technique for limb salvage and preservation of ambulatory independence in the subset of CN patients who would otherwise likely require amputation for unreconstructable deformity.

Category: Diabetes Introduction/Purpose: There are limited data in the literature regarding natural history of Charcot Neuroarthropathy (CN) of the foot and ankle. The utility of a classification system should be threefold: accurately describe the disease process, guide the appropriate treatment, and predict the long-term prognosis. This study investigates the natural history of CN of foot and ankle, and whether the Anatomic Classification is predictive of outcome and prognosis. Methods: A retrospective review of 334 patients treated at a single institution by a single surgeon from January 1986 to June 2010 was conducted. Clinical records, imaging studies, and operative reports were reviewed to tabulate the Anatomic Classification type, patient demographics (age, gender, BMI, diabetes, RA), number and types of surgeries performed, location of surgery, initial and final job status, ulcer status, ambulatory status and shoe wear type. ANOVA and Pearson Chi square were utilized to assess whether the classification was predictive of variables. P-values of < 0.05 were considered statistically significant. Results: Outcomes/p-values are listed in table 1. 35.3% of patients presented with a unilateral Type 1 Charcot foot(n=118), 17.1% presented with a unilateral Type 2(n=57), 13.8% presented with a unilateral Type 3(n=46), and 33.8% presented with bilateral disease(n=113). CN due to RA had increased bilateral involvement(12.4%; 14/113) compared to unilateral involvement(5%,11/221)(p=0.026). Comparing bilateral versus unilateral Types 1,2,or 3, a similar trend was noted(p=0.0939). The Anatomic classification predicted location/need for surgical intervention(p < 0.00001). The classification predicted distal disease was associated with increased likelihood to require shoe-wear modifications(p=0.0001). While a statistically significant difference was not detected, a trend for the classification to predict persistent ulceration at final follow-up was noted. Patients with bilateral involvement and more distal disease were more likely to have ulceration(p=0.0968). Conclusion: While the Anatomic classification did not predict ambulatory status, and only trended towards statistical significance for ulceration at the time of final follow-up, there is utility in the classification system for predicting location of surgery as well as shoe-wear at final follow-up. Additionally, patients with CN due to RA had an increased likelihood of having bilateral foot involvement. The Anatomic Classification has clinical utility when counseling patients on the overall course of their disease process.

Category: Ankle Introduction/Purpose: Numerous studies have attempted to study outcomes after total ankle arthroplasty (TAA). The majority of these studies are clinical in nature. There have been some reports that rheumatoid patients have better outcomes after TAA although there are papers that are contradictory. Objective outcome studies of gait after TAA usually measure outcome against a control group or ankle arthrodesis. No studies have attempted to measure objective outcomes of TAA based upon the preoperative diagnosis. Without objectively studying outcomes for patients with osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis, it is unclear whether a difference exists in outcomes after TAA. This study aims to answer the question: Is preoperative diagnosis predictive of outcome after total ankle arthroplasty? Methods: A retrospective review of 75 patients who underwent isolated TAA with a minimum one-year follow-up, including patient demographics, pre-operative diagnosis, and pre and postoperative gait studies was conducted. Gait function was evaluated for postoperative improvement using multivariate analysis to determine the influence of patient variables on parameters of gait. ANOVA was conducted to compare improvement in gait based on preoperative diagnosis. P-values of < 0.05 were considered statisticallysignificant. Results: Outcomes/p-values are listed in table 1. While not reaching statistical significance, a meaningful clinically important difference was seen across numerous parameters. Temporal Spatial Parameters Patients with RA had the slowest preoperative cadence the fastest postoperative cadence. They also had the greatest improvement in walking speed. Patients with osteoarthritis had the greatest increase in walking speed. KinematicParameters Patients with RA had the greatest improvement in maximum plantarflexion and the least improvement in maximum dorsiflexion. Patients with osteoarthritis had the least improvement in maximum plantarflexion and the most improvement in mean maximum dorsiflexion. Patients with osteoarthritis had the greatest improvement in total ROM. Kinetic Parameters Patients with RA had the greatest improvement in peak ankle power while patients with osteoarthritis had the greatest post-operative power. Conclusion: There is a lack of data supporting the optimal candidate for TAA. While statistical significance was not reached across a number of the parameters of gait analysis, a number approached statistical significance. Given the relatively small sample size, it is possible that a larger cohort would reach statistical significance. Patients with osteoarthritis generally had superior preoperative and postoperative parameters of gait while patients with RA had the greatest improvement in parameters of gait. Patients with post-traumatic arthritis consistently had less improvement than patients with either osteoarthritis or RA.

Category: Ankle Arthritis. Introduction/Purpose: Although recent studies have shown comparability of gait function following total ankle arthroplasty (TAA) and ankle arthrodesis, TAA is regarded to be functionally advantageous by preserving tibiotalar motion. However, it is unknown whether arthritic ankles with severe loss of sagittal plane motion are appropriate surgical candidates for arthroplasty. This study was undertaken to address the question: Is there a rationale for motion-preserving surgery in patients with little or no preoperative sagittal plane motion? Methods: A retrospective review of 76 patients who underwent isolated TAA with a minimum one-year follow-up, including patient demographics and pre and postoperative gait studies was conducted. Using a linear regression model, an effect size for total preoperative sagittal ROM was calculated, as well as effects of age, and patient demographics. Gait function was evaluated for postoperative improvement using multivariate analysis to determine the influence the variable on parameters of gait. P-values of < 0.05 were considered statistically significant. Results: Outcomes/p-values are listed in table 1. Temporal Spatial Older patients had slower preoperative/postoperative walking speeds, and increased age resulted in diminished function. Increased preoperative ROM predicted greater preoperative and trended towards greater postoperative step length. Greater preoperative ROM predicted less total improvement. Kinematic Age was predictive of improved postoperative plantarflexion with negligible clinical significance. Preoperative ROM predicted greater postoperative ROM although less improvement was noted. Preoperative/postoperative sagittal angle at toe off was greater with increased preoperative ROM. No improvement was detected. Preoperative and postoperative plantarflexion/dorsiflexion were both greater with increased preoperative ROM. Less overall improvement in plantarflexion was noted with greater preoperative ROM. Kinetic Preoperative ROM was predictive of greater preoperative/postoperative ankle power. Greater preoperative ROM resulted in less improvement in power. Conclusion: Irrespective of preoperative total sagittal range of motion, there was a statistically and clinically significant improvement in function as measured by multiple, objective parameters of gait. While pre-operative range of motion was predictive of overall post-operative gait function, patients with greater pre-operative range of motion experienced less overall improvement in gait. The data show that TAA can offer statistically significant, and clinically meaningful improvement in gait function and is a reasonable treatment alternative even in patients with end-stage tibiotalar arthritis who have very limited preoperative sagittal range of motion.

Category: Bunion Introduction/Purpose: Male hallux valgus (HV) is less common and more severe than in females, and has been reported to be associated with higher Distal Metaphyseal Articular Angle (DMAA). Although valgus-producing osteotomies should increase DMAA, this has not been documented. This study evaluated the results of a translational osteotomy that counter-rotates the distal metatarsal articular surface in a varus direction to re-align the articular surface, and correct the DMAA. Methods: Prospectively collected pre-op and post-op data on 26 males with HV were retrospectively reviewed, at a minimum one-year followup. Radiographic data included hallux valgus (HVA), first-second intermetatarsal (IMA) angles, DMAA, medial sesamoid position (MSP), and first MTPJ congruence. Clinical outcomes included Visual Analog Score (VAS), SF-36, and AOFAS forefoot score. MTP range of motion (ROM) was measured. Preoperative radiographic and clinical data were compared to previously published cohort of female patients for the same measures. Paired t-tests compared clinical and radiographic outcomes pre- and postoperatively. Bowker’s Test was used to compare the rate of joint congruence. An alpha of 0.05 was considered significant. Student t-test and Fisher’s Exact Test were for comparison between males and females. Mean age of males with HV was 53.8 (SD=17.7), mean follow-up was 1.68 years. Results: Mean radiographic improvement: HVA 36.5º to 15.3º (P=0.0001); IMA 15.9 to 8.1 (P=0.0001); DMAA 13.3º to 6.4º (P=0.0003); MSP 2.8 to 1.2 (P=0.0001); congruence 4/26 to 22/26 (P=0.0001). Mean clinical improvements: VAS 5.7 to 1.0 (P=0.0001); AOFAS 49.6 to 84.7 (P=0.0001); SF36-P 44.7 to 51.2 (P=0.0004). MTP dorsiflexion decreased 58.3º to 51.8º (P=0.0276); plantarflexion 5.8º to 3.0º (P=0.0217). Higher mean preoperative angles in males versus females: HVA 35.8º versus 29º (P=0.0016); IMA 15.9º versus 13.0º, (P=0.0002), MSP 2.7 versus 2.5 (P=0.2012). No difference in DMAA, 13.6 versus 16.4 (P=0.2551). Congruence in males lower (5/27 versus 22/40, P=0.0048). No difference in VAS (5.6 versus 6.3, P=0.1767), AOFAS (50 versus 47.9, P=0.5085), SF-36p (45.1 versus 42.4, P=0.2656), dorsiflexion (57.9º versus 49.4º, P=0.0728), plantarflexion (5.8º versus 4.8º, P=0.7204). Conclusion: Prior studies reported the results of mixes of surgical procedures. This is the first large series of adult male HV treated with a single procedure, and the first using this counter-rotational modification of the Scarf osteotomy. The modified Scarf osteotomy combines translation varus counter-rotation to direct the articular surface more medially, explaining decreased DMAA, and with excellent radiographic and clinical outcomes. We demonstrate excellent radiographic and clinical outcomes in a large group of male HV treated with translational osteotomies.