Search

Introduction/Purpose: Minimally invasive dorsal cheilectomy (MIDC) has become a popular alternative to an open approach for treating Hallux Rigidus, although the current literature is divided on its effectiveness regarding complications and patient reported outcomes. To combat a portion of the complications related to the MIDC approach, a first metatarsophalangeal (MTP) joint arthroscopy can often be added to the procedure. The combined procedure has been demonstrated to be effective at improving patient reported outcomes without increasing the complication rate relative to an open procedure. This study looks to examine the effectiveness of the MIDC with first MTP arthroscopy procedure in patients with hallux rigidus with minimum 1 year follow up. Methods: This was a multicenter retrospective review was conducted for adult patients treated with MIDC and first MTP arthroscopy between 3/1/2020 and 8/1/2022, with at least one year of postoperative follow-up data. Patient charts were reviewed for demographic information, operative time, pre and postoperative first MTP range of motion (ROM), visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOXFQ), and EQ5DLD scores. Continuous data was expressed as a mean and standard deviation, categorical data was expressed as a percentage. Wilcoxon Rank Sum test was used to compare continuous variables. All P < 0.05 was considered significant. Results: A total of 31 patients were included in the study with an average follow-up time of 16.5 months (range: 12 to 26.2). There was 1 (3.2%) complication of an underservice EHL tendon tear, 2 (6.5%) patients were converted to a MTP fusion, and 1 (3.2%) patient underwent revision cheilectomy and capsular release for MTP joint contracture. There was a significant improvement in patient’s ROM in dorsiflexion (50 vs 89.6 degrees, P=0.002), but not in plantarflexion (11.3 vs 18.6 degrees, P=0.07). There was a significant improvement in patient’s postoperative VAS pain scores (6.4 vs 2.1, P< 0.001), MOXFQ pain scores (58.1 vs 30.7, P=0.001), MOXFQ Walking/Standing scores (56.6 vs 20.6, P=0.001), MOXFQ Social Interaction scores (47.3 vs 19.36, P=0.002), and MOXFQ Index scores (54.7 vs 22.4, P< 0.001). Conclusion: We found that MIDC with first MTP arthroscopy was effective at improving patient reported outcomes, specifically patient’s pain scores, at one year with low complication and revision rates. These results demonstrate MIDC and first MTP arthroscopy’s is an effective treatment for early-stage hallux rigidus and may be considered as an alternative to an open approach.

Introduction/Purpose: Insertional Achilles tendinopathy (IAT) is a common source of posterior heel pain treated by orthopaedic foot and ankle surgeons. Traditional surgical treatment consists of an open Achilles tendon debridement with re-attachment as well as excision of the posterosuperior calcaneal prominence with or without a gastrocnemius recession. However, frequent complications include wound healing issue, scar pain, weakness and sural nerve injury. Accordingly, the percutaneous ZO is gaining popularity in the field as an alternative to an open midline splitting approach. Limited literature exists describing outcomes of the percutaneous ZO using a larger sample size. The purpose of this study was to analyze patient reported outcomes and complications after percutaneous ZO with a minimum two-year follow-up period. Methods: One hundred and eight cases treated with percutaneous ZO were retrospectively reviewed across October 2017-July 2021 and outcomes data was available for 104 cases with a minimum two-year follow-up. Patient sex, age, and pertinent comorbidities were recorded. Postoperative complications and patient satisfaction following intervention were evaluated. Foot Function Index score (FFI) was utilized to measure patients’ pain and functional outcomes. Visual Analyzing Scale score (VAS) was also utilized to evaluate pain. These measurements were taken at preoperative and final follow-up. Statistical comparisons were performed using two-tailed, paired t-test with p< 0.05. Results: Mean follow-up time was 41.2±13.1 months (range 24-65 months). The mean FFI score improved from 56.1±5.9 (range 47-88) preoperatively to 11.0±5.1 (range 7-59) postoperatively (p < 0.001). Average VAS score improved in patients receiving percutaneous ZO from 7.6±1.3 (range 5-10) to 0.4±0.9 (range 0-7) postoperatively (p < 0.001). The overall complication rate was 3.8% (N =4). Of 104 cases, 98.1% of patients were satisfied with their procedure (102/104). Conclusion: The percutaneous ZO is a safe and highly effective intervention for treatment of IAT. At a minimum of two-years follow-up, this intervention is associated with minimal complications, improved functional outcomes, reduced pain, and high patient satisfaction. Table 1 Functional and subjective pain preoperative and postoperative scores as evaluated by functional foot index (FFI) and visual analogue scale (VAS), respectively

Introduction/Purpose: Evidence in the literature suggests the negative effects of using High Heels (HH), becoming a challenge for clinicians and researchers since they are welcomed by women worldwide, mainly due to the subjective power of attractiveness given to them. Although some people blame HH as one of the causes of Hallux Valgus (HV), until now, there are no studies in the literature that effectively prove a cause-effect relationship between HH and HV. The objectives of this study are: (1) to analyze whether the increase in heel height can lead to HV and (2) to evaluate whether HV can increase in severity with increasing heels. We hypothesized that an increase in heel height could cause and increase the severity of HV deformity. Methods: Comparative cross-sectional study. Forty-one feet from twenty-one participants (11 males and 10 females, aged 30.8 ± 8.9 years, and with Body Mass Index 25.5 ± 2.0 m kg2) were recruited. HH shoes were designed for this study with three heights for each participant: 3, 6, and 9 cm. The inclusion criteria were: no regular wearing of heels. The exclusion criteria were: Hallux Valgus diagnosis and/or any orthopedic conditions that affect the Foot and Ankle joints. Hallux Valgus Angle (HVA), Intermetatarsal Angle (IMA), First-Metatarsal Phalangeal Angle, 1st-to-5th Intermetatarsal Angle, First Tarsometatarsal Angle (axial), Second tarsometatarsal angle (axial), Hindfoot Moment Arm (HMA) (mm), Saltzman 45 angle and, Foot Ankle Offset (FAO) were measurement using semiautomated software analysis. Multiple comparisons were performed (Bonferroni's for normal distributions and Wilcoxon test for no normal distributions) when there was a main effect on an outcome (p < 0.05). Results: With the increase in HH, we noticed a progressive increase in HVA (p < 0.001), IMA (p < 0.001), First-Metatarsal Phalangeal Angle (p < 0.001), First Tarsometatarsal Angle (axial) (p < 0.001), and the Second tarsometatarsal angle (axial) (p < 0.001). The Hindfoot Moment Arm (HMA) (mm), Saltzman 45 angle, and Foot Ankle Offset (FAO) had hindfoot varization behavior. When we stratified the groups and compared them, we noticed that an increase of 3 cm in heels slightly increased HVA and IMA (p > 0.05). However, heel increases above 6 cm significantly increased HVA and IMA (p > 0.001). Based on Coughlin's classification, a 3 cm heel increase promoted a mild HV and increases above 6 cm caused a moderate HV. Conclusion: Based on data from our study with patients without Hallux Valgus through analysis with WBCT versus high heels, we conclude that increasing heel height can lead to Hallux Valgus and can progressively increase the severity with increasing high heels. High heels above 6 cm can lead to moderate Hallux Valgus. These findings may be an essential step toward a better understanding of the effects of increasing high heels on Hallux Valgus pathology.

Background: Hallux rigidus (HR) is a common source of forefoot pain and disability. For those who fail nonoperative treatment, minimally invasive dorsal cheilectomy (MIDC) is an increasingly popular alternative to the open approach with early positive results. Early failures may be due to lose bone debris from the MIDC as well as other intra-articular pathology that cannot be addressed with MIDC alone. Metatarsophalangeal (MTP) arthroscopy can be used in addition to MIDC to assess the joint after MIDC and address any intra-articular pathology while still maintaining the benefits of minimally invasive surgery. We report our clinical outcomes following MIDC combined with MTP arthroscopy. Methods: From November 2017 to July 2020, a retrospective analysis of all MIDC cheilectomies with MTP arthroscopy performed by the 2 senior authors was done. Wound complications, infections, revision rates, need for future surgery, conversion to fusion rates, pre- and postoperative range of motion, visual analog scale (VAS) scores, time to return to normal shoe, intraoperative arthroscopic findings, and operative time were collected. Follow-up average was 16.5 months (range 3-33 months). Results: A total of 20 patients were included with an average follow-up of 16.5 months. The average VAS score improved from 7.05 preoperatively to 0.75 postoperatively ( P < .05). Average range of motion in dorsiflexion increased from 32 to 48 degrees ( P < .05) and plantarflexion increased from 15 to 19 degrees plantarflexion ( P < .05). All patients were weightbearing as tolerated immediately after surgery in a postoperative shoe and transitioned to a regular shoe at average of 2.1 weeks. We had no wound infections, wound complications, revision surgeries, tendon injuries or nerve damage. One patient required conversion to a fusion 3 years after the index procedure. Average tourniquet time was 30.39 minutes (range 17-60 minutes) and total average operating room time was 59.7 minutes (range 40-87 minutes). On arthroscopic evaluation of the MTP joint after MIDC, 100% of patients had bone debris, 100% had synovitis, 10% had loose bodies, and 30% had large cartilage flaps within the joint. Conclusion: MIDC and first MTP joint arthroscopy for treatment of hallux rigidus provide improved pain relief with minimal complications while still maintaining the benefits touted for minimally invasive operative procedures. Additionally, we have shown a high rate of intra-articular debris along with intra-articular pathology such as synovitis, loose chondral flaps, and loose bodies that exist after MIDC. This combined procedure has the potential for improving patient outcomes and may minimize risk of future revision surgeries compared with MIDC alone. Level of Evidence: Level IV, case series study.

Calcaneal fractures are the most common fracture of the tarsal bones and represent 1% to 2% of all fractures. Roughly 75% of these fractures include intra-articular involvement of the posterior facet of the calcaneus. Intra-articular calcaneal fractures are challenging injuries to manage for both patients and surgeons given their association with both early and late complications. This article aims to review the management, classification systems, surgical approaches, and care regarding intra-articular calcaneal fractures. A review of the current literature yielded treatment strategies that aim to reduce complications such as soft tissue injury or loss of articular reduction while maintaining satisfactory clinical outcomes. The purpose of this article is to review these current concepts in the management of intra-articular calcaneal fractures. Level of Evidence: Level V, expert opinion.

Background: The objective of this study was to define the volume (mLs) needed for a positive saline load challenge test in anterolateral (AL), anteromedial (AM), posterolateral (PL), or posteromedial (PM) ankle arthrotomy wounds using normal saline (NS) and methylene blue (MB). Another objective was to evaluate the use of fluoroscopy and iodinated contrast in the diagnosis of ankle arthrotomies. Methods: Four cadaveric ankle specimens underwent standardized arthrotomy creation in either the AL, AM, PL, or PM portion of each specimen. An 18-gauge needle was used to inject fluid into each ankle, and the volumes needed for positive fluid challenges were recorded. All 4 ankles were tested 10 times (n = 40) with NS and 10 times using MB (n = 40). A fifth cadaveric ankle was injected with radiopaque contrast solution, and an arthrotomy was simulated and imaged with fluoroscopy.Statistical analyses compared the volumes of NS and MB needed for a positive test. In addition, the 25th, 50th, 75th, 90th, and 95th percentiles of volumes needed for a positive test was calculated. Results: The volume of fluid necessary to detect 25%, 50%, 75%, 90%, and 95% of ankle arthrotomies from any site was 2.0 mL, 4.5 mL, 9.0 mL, 10 mL, and 10 mL, respectively. Anterior arthrotomies required less fluid (2.1 mL ± 0.5) than posterior arthrotomies (9.0 mL ± 1.2) for a positive test ( P < .0001). There was no difference between the amount of NS (5.5 mL ± 3.6) vs MB (5.6 mL ± 3.7) needed for a positive challenge test ( P = .739). Conclusion: Ninety-five percent of ankle arthrotomies could be diagnosed with 10 mL of injected fluid; there was no difference between the volume of NS vs MB needed. Fluoroscopy assisted with needle placement and can be combined with radiopaque contrast solution to diagnose ankle arthrotomies. Clinical Relevance: The findings of this study may improve sensitivity and efficiency in the diagnosis of traumatic ankle arthrotomies, for which there is currently a paucity of literature.

Category: Ankle Introduction/Purpose: Obesity is a public health concern in the United States, with an overall prevalence of greater than one-third. From a surgical perspective, obesity may increase risk for postoperative complications, including delayed wound healing, infection or compromise of fixation/repair constructs. The purpose of this study was to retrospectively review outcomes data from the American College of Surgeons: National Surgical Quality Improvement Program (NSQIP) to delineate the impact that obesity has on operative treatment of ankle fractures. Methods: Perioperative data was collected from patients undergoing operative intervention for distal fibular or bimalleolar ankle injuries. Patients were identified from the 2006-2015 NSQIP database using current procedural terminology (CPT) codes. Obese (body mass index>30 kg/m2) and non-obese (body mass index

Category: Trauma Introduction/Purpose: Diabetes mellitus is an epidemic affecting millions of individuals in the United States. This presents a challenging clinical problem from a surgical perspective, because of concerns for postoperative complications, including delayed wound healing, infection or compromise of fixation/repair constructs. The goal of this paper was to retrospectively review outcomes data from the American College of Surgeons: National Surgical Quality Improvement Program (ACS-NSQIP) to delineate more clearly the impact that diabetes has on operative treatment of ankle fractures, including bimalleolar and lateral malleolar injuries. Methods: Patients were identified from the 2006-2015 ACS-NSQIP database. Diabetic and non-diabetic cohorts were evaluated to compare demographics, comorbidities, perioperative details and 30-day outcomes. Univariate analysis was performed using chi-squared or Fisher’s exact and Wilcoxon signed-rank tests. A multivariate logistic regression model was created to identify independent risk factors for complications. Odds ratios were computed at the 95% confidence interval. Results: There were a total of 3745 (bimalleolar injuries [1579], lateral malleolar injuries [2166]) patients identified. With regard to treatment of distal fibular or bimalleolar injuries, diabetic patients were more likely to have a longer length of hospital stay (p < 0.05). Based on multivariate analysis, diabetic patients undergoing operative fixation of bimalleolar injuries are at higher risk for superficial incisional surgical site infection (SSI) (OR 3.26; p=0.01), any complication (OR 1.73; p

Category: Sports Introduction/Purpose: Diabetes Mellitus (DM) is an epidemic affecting millions of individuals in the United States. Multiple studies have demonstrated an increase in complications in foot and ankle surgery in patients with DM, including wound healing complications, surgical site infections (SSI), or surgical failure. The goal of this study was to retrospectively review outcomes data from the National Surgical Quality Improvement Program (NSQIP) to determine the impact of DM on operative treatment of achilles tendon ruptures. Methods: Using the NSQIP from 2006-2015, patients were identified using common procedure terminology (CPT) for Achilles tendon ruptures. Diabetic and non-diabetic cohorts were evaluated to compare demographics, comorbidities, perioperative details and 30-day outcomes. Statistical evaluation included a power analysis for the primary outcome measure of wound disruption as well as univariate analysis was performed using chi-squared or Fisher’s exact and Wilcoxon signed-rank tests. Results: A total of 2,014 patients were identified having sustained an Achilles tendon rupture. There were 1,981 patients without DM and 33 patients with DM. There were no significant differences in postoperative complications, including SSI, medical complications, and 30-day outcomes between patients with DM and non-DM patients undergoing surgical repair of acute Achilles tendon ruptures. The power analysis for wound disruption showed a P=0.9 with an alpha of 0.05, sample size of n=2014, and Pearson correlation coefficient of r=0.0721 Conclusion: While DM has been shown to have an increase in complications in various foot and ankle procedures, this study demonstrates that there is no significant difference in postoperative complications and 30-day outcomes between patients with DM and non-DM patients undergoing surgical repair of acute Achilles tendon ruptures using the NSQIP database from 2006-2015. Based on this data, patients with diabetes mellitus can be considered adequate surgical candidates for acute Achilles tendon rupture repair.

Category: Sports Introduction/Purpose: Obesity is increasingly common and has been highlighted as a comorbidity that may negatively impact outcomes following orthopaedic surgery. Operative versus nonoperative treatment of Achilles tendon ruptures continues to be controversial, as operative treatment may slightly reduce the likelihood of rerupture but carries the inherent surgical risks. To further delineate the patients who are at risk of postoperative complications it is of value to determine whether obese patients are particularly vulnerable. The purpose of this study was to determine the effect of obesity on surgical treatment of Achilles tendon ruptures. Methods: Patients who underwent a surgical repair of the Achilles tendon were retrospectively identified through the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). The patients were divided into two cohorts (obese and nonobese), and peri and postoperative factors were evaluated for association with obesity. Results: A total of 2128 patients were identified, of which 887 (41.7%) were classified as obese. Obesity correlated with an increased operative time, 60.9 minutes versus 56.1 minutes. The only postoperative complication that was associated with obesity was wound healing complication, based on univariate analysis. Multivariate analysis demonstrated obesity was not associated with an increased risk of wound healing complication, infection, deep venous thrombosis, or other systemic complication. Conclusion: A large segment of the patient population undergoing Achilles tendon repair is obese. In the current study, although obesity increased the likelihood of developing a wound complication following Achilles tendon repair based on univariate analysis, it was not significantly associated with any other complication.

Category: Other Introduction/Purpose: Hallux rigidus is one of the most common pathologies afflicting the foot. Various joint salvage techniques have been described with a multitude of different implants. Recently, a synthetic cartilage implant composed of polyvinyl alcohol (PVA) received FDA premarket approval for treatment of arthritis of the great toe and has been used in over 4,000 cases. The purpose of this study was to systematically review the clinical evidence supporting the use of a PVA implant in hallux rigidus. Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Using the terms “cartiva OR polyvinyl alcohol OR synthetic cartilage OR hemiarthroplasty AND hallux rigidus OR great toe arthritis OR first toe arthritis “ we searched the PubMed/Medline database in December 2017. In addition, the reference list of publications were scanned for further relevant studies. Results: 4 studies met the inclusion criteria, all of which were derived from a single randomized controlled trial. At short-term follow-up (2 years), patients undergoing placement of a PVA implant had significant improvement in Foot and Ankle Ability Measure (FAAM) sports and activity of daily living, as well as VAS pain scores. The outcomes of the surgery were found to be noninferior compared to arthrodesis. At intermediate follow-up (5 years), the improvement in clinical outcomes persisted and implant survivorship was 96%. Conclusion: There are limited studies available detailing the outcomes of a PVA implant for hallux rigidus, however the results that are available demonstrate a high level of evidence. There are no long-term publications assessing the outcomes of a PVA implant for hallux rigidus.

Category: Ankle Arthritis Introduction/Purpose: In the United States alone there are over 50,000 new cases of ankle arthritis every year. The financial healthcare burden for surgical management of ankle arthritis likely continues to rise with the volume of total ankle replacements (TAR) increasing 100-fold over the last 20 years. Healthcare consumers however are generally unaware of the costs of the services they use. Understanding the costs associated with operative management of ankle arthritis is an important facet of patient care although access to this information may not be readily available. The purpose of this study was to determine the access to the surgical cost of TARs and ankle arthrodesis and the variability of the cost between the two procedures. Methods: 50 foot and ankle centers (25 academic, 25 private) that perform TARs and ankle arthrodeses were contacted using a standardized patient script. The described patient was a healthy 63-year-old male who had failed conservative treatment of ankle arthritis. Each institution was contacted up to three times to attempt to obtain a full bundled operative quote for a TAR and an ankle arthrodesis. Results: 21 centers (42%, 14 academic, 7 private) were able to provide a quote for a TAR and ankle arthrodesis. The mean bundled price for a TAR was $50,332 (SD +/- $25,744) with the mean academic and private center quote being $56,529 and $37,937 respectively. The mean bundled price for an ankle arthrodesis was $41,756 (SD +/- $26,033) with the mean academic and private center quote being $48,116 and $29,037 respectively. There was no statistically significant difference between the bundled price for TAR and ankle arthrodesis. Conclusion: There was limited availability of consumer prices for TAR and ankle arthrodesis thus hindering healthcare consumers’ decision making. When comparing different institutions for surgical management of ankle arthritis, there was a wide range of quotes for both TAR and ankle arthrodesis. When comparing the choice of surgical management for ankle arthritis, there was no difference in price between TAR and ankle arthrodesis.

Category: Hindfoot, Diagnostic Imaging Introduction/Purpose: Multiple techniques have been described in determining the hindfoot alignment radiographically. While these studies have traditionally showed good reliability, the 2-dimensional nature of radiographs fails to consider the contribution of the remainder of the foot on the overall alignment. A new technique has been recently published in which the hindfoot alignment is calculated using the Ground Reaction Force Calcaneal Offset off radiographs. This technique accounts for the individual forefoot contributions on overall alignment, however is still limited by the 2-dimensional nature of plain radiographs. The purpose of this study is to compare two accepted radiographic measurements, the hindfoot moment arm (HMA) and the hindfoot alignment angle (HAA), with a novel technique determining the ground reaction force calcaneal offset (GRF-CT) using 3- dimensional weight bearing CT Scans. Methods: Retrospective chart review was performed over a two-year period from 2014-2016 to identify patients with weight bearing hindfoot alignment radiographs and PedCat (Curvebeam, Warrington, USA) 3-D weight bearing CT scans. The HMA, HAA, and GRF-CT were measured by three different investigators. Each of these measurements were calculated two times on separate occasions by each investigator to determine the intra- and inter-observer reliability with each of these techniques Results: One-hundred and four patients underwent weight bearing hindfoot alignment radiographs and 3-dimensional weight bearing CT scans. There were 33 patients with varus deformities and 71 patients with valgus deformities. There was excellent intra- and inter-observer reliability with all three measurement techniques, however the GRF-CT showed the best intra- and inter-observer reliability with the lowest standard deviation Conclusion: The GRF-CT technique is more reliable than traditional radiograph techniques for measuring the hindfoot alignment. While the intra- and inter-observer reliability is good for all three techniques, the GRF-CT technique resulted in the best intra- and inter-observer reliability with the lowest standard deviation. This technique provides the most accurate hindfoot alignment as it takes into account the effect of forefoot on overall alignment, preventing inaccuracies of projection and foot orientation in contrast to traditional radiographic techniques, which may be valuable in surgical decision making.