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Kristine Jensen,1 Thomas Egenod,2 Daniel P Franzen,3,4 Michael Perch1,5 1Department of Cardiology, Section for Lung Transplantation and Respiratory Medicine, Rigshospitalet Heart Center, Copenhagen, Denmark; 2Department of Interventional Pulmonology, Dupuytren University Hospital, Limoges, France; 3Department of Internal Medicine, Uster Hospital, Uster, Switzerland; 4Department of Pulmonology, University of Zurich, Zurich, Switzerland; 5Department of Clinical Medicine, University of Copenhagen, Copenhagen, DenmarkCorrespondence: Michael Perch, Department of Cardiology, Section for Lung Transplantation and Respiratory Medicine, Rigshospitalet, Heart Center, Inge Lehmanns Vej 7, Copenhagen, 2100, Denmark, Email Michael.perch@regionH.dkAbstract: Endoscopic lung volume reduction (ELVR) is an established treatment option for patients with severe emphysema. Not all patients are candidates for this type of intervention, and in the context of significant airway secretions, they may be excluded from treatment. Bronchial Rheoplasty (BR) was developed to treat mucus hypersecretion by delivering nonthermal pulsed electric fields to the airway epithelium and submucosa. The literature to date demonstrates that patients treated with BR in clinical studies have a reduction in airway goblet cell hyperplasia as well as substantive clinical improvement in the setting of chronic bronchitis (CB). In this case series, we present four patients treated at three different institutions who had previously undergone ELVR with beneficial outcome. However, over time, these patients subsequently developed worsening clinical issues, including complaints of increased and thickened mucus, along with exacerbations in the setting of a loss of some ELVR-associated benefits. These patients then underwent exploratory treatment with BR with the intent of reducing their secretion burden and potentially restoring the efficacy associated with the initial placement of the airway valves. All BR procedures were well tolerated, and three of the four patients showed substantial improvement in their symptom burden. Airway examinations during the second of the two BR procedures also revealed what appeared to be less airway mucosal inflammation and a decrease in the quantity of airway secretions. Therefore, treatment with BR may have the potential to improve and restore the initial benefits associated with ELVR, thus enhancing long-term outcomes. Further clinical studies with sufficient follow-up are warranted to assess this in a larger cohort of patients, and to determine whether treatment with BR prior to ELVR may make more patients eligible for this treatment through reduction in their secretions and/or symptoms.Keywords: bronchial rheoplasty, endobronchial valves, emphysema

Category: Ankle Arthritis; Other Introduction/Purpose: Patient-reported outcomes (PROs), such as PROMIS, are a key element of evaluating success after total ankle replacement (TAR). To date, most PROs are described using absolute values or parameters like the minimum clinically important difference. However, these interpretations do not explicitly tell the surgeon the most important factor of postoperative success: is the patient satisfied with their outcome after TAR? The patient acceptable symptom state (PASS) is a novel PRO metric that attempts to bridge this gap. PASS represents the symptom threshold above which patients consider themselves well. This study aimed to establish the PROMIS thresholds for PASS in a primary cohort of TAR patients. We hypothesized that TAR patients would meet PASS and that PASS would vary with demographic variables. Methods: This is a single-institution retrospective cohort study of primary TAR patients (n=127; mean age 63.2 years; mean BMI 29.0 kg/m 2 ; 58% male) with preoperative and 2-year postoperative PROMIS scores (domains: Physical Function, Pain Interference, Pain Intensity, Global Mental Health, Global Physical Health, & Depression). At 2 years postoperatively, patients also answered 2 PASS anchor questions with Likert-scale responses: 1) Are you satisfied with the results of your surgery?; and 2) the Delighted- Terrible symptom scale. PASS thresholds with 95% confidence intervals (CI) were calculated using the anchors “Very satisfied” or “Satisfied” for question 1 and “Delighted,” “Pleased,” or “Mostly Satisfied” for question 2. Using bootstrapping technique with 1000 iterations, the Youden Index was then calculated to determine the best coordinates of specificity and sensitivity to maximize the Area Under the Curve (AUC). Finally, we analyzed preoperative variables (demographics, clinical/surgical data, and preoperative PROMIS scores) on the likelihood of achieving PASS. Results: There was a strong association between PASS thresholds and PROMIS domains, especially Physical Function (PASS threshold >44.7, AUC 0.883), Pain Interference (< 56.0, AUC 0.940), and Pain Intensity (< 48.4, AUC 0.936). Covariate stratification demonstrated that the likelihood of achieving PASS was not affected by age, race, gender, ASA score, or BMI. PASS was less likely to be achieved by patients who had undergone prior orthopaedic surgery (P=0.013). Patients with diabetes mellitus and peripheral vascular disease were less likely to meet PASS for Physical Function (P=0.010, P=0.037), but did meet PASS for Pain domains. Patients with worse preoperative Physical Function and Depression scores were less likely to meet PASS for Physical Function postoperatively (P=0.028, P=0.041), but achieved similar PASS for Pain Interference and Pain Intensity domains. Conclusion: After TAR, the ability to reach the postoperative PASS was most strongly associated with postoperative pain scores, as evidenced by the Pain Interference and Pain Intensity domains. However, the thresholds for PASS were generally lower than population means. This demonstrates that TAR patients do not need to reach normal pain or physical function levels in order to have an acceptable symptom state postoperatively. Moreover, the ability to achieve PASS was not affected by demographic variables. Further research on PASS is warranted, and may shift how surgeons and researchers evaluate TAR patients pre- and post-operatively.

Category: Ankle Arthritis; Ankle Introduction/Purpose: As the number of total ankle replacements (TAR) performed annually increases, there is an increased demand for implants that can be used in revision scenarios when primary TARs fail. As indications for TAR expand, there is increased reliance on modular systems to treat challenging conditions including bone loss, avascular necrosis, and instability. The INVISION Total Ankle Arthroplasty System (Wright Medical Technology/Stryker, Memphis, TN), released in 2018, includes modular augmented tibial trays and talar plates of varied heights to compensate for bone loss. There is limited data on early survivorship and clinical outcomes of the INVISION. This novel study aims to determine the early implant survivorship, complications, patient-reported outcomes (PROMIS), and radiographic outcomes of the INVISION implant used in both the primary and revision arthroplasty setting. Methods: This study is a single-institution retrospective review of adult patients who underwent primary or revision TAR with the INVISION implant with minimum 2-year follow-up. Demographics, reason for use of INVISION, surgical data, complications, pre- operative and 2 year post-operative radiographic data, and pre-operative and 2-year post-operative patient-reported outcome scores were collected. The primary outcome was survivorship (retention of both tibial/talar components at final follow-up). Secondary outcomes were reoperation (return to OR with retention of both tibial and talar components), radiographic complications (peri-implant lucency, cysts, or subsidence), and patient-reported outcomes (PROMIS pre-operative and 2-year post-operative). PROMIS scores were collected across the following domains: physical function, pain interference, pain intensity, global mental health, and depression score. Results: Twenty-six patients (primary=7; revision=19) underwent INVISION TAR (mean age 62 years, weight 81.kg, BMI 29.3 kg/m 2 , 15/26 male) with mean follow-up 3.5 years. Reason for INVISION primary TAR included tibial (n=1) or talar (n=5) bone loss, and take-down fusion (n=1); INVISION revision TAR was used for tibial (n=6) or talar (n=7) component subsidence, recurrent tibiotalar malalignment (valgus=1, varus=3), and post-infection bone loss (n=2). Two-year implant survivorship was 100%. There were 2 reoperations (7.7%): 1 gutter debridement and 1 irrigation, debridement and polyethylene exchange for infection. Two-year follow-up PROMIS domains improved significantly (p < 0.05) from pre-operative in both the primary (pain interference, pain intensity) and revision cohorts (pain interference, pain intensity, global physical function). Two-year radiographic follow-up yielded 1 tibial peri-implant lucency and 1 tibial cyst. Conclusion: In this single-institution series, there was excellent short-term survivorship of the INVISION TAR implant with no failures in primary or revision cases. There were significant improvements in patient-reported outcomes scores. There were low rates of peri-implant lucencies and cysts. The results of this study support the use of the INVISION implant in both the complex primary and revision TAR setting. INVISION may offer an alternate surgical solution to fusion, custom printed cage implants, and total talus replacement in this complex patient population. Further research and follow-up data are warranted to report the longer-term outcomes and survivorship of this implant.

Category: Ankle Arthritis; Ankle Introduction/Purpose: There is limited evidence regarding risk factors for medial malleolar fractures after total ankle arthroplasty (TAA). A previous study showed that patients with medial pain following TAA had significantly thinner ( 4 weeks postoperatively (cases) were identified through radiologic assessment (radiograph, CT, or MRI) and matched to a control group of 129 patients. Radiographic evaluation included pre- and post-TAA tibial coronal alignment, postoperative medial malleolar width at the tibial component, and prophylactic screw fixation. Demographics and radiographic variables were compared between cohorts using the Mann-Whitney U test for continuous variables and Pearson Chi-square for categorical variables. Logistic regression was used to investigate the association of medial malleolar stress fractures with gender, coronal tibial implant size, postoperative coronal alignment, prophylactic screw fixation, and medial malleolar width using odds ratios (OR), and standard error (SE). Results: Of 838 TAAs, 2.51% sustained a postoperative medial malleolar fracture (n = 21). Of these, 13/21 (61.9%) required reoperation: internal fixation (12) and TAA revision (1). Mean (SD) medial malleolar width was significantly smaller in the fracture cohort (8.62 mm [1.63]) than in controls (11.78mm [1.75]), P

Category: Ankle Arthritis; Ankle Introduction/Purpose: Restoring the native joint line correlates with better clinical outcomes in total knee arthroplasty. Yet, the effect of joint line elevation on clinical outcomes after total ankle arthroplasty (TAA) remains unclear. A previous study reported that pre- and post-TAA joint line heights, as measured by the joint line height ratio (JLHR), were elevated compared to non- arthritic ankles. However, the clinical impact of this has yet to be determined. Therefore, this study assessed the relationship between the TAA joint line level with post-TAA range of motion (ROM) and PROMIS scores. We hypothesized that an elevated joint line would be associated with restricted post-TAA dorsiflexion and worse postoperative PROMIS scores. Methods: This is a single-center review of 150 patients who underwent primary TAA. Patients with (1)fibular or medial malleolar osteotomy, (2) component subsidence, and (3) incomplete radiographs or outcome scores were excluded. Demographic data, surgical protocol, pre- and postoperative radiographs, and 1-year postoperative PROMIS scores were reviewed. Radiographic measurements included JLHR, pre- and post-TAA tibiotalar dorsiflexion and plantarflexion, and tibial component sagittal alignment. Two graders measured post-TAA JLHRs, and the average of the two graders was used for the analysis. Rater agreement was assessed using intraclass correlation coefficients (two-way random effects model). Relationships between JLHR, post-TAA tibiotalar ROM, and PROMIS scores were investigated using Pearson correlation. Multiple linear regression models were used to investigate the association of JLHR with post-TAA tibiotalar total ROM, dorsiflexion, and plantarflexion, after adjusting for pre- TAA ROM, tibial component sagittal alignment, gastrocnemius release (GR), Tendo-Achilles lengthening (TAL), and polyethylene size. Results: The interobserver reliability of the JLHR was excellent (r=0.98). Mean JLHR decreased from 1.66 pre-TAA to 1.55 post- TAA (P < 0.001), indicating the joint line was significantly lowered postoperatively. Greater elevation of the post-TAA JLHR was associated with significantly decreased post-TAA dorsiflexion (r=-0.26, P< 0.001) and worse 1-year PROMIS physical function (r=- 0.22, P=0.046), pain intensity (r=0.22,P=0.042), and pain interference scores (r=0.29,P=0.007). There was no correlation between JLHR and post-TAA plantarflexion (P=0.76). Regression analysis identified a 5º reduction in post-TAA dorsiflexion with each 1.0 unit increase in JLHR (Coef=-5.13, P=0.005). Post-TAA total ROM (Coef=-3.6,P=0.21) and plantarflexion (Coef=0.91, P=0.67) were not associated with JLHR. Additionally, there was no association between post-TAA total ROM and tibial component sagittal alignment, GR, TAL, or polyethylene size. Conclusion: In this study, the joint line of the ankle was lowered after TAA, and the JLHR was a reliable and clinically applicable method for assessing it. An elevated joint line significantly correlated with restricted post-TAA dorsiflexion, but this may only be clinically relevant for patients with significant (>1.0 unit) changes in the joint line level. In addition, a higher joint line was correlated with worse 1-year PROMIS scores. These results suggest that surgeons should consider the joint line level during TAA preoperative planning to obtain improved clinical outcomes and ankle dorsiflexion.

Category: Ankle Arthritis; Ankle Introduction/Purpose: As the frequency of total ankle arthroplasties (TAA) performed annually has increased significantly over the past decade, several novel TAA implants have entered the market. The Infinity TAA (Stryker, Mahwah, NJ) is a low-profile fixed- bearing implant that was approved for use in the United States in 2014. Although the short-term survivorship and complication rates of the Infinity TAA have been well documented in the literature, mid- to long-term outcome studies of this implant are limited. The aim of this study was to describe the survivorship, reoperation rate, and radiographic and clinical outcomes of the Infinity implant at minimum 5-year follow-up. We hypothesized that there would be no significant drop-off in clinical outcome or alignment from 2-year to 5-year follow-up. Methods: This is a single-institution retrospective review of patients who underwent primary TAA with the Infinity implant from July 2014 to April 2017. Four fellowship-trained foot and ankle surgeons contributed patients. Out of 74 identified ankles, 65 ankles in 64 patients had minimum clinical follow-up of 5 years (mean, 6.5; range, 5.0-8.0) and were included for analysis. Medical records were reviewed to record demographics, surgical data, complications, reoperations, and revisions. Radiographs were assessed to measure preoperative and postoperative alignment, and the incidence of postoperative peri-implant lucencies and cysts. Preoperative, 2-year, and 5-year postoperative Foot and Ankle Outcome Score (FAOS) subscores in the categories of Pain, Symptoms, Activities of Daily Living, Sports, and Quality of Life were obtained. The primary outcome was 5-year survivorship. Secondary outcomes were reoperations with retention of tibial and talar components, radiographic alignment, peri-implant lucencies/cysts, and clinical outcomes (FAOS) scores. Results: Implant survivorship at 5 years was 93.8%, with 4/65 revisions. Three revisions occurred less than 2 years from the index surgery (2/3 for tibial subsidence; 1/3 for tibial and talar subsidence). The fourth revision occurred at 7.1 years due to cystic changes with tibial and talar subsidence. There were 11 reoperations in 10 ankles. Alignment correction achieved surgically (preop coronal deformity 9.0 ± 6.8°; 1Y postop 1.6 ± 1.5°) was maintained at final radiographic follow-up (1.8 ± 1.7°; P = 0.32). There were 16 ankles (24.6%) with peri-implant radiographic abnormalities: 14 cases of lucency (14 tibia, 0 talus) and 3 cases of cysts. FAOS outcomes demonstrated significant improvement from preop to postop in all five domains at 2 years, which were maintained at 5 years. Conclusion: The mid-term outcomes of the Infinity implant in this single-institution study demonstrated good survivorship of 93.8% and improved clinical outcomes at mean 6.3-year follow-up. This was a mid-term follow-up to the 2-year outcome study published at this institution. Radiographic assessment at final follow-up demonstrated that alignment correction was maintained, and there was a 21.5% incidence of asymptomatic periprosthetic lucencies. These results demonstrate that there was no significant change in radiographic or clinical outcomes with this implant after 5 years, which is valuable for surgeons in terms of counseling and following patients in the immediate and mid-term postoperative period.

Category: Ankle; Basic Sciences/Biologics Introduction/Purpose: Although double hindfoot arthrodesis (subtalar and talonavicular) provides pain relief and deformity correction for patients with end-stage arthritis, altered ankle biomechanics may occur following these procedures. Furthermore, it has been reported that hindfoot fusions may lead to progressive ankle degenerative changes and a higher failure rate in patients undergoing total ankle arthroplasty. Previous biomechanical studies demonstrated that hindfoot fusion altered ankle joint kinematics and contact mechanics during simplified loading scenarios, but the effect during dynamic activity is unknown. Therefore, this study sought to quantify the changes in ankle kinematics after a double hindfoot arthrodesis during the stance phase of simulated gait. In addition, we sought to assess whether the sequence in which joints are fused plays a role in altering ankle kinematics. Methods: Fourteen mid-tibia specimens underwent stance phase simulations of level walking using a validated six-degree of freedom robot. All specimens had neutral hindfoot alignment. An eight-camera motion system tracked reflective markers in the tibia, talus, calcaneus, and navicular bones. Simulated arthrodeses of the subtalar and talonavicular joints were performed using two 7.0mm and two 5.5mm crossing screws, respectively. The subtalar alignment was set at 5º valgus, and the talonavicular at neutral abduction/adduction. Fluoroscopic images confirmed proper screw position and hindfoot alignment. Each specimen was tested in three conditions: pre-arthrodesis(intact), isolated arthrodesis(subtalar or talonavicular joint), and double arthrodesis(double). Specimens were further divided into two groups depending on whether the subtalar(STDouble) or talonavicular(TNDouble) joint was fused first. Ankle kinematics were calculated for each condition for the entire cohort of specimens and each of the two groups. Bias-corrected 95% confidence intervals of the difference in ankle kinematics relative to the intact condition were constructed. Results: Double hindfoot arthrodesis significantly altered ankle kinematics(Figure1A). Ankle plantarflexion decreased during heel strike by up to 2.0° on average and increased during toe-off by 6.5° compared to the intact condition. Ankle eversion increased by 1.5º and 2.5º on average during mid- and late stance, respectively. Internal rotation decreased during midstance by 1.1º on average and increased in late stance by 4.5°. The order in which hindfoot joints were fused significantly influenced ankle kinematics(Figure1B). On average, the TNDouble condition produced 2.3º and 3.5º more ankle eversion during the mid- and late stance, respectively, and 2.10° more ankle internal rotation during the early stance compared to the STDouble condition (not shown). Significant changes were also present after isolated hindfoot arthrodeses and remained consistent after the double arthrodesis. Conclusion: Double hindfoot arthrodesis significantly altered ankle kinematics throughout stance. Ankle kinematics also differed depending on which joint was fused first. Notably, the TNDouble condition produced more ankle internal rotation during early stance and more ankle eversion during mid- and late stance compared to the STDouble condition. This finding suggests that the sequence in which joints are fused affects the resultant ankle kinematics. Finally, the kinematic changes after isolated hindfoot arthrodesis remained consistent after incorporating the second joint into the fusion. It appears that once one joint needs to be fused, avoiding the double arthrodesis may not necessarily protect the ankle.

Category: Ankle Arthritis Introduction/Purpose: Talar collapse can occur from a variety of etiologies and may pose a unique challenge to the foot and ankle surgeon due to the complexity of the deformity and associated adjacent joint degenerative change. Total talus replacement (TTR) has emerged as an attractive option to help patients return to activities sooner than with arthrodesis and improve pain and joint mechanics postoperatively. However, there is limited long-term data on the most recent generation of implants. In this multi- institution case series, we present the severe complications that can occur after TTR, including instability, infection, and adjacent joint osteoarthritis. Methods: We present three cases from Duke University Hospital in Durham, North Carolina, and the Hospital for Special Surgery In New York City, New York. All three patients were treated with a total talus replacement (TTR) during their clinical course and experienced subsequent complications. Clinical data and radiographs were collected from chart review under an IRB-exempt protocol. Results: Case 1 demonstrates the risk of ligamentous insufficiency leading to dislocation following placement of a TTR. This case highlights the posterior instability due to soft tissue mobilization and division. Case 2 highlights the risk for adjacent joint degeneration with TTR. Case 3 presents an instance of non-union following a total ankle and total talus replacement (TATTR) with subtalar arthrodesis. To our knowledge, this represents the first case of nonunion following TTR in the literature. Finally, we discuss our institution’s experience with infection following TTR and possible contributing factors to this specific procedural risk. Conclusion: TTR shows promise in the properly selected patient with end-stage talar collapse. However, heterogeneous surgical techniques, implant composition, indications, and patient demographic variables complicate the interpretation of the literature. Moreover, few studies report mid-to long-term outcomes after this procedure and the occurrence of adjacent joint OA is likely underreported in the literature. Thus, until further, high-quality studies with long-term follow-up validate the positive early outcomes of TTR, we urge extreme caution in patient selection, choice of implants, and surgical techniques.

Category: Ankle; Ankle Arthritis Introduction/Purpose: Prior studies on the INBONE II and Salto Talaris total ankle arthroplasty (TAA) systems have reported favorable outcomes for both implants. However, it is unclear whether there were significant differences in survivorship between and if this led to subsequent differences in clinical or radiographic outcomes the two. To date, no similar comparisons have been done in the literature, although it is important to understand the clinically relevant distinctions between these more recent third generation TAA systems. This retrospective study aimed to compare the midterm differences between INBONE II and Salto Talaris TAA. Methods: Between 2007 and 2015, 44 INBONE II consecutive cases and 85 Salto Talaris consecutive cases had minimum 5-year clinical and radiographic follow-up. The endpoints for survivorship were revision, defined as removal or replacement of any implant component, and reoperation, defined as a non-revision surgery. Preoperative and midterm postoperative Foot and Ankle Outcome Score (FAOS), which has been validated for ankle osteoarthritis, and radiographic measures including tibiotalar alignment (TTA) and medial distal tibial angle (MDTA) were compared. Talar inclination angle (TIA) was compared to examine subsidence and cysts were examined for osteolysis. Average midterm follow-up for these patients was 6.4 +- 1.1 (range, 5-9) years for the INBONE II group, and 7 +- 1.9 (range, 5-12.7) years for the Salto Talaris group. Results: Survivorship to revision was 97.6% (95% CI, 93.1%-100%) for the INBONE II group and 97% (95% CI, 93%-100%) for the Salto Talaris group (P = .93). Survivorship to reoperation was significantly different; 95.5% for the INBONE II and 76.4% for Salto Talaris (P = .021) (Figure 1). All FAOS improved postoperatively (P < .001), although the INBONE II had superior postoperative scores in pain (P = .01), symptoms (P = .004), and sports activity (P = .02). There were no differences between groups in postoperative radiographic alignment, despite the INBONE group having greater preoperative deformity. There was one instance of subsidence in each group and similar rates of cyst occurrence across the INBONE II (18.2%) and Salto Talaris (21.2%) groups. Conclusion: Although both implants had similar longevity and postoperative alignment, the INBONE II resulted in greater clinical improvement and fewer reoperations than the Salto Talaris at midterm follow-up. The majority of reoperations in the Salto Talaris group were due to gutter impingement. The contrasting reoperation rates between groups may be explained by differences in implant design and technique, such as rotational malpositioning of the talus and the lateral sulcus design of the Salto Talaris. Additionally, the INBONE II TAA system was able to correct deformity and improve clinical outcomes even though this cohort exhibited greater preoperative deformity.

Category: Ankle; Ankle Arthritis; Hindfoot; Midfoot/Forefoot; Other Introduction/Purpose: Subtalar fusion is a powerful option for correcting hindfoot deformity in progressive collapsing foot deformity (PCFD). Despite successful correction through subtalar fusion, the development of valgus tibiotalar tilt at the ankle joint has been documented as a significant complication. This can be detrimental since abnormal forces on the ankle joint can induce cartilage wear and subsequent ankle arthritis over time. However, the incidence of valgus tilt of the ankle following subtalar fusion for PCFD reconstruction has not been extensively studied, and little is known about its etiological factors. The purpose of this study was to define the incidence of valgus tibiotalar tilt after subtalar fusion for PCFD reconstruction, and to determine if any demographic and radiographic parameters predict which patients develop this complication. Methods: This study reviewed 59 patients (median age: 59 years) who underwent PCFD reconstruction with subtalar fusion and had pre-and postoperative weightbearing anteroposterior radiographs of the ankle in the registry. Patients with a tibiotalar tilt prior to surgery were excluded. On standard weightbearing radiographs, the talonavicular coverage angle, talo-1st metatarsal angle, calcaneal pitch, and hindfoot moment arm (HMA), and medial distal tibial angle were measured. Weightbearing computed tomography (WBCT) was used to determine the presence of preoperative sinus tarsi or calcaneofibular bony impingement. A radiologist evaluated the superficial and deep deltoid ligaments using magnetic resonance imaging (MRI). Postoperative valgus tibiotalar tilt was defined as tilt >2 degrees. Univariate regression analysis was used to identify the factors associated with development of postoperative valgus tibiotalar tilt. These factors included age, gender, BMI, as well as concomitant procedures, radiographic parameters, lateral bony impingement on WBCT, and deltoid ligament status on MRI. Results: A total of 17 patients (28.8%) developed postoperative valgus tibiotalar tilt at a mean of 7.7 (range, 2-31) months. Eight (47.1%) of the 17 patients developed valgus tibiotalar tilt (mean talar tilt of 5.3 degrees, range: 4-8) on postoperative weightbearing within 3 months. In bivariate analysis, male gender and preoperative HMA were significantly associated with development of valgus tibiotalar tilt (Table 1). Univariate logistic regression demonstrated that preoperative HMA was associated with postoperative valgus tibiotalar tilt (odds ratio 1.06, P = .026), with a 6% increase in risk per millimeter of increased HMA. Deltoid ligament status on MRI and concomitant procedures on other joints including fusion did not correlate with postoperative valgus tibiotalar tilt. Conclusion: The incidence of valgus tibiotalar tilt after subtalar fusion in PCFD reconstruction was 28.8% in this study. Preoperative valgus hindfoot alignment rather than the condition of the deltoid ligament was a significant predictor of postoperative valgus tibiotalar tilt. Our findings indicate that surgeons should be cognizant of patients with a greater degree of hindfoot valgus and of their propensity to develop a valgus ankle deformity. Additionally, our relatively high incidence of valgus tibiotalar tilt suggests that weightbearing ankle radiographs should be included in the initial and subsequent follow-up of PCFD patients with hindfoot valgus treated with subtalar fusions.

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: The Cadence Total Ankle System (Smith and Nephew, Memphis, TN) is a two-component, fixed-bearing fourth generation total ankle arthroplasty (TAA) system that was introduced for clinical use in 2016. Few studies have investigated short-term outcomes of this new TAA system, and no outcomes have yet been reported by independent authors. The purpose of this study was to report non-inventor, non-industry funded survivorship, radiographic and clinical outcomes, and early complications following use of the new fourth generation TAA system at a minimum of 2 years. Methods: This is a single-center retrospective study of patients who underwent TAA by two surgeons with the Cadence between January 2017 and September 2018. There were 50 ankles in 50 patients, and 48 (96%; mean age of 66.1 years) patients were evaluated at a minimum 2-year follow-up. Two patients were lost due to death and refusal to participate in the study. Patients had an average follow-up of 33.6 (range, 24-50) months. Radiographic outcomes included preoperative and postoperative tibiotalar alignment (TTA) on anteroposterior radiographs of the ankle, sagittal tibial alignment (STA) on lateral radiographs of the ankle, and periprosthetic cyst formation (greater than 5mm in size) and cyst location. Data regarding reoperations and revisions were also collected. Patient-reported outcomes were assessed using Patient Reported Outcomes Measurement Information System (PROMIS). Subgroup analysis was performed to assess for associations between preoperative deformity, postoperative implant alignment, PROMIS scores, and periprosthetic cyst formation. Results: Survivorship of implant was 93.7%, with 3 revisions, 1 due to infection and 2 due to loosening of the implant (one tibial and one talar component). Three patients had reoperations (6.3%): 2 for irrigation and debridement for cellulitis, and 1 for gutter debridement due to medial gutter impingement. Preoperatively, 9 ankles had varus alignment (mean TTA 77.9 degrees), 20 had neutral alignment (mean TTA 90.2 degrees), and 13 had valgus alignment (mean TTA 102.9 degrees). Postoperatively, TTA and STA significantly improved, and all patients demonstrated neutral coronal alignment (TTA between 85 and 95 degrees). Fifteen patients (35.8%) developed periprosthetic cysts, all on the tibial side. PROMIS scores improved after surgery in all domains except Depression (Table 1). Patients with postoperative periprosthetic cysts had a smaller preoperative STA and a worse postoperative PROMIS Physical function and Pain interference domain than patients without periprosthetic cysts (p

Category: Ankle Arthritis; Ankle Introduction/Purpose: In the last decade, there has been a rapid increase in the number of total ankle arthroplasties (TAA) performed annually. In addition, multiple novel TAA implants have been introduced onto the market. The Exactech Vantage TAA is a fixed-bearing implant that has been in use since 2016. The tibial component is low-profile with vertically oriented pegs and a cage, while the talus is curved with an anterior flange to prevent subsidence. This study sought to describe the early experience with the Vantage TAA, including reoperation, revision, and radiographic outcomes. Methods: This is a single-center retrospective review of patients who underwent primary TAA using the Vantage Total Ankle (Exactech, Gainesville, FL). Concomitant procedures at the time of index surgery were recorded. Five surgeons contributed patients. Demographics, clinical and operative data, postoperative complications, reoperations, and revisions were collected. Revisions and reoperations were classified by standardized criteria. Radiographs were reviewed by a fellowship-trained foot and ankle surgeon to assess for alignment and peri-implant complications. There were 190 patients included in the study who were all minimum 2 years post-TAR, with mean clinical follow-up of 1.8 years (range: 1-48 months), and mean age 63.3 +- 9.4 years. Ankle arthritis etiologies were 45% post-traumatic (fracture history), 33% instability, 12% primary osteoarthritis, 5% flatfoot, 2% inflammatory arthritis, and 4% other. Thirteen patients (7%) had hindfoot fusion performed previously or at the time of index surgery. Concomitant procedures are shown in Table. Results: Overall implant survivorship was 95.3%. There were 5 intraoperative complications: 4 anterolateral tibial fractures and 1 medial malleolar fracture, all treated with internal fixation at the time of surgery with no further complications. Nine patients (4.8%) underwent revision: 7/9 for tibial loosening, 1 for talar loosening, and 1 for periprosthetic joint infection. Eleven patients (5.8%) underwent reoperation: open gutter debridement (5); irrigation and debridement for superficial infection (4); and bone grafting for cysts (2). Radiographically, preoperative coronal alignment was mean 10.1°, with 87 (49%) ankles with >10° deformity. Three patients had tibial component subsidence that was stable, 3 had stable radiolucency around the tibial component, and 1 had valgus failure through the ankle joint. Nineteen had asymptomatic peri-implant cysts; 16/19 were at the tibia. Conclusion: Short-term results of the Vantage TAA implant demonstrate survivorship of 95.3% at 2 years, which is comparable to similar studies of low-profile, non-stemmed implants. Asymptomatic radiographic complications were primarily cystic changes at the tibial component. Revisions occurred primarily due to loosening of the tibial component. Additional follow-up and multi- institutional support are warranted to further quantify survivorship and risk factors.

Category: Ankle Arthritis; Ankle Introduction/Purpose: Total ankle replacements (TAR) have rapidly advanced in terms of volume, technique, design, and indications. However, they are still at risk for failure and need for revision, even early in the postoperative period. Although recently there has been extensive research on TAR, many studies are limited in their power and sample size to assess risk factors for failure/revision. Using a large multi-surgeon retrospective database, we sought to describe the incidence and etiology of mechanical failure across modern implants. We also aimed to identify risk factors for early mechanical failure. We hypothesized that greater body mass index (BMI) and ipsilateral hindfoot fusion would be predictors of mechanical failure, and that implants with greater extent of tibial fixation (stems and keels) would be protective against mechanical failure. Methods: This is a single-center retrospective review of TAR patients in a prospective database. Adults undergoing primary TAR using any implant (Cadence, Inbone, Infinity, Invision, Salto, STAR, Vantage, Zimmer) who were minimum 2 years post-surgery were included. Exclusion criteria included revision TAR or patients undergoing ankle fusion takedown and conversion to TAR. Five surgeons contributed patients. Demographics, etiology of arthritis, operative data, and postoperative complications, reoperations, and revisions were collected. Revisions and reoperations were classified by standard criteria. Cause of revision was recorded. There were 560 TARs eligible for 2-year follow-up (mean 3.9 +- 1.1 years postoperative), with mean follow-up of 2.2 +- 1.4 years (range 1-71 months). The cohort had mean age 63.8 +- 9.1 years, BMI 29.4 +- 5.2 kg/m2, and 57% were male. Kaplan- Meier survival plots were created. Risk factors for revision due to mechanical failure were analyzed using multivariable logistic regression with partial Wald chi square statistics. Results: Most implants were low-profile (n=444, 79.3%), with 28 implants having tibial keels (5%) and 88 with tibial/talar stems (15.7%). There were 25 (4.5%) revisions of tibial and/or talar components at mean 1.6 years after index surgery (Figure). Preoperative coronal deformity did not impact revision rates (p=0.433). Patients who underwent revision for mechanical failure had significantly higher rates of concomitant hindfoot fusion (20% vs. 8.4%, p=0.047) and greater BMI (31.4 kg/m2 vs. 29.3 kg/m2, p=0.04). In multivariable logistic regression, hindfoot fusion was just short of statistical significance (odds ratio [OR] 2.96, p=0.056), and BMI was not significant (OR 1.05, p=0.417). Stemmed or keeled implants did not significantly decrease revision rates compared to low-profile implants, although the revision rate of stemmed implants was substantially low (1/88, 1.1%). Conclusion: Among 560 modern TAR implants, short-term survivorship was 95% at 2-year follow-up, which is consistent with existing studies. Patients who underwent revision for early mechanical failure had significantly higher BMI and rates of hindfoot arthrodesis. However, these variables fell short of statistical significance in multivariable regression, suggesting that there are either additional factors contributing to revision, or a larger cohort is needed. In addition, these results are likely biased by surgeons' tendencies to use stemmed implants in patients with hindfoot fusions. Further research is warranted to determine if stemmed implants provide a protective effect in these high-risk patients.

Category: Other; Ankle; Ankle Arthritis; Bunion; Hindfoot; Midfoot/Forefoot; Sports; Trauma Introduction/Purpose: Fulfilment of patients' expectations following foot and ankle surgery has been previously studied, and shown to be an effective modality in assessing patient-reported outcomes (PROs). While this assessment has been shown to correlate well with patient satisfaction and other validated PROs, the impact of postoperative complications on fulfilment of expectations is unknown. The aim of this study is to therefore investigate the impact of postoperative complications on fulfilment of patients' expectations. Methods: Preoperatively, patients completed a validated Foot and Ankle Expectations Survey consisting of 23 questions encompassing domains including pain, ambulation, daily function, exercise, and shoe wear. At 2 years postoperatively, patients answered how much improvement they received for each item cited preoperatively. A fulfilment proportion (FP) was calculated as the amount of improvement received versus the amount of improvement expected. Chart review was performed to identify patient demographics, comorbidities, pain management, and postoperative complications, which were classified as minor (infection requiring antibiotics) or major (return to OR for revision, deep infection). FP in patients with a complication was compared to patients who did not experience a complication. In addition, the Foot and Ankle Outcomes Score (FAOS), satisfaction, and Delighted-Terrible scale (how they would feel if asked to spend the rest of their life with their current foot/ankle symptom) were collected at final follow-up. Results: Of the 271 patients (mean age 55.4 years, 65% female), 31 (11.4%, mean age 53.6, 58% female) had a postoperative complication: 25 major (19 revisions, 6 deep infections requiring I&D), 4 minor (4 superficial infections requiring antibiotics), and 2 major and minor (revision and superficial infection). Average time from complication to completion of fulfilment survey was 15 (+- 3.6) months. The groups were similar in diagnoses. Complications were associated with significantly worse FP (0.69 +- 0.45 vs 0.86 +- 0.40, p=0.02). Having a complication significantly correlated with worse satisfaction, Delighted-Terrible scale, and FP (p

Category: Basic Sciences/Biologics; Hindfoot Introduction/Purpose: Progressive collapsing foot deformity (PCFD) is a 3-dimensional pathology associated with insufficiency of the posterior tibial tendon (PTT), ligamentous failure, joint malalignment, and aberrant plantar force distribution. Existing knowledge of PCFD consists of static measurements, which provide information about the structure of the foot but none about its function. Cadaveric gait models provide an opportunity to measure motion both at the joints primarily affected in PCFD and the adjacent joints that are at risk for progressive subluxation and arthritis. This study sought to develop a flatfoot model for a robotic gait simulator and quantify gait kinematics and plantar pressure between normal and flatfoot conditions, which we hypothesized would be altered after the creation of a flatfoot deformity model. Methods: Cadaveric specimens were loaded on a 6-degree of freedom robotic gait simulator and the extrinsic tendons were attached to linear motors. Ground reaction forces and muscle forces were optimized utilizing an established iterative process. An 8-camera motion capture system was utilized to calculate joint kinematics using reflective markers attached by k-wires into bone. A plantar pressure mat attached to the force platform was used to calculate the center of pressure excursion index (CPEI) for each condition. The flatfoot model was created via sectioning of the spring ligament and medial talonavicular joint capsule followed by cyclic axial compression until 5-15° of talonavicular abduction was achieved in a static, loaded pose. Testing of the flatfoot state was then performed with inactivation of the PTT. Bias-corrected bootstrapped 95% confidence intervals were constructed from the repeated measures difference between flatfoot and normal conditions. Paired t-tests were used to compare the CPEI between conditions. Results: Twelve mid-tibia cadaveric specimens (mean age 73 years, 8 female) with no prior foot/ankle surgery were used. There were significant differences in kinematics between normal and PCFD conditions at the ankle, subtalar, and talonavicular joints (Figure). There was significantly increased ankle plantar flexion in flatfoot in the first 80% of stance phase. There was significantly greater subtalar eversion in flatfoot compared to normal from 10-90% of stance phase. Talonavicular abduction and eversion were also significantly greater in flatfoot from 10-100% of stance. The CPEI was significantly decreased in the flatfoot condition (Figure), indicating a medialization in center of pressure (p

Category: Basic Sciences/Biologics; Hindfoot Introduction/Purpose: Progressive collapsing foot deformity (PCFD) is a complex 3-dimensional pathology with a wide variety of surgical treatments. Regardless of technique, operative management of PCFD aims to restore normal foot architecture with attention to avoid the consequences of under- or over-correction. However, current methods of evaluating PCFD correction rely on static measurements, which do not assess dynamic function of the foot. Recent advances in robotic technology allow for the dynamic assessment of surgical correction of PCFD. This study sought to assess the effects of 2 osteotomies for PCFD, the medializing calcaneal osteotomy (MCO) and lateral column lengthening (LCL), on kinematics and plantar pressure during simulated gait. We hypothesized that the combination of LCL and MCO would restore joint kinematics and plantar pressure values to normal levels. Methods: Twelve cadaveric mid-tibia specimens (mean age 73 years, 8 female) were loaded on a 6-degree of freedom robotic gait simulator. Ground reaction forces and muscle forces were optimized utilizing an established iterative process. An 8-camera motion capture system was utilized to calculate joint kinematics using reflective markers attached by k-wires into bone. Plantar pressures were recorded using a pedography mat attached to the force platform. Testing was performed first in the native intact state, and again after creation of the flatfoot model. After flatfoot testing, surgical reconstruction and testing were performed in stages with MCO, and LCL with sequential 6mm and 8mm grafts. Bias-corrected bootstrapped 95% confidence intervals were calculated from the repeated measures difference between normal, flatfoot, post-MCO, post-MCO and post-reconstructive conditions. Center of plantar pressure excursion index (CPEI) was calculated and compared between conditions using a repeated measures ANOVA with Tukey post hoc analysis. Results: Overall, surgical correction restored kinematics to normal levels (Figure). MCO alone resulted in statistically significant improvement in subtalar eversion in the first 20% of stance, and post-MCO subtalar kinematics were statistically similar to normal. LCL (either 6mm and 8mm) alone did not significantly correct talonavicular abduction after PCFD. However, in conjunction with MCO, LCL was able to significantly correct talonavicular kinematics throughout the majority of stance phase, with kinematics statistically similar to normal levels. Each surgical step (LCL 6mm, LCL 8mm, MCO) resulted in sequential lateralization of the center of plantar pressure. At the culmination of surgical reconstruction (MCO + LCL), plantar pressure was significantly corrected compared to PCFD (P

Category: Ankle; Ankle Arthritis; Arthroscopy; Basic Sciences/Biologics; Bunion; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports; Trauma; Other Introduction/Purpose: Patients’ expectations - and whether they are met - are an integral component of orthopaedic foot and ankle surgery. An expectations survey has been developed and validated to quantify patients’ expectations preoperatively and the fulfillment of those expectations postoperatively. The fulfillment of expectations correlates highly with perceived improvement, outcomes scores, and overall satisfaction with surgery, both in foot and ankle surgery and across orthopaedic subspecialties. Yet unlike other orthopaedic specialties, foot and ankle contains an inherently wide variety of patient diagnoses and procedures. This study sought to identify the effect of foot and ankle diagnosis on postoperative outcomes in terms of the extent to which expectations are fulfilled. We hypothesized that the fulfillment of expectations would vary with diagnosis. Methods: This is a prospective single-center study of adult patients undergoing elective foot and ankle surgery. Preoperatively, all patients completed the validated Expectations Survey (range 0-100, with 100 indicating maximum expectations), which asks about anticipated improvement in items like pain, ambulation, function, and more generalized items like ‘going back to normal.’ Two years postoperatively, patients noted how much improvement (none, a little, moderate, a lot, or complete) actually attained for each item cited preoperatively. This allowed for calculation of a ‘Fulfillment Proportion (FP),’ a numerical representation of whether each patient’s expectations were unmet (FP=0), partially met (FP 0-1), met as expected (FP=1), or surpassed (FP>1). FP was compared across diagnoses, and bivariate analysis between diagnoses and expectation fulfillment was performed using ordinal regression. Multivariate ordinal regression was then used to analyze the effect of diagnosis, clinical variables, and preoperative expectations on expectation fulfillment. Results: 271 of 340 (80%) patients had both preoperative and 2-year postoperative expectations data. Mean age was 55.4 years, mean BMI was 27.5 kg/m2, and 65% were female. Patients with diagnoses of midfoot/hindfoot arthritis (FP 0.68 +- .46) and neuroma (FP 0.69 +- .89) had the lowest proportion of expectations fulfilled (Table). Conversely, ankle arthritis patients had the highest proportion of expectations fulfilled (FP 0.94 +- .41). In multivariate regression analysis, diagnosis and preoperative expectations scores were significant independent predictors of low expectation fulfillment. Despite having lower preoperative expectations, neuroma patients were 5 times more likely (95% CI 1.5-14.6, p=.008) and midfoot/hindfoot arthritis patients were 3 times more likely (95% CI 1.3-8.5, p= .013) to have unfulfilled expectations. Conclusion: In orthopaedic foot and ankle surgery, the fulfillment of expectations varies with preoperative diagnosis. Patients with diagnoses of midfoot/hindfoot arthritis and neuroma were significantly more likely to have lower proportions of expectations fulfilled. Although the exact causes are unknown, possible explanations include the need for subsequent procedures, continued need for orthotics, progression of arthritis to adjacent joints in midfoot/hindfoot arthritis patients, and recurrent or residual symptoms in neuroma patients. Preoperatively, surgeons should emphasize the risks of surgery as well as the importance of realistic expectations in these patients in order to optimize their outcomes postoperatively.

Category: Other Introduction/Purpose: In foot and ankle surgery, the fulfillment of patients’ preoperative expectations is a unique and validated method to assess postoperative success. Expectation fulfillment is closely associated with postoperative outcomes, satisfaction, and patient-reported improvement. Ideally, foot and ankle patients should have realistic expectations of surgery so that they are appropriately prepared for their postoperative symptoms and function. Inappropriately high expectations may predispose to worse outcomes because patients have unrealistic views about what their surgery can actually accomplish. Conversely, inappropriately low expectations may represent a lack of motivation to improve or participate in rehabilitation and postoperative protocols. This study aimed to identify the relationship between preoperative expectations and postoperative fulfillment. These results may facilitate surgeon-patient communication and help patients prepare for their operation and their postoperative function. Methods: Adult patients undergoing elective foot and ankle surgery at a single center were prospectively enrolled. Demographics, diagnosis, and outcomes surveys (Short Form [SF]-12, Foot & Ankle Outcome Score, improvement, satisfaction) were collected. Preoperatively, each patient completed the Expectations Survey (range 0-100, with 100 indicating maximum expectations), which asks about anticipated improvement in domains like pain, ambulation, function, and shoewear. Two years after surgery, for each expectation cited preoperatively, patients answered how much improvement they actually achieved. Using a ratio of the postoperative and preoperative scores, a Fulfillment Proportion (FP) was calculated, along with the minimal clinically important difference (MCID). This permitted identification of patients with unfulfilled, fulfilled, and surpassed expectations. Bivariate correlations, chi-square analyses, and multivariate regressions with 95% confidence intervals (CI) were performed to identify the relationship between preoperative expectations, clinical variables, and postoperative expectation fulfillment. Results: There were 271/340 (80%) patients with 2-year follow-up, with mean age 55.4 years and 65% female. Most common diagnoses were hallux valgus (25%), flatfoot (11%), hallux rigidus (11%), ankle arthritis (10%), and chronic tendon injury (9%). Expectation fulfillment differed significantly with extent of preoperative expectations (Figure). Patients with average/high expectations had higher rates of unfulfillment compared to patients with low preoperative expectations (40-41% vs. 22%). Rates of surpassed expectations were highest in patients with low preoperative expectations (23%) compared to average (12%) or high (0%) preoperative expectations (p

Category: Other Introduction/Purpose: Fulfillment of patients’ expectations following foot and ankle surgery has been previously studied and validated in assessing patient-reported outcomes (PROs). While this assessment has been shown to correlate well with patient satisfaction and PROs, the impact of postoperative complications on fulfillment of expectations is unknown. The aim of this study is to therefore investigate the impact of postoperative complications on fulfillment of patients’ expectations. Methods: Preoperatively, patients completed a validated Foot and Ankle expectations survey consisting of 23 questions encompassing domains including pain, ambulation, daily function, exercise, and shoe wear. At 2 years postoperatively, patients answered how much improvement they received for each item cited preoperatively. A fulfillment proportion (FP) was calculated as the amount of improvement received versus the amount of improvement expected. The FP ranges from 0 (no expectations fulfilled), between 0 and 1 (expectations partially fulfilled), 1 (expectations met), to greater than 1 (expectations surpassed). In addition, patient-reported outcomes (FAOS), satisfaction, and Delighted-Terrible scale (how they would feel if asked to spend the rest of their life with their current foot/ankle symptom) were collected at final follow-up. Chart review was performed to identify patient demographics, comorbidities, pain management, and postoperative complications, which were classified as minor (infection requiring antibiotics) or major (unplanned return to OR, reoperation, or revision). Results: Of the 271 patients (mean age 55.4 years, 65% female), 31 (11.4%, mean age 53.6, 58% female) had a postoperative complication; 27 major (17 revisions, 10 removal of hardware due to pain/infection) and 6 minor (6 superficial infections requiring antibiotics). Complications were associated with significantly worse FP (0.69 +- 0.45 vs 0.86 +- 0.40, p=0.02). Average time from complication to completion of fulfillment survey was 15 (+-3.6) months. Having a complication significantly correlated with worse satisfaction, Delighted-Terrible scale, and FP (p

Category: Other Introduction/Purpose: Aligning patient and surgeon expectations is important, as it allows for informed and shared decision- making and may improve postoperative satisfaction. Patient-provider communication factors have been found to affect differences between patient and surgeon expectations of total knee arthroplasty. Patients with limited health literacy have been found to ask fewer questions and spend less time with their surgeons, and to perceive themselves to have a more passive decision-making role in hand surgery clinic visits. Understanding how these factors affect differences in expectations of foot and ankle surgery is important in order to increase patient-surgeon agreement. This study aimed to assess associations between patient-reported physical and mental status, patient-surgeon communication factors, and musculoskeletal health literacy with differences between patient and surgeon expectations of foot and ankle surgery. Methods: Two hundred two patients scheduled to undergo foot or ankle surgery by one of seven fellowship-trained foot and ankle surgeons at an academic hospital were enrolled. Preoperatively, patients and surgeons completed the Hospital for Special Surgery Foot & Ankle Surgery Expectations Survey independently. Patients also completed Patient-Reported Outcomes Measurement Information System (PROMIS) scores in Physical Function, Pain Interference, Pain Intensity, Depression, and Global Health. Patient involvement in care, provider partnership building, and provider information giving were assessed with the modified Patients’ Perceived Involvement in Care Scale (PICS). Musculoskeletal health literacy was assessed with the Literacy in Musculoskeletal Problems (LiMP) questionnaire. A score >= 6 reflects adequate musculoskeletal literacy and a score < 6 reflects limited musculoskeletal literacy. Associations between scores and differences between patient and surgeon expectations were assessed with Pearson Correlation coefficients. Associations between musculoskeletal health literacy and differences were assessed with Student’s t-tests and Mann Whitney U tests. Results: Greater differences in patient and surgeon overall expectations scores were associated with worse PROMIS scores in Physical Function (p = 0.003), Pain Interference (p = 0.001), Pain Intensity (p = 0.009), Global Physical Health (p < 0.001), and Depression (p = 0.009). A greater difference in the number of expectations between patients and surgeons was associated with all of the above (p = 0.155). Conclusion: Worse baseline patient physical and mental status and higher patient perceptions of provider partnership building were associated with greater patient to surgeon differences in expectations of foot and ankle surgery. It may be beneficial for surgeons to set more realistic expectations with patients who have greater disability and in those whom they have stronger partnerships with in order to increase agreement in expectations. Further studies are warranted to understand how modifications in patient and surgeon interactions affect agreement in their expectations of foot and ankle surgery, and whether musculoskeletal literacy affects these interactions.

Background: Hallux rigidus (HR) is a common pathology of the first metatarsophalangeal (MTP) joint causing pain and stiffness. However, severity of symptoms and radiographic findings are not always concordant. A novel flexibility device, which measures the mobility of the MTP joint through its arc of motion, has been validated. This study compares flexibility in patients before and after cheilectomy (with or without proximal phalanx osteotomy) for HR. Methods: This is a single-center study of adult patients with HR who were indicated for cheilectomy or cheilectomy and Moberg (dorsiflexion closing wedge) osteotomy of the proximal phalanx based on symptoms and radiographs from 2013 to 2015. Pre- and postoperatively, patients underwent testing with a validated flexibility protocol to generate flexibility curves. Parameters included early and late flexibility, laxity torque, and laxity angle. Patients completed Foot and Ankle Outcomes Scores (FAOS) pre- and postoperatively. Twelve operative patients underwent preoperative testing, with 9 completing postoperative testing (mean age, 53.0 years; 67% female; mean 2.8-year follow-up). Results: Patients had significant improvements in early sitting and standing flexibility, sitting and standing laxity angles, standing laxity torque, and both sitting and standing maximum dorsiflexion after surgery (all P < .05). While preoperative early flexibility, laxity angle, and maximum dorsiflexion all differed significantly between patients and controls ( P < .015), postoperative early flexibility was similar to controls ( P > .279). FAOS scores for pain, symptoms, sport, and quality improved significantly after surgery. Conclusion: Surgical treatment with cheilectomy was associated with significant improvements in nearly all flexibility parameters for sitting and standing positions. However, most postoperative flexibility parameters did not improve to the level of normal controls. Regardless, patients still experienced significant improvements in outcomes. This study demonstrated that surgical correction is associated with significant biomechanical and clinical results. The flexibility device can be used in further studies to assess outcomes after other HR procedures. Level of Evidence: Level II, prospective comparative study.

Category: Ankle, Ankle Arthritis, Bunion, Hindfoot, Lesser Toes, Midfoot/Forefoot, Sports, General foot/ankle elective procedures, outcomes Introduction/Purpose: The setting and fulfillment of expectations represent a unique aspect of patient-reported outcomes that is closely associated with satisfaction. Within foot and ankle surgery, patients may expect improvement in pain, mobility, shoe wear, and function in daily life, whether in basic activities or exercise/sports. Within foot and ankle surgery, a 23-item expectation survey has been developed based on patient responses and validated in patients undergoing elective surgery. However, to date, postoperative fulfillment of expectations has not been reported. This study aimed to describe overall rates of expectation fulfillment as well as fulfillment among specific domains. We hypothesized that patients would have the most improvement in pain and ambulation items, with greater rates of unfilled expectations for generalized items like improving confidence and returning to normal. Methods: This is a single-center study of adult patients undergoing elective foot/ankle surgery with 2-year follow-up. Demographic and clinical data were collected along with pre/postoperative Foot and Ankle Outcomes (FAOS) scores. Preoperatively, patients completed the expectations survey, citing the amount of improvement anticipated for each item using Likert-style responses. At 2 years postoperatively, patients repeated the survey, responding with the amount of improvement actually achieved. The total scores for the preoperative and postoperative surveys were used to create a ratio representing the proportion of expectations fulfilled (1: expectations surpassed), which was analyzed with descriptive statistics. Responses for each item (pre/postoperatively) were also assessed. Responses of “moderate,” ”a lot,” or “complete” were considered fulfilled, while ”little” or “no” indicated not fulfilled. FAOS scores were compared from baseline to follow-up using paired t-tests. Results: There were 271 patients (mean age 55.4, BMI 27.5, 65% female). Most common diagnoses were hallux valgus (25%), flatfoot (11%), hallux rigidus (11%), ankle arthritis (10%), and chronic tendon injury (9%). Patients had significant improvement in all FAOS domains (P

Category: Ankle, Ankle Arthritis, Arthroscopy, Bunion, Hindfoot, Midfoot/Forefoot, Sports, Trauma Introduction/Purpose: Depression and anxiety are increasingly recognized to have a dramatic impact on patients with musculoskeletal pathologies. They complicate treatment due to complex relationships between pain, function, and affective symptoms. Depression/anxiety can cause social isolation, attention towards painful symptoms, and avoidance of physical exertion, all which may affect patient outcomes in orthopaedic surgery. Prior work has demonstrated that patients with depression/anxiety have greater preoperative expectations of foot/ankle surgery. However, no study to date has investigated the effect depression/anxiety on fulfillment of expectations and patient satisfaction postoperatively. We hypothesized that patients with preoperative depression or anxiety symptoms would have lower rates of expectation fulfillment than patients without affective disorders, particularly for expectations of pain relief and going back to normal. Methods: Patients undergoing elective foot/ankle surgery at a single center were prospectively enrolled. Demographics, diagnoses, and preoperative Foot and Ankle Outcomes Scores (FAOS) were collected. Preoperatively, patients completed an expectations survey, which asks about anticipated improvement in items including pain control, ambulation, function, and more generalized items like going back to normal and preventing foot/ankle pathology from worsening. Depression and anxiety were assessed using the Patient Health Questionnaire (PHQ-8) and Generalized Anxiety Disorder screener (GAD-7) respectively; for both surveys, scores of 10 or more were used to designate depression and anxiety. Patients repeated the expectations survey 2 years postoperatively, answering how much improvement was actually attained for each item. Patients also reported satisfaction with surgery, perception of overall improvement, extent to which expectations were fulfilled, and answered the Delighted- Terrible scale. Survey responses were compared between patients with depression and/or anxiety (D/A) and no D/A patients using t-tests and Chi-square analyses (p0.225). D/A patients had significantly less expectation fulfillment for ambulation tolerance (77% vs 90%, p=0.017), improving confidence in foot/ankle (77% vs 88%, p=0.049), and going back to normal (76% vs 87%, p=0.043). D/A patients were significantly more dissatisfied (21% vs 9%, p=0.013), had less perceived improvement, and were less likely to want to repeat surgery (p=0.019) or recommend surgery to someone else (p=0.017). Conclusion: D/A patients had significantly lower postoperative rates of overall perceived improvement and satisfaction with surgery compared to patients without affective symptoms. A majority of D/A patients did not meet their expectations for ambulation tolerance, confidence, and returning to normal. However, despite having worse baseline outcomes scores and more preoperative expectations, patients with depression/anxiety had similar improvements in FAOS and proportions of expectations fulfilled postoperatively. Therefore, despite perceived poor outcomes, D/A patients have similar improvements in outcomes and expectation fulfillment. These findings may improve surgeon/patient communication and management of expectations.

Category: Ankle, Ankle Arthritis, Arthroscopy, Bunion, Hindfoot, Lesser Toes, Midfoot/Forefoot, Sports, General Foot/Ankle, Outcomes, Satisfaction Introduction/Purpose: Success in orthopaedic surgery was traditionally defined by postoperative radiographs or legacy outcomes scores, but increasingly incorporates more patient-centered metrics. Patient expectations are one such measure, and have been described using a new validated survey for foot/ankle patients. Understanding patients’ expectations of surgery is critical in order to facilitate shared decision-making and set reasonable goals for outcomes. In other specialties, postoperative expectations surveys have also been created and shown to correlate with measures of satisfaction and traditional patient-reported outcomes scores. However, there are no such studies in the foot and ankle literature. This study aimed to validate a method of assessing expectation fulfillment in foot/ankle patients postoperatively. We hypothesized that the survey would significantly correlate with measures of improvement, satisfaction, and clinical outcomes scores. Methods: This is a single-center prospective study of patients undergoing elective foot and ankle procedures. Preoperative demographics, clinical data, and Foot & Ankle Outcomes Score (FAOS) were collected. Patients completed the expectations survey, consisting of 23 questions for domains including pain, ambulation, daily functioning, exercise/sports, shoe wear, and generalized items like “improving confidence in foot/ankle” and ”going back to normal.” Postoperatively, patients answered how much improvement they received for each item listed on the preoperative survey. Using previously validated methods, the proportion of expectations fulfilled was calculated as a ratio of the preoperative to postoperative expectations score, with values of 0 -1 indicating some expectations met, 1 indicating expectations met; and >1 indicating expectations surpassed. Receiver operator characteristic (ROC) curves and areas under the curve (AUC) with 95% confidence intervals (CI) were used to compare the expectations survey to other outcomes scales, including FAOS, perceived improvement, overall fulfillment, Delighted-Terrible scale, and satisfaction. Results: 271/340 (80%) of patients with preoperative data completed 2-year follow-up (mean age 55.4 years, mean BMI 27.5, 65% female). Most common diagnoses were hallux valgus (25%), flatfoot (11%), hallux rigidus (11%), and ankle arthritis (10%). Mean proportion of expectations fulfilled was 1.15, indicating surpassed expectations. The proportion of expectations fulfilled correlated best with perceived improvement, global expectation fulfillment, and the Delighted-Terrible scale, and to a lesser degree with satisfaction and change in FAOS (all except activity). Based on the inflection point of the ROC curves corresponding to greatest AUC (Table), a clinically important proportion of expectations fulfilled was 0.81 and correlated with feeling delighted (sensitivity 0.88, specificity 0.85), improvement (sensitivity 0.89, specificity 0.83), overall expectations (sensitivity 0.91, specificity 0.81), and satisfaction (sensitivity 0.85, specificity 0.81). Conclusion: The proportion of expectations fulfilled is a valid outcome tool for foot and ankle surgery. It is uniquely able to capture pre- and postoperative data in one value and can be tailored to each patient’s specific goals. This survey can be used by surgeons after a variety of procedures to assess if a patient’s specific expectations have been fulfilled after surgery. We can use this tool to assess which patient and surgical factors may influence the fulfillment of expectations. This, in turn, will help surgeons better indicate the appropriate procedure in the optimal patient to achieve the greatest postoperative success.

Adult-acquired flatfoot deformity (AAFD) comprises a wide spectrum of ligament and tendon failure that may result in significant deformity and disability. It is often associated with posterior tibial tendon deficiency (PTTD), which has been linked to multiple demographic factors, medical comorbidities, and genetic processes. AAFD is classified using stages I through IV. Nonoperative treatment modalities should always be attempted first and often provide resolution in stages I and II. Stage II, consisting of a wide range of flexible deformities, is typically treated operatively with a combination of soft tissue procedures and osteotomies. Stage III, which is characterized by a rigid flatfoot, typically warrants triple arthrodesis. Stage IV, where the flatfoot deformity involves the ankle joint, is treated with ankle arthrodesis or ankle arthroplasty with or without deltoid ligament reconstruction along with procedures to restore alignment of the foot. There is limited evidence as to the optimal procedure; thus, the surgical indications and techniques continue to be researched.