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Category: Midfoot/Forefoot Introduction/Purpose: Hallux rigidus (HR) of the first metatarsophalangeal joint (MTPJ) is a common arthritic disease which causes pain and stiffness. Synthetic cartilage implant (SCI) resurfacing has become a popular treatment option since it has similar biomechanical properties as native cartilage, reduces pain, and preserves MTPJ motion. However, recent studies have reported on implant subsidence leading to SCI treatment failure and subsequent revision surgery. A novel solution involves proximally inserting a custom 3D printed baseplate in the metatarsal head to prevent SCI subsidence. The purpose of this study is to evaluate the clinical and radiographic outcomes of patients who underwent SCI resurfacing augmented with a 3D printed beasplate for the treatment of HR by a single surgeon. Methods: Electronic health records were queried from August 2017 to August 2021 for patients who were treated with SCI (Cartiva Synthetic Cartilage Implant; Cartiva Inc., Alpharetta, GA) augmented with a custom 3D printed baseplate by a single surgeon. Through a dorsal approach to the MTPJ, the custom 3D printed baseplate is inserted in the metatarsal head and the SCI implant is positioned two millimeters proud from the cortex. An akin osteotomy is then performed and fixed with a staple. For the study, surgical indications included symptomatic HR and revision of previously failed SCI treatment. Patient demographics, body mass index (BMI), medical comorbidities, and followup periods were recorded. Preoperative and postoperative range of motion, visual analog scale (VAS) pain scores, and x-ray imaging were compared. Descriptive and univariate statistics were used to analyze data. Results: Twenty-one patients underwent SCI resurfacing augmented with a 3D printed baseplate. The cohort consisted of 18 females, and presented with a mean BMI of 30.4+-5 Kg/m2, mean age of 56.4+-10 years, and mean followup of 9.8+-13 months since the procedure. Patients experienced a significant improvement in VAS pain (P=0.002) scores. The SCI augmented with 3D printed baseplate survivorship was 90.4%, with only two (9.5%) patients requiring revision to first MTPJ arthrodesis for SCI subsidence and sesamoidal arthritis. Two (9.5%) patients additionally underwent reoperation for staple removal and infection. The first MTPJ space was maintained on x-ray imaging for 19 (90.5%) patients, with only two (9.5%) patients demonstrating implant subsidence. Conclusion: SCI resurfacing augmented with a custom 3D printed baseplate demonstrated significant improvements in pain and prevented implant subsidence in patients suffering from symptomatic HR. Future prospective studies should be performed to expand upon the clinical outcomes data analyzing this novel technique to prevent SCI subsidence in the treatment for HR.

Category: Hindfoot Introduction/Purpose: Talar avascular necrosis (AVN) is a difficult pathology to diagnose and manage. Traditional treatment options include both joint sparing procedures (vascularized bone graft, core decompression, intraosseous stem cell injection) and joint sacrificing procedures (arthrodesis or arthroplasty). Three dimensional (3D) printed total talus replacement (TTR) has recently gained more popularity as an intervention to salvage joint motion in patients with talus pathology. Although vascularized bone grafting can treat localized talar AVN, failure of this procedure to improve talar vascularity and prevent further subchondral collapse may require revision surgery. This is the first study to compare outcomes of patients with talar AVN who underwent primary 3D printed TTR and patients who underwent a secondary TTR subsequent to failure of a free vascularized medial femoral condyle (MFC) flap. Methods: This case series analyzed the outcomes of two patients who underwent a secondary 3D printed TTR subsequent to failure of the index revascularization procedure using an MFC flap in 2016. These patients were compared to a cohort of patients who underwent a primary 3D printed TTR to treat talar AVN between 2016 and 2019. Preoperative and postoperative assessment included ankle range of motion, foot and ankle outcome score (FAOS), visual analogue scale (VAS) pain scores, and radiographic imaging. A minimum 12-month follow-up period was reported for patients. Results: Within the group that underwent a secondary TTR after a failed revascularization, both patients had a mean followup of 23.5 months. The 25 patients in the comparison group who all underwent a primary 3D printed TTR had an mean follow-up period of 22.1 (range:12-43) months. All patients in the study experienced improved VAS pain scores and ankle dorsiflexion post- operatively. In the secondary 3D printed TTR group, both patients demonstrated reduced plantarflexion of 20 degrees and ankle motion of 15 degrees relative to the comparison group which showed a minimal increase in both. When analyzing FAOS functional outcome score subscales, patient two demonstrated improvement in pain from 44 to 46, symptoms from 29 to 46, and activities of daily living from 47 to 76. Patient one experienced a decrease in sports and recreation from 15 to 5 and quality of life from 38 to 31. Conclusion: This case series demonstrated poor functional outcomes of two patients who underwent 3D printed TTR after talar revascularization with MFC grafts when compared to the cohort of patients who solely underwent a primary 3D printed TTR for talar AVN. Further investigation is warranted to determine which patients may benefit from a revascularization procedure or a primary 3D printed TTR.

Category: Other Introduction/Purpose: Foot and ankle surgery is a growing subspecialty within orthopaedic surgery due to the increasing demand for lower extremity trained specialists. Fellowship directors for foot and ankle surgery are uniquely tasked with the responsibilities of creating an educational experience while teaching trainees to manage lower extremity pathology. Similarly, foot and ankle division chiefs serve as clinical leaders who oversee their department's delivery of lower extremity care while acting as mentors. The primary aim of this study was to quantitatively describe and compare the demographic and professional characteristics of current foot and ankle surgery fellowship directors and division chiefs. Methods: The American Orthopaedic Foot & Ankle Society (AOFAS) fellowship directory for 2021 to 2022 was reviewed for the 48 AOFAS-recognized fellowship programs in the United States. After screening all institutional websites, fellowship directors and division chiefs were directly contacted via email. Surveys were administered between March 31, 2021 and June 1, 2021 to collect demographic, education, and professional data. Publicly accessible online sources such as institutional biographies, media accounts, uploaded curriculum vitae, and the Scopus Web of Science database were accessed to collect any missing information. The H-index value was determined for each leader by accessing the Scopus Web of Science search engine, a database that analyzes peer-reviewed scientific publications with a built-in citation tracking feature. Univariate and bivariate statistical analyses were performed. Results: A total of 42 of the 48 (87.5%) fellowship directors and 18 of the 23 (78.3%) division chiefs responded to the questionnaire. Of the 48 fellowship directors, 45 (93.8%) were male, 43 (89.6%) identified as Caucasian, their average age at leadership appointment was 42.6+-7.5 (range, 32-70) years, and the average time between fellowship graduation and leadership appointment was 9.9+-7.8 (range, 0-36) years. Most of the fellowship directors graduated from OrthoCarolina (10.4%), Oakland Bone and Joint Specialists (Roger Mann) (10.4%), and Mercy Medical Center (8.3%) (Figure 1). Of the 23 chiefs, 22 (95.7%) were male, 20 (87.0 %) identified as Caucasians, their average age at leadership appointment was 41.7+-7.8 (range, 32-53) years, and the average time between fellowship graduation and leadership appointment was 9.8+-6.8 (range, 2-21) years. The average H-index for the chiefs was greater than that of the fellowship directors (18.4 vs 13.4, P=.0373) when controlling for years of training. Conclusion: This is the first study to record professional and demographic characteristics amongst orthopaedic foot and ankle surgery fellowship directors and division chiefs. The utility of this analysis comes from highlighting common attributes of successful leaders within the field for aspiring trainees, while also drawing attention to the lack of diversity within the foot and ankle surgery community.

Category: Midfoot/Forefoot Introduction/Purpose: Second metatarsophalangeal joint (MTPJ) arthritis can be caused by both traumatic and non-traumatic conditions such as inflammation, osteoarthritis, and Freiberg's disease. Although many treatment options for second MTPJ arthritis are available, resurfacing with a synthetic cartilage implant (SCI) has recently gained popularity since it demonstrates similar biomechanical properties as native cartilage, eliminates pain, and preserves second MTPJ motion. With limited data available on the efficacy of SCI resurfacing for the lesser toes, the purpose of this study was to report on the clinical outcomes of SCI resurfacing in patients with second MTPJ arthritis. Methods: Electronic health records were queried from July 2017 to December 2020 for patients who were experiencing symptomatic second MTPJ pain and were treated with SCI (Cartiva Synthetic Cartilage Implant; Cartiva Inc., Alpharetta, GA) by a single surgeon. Patient demographics such as body mass index (BMI), age, sex, medical comorbidities, American Society for Anesthesiologists (ASA) physical status, past surgical history, and followup periods were recorded. Preoperative and postoperative range of motion, visual analog scale (VAS) pain scores, and x-ray imaging were compared. Descriptive and univariate statistics were used to analyze data. Results: A total of six patients received SCI resurfacing for second MTPJ pathologies including Freiberg's disease (50%), osteoarthritis (67%), and subluxation (50%). All six patients were female and the mean BMI and age were 28.3+-6 Kg/m2 and 56.3+-14 years, respectively. Three patients (50%) received index SCI resurfacing, while three patients (50%) received SCI resurfacing as a revision procedure. No significant differences were observed between preoperative and postoperative pain VAS, dorsiflexion, and plantarflexion measurements. The mean followup period was 16.4+-14 (range, 5-38) months and no postoperative complications were reported. When reviewing imaging, all patients demonstrated second MTPJ alignment within 10 degrees of valgus and maintenance of articular space (Table 1). Conclusion: SCI resurfacing can be utilized as a treatment option for second MTPJ arthritis. Future prospective studies should be performed to expand upon the limited clinical outcomes data presently available.

Category: Midfoot/Forefoot Introduction/Purpose: Hallux rigidus (HR) of the first metatarsophalangeal joint (MTPJ) is a prevalent arthritic disease which causes pain and stiffness. While MTPJ arthrodesis is regarded as the gold standard treatment option for HR (Grade II and III), synthetic cartilage implant (SCI) resurfacing has gained popularity since it demonstrates similar biomechanical properties as native cartilage, eliminates pain, and preserves MTPJ motion. However, recent studies have reported variable failure rates on SCI treatment, with implant subsidence most commonly leading to a revision. The purpose of this study was to identify the SCI resurfacing failure rate by a single surgeon, while also comparing clinical outcomes of patients who underwent SCI replacement or MTPJ arthrodesis after failed index SCI resurfacing. Methods: Electronic health records were queried from 2016 to 2021 for patients who were experiencing symptomatic HR and were treated with SCI (Synthetic Cartilage Implant) by a single surgeon. Patient demographics, body mass index (BMI), medical comorbidities, American Society for Anesthesiologists (ASA) physical status, past surgical history and followup periods were recorded. Preoperative and postoperative range of motion, visual analog scale (VAS) pain scores, hallux valgus (HV) angles, and x- ray imaging were compared. Subgroup analysis was performed on patients who underwent revision with either a SCI replacement or MTPJ arthrodesis. SCI replacement included the use of bone graft and/or a custom 3D-printed baseplate to prevent implant subsidence. Descriptive and univariate statistics were used to analyze data. Results: A total of 219 SCI resurfacing procedures were performed by a single surgeon, including 23 revisions. When only analyzing index procedures, a revision rate of 8.2% was determined. The revision cohort (n=23) consisted of 19 females, and presented with a mean BMI of 29.5+-5 Kg/m2, mean age of 52.8+-11 years, and mean followup of 22.3 (range, 3-54) months. Patients underwent revision surgery at an average of 12.1+-12 (range, 1-50) months after index SCI resurfacing. Specifically, 12 procedures resulted in an SCI replacement, while 11 procedures resulted in arthrodesis. There was significantly lower postoperative pain VAS (P=0.04) and a significant improvement from preoperative to postoperative pain VAS for the arthrodesis cohort (P

Category: Midfoot/Forefoot Introduction/Purpose: Hallux rigidus (HR) is the most common arthritic condition of a foot with a prevalence of up to 45% in people aged >75 years-old. First metatarsophalangeal joint (MTPJ) arthrodesis has been the historical gold standard treatment for late-stage HR. Polyvinyl alcohol (PVA) hydrogel implants have similar biomechanical properties as native cartilage, and thus have gained popularity as a joint-sparing technique that provides preservation of MTPJ motion. Initial literature demonstrated pain relief and functional outcomes equivalent to first MTPJ arthrodesis and excellent five-year survivorship. However, recent studies report variable failure rates on PVA hydrogel implants for HR. The purpose of this study was to report the five-year experience and outcomes of PVA hydrogel implants for the treatment of HR performed by a single surgeon. Methods: Electronic health records were queried from August 2016 to August 2021 for patients who underwent primary PVA hydrogel implant hemiarthroplasty (Cartiva Synthetic Cartilage Implant; Cartiva Inc, Alpharetta, GA) for symptomatic late-stage HR. All patients were treated by a single foot and ankle fellowship trained orthopaedic surgeon. A minimum of six months follow- up was required. Patient demographics and perioperative data were collected. Preoperative and postoperative range of motion, visual analog scale (VAS) pain scores, and radiographs were evaluated. Complications and the overall implant survivorship were reported. A Kaplan-Meier analysis was used to evaluate implant survival. Descriptive and univariate statistics were used to analyze data. A total of 196 primary PVA hydrogel implant procedures were performed of which 146 had a minimum six-month follow-up and were included. The mean follow-up was 14.5 (+- 11.9) months. Results: The majority of patients were female (n=103, 70.5%) with a mean age of 58.1 (+-10.1) years-old, BMI of 27.3 (+-5.2) Kg/m2, and an ASA score < 3 (n=131, 89.7%). The majority of patients had stage II or III disease (n=115, 78.8%). Patients experienced significant improvement in VAS (p

Hallux valgus is a common progressive forefoot deformity. Although open techniques have shown good outcomes, no technique has been shown to be superior to other techniques. The current third generation of minimally invasive Chevron–Akin (MICA) technique features a percutaneous procedure with a stable internal fixation. The technique used in this study resulted in stable internal fixation; however, 1 screw was used in intramedullary fashion in the majority of cases. The purpose of this study is to review the early outcomes of MICA. Electronic Health Records (EHR) were queried for patients who underwent MICA to treat hallux valgus (HV) deformity, by a single surgeon. The primary clinical outcomes assessed were visual analog pain score (VAS), rate of revision surgery, and recurrence. Radiographic outcomes were assessed including pre and postoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), and bony foot width. The secondary outcomes included postoperative complications. A total of 91 feet underwent MICA to correct symptomatic HV deformity. The mean age of this cohort was 53.63 ± 15.42 years, mean body mass index (BMI) of 26.81 ± 6.21 kg/m2, mean follow-up of 6.33 ± 6.39 months and 87 feet belonged to female patients. Patients showed significant improvement in VAS and radiographic outcomes at final follow-up, with a mean improvement of 10.70° ± 6.42°, 2.39° ± 3.55°, and 5.30 mm ± 4.23 mm for the HVA, IMA, and bony foot width, respectively. Two patients (2.2%) required revision surgery for nonunion and removal of symptomatic hardware. One patient had a second metatarsal fracture treated nonoperatively. No feet had recurrence, hardware loosening, infection, or scar hypersensitivity. The current study reported on early outcomes for MICA. This technique appears to be effective and safe with no failure of fixation in our patients. We showed in our short-term follow-up, MICA led to significant improvement in pain and radiographic scores. Levels of Evidence: III, retrospective study [ABSTRACT FROM AUTHOR]

Background: While metatarsophalangeal joint (MTPJ) arthrodesis is regarded as the gold standard treatment option for end-stage hallux rigidus (HR), synthetic cartilage implant (SCI) resurfacing has gained popularity. This study aimed to identify the SCI resurfacing failure rate for a single surgeon, while also comparing clinical outcomes of patients who underwent SCI replacement or MTPJ arthrodesis after failed index SCI resurfacing. Methods: Health records were queried from 2016 to 2021 for patients with HR who were treated with SCI resurfacing by a single surgeon. Preoperative and postoperative range of motion, visual analog scale (VAS) pain scores, and hallux valgus angles were compared. A subgroup analysis was performed on patients who underwent revision with SCI replacement or MTPJ arthrodesis. SCI replacement included the use of bone graft, bone putty, or a custom 3D printed baseplate to prevent implant subsidence. Results: A total of 219 SCI resurfacing procedures were performed by a single surgeon, including 23 revisions. When analyzing index procedures, an 8.2% revision rate was determined. The revision cohort (n = 23) consisted of 19 female patients and presented with a mean body mass index of 29.5 ± 5 kg/m2, mean age of 52.8 ± 11 years, mean follow-up duration of 22.3 (range, 3-54) months, and mean time to a revision surgery of 12.1 ± 12 (range, 1-50) months. Specifically, 12 procedures resulted in an SCI replacement, while 11 procedures resulted in arthrodesis. While all patients experienced significant improvement in their VAS pain scores (P <.001), the arthrodesis cohort experienced a greater improvement than the SCI revision cohort (P =.04). Conclusion: When analyzing SCI revision procedures, MTPJ arthrodesis reduced pain more significantly than SCI replacement. Levels of Evidence: Level IV: Retrospective case series [ABSTRACT FROM AUTHOR]

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Hallux Valgus (HV) is a common progressive forefoot deformity. Although traditional open techniques have shown good outcomes, no technique has been shown to be superior to other techniques and 15% of patients have procedure related complications. This has significant functional restrictions, pain, and reduced quality of life. Minimally Invasive (MIS) percutaneous techniques became more popular in Orthopaedics. The current third generation of hallux valgus MIS technique developed by Vernois and Redfern features a percutaneous procedure with a stable internal fixation. The purpose of this study is to review the early outcomes of MIS hallux valgus operation by a single surgeon. Methods: Electronic health records were queried from January 1, 2015, through February 01, 2021, for patients who underwent MIS to treat HV deformity. Patients were treated by a single surgeon. The primary clinical outcomes assessed were visual analog pain score (VAS), rate of revision surgery, and recurrence. Additionally, radiographic outcomes were assessed including pre-and postoperative hallux valgus angle (HVA), inter-metatarsal angle (IMA), and foot width. The secondary outcomes included postoperative complications: infection, scar hypersensitivity, hardware irritation, hardware loosening, removal of hardware, and metatarsal fracture. Results: A total of 91 feet underwent MIS to correct symptomatic HV deformity. The mean age of this cohort was 53.63 +- 15.42 years, mean BMI of 26.81 +- 6.21, mean follow-up of 6.33 +- 6.39 months and 87 feet belonged to female patients. Patients showed a statistically significant (P < 0.001) improvement in VAS score after surgery. The radiographic outcomes showed significant (P < 0.001) improvement for all three variables at final follow up, with a mean improvement of 10.70° +- 6.42, 2.39° +- 3.55, and 5.30 mm +- 4.23 for the HVA, IMA, and foot width respectively. Two patients (2.2%) required revision surgery, one due to nonunion and one due to persistent pain. One patient had a hardware irritation that did not require hardware removal and one patient had a second metatarsal fracture. No feet had HV recurrence, hardware loosening, infection, or scar hypersensitivity. Conclusion: The current study showed that minimally invasive percutaneous Chevron/Akin for symptomatic hallux valgus correction is an effective and safe technique. In addition to a low complication rate, significant improvement in pain score and radiographic parameters at final follow up were demonstrated. Future randomized trials with long term follow up are needed to validate the outcomes of minimally invasive techniques.

Leaf spot diseases caused by Alternaria species have been reported worldwide in plants belonging to the Arecaceae family. However, limited information is available on the molecular identification of Alternaria species responsible for causing leaf spot diseases in date palm trees. In this study, Alternaria spp. isolated from date palm leaves collected from three districts in the Basrah governorate were characterized based on their morphology, physiology and molecular markers. By employing techniques in morphology and molecular biology, along with analysis using the neighbor-joining approach and alignment of the internal transcribed spacer (ITS) sequences, we successfully isolated and identified the fungal pathogen as Alternaria alternata. A. alternata colony showcase dark black mycelia encircled by a white-gray mycelium. Microscopic observation revealed that the isolated conidia were obclavate, cylindrical and dark brown. The conidiophores exhibited a septate, branching structure and had an olivaceous brown color. Through sequencing, it was discovered that the isolate showed a high degree of similarity (100%) to Alternaria alternata, specifically in their ITS regions. The DNA sequences have been submitted to the National Center for Biotechnology Information (NCBI), and the sequence accession number obtained from GenBank for the Alternaria alternata sequence used in the phylogenetic study is PP194367.1. [ABSTRACT FROM AUTHOR]

Poly(methyl methacrylate) (PMMA) is the most common material used to fabricate complete and partial dentures. Despite its desirable properties, it cannot fulfill all mechanical requirements of prosthesis. Flexural fatigue due to repeated masticatory and high-impact forces caused by dropping are the main causes of denture fractures. In the past, different reinforcing agents such as rubbers, macro fibers, and fillers have been employed to improve the mechanical properties of denture base resins. Development of Nano dentistry has introduced new approaches for reinforcement of dental materials. Interest in nanostructure materials is driven by their high surface area to volume ratio, which enhances interfacial interaction and specific new biological, physical, and chemical properties. Researchers to reinforce PMMA resins have used Nanoparticles (Nps) which were comprised of silver, Titania (TiO2), zirconia (ZrO2), alumina, and ceramic. Although different reports describe the use of nanofiber and nanotubes in dental composites, few studies have evaluated the reinforcement potential of nanofiber and nanotubes in PMMA denture base resins. The current article aims to review the different attempts to enhance the mechanical properties of denture base materials. We also focus on recent advances and potential future developments for reinforcement of the PMMA acrylic resins.