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Objective: We examined the effect of frailty on in-hospital mortality, readmission rates, and hospitalization costs after transcatheter and surgical aortic valve replacement in a population-level cohort. Methods: The Nationwide Readmissions Database was queried for patients who underwent transcatheter or surgical aortic valve replacement during 2016-2018. Multivariate logistic regression was used to discern independent effects of frailty on outcomes. Kaplan–Meier time-to-event analysis was used to evaluate the effect of frailty on freedom from readmission. Results: A total of 243,619 patients underwent aortic valve replacement: 142,786 (58.6%) transcatheter aortic valve replacements and 100,833 (41.4%) surgical aortic valve replacements. Frail patients constituted 16,388 (11.5%) and 7251 (7.2%) in the transcatheter aortic valve replacement and surgical aortic valve replacement cohorts, respectively. Compared with nonfrail patients, frail patients had greater in-hospital mortality (transcatheter aortic valve replacement: 3.2% vs 1.1%; surgical aortic valve replacement: 6.1% vs 2.0%; both P

Background: The use of rapid-deployment valves (RDVs) has been shown to reduce the operative time for surgical aortic valve replacement (AVR). Long-term core laboratory–adjudicated data are scarce, however. Here we report final 7-year data on RDV use. Methods: TRANSFORM was a prospective, nonrandomized, multicenter, single-arm trial implanting a stented bovine pericardial valve with an incorporated balloon-expandable sealing frame. A prior published 1-year analysis included 839 patients from 29 centers. An additional 46 patients were enrolled and implanted, for a total of 885 patients. Annual clinical and core laboratory–adjudicated echocardiographic outcomes were collected through 8 years. Primary endpoints were structural valve deterioration (SVD), all-cause reintervention, all-cause valve explantation, and all-cause mortality. Secondary endpoints included hemodynamic performance assessed by echocardiography. The mean duration of follow-up was 5.0 ± 2.0 years. Results: The mean patient age was 73.3 ± 8.2 years. Isolated AVR was performed in 62.1% of the patients, and AVR with concomitant procedures was performed in 37.9%. Freedom from all-cause mortality at 7 years was 76.0% for isolated AVR and 68.2% for concomitant AVR. Freedom from SVD, all-cause reintervention, and valve explantation at 7 years was 97.5%, 95.7%, and 97.8%, respectively. The mean gradient and effective orifice area at 7 years were 11.1 ± 5.3 mm Hg and 1.6 ± 0.3 cm2, respectively. Paravalvular leak at 7 years was none/trace in 88.6% and mild in 11.4%. In patients undergoing isolated AVR, the cumulative probability of pacemaker implantation was 13.9% at 30 days, 15.5% at 1 year, and 21.8% at 7 years. Conclusions: AVR for aortic stenosis using an RDV is associated with low rates of late adverse events. This surgical pericardial tissue platform provides excellent and stable hemodynamic performance through 7 years.

Objectives: Deep venous thrombosis (DVT) is a known surgical complication that can lead to pulmonary embolism with subsequent morbidity and mortality. The incidence of DVT following coronary artery bypass grafting is unclear. Prophylaxis regimens vary and some guidelines advocate against use of routine chemoprophylaxis in patients at low-moderate risk for venous thromboembolism. We utilized postoperative lower extremity venous ultrasound to determine the incidence of DVT following coronary artery bypass grafting in patients with low- to moderate-risk of venous thromboembolism receiving aggressive postoperative DVT prophylaxis. Methods: This is a single-center, retrospective study of all patients who underwent coronary artery bypass grafting between April 2022 and January 2023. All patients who completed postoperative venous ultrasound of the bilateral lower extremities were initially included. Patients who underwent concurrent valve or aortic surgery, were at high risk of venous thromboembolism, or were receiving anticoagulation therapy for nonvenous thromboembolism indications were excluded. The primary outcome was in-hospital incidence of DVT. Secondary outcomes were rates of mortality, postoperative bleeding, and thromboembolic events from discharge to 30 days postoperatively and from 30 days to 3 months postoperatively. Results: No DVTs were observed in 211 included patients. In hospital, there were 3 significant bleeding events and 1 stroke. Following discharge there were 3 additional bleeding events, 1 death, 1 transient ischemic attack, and 1 pulmonary embolism. Conclusions: We observed a 0% rate of DVT in low- to moderate-risk patients undergoing isolated coronary artery bypass grafting and receiving a comprehensive DVT prophylaxis regimen. In hospital bleeding and other thromboembolic event rates were 2.84% and 0.47% respectively.

Background: Long-term survival in patients who receive bone marrow transplantation (BMT) is increasing. However, osteonecrosis and secondary osteoarthritis (OA) of the hip and knee are common complications in this population due to post-transplant steroid treatment to prevent graft vs host disease. The purpose of this study was to evaluate the outcomes of total joint arthroplasty (TJA) in patients with prior BMT and compare them to those of patients undergoing TJA for primary OA. Methods: Patients with a history of BMT undergoing primary TJA from 2013 to 2021 were retrospectively reviewed. Patients were matched 1:1 by surgical site, sex, age, body mass index, American Society of Anesthesiologists score, and Elixhauser Comorbidity Index to patients undergoing TJA for primary OA. Demographics, intraoperative blood loss, perioperative transfusion requirements, hospital length of stay, 90-day emergency department visits and readmissions, all-cause revisions, and 2-year mortality were compared between cohorts. Results: There were 17 patients undergoing total knee arthroplasty (TKA) after BMT (TKA-BMT) and 43 patients undergoing total hip arthroplasty (THA) after BMT (THA-BMT). More TKA-BMT and THA-BMT patients were immunosuppressed preoperatively compared to 17 matched TKA-OA and 43 THA-OA patients (P = .018 and P < .001). There were no other significant perioperative differences between BMT and OA groups. Two-year patient and implant survivorship for TKA-BMT and THA-BMT patients were high and not statistically different from TKA-OA and THA-OA cohorts. Conclusions: TJA after BMT provides satisfactory perioperative and short-term outcomes and is a viable treatment option for patients with osteonecrosis and secondary OA after BMT treatment.

The 2023 report represents a full decade of published annual reports of the American Joint Replacement Registry (AJRR). The number of cases being captured continues to rapidly grow, as are over 3.2 million patients included in AJRR. Matched-pair primary and revision data is more robust with 10-year survivorship being available. Similarly, implant-specific survivorship has been included for common implants being used in the United States. The data mined from the AJRR have led to numerous publications and presentations. Numerous trends have emerged, and others have been reinforced with the most recent data. The authors encourage readers to more thoroughly review the full report at the following link: https://www.aaos.org/registries/publications/ajrr-annual-report/.

Background: Robotic-assisted total joint arthroplasty (rTJA) has growing interest among patients and surgeons. However, patient interest in and perceptions of rTJA have not been well explored. We sought to investigate the influence of patient demographics on interest in rTJA and patient perceptions regarding rTJA. Methods: Patients presenting for their initial adult reconstruction consultation received an optional anonymous survey prior to seeing the provider. Patient sociodemographic parameters were recorded. Additional questions assessed interest in and perceptions surrounding rTJA. Results were analyzed to determine whether patient factors correlated with survey responses. Results: A total of 360 patients participated. Analysis of responses revealed 77.8% of patients were interested in rTJA. Interest level positively correlated with patient age (Rs = 0.139, P = .010), education level (Rs = 0.168, P = .002), household income (Rs = 0.274, P < .001), and White race (F = 4.157, P = .016). At least 100 patients believed rTJA was easier and more accurate, but more expensive and had a significant learning curve for the surgeon. Over 100 patients believed robots were capable of independently performing most or all of the rTJA operation. Conclusions: Patient interest in rTJA varies between patients. Many patients have an incomplete understanding of rTJA, and orthopaedic surgeons should address patient perceptions during surgical consultation. Level of Evidence: IV, Cross-sectional study.

Objectives: Safety-net hospitals (SNHs) provide essential services to predominantly underserved patients regardless of their ability to pay. We hypothesized that patients who underwent coronary artery bypass grafting (CABG) would have inferior observed outcomes at SNHs compared with non-SNHs but that matched cohorts would have comparable outcomes. Methods: We queried the Nationwide Readmissions Database for patients who underwent isolated CABG from 2016 to 2018. We ranked hospitals by the percentage of all admissions in which the patient was uninsured or insured with Medicaid; hospitals in the top quartile were designated as SNHs. We used propensity-score matching to mitigate the effect of confounding factors and compare outcomes between SNHs and non-SNHs. Results: A total of 525,179 patients underwent CABG, including 96,133 (18.3%) at SNHs, who had a greater burden of baseline comorbidities (median Elixhauser score 8 vs 7; P = .04) and more frequently required urgent surgery (57.1% vs 52.8%; P

Background: Indications for removal of syndesmotic screws are not fully elucidated. This study aimed to determine factors related to elective syndesmotic screw removal. Methods: Patients who underwent fixation of ankle syndesmotic injuries were included. Screw removal was offered after a minimum of 12 weeks after surgery for pain, stiffness or patient desire to remove painful or broken hardware. Patient demographics, surgical data, distance of the syndesmotic screw from the joint, location of the screw at the physeal scar, and number of syndesmotic screws placed were collected for all patients. Bivariate and multivariate analyses were performed to determine the relationship between patient characteristics and screw removal and independent predictors of hardware removal. Results: Of 160 patients, 60 patients (38%) with an average age of 36.1 (range: 18-84) years underwent elective syndesmotic screw removal at a mean of 7 (range, 3-47) months after initial fixation. The most common reason for screw removal (50/60 patients) was ankle stiffness and pain (83%). Patients who underwent screw removal were more likely to be younger (36.1 years ± 13.0 vs 46.6 years ± 18.2, P

Drivers know that smartphones distract. Trying to limit distraction, drivers can use handsfree devices, where they onlybriefly glance at the smartphone. However, the cognitive cost of switching tasks from driving to communicating back todriving adds an underappreciated, potentially long period to the total distraction time. This project measured the effectsof handsfree smartphones on driving behaviors by engaging ninety-seven 21- to 78-year-old individuals whoselfidentified as active drivers and smartphone users in a simulated driving scenario that included smartphonedistractions. Peripheral-cue and car-following tasks were used to assess driving behavior, along with synchronized eyetracking. This research found that simulated driving performance drops to dangerous levels after smartphone distractionfor all ages and for both voice and texting. The participants swerved for 15.1 seconds after a voice distraction and for alonger 20.6 seconds after a text distraction. Participants from the 71+ age group missed seeing about 50% of peripheralcues within 4 seconds of the distraction. Coherence with the lead car during following task dropped from 0.54 to 0.045during distraction, and seven participants rear-ended the lead car.

Drivers know that smartphones distract. Trying to limit distraction, drivers can use handsfree devices, where they onlybriefly glance at the smartphone. However, the cognitive cost of switching tasks from driving to communicating back todriving adds an underappreciated, potentially long period to the total distraction time. This project measured the effectsof handsfree smartphones on driving behaviors by engaging ninety-seven 21- to 78-year-old individuals whoselfidentified as active drivers and smartphone users in a simulated driving scenario that included smartphonedistractions. Peripheral-cue and car-following tasks were used to assess driving behavior, along with synchronized eyetracking. This research found that simulated driving performance drops to dangerous levels after smartphone distractionfor all ages and for both voice and texting. The participants swerved for 15.1 seconds after a voice distraction and for alonger 20.6 seconds after a text distraction. Participants from the 71+ age group missed seeing about 50% of peripheralcues within 4 seconds of the distraction. Coherence with the lead car during following task dropped from 0.54 to 0.045during distraction, and seven participants rear-ended the lead car.

Background: There are few large studies evaluating total knee arthroplasty (TKA) in young patients. Therefore, we sought to evaluate patients aged 45 years or younger undergoing a primary TKA. Methods: This was a retrospective, single-institution study, from 2003 to 2018, evaluating primary TKA in patients aged 45 years or younger. We identified 162 TKAs with a minimum follow-up duration of 2 years. Common surgical indications were degenerative joint disease (50%), post-traumatic arthritis (21%), and inflammatory arthritis (20%). Forty-nine knees had a prior significant knee surgery. We evaluated survivorship free of revision for any reason and aseptic revision. In addition, we characterized complication rates and risk factors for failure. Results: The mean age was 39 years, 70% were female, and the mean clinical follow-up duration was 7 years. At 8 years, survivorship free of revision for any reason was 82%, and survivorship free of aseptic revision was 87%. Fifty-five knees experienced at least 1 complication, with an overall complication rate of 34%. There were 6 (4%) periprosthetic joint infections (PJIs), and 24 (15%) knees of patients underwent manipulation under anesthesia with or without arthroscopic lysis of adhesions. There were no specific risk factors for revisions identified. Age less than 40 years was associated with PJI (P = .031), and marital status at the time of TKA was associated with arthrofibrosis requiring an intervention (P = .045). Conclusions: TKAs in patients aged 45 years or younger are associated with acceptable survivorship at a mean follow-up duration of 7 years. Patients should be counseled about the elevated risk of complications, specifically PJI and arthrofibrosis.

Objective: We examined readmissions and resource use during the first postoperative year in patients who underwent thoracic endovascular aortic repair or open surgical repair of Stanford type B aortic dissection. Methods: The Nationwide Readmissions Database (2016-2018) was queried for patients with type B aortic dissection who underwent thoracic endovascular aortic repair or open surgical repair. The primary outcome was readmission during the first postoperative year. Secondary outcomes included 30-day and 90-day readmission rates, in-hospital mortality, length of stay, and cost. A Cox proportional hazards model was used to determine risk factors for readmission. Results: During the study period, type B aortic dissection repair was performed in 6456 patients, of whom 3517 (54.5%) underwent thoracic endovascular aortic repair and 2939 (45.5%) underwent open surgical repair. Patients undergoing thoracic endovascular aortic repair were older (63 vs 59 years; P

BACKGROUND:. In patients who require systemic anticoagulation, a reliable monitoring method is required to ensure anticoagulation is maintained within the correct therapeutic window and patients are treated appropriately. When titrating direct thrombin inhibitors (DTIs), dilute thrombin time (dTT) measurements have been demonstrated to be more reliable and accurate than activated partial thromboplastin time (aPTT) measurements and thus often the preferred DTI assessment. However, a clinical need arises when both dTT measurements are not readily available and aPTT measurements are unreliable. CASE SUMMARY:. A 57-year-old woman with a history of antiphospholipid antibody syndrome, heparin-induced thrombocytopenia, and multiple prior deep venous thromboses and pulmonary emboli was admitted with COVID-19 pneumonia and intubated due to hypoxic respiratory failure. Argatroban was initiated in place of her home medication warfarin. However, the patient had a prolonged aPTT value at baseline and overnight dTT assay measurements were limited at our institution. A multidisciplinary team of hematology and pharmacy clinicians created a modified patient-specific aPTT target range and argatroban dosing was titrated accordingly. Subsequent aPTT values in the modified target range corresponded to therapeutic dTT values, indicating therapeutic anticoagulation was successfully achieved and maintained. Patient blood samples were additionally evaluated retrospectively using an investigational novel point-of-care test that detected and quantified the argatroban anticoagulant effect. CONCLUSIONS:. Therapeutic anticoagulation with a DTI in a patient with unreliable aPTT measurements can be achieved with use of a modified patient-specific aPTT target range. Early validation of an investigational rapid testing alternative for DTI monitoring is promising.

Objective: To compare physical activity (PA) levels between individuals with femoroacetabular impingement syndrome (FAIS) and uninjured controls and determine correlates of moderate to vigorous physical activity (MVPA). Design: Cross-sectional, comparative study. Setting: University laboratory. Participants: A total number of 25 individuals with FAIS (15 female; age, 31.0±9.2 years; symptom duration, 4.7±7.1 years) and 14 uninjured controls (9 female; age, 28.0±9.1 years) (N=39). Interventions: Not applicable. Main Outcome Measures: All individuals wore an accelerometer around the waist during waking hours for 7 days. We compared demographic, clinical data, and PA levels between groups using independent samples t tests and compared the proportions of those meeting the PA guideline cutoff (150min/wk) using a chi-square test. Additionally, we examined correlates of mean daily MVPA using linear regression in both groups. Results: Individuals with FAIS spent less time in MVPA (controls, 52.1±25.6min/d; FAIS, 26.9±19.1min/d; P=.001) and took fewer steps (controls, 8428±2931 steps/d; FAIS, 6449±2527 steps/d; P=.033) than uninjured controls. A lower proportion of individuals with FAIS met the PA cutoff (40.0%) compared with uninjured controls (78.6%; P=.020). Higher body mass index (BMI) values and lower (worse) Hip Disability and Osteoarthritis Outcome Score (HOOS)–Quality of Life subscale scores were associated with lower mean daily MVPA in those with FAIS (R2=21.2%, P=.021; R2=22.0%, P=.018; respectively) but not in uninjured controls. Conclusions: Individuals with FAIS spent less time in daily MVPA, took fewer daily steps, and met recommended PA guideline cutoffs at lower proportions compared with uninjured controls. Higher BMI and lower HOOS-Quality of Life scores were associated with lower mean daily MVPA. Interventions should be developed for individuals with FAIS to increase PA engagement to potentially lessen the risk of future comorbidities associated with decreased PA and increased BMI.

Background. The Banff classification scheme provides a framework for interpreting transplant kidney biopsies and has undergone various updates in the past 2 decades especially related to antibody-mediated rejection. The clinical significance of early glomerulitis seen within 4 mo on protocol biopsies has received limited attention. We hypothesized that early glomerulitis seen on protocol biopsies will lead to significant adverse outcomes as assessed by histopathology and allograft outcome. Methods. A single-center retrospective study of a cohort of patients who underwent protocol biopsies within 4 mo after transplantation with timely follow-up protocol biopsies were assessed. Patients with recurrent glomerulonephritis were excluded. Results. We calculated glomerulitis (g) scores for 2212 biopsy specimens and identified 186 patients with glomerulitis (g > 0) and 2026 patients without glomerulitis (g = 0). The progression to chronic transplant glomerulopathy at 1 and 2 y was higher in patients with g > 0 as compared with g = 0 (year 1, 10.7% versus 2.3% [P 0 as compared with g = 0 (hazard ratio, 1.68 [95% CI, 1.07-2.65]; P = 0.02). We did not find any difference in outcomes in glomerulitis group based on donor-specific antibody. Conclusion. Our findings suggest that early glomerulitis (seen within 4 mo after transplantation) may lead to clinically significant long-term changes and thus could be a target for early intervention therapies.

Background: This study compares postoperative pain scores and functional outcomes between liposomal bupivacaine peri-articular injection (LB-PAI) vs a single-shot adductor canal block (ACB) using bupivacaine HCl in patients undergoing primary total knee arthroplasty (TKA). Methods: This is a randomized controlled trial of 56 patients who were treated with TKA for arthritis. Patients were randomized to receive an intraoperative LB-PAI (n = 27) or preoperative ACB using bupivacaine HCl (n = 29). Both groups were otherwise given our institutional standard multimodal pain protocol. Data on Visual Analog Scale (VAS) pain scores, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, knee range of motion, postoperative ambulation distance, hospital length of stay, and opioid use were collected. The total cost of each intervention was compared at the conclusion of the study. Results: Age, gender, or body mass index was similar between groups. Compared to the ACB group, the LB-PAI group trended to lower average VAS pain scores on postoperative days 0, 1, and 2 (average difference [95% confidence interval] = −0.5 [−0.7, 1.7], −1.0 [−0.1, 2.0], −0.2 [−0.8, 1.3]), and identical average VAS pain scores on postoperative days 4 and 7. These differences and all postoperative outcome measures were not statistically significant at any time point. A single 266-milligram vial of liposomal bupivacaine costs $351, and a single-shot ACB costs $893 at our institution. Conclusions: This randomized controlled trial shows similar postoperative pain control, functional outcomes, and opioid use between LB-PAI and a single-shot ACB in patients undergoing primary TKA. However, the single-shot ACB costs $542 more than the LB-PAI at our institution.

3-Hydroxyisobutyryl-CoA hydrolase (HIBCH) deficiency is a rare mitochondrial disorder of valine metabolism which may present with motor delay, hypotonia, ataxia, dystonia, seizures poor feeding, and organic aciduria. Neuroimaging findings include signal abnormalities of the deep gray matter, particularly the globus pallidi, and cerebral peduncles. We report a 15-month-old male patient with HIBCH deficiency who presented with paroxysmal tonic upgaze of infancy, motor delay, and hypotonia. MRI revealed characteristic bilateral, symmetric signal abnormalities in the basal ganglia and a mutation in HIBCH was confirmed with whole exome sequencing. HIBCH should be a consideration in patients with Leigh-like features, especially if neuroimaging changes primarily affect the globus pallidi. Recognition of this pattern may help guide targeted testing and expedite the diagnosis and treatment of this rare disease.

Presented is a patient with carotid artery stenosis resulting in crescendo anterior and posterior circulation transient ischemic attacks. Treatment was complicated by a rare persistent hypoglossal artery (HGA) arising from the left internal carotid artery in addition to severe contralateral carotid disease, hypoplastic vertebral arteries, and incomplete circle of Willis. A carotid endarterectomy with shunting was performed, maintaining perfusion of both the proper left internal carotid artery and HGA. This is a rare case of carotid stenosis in the setting of a persistent HGA with contralateral carotid disease and highlights the importance of planning intracranial perfusion before carotid surgery.

Category: Ankle; Sports Introduction/Purpose: Stress radiographs have demonstrated superior efficacy in the evaluation of ankle instability. The purpose of this study is to determine if there is a degree of instability evidenced by stress radiographs that is associated with pathology concomitant with ankle ligamentous instability. Methods: A retrospective review of 87 consecutive patients aged 18-74 who had stress radiographs performed at a single institution between 2014 and 2020 was performed. These manual radiographic stress views were then correlated with MRI and operative findings. Results: A statistically significant association was determined for the mean and median stress radiographic values and the presence of peroneal pathology (p=0.008 for tendonitis and p= 0.020 for peroneal tendon tears). A significant inverse relationship was found between the presence of an osteochondral defect and increasing degrees of instability (p=0.043). Conclusion: Stress radiographs may assist the surgeon in clinical decision making.

Category: Bunion; Other Introduction/Purpose: Hallux valgus affects 23 -36% in general populations. The purpose of this study was to evaluate return to run following either a modified Lapidus procedure or a metatarsal osteotomy. We hypothesized that there would be no difference in the ability to return to running. Methods: A Retrospective review of a consecutive series of patients at a single institution with surgical correction was performed. 51 patients were identified. 35 were treated with a metatarsal shaft osteotomy and 16 with a modified Lapidus. Results: No difference was found between the cohorts in terms of age, sex, or pre- operative hallux valgus angle (HVA). 27/35 (77%) with metatarsal shaft osteotomy were able to return to running versus 13/16 (81%) with modified Lapidus. There was no significant difference in the ability to return to running between cohorts (p=1.00). Conclusion: Our study showed no statistical difference for the modified Lapidus versus metatarsal osteotomies relative to return to running.

Hydatidosis is a common parasitic zoonosis in Middle Eastern, African, and Mediterranean populations whit primarily and well known involve of liver and lungs, but some complications are extremely rare and underrated. Particularly Hydatid cystic disease of the skeletal is one of the rarest clinical manifestations and when occurs involve in almost 50% of cases the spine. This manifestation is extremely debilitating, hard to correctly identify and manage. We want to underline this rare involve of spine to avoid misdiagnosis and complications. Keywords: Echinococcus, Hydatid, Hydatid spine disease

Acute mesenteric ischemia secondary to aortic dissection in type A and type B is a true vascular surgical emergency. Presentation can be subtle or dramatic, and time to revascularization is limited before irreversible changes occur. The literature recognizes the catastrophic consequences of acute superior mesenteric artery occlusion and the need for urgent revascularization, often before central aortic repair in type A. There is no optimal revascularization technique described in this scenario. We present a case of type A aortic dissection with acute dynamic and static superior mesenteric artery occlusion and describe treatment that resulted in successful salvage of the bowel and the patient's life. Keywords: Mesenteric ischemia, Aortic dissection, Type A, Revascularization, Superior mesenteric artery, Laparotomy

The burden of psoriasis is particularly high for women, who report lower levels of happiness (women: 18.5%; men: 11.3% lower vs. general population) and are more likely to experience stress (women: >60%; men: 42%), loneliness (women: 25-28%; men: 19-24%), stigmatization (Feelings of Stigmatization Questionnaire score; women: 93.2; men: 78.0), and reduced sexual activity (women: 33%; men: 19%) compared with men. The onset of psoriasis is bimodal, with one incidence peak (15-30 years) that coincides with the prime reproductive age for women, which poses specific challenges for their treatment. However, well-established guidelines for the treatment of women of childbearing age are lacking. Many women experience stabilization (21%) or improvement (55%) of their skin during pregnancy, but up to a quarter can experience disease worsening, and postpartum flares are common (>50%). Therefore, balancing the risk of treatment with the risk of uncontrolled disease is important. Because half of pregnancies are unplanned, the implications of therapeutic options must be considered for all women with psoriasis who are sexually active, irrespective of intentions to start a family. Timely initiation of these discussions by health care professionals is paramount to prevent unintentional toxicity to the developing fetus. For example, acitretin, methotrexate, and oral psoralen/ultraviolet A are all contraindicated in pregnancy. Reassuringly, safety data for other psoriasis treatments during pregnancy are increasingly available, particularly for anti-tumor necrosis factor therapies. Despite encouraging data from pregnancy exposure registries and clinical studies now being included in anti-tumor necrosis factor drug labels, comfort with prescribing these therapies to pregnant women remains low (U.S. dermatologists: 21%; EU-5 dermatologists: 10%). In this article, we review issues specific to treating women of childbearing age with psoriasis and highlight the need for treatment guidelines to ensure consistent care and optimal outcomes for these patients. Keywords: psoriaris, psoriatic arthritis, women, treatment, pregnancy, lactation

Open technique for elective repair of iliac artery aneurysms can be safely performed with good outcomes but not inconsequential morbidity. An endovascular approach has been shown to have both periprocedural and postoperative advantages with equivalent outcomes. Endovascular repair of common iliac arteries (CIAs) without sacrificing the hypogastric artery using an iliac branch device is a complex endovascular technique requiring a proximal seal zone that may be absent in larger CIA aneurysms. We present two cases in which CIA aneurysms were repaired with a customized endovascular technique using the benefit of the aortic bifurcation for stability in addition to providing a long proximal seal zone with the AFX device (Endologix, Irvine, Calif) paired with the iliac branch device (W. L. Gore & Associates, Flagstaff, Ariz) for internal iliac artery preservation. Keywords: Common iliac artery aneurysm, Endovascular

Slipped capital femoral epiphysis (SCFE) commonly occurs in overweight or obese adolescents, but can also be associated with endocrine disorders including hypothyroidism, pituitary tumors, and growth hormone deficiency. In this article, we present a case of panhypopituitarism that initially presented with SCFE. A 16-year-old male presented with right SCFE. After a right hip open reduction and percutaneous pinning procedure, findings of skeletal maturity that lagged behind his chronologic age and a delayed Tanner stage resulted in a referral to an endocrine specialist. Endocrine laboratory evaluation identified elevated prolactin levels (1493 ng/mL), hypogonadotropic hypogonadism, and central adrenal insufficiency as evidenced by low morning cortisol level of 1.0 µg/dL. Magnetic resonance imaging revealed a large pituitary T2 isointense mass measuring 1.8 × 2.7 × 2.3 cm. The patient was diagnosed with panhypopituitarism due to a pituitary macroadenoma. Multidisciplinary collaboration for treatment of this patient consisted of oral cabergoline, oral levothyroxine, oral hydrocortisone therapy, intramuscular testosterone therapy, and a prophylactic closed reduction percutaneous pinning of the left hip due to high risk of also developing SCFE of the left hip. Panhypopituitarism should be considered as a diagnosis after atypical presentations of SCFE. In our case, an astute clinical assessment resulted in prompt endocrine referral and management of panhypopituitarism. Our report highlights the importance of multidisciplinary collaborations to guarantee early detection of endocrinopathies in patients with SCFE undergoing surgical interventions in order to avoid potential complications, such as adrenal crisis during surgery.

Category: Ankle Arthritis; Ankle; Diabetes Introduction/Purpose: Total ankle arthroplasty (TAA) results in improved patient outcomes and preserved range of motion for patients with end-stage arthritis. Wound complications following these procedures, while rare, can have a significant impact on patient morbidity, particularly when they require return to the operating room and flap coverage. We sought to determine the risk factors associated with the need for flap coverage over TAA, and hypothesized that intraoperative variables such as additional procedures to provide angular correction would play a more important role than patient-specific variables. Methods: We performed a single center retrospective review of primary total ankle arthroplasties from April 2007 - February 2019. Patients demographics and medical comorbidities were collected in addition to concomitant procedures performed at the time of TAA such as tibial osteotomies, removal of hardware, and subtalar fusion. Multivariable, main effects logistic regression models were performed to evaluate the impact of specific concomitant procedures during primary TAA on the rate of subsequent flap coverage with adjustment for age, sex, and medical comorbidities. Results: 2,124 TAA resulted in 29 flaps after an average of 1.1 (range 0-5) surgeries and 89.7 (range 18-591) days after the index arthroplasty. The most common flap was a radial forearm free flap performed in 15 (51.7%) patients. Patients requiring flap coverage were significantly older (p=0.044), were more likely to be diabetic (p=0.029), and were more likely to present to the ED and be readmitted within 90-days of their surgery (p

Category: Ankle; Trauma Introduction/Purpose: Syndesmotic screw fixation is frequently required in rotational ankle injuries. Fibular malreduction after syndesmotic screw fixation occurs in as many as 52% of cases, which has been shown to detrimentally affect subjective outcomes and increase the probability of developing arthritis. The glidepath technique has been proposed as a useful technique to prevent malreduction. We hypothesize that the glidepath technique reduces the occurrence of fibular malreduction and results in improved outcomes compared to clamping. Methods: A retrospective cohort study comparing 25 patients reduced with a clamp compared to 18 patient using the glidepath technique. The glidepath technique, described by Needleman, the fibula is manually reduced and a Kirschner wire is placed through the fibula and tibia along the transmalleolar axis, parallel to the superior border of the ankle mortise. CT scans of the injured and contralateral ankles were obtained postoperatively to assess reduction. Malreduction is defined as >2mm difference between the anterior or posterior incisura-fibular distance of the injured ankle compared to the contralateral side. Prospective outcomes were assessed using the AOFAS and VR-12 scores at preoperative, 3 month, 6 month and 1 year followup of the glidepath cohort only. Results: We found a statistically significant reduction in malreduced syndesmoses using the glidepath technique when compared with the clamping technique. In our study, 17% (3/18) were malreduced using the glidepath technique, compared with 48% (12/25 patients) with clamping (p=0.005). The three malreductions seen in our study were anterior, we had no posterior malreductions. Compared with the clamping cohort that had 10/25 posterior malreductions and 2/25 anterior malreductions. Mean outcomes at 3,6 and 1 year scores were AOFAS 76, 86,86; VR-12 46,53,50/ 42,44,47 (physical/mental) respectively. Conclusion: Historically, malreduction for syndesmotic fixation is as high as 52%. The glidepath technique is a viable reduction maneuver that has lower rates of malreduction compared to clamping in our study. This is the first ever CT confirmed study measuring syndesmosis reduction utilizing manual reduction. The value of this technique is that is does not require an open reduction, arthroscopic visualization/reduction or CT guidance to achieve syndesmotic reduction.

ABSTRACT: Objective: Euglycemic diabetic ketoacidosis (DKA) is a known potential complication from sodium-glucose cotransporter 2 (SGLT2) inhibitor use. We present a unique case presentation of a 44-year-old, male patient on an SGLT2 inhibitor who developed euglycemic DKA while following a carbohydrate-restricted diet, the Atkins diet.Methods: The patient was on sitagliptin and metformin after a hemoglobin A1c result of 9.3% (78 mmol/mol). Motivated to obtain better glycemic control and weight loss, he started on the Atkins diet, but stayed in the carbohydrate-restricted first phase of the diet. Canagliflozin was added to his regimen 1 month later. Three to four days after starting on the medication, he developed severe abdominal pain.Results: The patient was found to have anion gap metabolic acidosis with an elevated beta-hydroxybutyrate level of 75.50 mg/dL (the reference range is 0.20 to 2.80 mg/dL) and a blood glucose value of 180 mg/dL.Conclusion: The low-carbohydrate diet likely predisposed our patient to a ketogenic metabolic state and the addition of canagliflozin likely precipitated the worsening of his ketosis and subsequent DKA. For patients taking SGLT2 inhibitors, carbohydrate-restricted diet plans may increase the risk of developing euglycemic DKA.Abbreviations: DKA diabetic ketoacidosis SGLT2 sodium-glucose cotransporter 2

Purpose: To describe the outcomes and toxicities of the largest cohort to date of patients with anal squamous cell carcinoma uniformly treated with concurrent chemoradiation using dose-painted intensity modulated radiation therapy (DP-IMRT) according to RTOG 0529. Methods and materials: We identified 99 eligible patients with anal cancer who were treated at our institution with definitive chemoradiation using DP-IMRT between 2005 and 2015 per RTOG 0529 dosing guidelines. Primary study endpoints included event-free survival (defined as recurrence, colostomy, or death) and overall survival. Secondary endpoints were treatment duration and acute and late toxicity. Results: At a median follow-up of 49 months (range, 2-114 months), 92% of patients had a clinical complete response. Fifteen percent underwent colostomy, including 4 pretreatment colostomies, 6 planned abdominoperineal resections (APRs), 4 salvage APRs, and 1 APR for treatment-related complications. Thirteen patients developed local recurrence, of whom 6 developed synchronous metastatic disease. The 4-year overall survival was 85.8%, and 4-year event-free survival was 75.5%. Median treatment duration was 43 days (range, 10-68 days). The overall rate of non-hematologic grade 3+ acute and grade 2+ late toxicities was 20% and 15%, respectively. Conclusions: Long-term outcomes and tolerability were excellent In the largest cohort to date of patients with anal cancer who received DP-IMRT prescribed per RTOG 0529.

Background: Osteochondral lesions of the talus (OLTs) are common injuries in young, active patients. Microfracture is an effective treatment for lesions less than 150 mm 2 in size. Most commonly employed postoperative protocols involve delaying weightbearing for 6 to 8 weeks (DWB), though one study suggests that early weightbearing (EWB) may not be detrimental to patient outcomes. The goal of this research is to compare outcomes following EWB and DWB protocols after microfracture for OLTs. Methods: We performed a prospective, randomized, multicenter clinical trial of subjects with unilateral, primary, unifocal OLTs treated with microfracture. Thirty-eight subjects were randomized into EWB (18 subjects) and DWB (20 subjects) at their first postsurgical visit. The EWB group began unrestricted WB at that time, whereas the DWB group were instructed to remain strictly nonweightbearing for an additional 4 weeks. Primary outcome measures were the American Academy of Orthopaedic Surgery (AAOS) Foot and Ankle score and numeric rating scale (NRS) pain score. Results: The EWB group demonstrated significant improvement in AAOS Foot and Ankle Questionnaire scores at the 6-week follow-up appointment as compared to the DWB group (83.1 ± 13.5 vs 68.7 ± 15.8, P = .017). Following this point, there were no significant differences in AAOS scores between groups. At no point were NRS pain scores significantly different between the groups. Conclusions: EWB after microfracture for OLTs was associated with improved AAOS scores in the short term. Thereafter and through 2 years’ follow-up, no statistically significant differences were seen between EWB and DWB groups. Level of Evidence: Level II, prospective randomized trial.

Background: While proximal first metatarsal osteotomy combined with distal soft tissue realignment is accepted as standard treatment of moderate to severe hallux valgus with metatarsus primus varus, none of the described proximal metatarsal osteotomies address the hyper-obliquity of the first metatarsocuneiform joint. An opening-wedge osteotomy of the medial cuneiform can potentially correct the 1-2 intermetatarsal angle (IMA) in addition to normalizing the hyper-obliquity of the first tarsometatarsal (TMT) joint. The purpose of this study was to retrospectively review the early radiographic and clinical results of the use of a medial cuneiform opening-wedge osteotomy fixed with a low-profile wedge plate combined with distal soft tissue realignment for the treatment of hallux valgus. Methods: Fourteen feet (13 patients; 2 male and 11 female, average age 56 years, range 22-75) with hallux valgus underwent an opening-wedge osteotomy of the medial cuneiform fixed with a low-profile nonlocking wedge plate combined with distal soft tissue realignment. The mean preoperative hallux valgus angle (HVA) was 32 degrees and the IMA was 16 degrees. HVA, 1-2 IMA, proximal first metatarsal inclination (PFMI), and presence of osteoarthritis of the first TMT joint were assessed on preoperative and final postoperative radiographs. Final postoperative radiographs were also evaluated for radiographic union and hardware failure at an average of 7 months (range, 3-19 months) postoperatively. Results: A mean intraoperative correction of 19 degrees and 7 degrees was achieved for the HVA and IMA, respectively. The mean HVA was 22 degrees and the mean IMA was 11 degrees at the time of final follow-up. At final follow-up, a recurrence of the deformity was observed in 12/14 feet. There were 2 nonunions—one plate failure and one screw failure. No first TMT joint instability or arthritis was observed. All patients were ambulatory without assistive device in either fashionable or comfortable shoe wear. Conclusion: Medial cuneiform opening-wedge osteotomy resulted in unreliable correction of HVA and IMA at short-term follow-up with a high rate of early recurrence of hallux valgus deformity and a complication rate similar to that of the Lapidus procedure. This procedure cannot be recommended for addressing hallux valgus in the setting of increased obliquity of the first TMT joint. Level of Evidence: Level IV, case series.

Summary: There has been considerable focus on the potential role of nitric oxide (NO) and phosphodiesterase (PDE)-5 inhibition in treating heart failure with preserved ejection fraction (HFpEF). However, the results from studies have been conflicting. In a preclinical study, pre-treatment of diabetic rats with a PDE-5 inhibitor, vardenafil, resulted in a significant decrease in left ventricle stiffness. However, the results from clinical trials have been neutral. In this perspective piece, the authors discuss whether or not it is time to move on from targeting NO and PDE5 for the treatment of HFpEF. Key Words: nitrates, nitrites, phosphodiesterase, pulmonary arterial hypertension, sildenafil

Chronic myeloid leukemia (CML) is a clonal myeloproliferative disorder, characterized by proliferation of granulocytes, caused by a translocation that produces the Philadelphia chromosome resulting in constitutively active BCR-ABL tyrosine kinase. Imatinib and dasatinib are 2 BCR-ABL tyrosine kinase inhibitors (TKI) used in the treatment of CML. Since the introduction of dasatinib earlier this decade, more than 100 cases of dasatinib-induced pulmonary arterial hypertension PAH have been reported in Europe. When imatinib was introduced, no such increase in pulmonary vasculopathy was identified. In this perspective piece, the author discusses the work of Guignabert et al., recently published in the Journal of Clinical Investigation, which examined the mechanism through which dasatinib mediates its toxic pulmonary vascular effects.

Category: Hindfoot Introduction/Purpose: Insertional Achilles tendinopathy is a common musculoskeletal disorder that can impair physical function in daily living and athletic and occupational performance. It has been previously reported that up to one-third of patients who present with this condition will undergo surgical treatment due to failure of conservative management. To date, insertional Achilles tendinopathy outcomes within the military have not been reviewed. Furthermore, surgical correction of symptomatic Achilles tendinopathy often does not lead to a return to restriction-free active duty. Therefore, it is of great interest to evaluate the outcomes of non-operative and operative management and the ability for the service member to return to duty following treatment of insertional Achilles tendinopathy. Methods: A single center retrospective review of consecutive patients with ICD-9, ICD-10 and CPT codes for diagnosis of Achilles tendon and calcaneal coding were reviewed from January 2007-May2017. Inclusion criteria included active duty military, failure of at least 3 months of conservative management and surgical treatment utilizing a retrocalcaneal exostectomy, Achilles tendon debridement followed by reattachment as necessary. Radiographic and clinical data collection was completed on all patients who met inclusion criteria to determine pre- and post-operative changes in pain and function. VAS pain scores were collected pre-op, and at 3, 6 12 and 24mo post-op. Operative reports were reviewed to confirm specific operative findings and repair technique. Surgical treatment was achieved with medial incision, fluoroscopy guided spur/Haglund deformity resection and reattachment of the Achilles tendon utilizing suture anchor constructs. Return to duty and profile status were recorded as outcome measures. Results: Our data analysis included 70 patients with the majority of patient from the Army (41 pts). Average age at treatment was 36.6yo (range, 21-54). Tobacco use was observed in 13 patients (18.57%). Length of pre-operative physical therapy averaged 6.5 months (range, 2-36mo). Other modalities prior to operative correction were also recorded with 20% receiving a PRP injection, 1.43% received a steroid injection, 14% of patients received ECSWT. Surgical treatment complications were observed in 16 patients (13%). VAS scores significantly improved at one year from 5.6 pre-op to 3.2 post-op (n=26.) At 1 year,60% of patient went onto return to full duty, 25% of patients remained on profile, 5% of patients retired, 10% of patients went onto medical evaluation board for separation from the military. Conclusion: To our knowledge, this is the first study to evaluate the outcomes of insertional Achilles tendinopathy in an active military population. Insertional Achilles tendinopathy prevalence within the military is a common condition with incidence rates likely higher than the general population which previously reported to between 15-24%. In conclusion, with a 60% return to duty rate and significant reduction of subjective pain scores, this is a viable treatment option for patients who could not otherwise remain on active duty but the complication rate is high (13%) and patients and providers should consider the risks during their shared decision making process.

Category: Ankle Introduction/Purpose: Numerous treatment modalities are in use today to treat symptomatic osteochondral lesions in the ankle; however, there are ongoing challenges with the treatment of certain types of lesions and concern regarding the long-term effectiveness of current common techniques. Methods: The purpose of this study was to collect mid and long-term clinical outcomes of pain, function, and activity level (VAS, SF-12, FAAM ADL, FAAM sports) Single-arm, multi-center study collected outcomes prospectively in standard clinic patients who would be undergoing or who had previously undergone treatment with DeNovo NT. The main exclusion criteria were high surgical risk, clinically diagnosed autoimmune diseases, or an active joint infection; all other patients receiving DeNovo NT could be approached for the study. The outcome analysis for this abstract focused on enrolled subjects’ final follow-up to date. Results: Clinical outcomes have been prospectively collected for 24 subjects with a total of 48 months follow-up. Twenty four of the treated lesions were located on the talus, none on the tibia. Out of the 24 patients, 23 had a single lesion and 1 had more than one. The average lesion size was 108.1 mm +/- 60.0 [23]. The Hepple classification was used to categorize each lesion. Interestingly, 19/24 were classified as 3 or higher. Cartilage ICRS was also used for classification. Out of the subjects, 23/24 were ICRS grade 3 or 4. There was also a concomitant procedure for 22/24 patients. Pre and post op VAS scores of 47.5 (+/- 23.1) and 12.2 +/- 17.8. SF-12 scores pre and post of 38.0 +/- 8.5 and 50.1 +/- 8.2. FAAM ADL’s pre and post 60.4 +/- 16.3 and 90.4 +/-11.8. FAAM sport scale scores pre and post 28.8 +/- 16.7 and 74.5 +/- 22.4. all outcome measures were statistically significant. Conclusion: Four year complete data is a challenge in this particular clinical population. This data set encompasses symptomatic osteochondral lesions of the talus treated with particulated juvenile cartilage allograft. The outcomes reflect an improvement in symptoms and patient satisfaction when treated with this technique. Based on these final outcome measures (V AS, SF-12, FAAM ADL’s, FAAM sport scale score) and satisfaction, it can be concluded that this is a viable option to get patients back to their pre-injury state.

Category: Arthroscopy Introduction/Purpose: Bone marrow stimulation techniques, specifically arthroscopic microfracture, have become the therapy of choice for osteochondral lesions of the talus (OLTs) less than 15 mm2 in size. Traditionally, the microfracture site is protected with a postoperative non-weightbearing period of 6-8 weeks. However, recent research has suggested postoperative early weight bearing (EWB) after microfracture may produce outcomes equivalent to delayed weight bearing (DWB). We performed a prospective, randomized trial to determine whether the results of EWB after microfracture for OLTs are equivalent to DWB. Methods: We randomized 37 patients (37 ankles) undergoing arthroscopic microfracture for OLTs to either EWB or DWB protocols. The EWB cohort was allowed to bear weight as tolerated two weeks after surgery, while the DWB cohort was held non-weightbearing until six weeks postoperatively. We collected demographic data, mechanism of injury, lesion size and stage, Numeric Rating System pain scores (NRS), and American Academy of Orthopaedic Surgery Foot and Ankle Questionnaire (AAOS) functional scores preoperatively, then at 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively. Results: There were no differences between the two cohorts in terms of patient age, mechanism of injury, lesion size, or lesion stage. The mean age at surgery was 34.1 years (range 21-50 years). 70.4% of the lesions were lateral, 22.2% were medial, and the remainder were central. The EWB group demonstrated statistically significant improvement in AAOS scores at the six week follow-up appointment. There were no significant AAOS score differences at the other time points. NRS pain scores were not significantly different at any time point. Both groups showed mild deterioration of results over time. Conclusion: Early weightbearing after microfracture for OLTs was associated with improved AAOS scores in the short term, without demonstrating poorer function or pain at 2 year follow up. This study supports early weightbearing after arthroscopic microfracture for osteochondral lesions of the talus.

Category: Trauma Introduction/Purpose: The United States Medical Corps has continued to evaluate and define the injury patterns of our service members in an effort to prevent injury and improve combat casualty care. The pattern of injury can be predicted by the mechanism of injury. One of the more recently described and studied mechanisms has been coined the ‘dismounted complex blast injury. This injury pattern involves traumatic amputation of at least one leg with a second injury involving another extremity in addition to an injury to either the pelvis, the abdomen, or the urogenital region. The purpose of this study was to better define and describe the injuries occurring to the non amputated extremity. Methods: This is a retrospectively review of data from the US and UK Joint Theater Trauma Registries (JTTR) of consecutive patients admitted to the UK Role 3 hospital at Camp Bastion, Afghanistan, from January 1, 2009, to February 29, 2012. Data was obtained from the US JTTR (Joint Theatre Trauma Registry). Each patient was assigned an Injury Severity Score (ISS) and an Abbreviated Injury Scale (AIS) score. Only those patients with an AIS of 3 or greater (a serious injury) were included. All xrays and CT scans were evaluated by two board certified orthopaedic surgeons and one board certified musculoskeletal radiologist. Fisher’s exact test was used to compare categorical data and binomial logistic regression was be used to compare proportions of types of injuries by traumatic amputation level observed. Results: There were 295 patients with lower extremity injuries identified. 201 had traumatic lower extremity amputations, 140 with bilateral lower extremity amputations, 61 with single leg amputations. The mean age was 23.38 +/-3.77 years. All were male. Below the knee amputation was the most frequent amputation type observed, representing 55.7% of the amputations (29/52), the next most frequent was the through knee amputation representing 25%. The least frequent was the through ankle amputation. The presence of a symes level amputation was associated with an 8.1% increase in the odds of the presence of a skeletal foot injury in the rear lower extremity. There was also an association found between AKA level amputation and skeletal injury in the contralateral upper extremity . Conclusion: This is among the first studies to correlate level of injury and associated musculoskeletal injury for the Afghanistan theater of operations. The results of this data set demonstrate that proximal lower extremity amputation levels are significantly associated with distal upper extremity skeletal injury. In addition, the Symes level of amputation is significantly associated with contralateral foot fractures. Amputation levels proximal to the ankle often present with associated Genitourinary injuries. Unique to this study is the demonstration of a significant association of upper extremity injury with a more proximal lower extremity amputation level .

Category: Ankle Introduction/Purpose: Treatment of osteochondral defects of the talus with particulated juvenile cartilage allograft is a relatively new procedure. Although other treatment options exist for large osteochondral defects of the talus, the potential advantage of particulated juvenile allograft is the ability to perform the procedure arthroscopically or through a minimal approach. No previous studies have looked at the results of an arthroscopic approach and no previous studies have compared an arthroscopic technique to an open approach. The purpose of this study was to compare the outcomes of an arthroscopic transfer technique to the previously published open technique. Methods: A total of 34 patients underwent treatment of talar cartilage lesions with juvenile particulated cartilage allograft. Twenty of these were done arthroscopically and 14 were done with an open arthrotomy. There was no statistically significant difference between the groups with respect to age, lesion width, lesion depth, lesion length, or operative time. Scores for 6 different validated outcome measures were recorded for patients in each group pre-operatively and subsequently at 6 months, 1 year, 18 months, and 2 years. Results: Comparing outcome measurements at each data point to baseline, there were no statistically significant post-operative differences found between open and arthroscopic approaches with regards to VAS Pain Scale, AOFAS Ankle-Hindfoot Scale, Foot and Ankle Ability Measure - Sport Scale, or SF12 Physical Health Scale. Conclusion: Treatment of talar articular cartilage lesions with particulated juvenile cartilage allograft is associated with improved outcomes at 2 years with regards to several validated outcome measures regardless of technique utilized. At 2 years follow up, there were no statistically significant differences in outcomes utilizing an arthroscopic technique versus open technique with the numbers given. This data supports the use of particulated juvenile cartilage allograft utilizing either arthroscopic or open techniques.

Category: Sports Introduction/Purpose: Return to sport criteria after surgical treatment of lower extremity injuries are highly variable and without consensus. Thigh measurements assessing atrophy, single-leg hop testing and isokinetic strength measurements are commonly used metrics when considering return to sport after surgical treatment of lower-extremity injuries. Yet, these modalities are limited in scope, as they do not fully or accurately evaluate functional movements required in elite athletics. Alternatively, using new Global Positioning System (GPS) technology, a wide breadth of functional movements can be tracked for each athlete, which can be used as a comparative self-control in the event of an injury. This data proposes a more comprehensive, dynamic and longitudinal comparison of athlete performance, which may more accurately reflect functional return to sport in elite athletes after surgery. Methods: Over a three-year period, GPS data was collected on thirteen elite American College Football players at a single FBS Subdivision University. A total of 300 data points per athlete were collected for every practice, scrimmage and game starting in spring prep and extending through regular season, and post-season play. A total of 5.7 million data points including total distance traveled, average and maximum velocity, acceleration profiles, and explosive change of direction through inertial movement analysis were prospectively collected and analyzed. Individual pre-injury GPS functional profiles for each of the thirteen athletes were used as baseline, healthy comparisons, and functional recovery was determined prospectively during return to play progression after lower extremity surgery. Return to sport was allowed when post-operative GPS profiles demonstrated equivalence or superiority of all parameters compared to pre-injury measurements. Results: All thirteen players returned to sport after all measured parameters were equal to or greater than pre-injury levels. Conclusion: Modern GPS technology employed during preseason, regular season and post-season establishes an individualized, baseline, profile of lower-extremity function which allows for postoperative comparison and prospective assessment of safe return to play in elite football players.

Category: Hindfoot Introduction/Purpose: Reconstruction of a symptomatic adult flatfoot is an involved operation with a long recovery period. No previous studies have looked at the occupational or functional results of athletically active patients who have undergone this surgery. In the United States military, the rates of return to unrestricted active duty are unknown. Methods: A retrospective review of all active duty military patients who underwent a reconstructive surgery for adult acquired flatfoot surgery at a single institution from January 2001-2015 was performed. Surgical, inpatient, and outpatient databases were searched via CPT and ICD9 codes. Approximately 1300 cases with potential flatfoot reconstructive surgery were identified. Only those patients with the diagnosis of flatfoot treated with both a boney procedure and a soft tissue procedure were included. Patients had to have at least one year follow-up or follow-up to the point of maximum medical benefit as defined by the operative provider. Final disposition of the patients had to have been recorded in the medical record. Three possible outcomes were utilized in the review of this cohort: patient returned to duty without restrictions, patient returned to active duty with restrictions, or patient separated from active duty due all or in part to this medical condition. Results: Fifty patients met inclusion criteria. 30/50 patients (60%) remained on active duty with permanent duty restrictions, and only two of 50 patients (4%) returned to full duty without restrictions. 20/50 (40%) underwent a Medical Evaluation Board (MEB) to separate from the military. A difference was noted in terms of the hindfoot realignment procedure performed: the probability of an MEB is higher for those patients who had a lateral column lengthening procedure than those who were treated with a medializing calcaneal osteotomy. Conclusion: The sample size is the largest study to date of patients with surgical correction for symptomatic pes planus. The results demonstrate that a service member with symptomatic pes planus requiring surgery faces a 96% chance of failure to return to pre-injury level of function. While some (60%) were able to remain on active duty with restrictions, there is a 40% chance that service members will face separation from the military due to their foot pain. Furthermore, patients treated with a lateral column lengthening had a higher probability of being medically discharged than those who had a medializing calcaneal osteotomy.