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The use of midfoot wedges for the correction of flatfeet disorders, such as progressive collapsing foot disorder, has increased greatly in recent years. However, the wedge material/composition has yet to be standardized. Metallic wedges offer advantages such as comparable elasticity to bone, reduced infection risk, and minimized osseous resorption, but a comprehensive review is lacking in the literature. Therefore, the objective of this systematic review was to organize all studies pertaining to the use of metallic wedges for flatfoot correction to better understand their efficacy and safety. This systematic review adhered to PRISMA guidelines, and articles were searched in multiple databases (PubMED, SPORTDiscus, CINAHL, MEDLINE, and Web of Science) until August 2023 using a defined algorithm. Inclusion criteria encompassed midfoot surgeries using metallic wedges, observational studies, and English-language full-text articles. Data extraction, article quality assessment, and statistical analyses were performed. Among 11 included articles, a total of 444 patients were assessed. The average follow-up duration was 18 months. Radiographic outcomes demonstrated that patients who received metallic wedges experienced improvements in lateral calcaneal pitch angle and Meary’s angle, with an enhancement of up to 15.9 degrees reported in the latter. Success rates indicated superior outcomes for metallic wedges (99.3%) compared to bone allograft wedges (89.9%), while complications were generally minor, including hardware pain and misplacement. Notably, there were no infection complications due to the inert nature of the metallic elements. This review summarizes the effectiveness, success rates, and safety of metallic wedges for flatfoot correction. Radiographic improvements and high success rates highlight their efficacy. Minor complications, including pain and mispositioning, were reported, but the infection risk remained low. Our results demonstrate that metallic midfoot wedges may be a viable option over allograft wedges with proper planning. Future research should prioritize long-term studies and standardized measures.

Background: The incidence of primary total ankle arthroplasty (TAA) is rising, with a corresponding increase in revision surgeries. Despite this, research on risk factors for revision TAA following primary TAA remains limited. Radiographic soft tissue thickness has been explored as a potential predictor for outcomes in hip, knee, and shoulder arthroplasty, but its role in TAA has not been assessed. This study aimed to assess the predictive value of radiographic soft tissue thickness for identifying patients at risk of requiring revision surgery following primary TAA. Methods: A retrospective study was conducted on 323 patients who underwent primary TAA between 2003 and 2019. Radiographic measurements of soft tissue thickness were obtained from preoperative radiographs. Two novel radiographic measures of soft tissue thickness were developed and assessed (tibial tissue thickness and talus tissue thickness). Clinical variables including age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, diabetes, smoking status, primary diagnosis, and implant type were recorded. Logistic regression analysis was used to assess the predictive value of soft tissue thickness and BMI for revision TAA. Results: The rate of revision surgery was 4.3% (14 of 323 patients). Patients requiring revision had significantly greater tibial tissue (3.54 vs 2.48 cm; P = .02) and talus tissue (2.79 vs 2.42 cm; P = .02) thickness compared with those not requiring revision. Both the tibial tissue thickness (odds ratio 1.16 [1.12-1.20]; P

Introduction: Launched in 2018 for revision total ankle arthroplasty (rTAA), the INVISION talar component addresses subsidence when poor talar bone stock is present. Due to the recency of the market-availability of the INVISION, studies evaluating its efficacy are lacking. This study presents the first analysis of early-term outcomes of patients undergoing rTAA with the INVISION talar component. Methods: This was a single-center, retrospective review of 28 patients undergoing rTAA with the INVISION talar component and INBONE II tibial component performed between 2018 and 2022. Data on preoperative characteristics, postoperative complications, secondary procedures, and survivorship were collected. The primary outcome measures were rates of major complications, re-operation, and implant failure. Secondary outcomes included post-operative changes in varus and valgus alignment of the tibia and talus. Results: The most common secondary procedures performed with rTAA were medial malleolus fixation (n = 22, 78.6%) and gastrocnemius recession (n = 14, 50%). Overall, 10.7% (n = 3) of patients underwent reoperation and 14.3% (n = 4) suffered major complications. Incidence of implant failure was 10.7% (n = 3). All reoperations were caused by infection. Mean varus alignment of the tibia and talus improved from 4.07 degrees and 4.83 degrees to 1.67 degrees and 1.23 degrees, respectively. Mean valgus alignment of the tibia and talus improved from 3.67 degrees and 4.22 degrees to 2.00 degrees and 2.32 degrees, respectively. Conclusions: In a series of 28 patients undergoing rTAA with the INVISION talar component, we discovered comparatively low rates of reoperation, major complication, and implant failure (10.7%, 14.3%, and 10.7%). The INVISION system appears to have a reasonable safety profile, but further studies evaluating long-term outcomes are required to assess the efficacy of the INVISION system.

Osteochondral lesions of the talus are common injuries that are most often the result of trauma. The natural progression of osteochondral lesions is not well understood. It is still unclear which lesions eventually lead to joint degeneration and osteoarthritic changes and if the treatment method affects the progression. The existing literature surrounding this topic is sparse, with inconsistent findings. The presented images are taken from a 72-year-old man with bilateral osteochondral lesions of the talus. To our knowledge, this is the first published series of images illustrating the natural progression of a patient with bilateral osteochondral lesions of the talus over a 12-year time period.

Charcot neuroarthropathy (CN) is a rare but serious sequela of diabetes and other diseases that cause peripheral neuropathy. It is most commonly characterized by degeneration of the foot and/or ankle joints leading to progressive deformity and altered weight-bearing. If left untreated, the deformities of CN lead to ulceration, infection, amputation, and even death. Because of the associated peripheral neuropathy and proprioception deficits that accompany CN, patients typically do not perceive the onset of joint destruction. Moreover, in the hands of the untrained clinician, the initial presentation of CN can easily be mistaken for infection, osteoarthritis, gout, or inflammatory arthropathy. Misdiagnosis can lead to the aforementioned serious sequelae of CN. Thus, an early accurate diagnosis and off-loading of the involved extremity, followed by prompt referral to a specialist trained in the care of CN are crucial to prevent the late-term sequelae of the disease. The purpose of this article was to create an opportunity for enhanced understanding between orthopedic surgeons and emergency physicians, to improve patient care through the optimization of diagnosis and early management of CN in the emergent setting.

Cartilage damage presents a significant clinical challenge due to its intrinsic avascular nature which limits self-repair. Addressing this, our study focuses on an alginate-based bioink, integrating human articular cartilage, for cartilage tissue engineering. This novel bioink was formulated by encapsulating C20A4 human articular chondrocytes in sodium alginate, polyvinyl alcohol, gum arabic, and cartilage extracellular matrix powder sourced from allograft femoral condyle shavings. Using a 3D bioprinter, constructs were biofabricated and cross-linked, followed by culture in standard medium. Evaluations were conducted on cellular viability and gene expression at various stages. Results indicated that the printed constructs maintained a porous structure conducive to cell growth. Cellular viability was 87% post printing, which decreased to 76% after seven days, and significantly recovered to 86% by day 14. There was also a notable upregulation of chondrogenic genes, COL2A1 (p = 0.008) and SOX9 (p = 0.021), suggesting an enhancement in cartilage formation. This study concludes that the innovative bioink shows promise for cartilage regeneration, demonstrating substantial viability and gene expression conducive to repair and suggesting its potential for future therapeutic applications in cartilage repair.

Background: Artificial intelligence (AI) platforms, such as ChatGPT, have become increasingly popular outlets for the consumption and distribution of health care–related advice. Because of a lack of regulation and oversight, the reliability of health care–related responses has become a topic of controversy in the medical community. To date, no study has explored the quality of AI-derived information as it relates to common foot and ankle pathologies. This study aims to assess the quality and educational benefit of ChatGPT responses to common foot and ankle–related questions. Methods: ChatGPT was asked a series of 5 questions, including “What is the optimal treatment for ankle arthritis?” “How should I decide on ankle arthroplasty versus ankle arthrodesis?” “Do I need surgery for Jones fracture?” “How can I prevent Charcot arthropathy?” and “Do I need to see a doctor for my ankle sprain?” Five responses (1 per each question) were included after applying the exclusion criteria. The content was graded using DISCERN (a well-validated informational analysis tool) and AIRM (a self-designed tool for exercise evaluation). Results: Health care professionals graded the ChatGPT-generated responses as bottom tier 4.5% of the time, middle tier 27.3% of the time, and top tier 68.2% of the time. Conclusion: Although ChatGPT and other related AI platforms have become a popular means for medical information distribution, the educational value of the AI-generated responses related to foot and ankle pathologies was variable. With 4.5% of responses receiving a bottom-tier rating, 27.3% of responses receiving a middle-tier rating, and 68.2% of responses receiving a top-tier rating, health care professionals should be aware of the high viewership of variable-quality content easily accessible on ChatGPT. Level of Evidence: Level III, cross sectional study.

Background: Since the Physician Payments Sunshine Act in 2010, a substantial body of work has explored the supplemental income received by physicians to understand trends in industry payments and investigate sources of bias. To date, no study has examined how various fellowship characteristics impact industry earning levels at foot and ankle orthopaedic surgery fellowships. The purpose of this study is to examine the various fellowship and faculty-specific variables in correlation with industry earnings in foot and ankle orthopaedic surgery fellowships. Methods: This study is a retrospective analysis of foot and ankle orthopaedic surgery fellowships and respective faculty along with various fellowship characteristics in correlation to industry lifetime earning levels as of March 2023. Industry total lifetime earnings represent income directly paid to physicians, is not part of the physician's salary, and does not include any research grants or funding. Lifetime earnings represent all years recorded on the Open Payments Database website (2015-2021). Results: There are 165 faculty physicians and 48 programs with complete data out of all foot and ankle orthopaedic surgery fellowship programs in the United States. The mean fellowship H-Index per fellowship was 48.94 ± 38.92, and the mean fellowship lifetime earning was $1 551 791.66 ± $4 136 091.64. There was no significant association between fellowship lifetime earnings and Newsweek ranking of fellowship-affiliated hospitals (P = .906), Doximity ranking of fellowship-affiliated residencies (P = .703), and region of the United States (P = .126). There was a statistically significant increase in total lifetime earnings in programs with 4 fellows as compared to 1 fellow (P = .035). Conclusion: There was no statistically significant correlation between a variety of foot and ankle fellowship-specific factors and lifetime industry earnings, aside from increased earnings in programs having 4 fellows. Prestige factors, such as Doximity and Ranked Hospital Newsweek List rank, as well as region of the United States is not associated with industry earnings. Level of Evidence: Level III, retrospective cohort study.

Purpose: The purpose of this study was to compare bone marrow stimulation using micro-computed tomography (micro-CT) analysis of an abrasion arthroplasty technique, drilling k-wire technique, traditional microfacture awl, or a microdrill instrument for subchondral bone defects. Methods: Eleven cadaveric distal femoral specimens were obtained and divided into 3 common areas of osteochondral defect: trochlea and weightbearing portions of the medial and lateral femoral condyles. Each area of interest was then denuded of cartilage using a PoweRasp and divided into quadrants. Each quadrant was assigned either a 1.6 mm Kirschner wire (k-wire), 1.25 mm microfracture awl, 1.5 mm fluted microdrill, PowerPick, or a curette (abrasion arthroplasty) to create 4 channels into the subchondral bone sing the same instrument. Subchondral bone and adjacent tissue areas were then evaluated using micro-CT to analyze adjacent bone destruction and extension into the bone marrow. Results: Overall, there was a significantly decreased area of bone destruction or compression using the microdrill (0.030 mm) as compared to the microfracture awl (0.072 mm) and k-wire (0.062 mm) (P < .05). Within the trochlea and the medial femoral condyle, there was significantly decreased bony compression with the microdrill as compared to the awl and k-wire (P < .05); however, when stratified, this was not significant among the lateral femoral condylar samples (P = .08). Conclusion: Bone marrow stimulation causes bony compression that may negatively impact subchondral bone and trabecular alignment. It is important to understand which tools used for bone marrow stimulation cause the least amount of damage to the subchondral bone. Clinical Relevance: This study demonstrates the decreased subchondral bony defects seen with the microdrill versus the traditional microfracture awl indicating that when performing bone marrow stimulation, the microdrill may be a less harmful tool to the subchondral bone.

Background: Total ankle arthroplasty (TAA) provides a surgical alternative to tibiotalar arthrodesis when treating end-stage ankle arthritis. TAA preserves range of motion at the tibiotalar joint leading to improved postoperative function. Many patients who undergo TAA wish to maintain a high level of activity, including participation in low-impact sports such as golf. There are several studies in the total hip and total knee arthroplasty literature that have looked at the effect of total joint arthroplasty on golf handicap. We hypothesized that similar to hip and knee arthroplasty research, TAA is likely to result in a postoperative increase in golf handicap. Methods: After obtaining institutional review board approval, we retrospectively identified 60 patients (from 140 consecutive TAAs performed between August 2016 and February 2017) who had undergone TAA, played golf pre- and postoperatively, and had at least 1 year of postoperative follow-up. The average postoperative follow-up for the cohort was 28.1 months. Variables including preoperative and postoperative golf handicaps, swing laterality, age, gender, surgical laterality, implant used, and operating surgeon were recorded. Results: The average preoperative and postoperative handicaps were 19.7 and 17.9, respectively, which did not represent a statistically significant difference ( P = .07). Patients who played 3 or more rounds per week had better preoperative and postoperative handicaps compared to patients who played 2 rounds or less; however, the change in their handicap following TAA and the number of rounds played per week was not affected. There was no association between the change in handicap and the follow-up period, handedness of golf shot, surgical laterality, implant used, or the operating surgeon. Conclusion: Our findings showed that golf handicap was not negatively affected following TAA in this series. Level of Evidence: Level IV, case series.

Osteochondral lesions of the talus (OLTs) are a difficult pathologic entity to treat. They require a strong plan. Lesion size, location, chronicity, and characteristics such as displacement and the presence of subchondral cysts help dictate the appropriate treatment required to achieve a satisfactory result. In general, operative treatment is reserved for patients with displaced OLTs or for patients who have failed nonoperative treatment for 3 to 6 months. Operative treatments can be broken down into cartilage repair, replacement, and regenerative strategies. There are many promising treatment options, and research is needed to elucidate which are superior to minimize the morbidity from OLTs.

The Lisfranc joint connects the forefoot to the midfoot. Tarsometatarsal (TMT) arthrodesis is commonly employed for Lisfranc joint injuries; however, there is active discussion regarding the optimal method of fixation for TMT arthrodesis. The purpose of this systematic review is twofold: to assess the stability of various constructs used in TMT arthrodesis and to evaluate joint motion and force distribution in the foot following arthrodesis. The PubMed, CINAHL, MEDLINE, and Web of Science databases were searched for articles evaluating biomechanical and kinetic properties of TMT arthrodesis constructs in accordance with PRISMA guidelines. The preliminary search yielded 367 articles and the final review included 14 articles with 195 cadaveric and 70 synthetic bone constructs. Plantar plates and intramedullary screw fixation at the first TMT joint were consistently found to bear significantly greater loads and resist diastasis more effectively than crossed screws. Furthermore, whole foot and lateral column arthrodesis significantly elevate calcaneocuboid and lateral column pressures. This increase was not observed with isolated fourth or fifth TMT arthrodesis. TMT arthrodesis should aim to avoid the lateral column and fuse as few joints as possible. Overall, plantar plates are an effective construct for first TMT arthrodesis due to their ability to withstand both compressive and tensile forces while maintaining stable alignment of the foot via reinforcement of the transverse arch. Intramedullary fixation devices are an alternative option that provide a high degree of active compression across the joint space while avoiding irritation of surrounding soft tissue structures.

Hallux valgus deformity (HVD) involves subluxation of the first metatarsophalangeal joint. While HVD is primarily considered a forefoot condition, midfoot instability may play a significant role in its development and severity. However, very few studies have placed a heavy emphasis on studying this phenomenon. Therefore, this review had a particular focus on understanding midfoot instability based on weightbearing imaging assessments of the TMT joint. This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and searched five databases for studies on midfoot instability in HVD patients. The severity of HVD was defined by hallux valgus angle (HVA) and distal metatarsal articular angle (DMAA). Data was extracted, and articles were graded using the Methodological Index for Non-Randomized Studies (MINORS). Of 547 initially retrieved articles, 23 met the inclusion criteria. Patients with HVD showed higher HVA and DMAA on weightbearing radiographs (WBRG) and weightbearing computed tomography (WBCT) compared to healthy individuals. Midfoot instability was assessed through intermetatarsal angle (IMA) and tarsometatarsal angle (TMT angle). Patients with HVD exhibited greater IMA and TMT angles on both WBRG and WBCT. This review highlights the importance of weightbearing imaging assessments for midfoot instability in HVD. IMA and TMT angles can differentiate between healthy individuals and HVD patients, emphasizing the significance of midfoot assessment in understanding HVD pathology. These findings validate the limited evidence thus far in the literature pertaining to consistent midfoot instability in HVD patients and are able to provide ample reasoning for physicians to place a larger emphasis on midfoot imaging when assessing HVD in its entirety.

Background: Social media platforms, like TikTok, have become popular options for the distribution of health care information. Because of the lack of scientific oversight, the quality of health care–related videos has become a focus of the current literature. However, orthopaedic surgery has lagged behind other fields in acknowledging the widespread utilization of TikTok videos for medical information consumption. This study aims to assess the quality and educational benefits of ankle sprain–related TikTok videos. Methods: TikTok was queried using the hashtag “#anklesprainexercises.” One hundred videos were included after applying the exclusion criteria. The number of views, likes, shares, comments, and favorites was recorded. The content was graded using DISCERN (a well-validated informational analysis tool) and ASEES (a self-designed tool for exercise evaluation). We hypothesized that information on TikTok related to ankle sprain exercises would be poor in quality. Results: The total number of views of the 100 videos was 6 483 412, with a median of 5377.5 (IQR = 1074-20 275). The videos collectively received 385 847 likes, 3642 comments, 55 574 favorites, and 14 918 shares with a median of 267.5 (IQR = 41.5-1678.0), 4.0 (IQR = 0.0-23.0), 42.0 (IQR = 4.8-264.5), and 13.0 (IQR = 1.8-67.8), respectively. General users had a higher percentage of their videos graded as “very poor” (61.8%) in comparison to the number of videos uploaded by health care professionals deemed “very poor” (34.4%). Neither general user nor health care professionals had videos graded as “good” or “excellent.” There were significant differences between the 2 groups for DISCERN 1, 3, and ASSES scores. Conclusion: Although TikTok is a powerful tool for information distribution, the educational value of the videos related to ankle sprain injury exercises was poor. With only 2% of videos receiving a grade of “fair,” and no videos reaching a score of “good” or “excellent,” health care professionals should be aware of the low-quality content easily accessible on TikTok. Level of Evidence: Level III, cross-sectional study.

The first metatarsophalangeal (MTP) joint is a frequently loaded joint, handling loads up to 90% of bodyweight. First MTP arthrodesis is a frequently performed procedure designed to improve pain in patients with degenerative MTP joint disease. There are a wide variety of fixation constructs for this procedure without consensus on the most effective method. The purpose of this study was to compare the biomechanical integrity of various constructs utilized for first MTP arthrodesis. A systematic review of the literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, CINAHL, MEDLINE, and Web of Science databases were searched from inception to 18 June 2023. Articles discussing the biomechanics of first MTP arthrodesis constructs were included. A total of 168 articles were retrieved. A total of 20 articles involving 446 cadaveric and synthetic bone constructs were included in the final review. Of the six articles comparing dorsal plating with compression screws to crossed interfragmentary screws, five found that dorsal plating had significantly higher stiffness. All three studies assessing shape-memory staples found them to be significantly less stable than crossed screws or dorsal plates alone. Both studies evaluating fully threaded screws found them to be stronger than crossed cancellous screws. Wedge resections have been shown to be 10 times stronger than standard planar or conical excision. Dorsal plating with compression screws is the gold standard for MTP arthrodesis. However, more research into newer methods such as fully threaded screws and wedge resections with an increased focus on translation to clinical outcomes is needed.

Background: The Malerba calcaneal Z-osteotomy is an operative procedure to treat the hindfoot varus component of adult cavovarus deformity. Basic science studies support the corrective ability of this osteotomy. However, there have been no published midterm clinical and radiographic results. The purpose of this article is to describe the radiographic and clinical improvement in a series of patients treated with this osteotomy. Methods: A retrospective chart review identified 14 feet in 12 patients from January 2013 to August 2018 who met minimal follow-up criteria. Preoperative visual analog scale (VAS) scores, Foot Function Index (FFI) scores, and American Orthopaedic Foot & Ankle Society (AOFAS) scores were compared with postoperative scores. Preoperative Meary angle, calcaneal pitch, and hindfoot alignment were also compared with postoperative measurements. Complications and radiographic union were recorded. Results: At a mean of 80 months, VAS, FFI, and AOFAS scores improved from 7.86 to 1.64, 57.78% to 18.11%, and 39.57 to 80.71, respectively (all P

Category: Midfoot/Forefoot Introduction/Purpose: Functional hallux rigidus is characterized by limited first metatarsophalangeal (MTP) dorsiflexion during weight bearing conditions, but normal motion when the metatarsal is allowed to plantarflex. This phenomenon alters the mechanics of the foot, potentially leading to lateral column overloading and dynamic cavovarus. Furthermore, it is suspected that the abnormal forces across the first MTP alters its biomechanics, leading to cartilage destruction and eventual structural hallux rigidus. The purpose of this study is to assess the role of the flexor hallucis longus (FHL) and plantar fascia in functional hallux rigidus and to determine the best surgical treatment. Methods: Six cadaveric lower limbs disarticulated at the hip were analyzed. The feet were positioned manually in the same manner that would be used in a clinical exam of patients. The examiner's thumb was used to stabilize the first metatarsal head and prevent plantarflexion to simulate the closed-chain kinetics of weight bearing. The same hand was used to hold the ankle neutrally aligned to the leg. The other hand was used to maximally dorsiflex the great toe. X-ray was used to obtain images of the feet. The plantar fascia was transected with a Z cut, shortened approximately 5 mm, then repaired. The fiberosseous tunnel was released. The FHL was transected with a Z cut then shortened approximately 5 mm. Great toe dorsiflexion was assessed and X-rays taken after each of the manipulations. Range of motion of the first MTP was measured on Xrays and analyzed using Student's T-test. Results: Average passive dorsiflexion of the first MTP is 29.8° (range 17-46°) prior to manipulation. Shortening the plantar fascia and FHL did not decrease the MTP dorsiflexion significantly beyond baseline (P = 0.08, 0.09 respectively). Transecting the plantar fascia increased the dorsiflexion by 14° (standard deviation (SD) 9.5) and transecting the FHL increased dorsiflexion by 13.7° (SD 4.0). Dorsiflexion increased significantly beyond baseline with both these methods (P = 0.02 and P < 0.001 respectively), but the difference between the two methods was not significant (P = 0.93). Releasing the fiberosseous tunnel alone increased the dorsiflexion 8.8° (SD 5.7). Increased dorsiflexion beyond baseline was significant (P = 0.03). The increase in dorsiflexion with fiberosseous tunnel release was not significantly different than transecting the plantar fascia or the FHL (P = 0.40 and 0.42 respectively). Conclusion: By definition, functional hallux rigidus is diagnosed when first MTP dorsiflexion cannot reach 60°. Its prevalence may be more widespread than previously identified. Both the FHL and plantar fascia are implicated in functional hallux rigidus, as transection of either improves the dorsiflexion of the great toe. However, accessing the plantar fascia comes with significant risks and complete transection of the FHL is not feasible. As an alternative, releasing the fiberosseous tunnel is a simple, minimally morbid procedure that can also significantly improve functional hallux rigidus to a similar degree.

Category: Ankle; Ankle Arthritis Introduction/Purpose: Even as its popularity increases, there remain many unanswered questions regarding total ankle arthroplasty. One debate considers how best to restore proper rotation of the talar component relative to native, non- osteoarthritic anatomy. At present, two common schools of thought are to parallel the talar component rotation with the medial gutter line or to choose a line that bisects the gutters. These axis' are then considered with respect to a chosen foot axis, often defined by the second metatarsal or second toe clinically. The present study sought to define the foot center axis relative to the ankle on weight-bearing CT in patients without ankle osteoarthritis to inform talar component positioning in total ankle arthroplasty. Methods: Following IRB approval, charts were reviewed to identify patients without ankle osteoarthritis, trauma or other deformity who received a weightbearing CT scan. A pilot group of n=34 patients were included for a total of n=50 limbs. Average age was 50.3 +/- 7 and there were = 54% female patients. All measurements were made on MPR (multiplanar reformation) axial reconstructions. Cobb angle measurements between the anatomic foot center, the second, the fourth metatarsal and the gutter bisector or medial gutter line were recorded. Statistical analysis was performed by IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY. Results: The mean gutter bisector angle was 5.7 deg +/- 2.0. The mean cobb angle between the anatomic foot center and the medial gutter line was 6.1 deg +/- 4.4 and between the anatomic foot center and gutter bisector was 6.3 deg +/- 4.8, there was no statistical difference between measurements (p=0.62, Table 1). The mean cobb angle between the second metatarsal and the gutter bisector was 9.9 deg +/- 6.8, whereas the mean cobb angle between the fourth metatarsal and the gutter bisector was 7.5 deg +/- 5.2, which was not statistically significant (p=0.053). There was no statistical difference between mean cobb angle measurements between the anatomic foot center and the gutter bisector and the fourth metatarsal and the gutter bisector (p=0.243), but there was statistical difference between mean cobb angle measurements of the second metatarsal and the gutter bisector and the anatomic foot center and the gutter bisector (p=0.003). Conclusion: The axial alignment of the foot center axis relative to the ankle in patients without deformity or osteoarthritis is most collinear with the medial gutter line. In general, the axial alignment of the ankle joint relative to the foot in patients without osteoarthritis tends towards

Category: Ankle; Ankle Arthritis Introduction/Purpose: Even as its popularity increases, there remain many unanswered questions regarding total ankle arthroplasty. One debate considers the proper rotation of the talar component to restore native, non-osteoarthritic anatomy. The foot center axis is a unique anatomic concept that considers the position of the native foot relative to the ankle. The present pilot study sought to evaluate the reproducibility of axial alignment measurements, including the foot center on weight-bearing CT in patients without ankle osteoarthritis. Methods: Following IRB approval, charts were reviewed to identify patients without ankle osteoarthritis, trauma or other deformity who received a weightbearing CT scan. A pilot group of n=8 patients were included for a total of n=10 limbs. Average age was 50.1 +/- 14 and there were 38% female patients. All measurements were made on MPR (multiplanar reformation) axial reconstructions. Cobb angle measurements between the anatomic foot center, the second, the fourth metatarsal and the gutter bisector or medial gutter line were recorded by n=4 observers. Intraclass correlation (ICC) was produced using a two-way random effects model with absolute agreement and other statistical testing was performed by IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY. Results: The average gutter bisector angle was 6.2 deg +/- 2.0 and the average angle between the medial base of the 1st metatarsal head, lateral base of the 5th metatarsal head and the posterior calcaneus was 33.0 deg +/- 2.6. Amongst the observers, the ICC for these landmarks were 0.95 and 0.96 respectively. The average cobb angle measurement between the gutter bisector angle and the second metatarsal was 8.3 deg +/- 7.3, with a corresponding ICC of 0.96. The average cobb angle measurement between the gutter bisector angle and the anatomic foot center was 5.6 deg +/- 4.3 and the average cobb angle measurement between the medial gutter line and the anatomic foot center was 6.23 deg +/- 6. Amongst the observers, the ICC for these measurements were 0.81 and 0.81 respectively. Conclusion: In a small pilot study of patients without osteoarthritis who underwent weight-bearing CT scans there was good (ICC>0.75-0.90) to excellent (ICC>0.90) agreement amongst observers for measurements of foot center axis and ankle rotation. These findings validate the reproducibility and agreement of these manually constructed measurements for assessing the relationship between the foot center axis and ankle rotation. Future studies will expand upon the use of these measurements to define non-arthritic anatomy. The anatomic foot center may be a useful guide for establishing intra-operative foot orientation when performing total ankle arthroplasty.

Category: Ankle; Hindfoot; Trauma Introduction/Purpose: Prosthetic substitution of the talus presents a unique challenge to the foot and ankle surgeon. The shear and compressive forces on the talus and its tenuous blood supply lead to high rates of avascular necrosis with possible talar collapse. The purpose of this systematic review is to evaluate whether total talus replacements (TTR) lead to improved clinical outcomes with appropriate safety metrics in patients with a history of avascular necrosis or significant trauma. Methods: Concepts of talus and arthroplasty were searched in MEDLINE (PubMed), Embase (Elsevier), CINAHL Complete (EBSCOhost), and Scopus (Elsevier) from the database's inception through November 4, 2021. Inclusion Criteria were 1) previous trauma to the talus, 2) post-traumatic or degenerative arthritis to the tibiotalar joint, 3) avascular necrosis of talus, 4) multiple failed prior interventions, 5) degenerative osteoarthritis to the tibiotalar joint, and 56) inflammatory arthropathy to tibiotalar joint. Manuscripts in non-English languages or those with concomitant total ankle arthroplasty or revision arthroplasty were excluded. All study designs were eligible according to the Journal of Bone and Joint Surgery criteria level I-IV. The modified Coleman Methodology Score was used to evaluate study quality and the Methodological Index for Non-Randomized Studies criteria was used to assess risk of bias. Results: Twenty-two studies of 191 patients (196 tali) at an average age of 50 (14-80) years were included (Figure 1a). Nineteen studies utilized third generation implants, two studies used first generation (n=9), and one study used second generation implants (n = 14) made of ceramic (n=82), cobalt chrome (n=49), or titanium (n=23) (Figure 1b). Radiographic and patient-reported outcomes are outlined in Figure 1c. The most common adverse outcome was osteosclerosis of the tibia (n=24), calcaneus (n=19), and navicular (n=5). Additionally, hindfoot varus (n=3), ankle discomfort (n = 3), decreased subtalar motion (n=7), periprosthetic fracture (n=1), calcaneal fracture (n=1), delayed wound healing (n=3), hindfoot valgus (n=1), prosthetic stem sunken into the talar neck (n=1), superficial peroneal nerve neuroma (n=1), loosening (n=2) were reported. Eight revisions were reported. Conclusion: TTR is an appealing option to maintain range of motion through the tibiotalar joint and allow for maintenance of more normal foot and ankle biomechanics. Given promising early- and mid-term outcomes, TTR is becoming more widely used in the setting of talar collapse. Still, high complication rates, especially adjacent joint osteoarthritis, may remain under-reported in the literature given inadequate long-term follow-up. Future research should aim to expand upon the indications of TTR, elucidate survivorship and complication rates, and directly compare TTR to existing forms of salvage options for advanced talar avascular necrosis.

Category: Ankle; Hindfoot Introduction/Purpose: End-stage ankle osteoarthritis is a debilitating condition that often results in limited tibiotalar range of motion. Total ankle replacement (TAR) preserves ankle range of motion and improves the patient's functionality. Tendo-Achilles lengthening (TAL) and gastrocnemius recession (GR) are concomitant procedures often performed with TAR to improve tibiotalar dorsiflexion. The purpose of this study is to determine the effect of a TAL and GR during TAR on radiographic range of motion compared to a control group without a lengthening procedure. Methods: A retrospective review of a prospectively maintained TAR database was conducted from November 2015 - June 2020 at a single academic institution. All surgeries were performed by fellowship-trained foot and ankle surgeons. Inclusion criteria included greater than18 years of age and a minimum of one-year radiographic follow-up with both preoperative and postoperative weight-bearing, range of motion radiographs. Exclusion criteria included concomitant 1) calcaneal osteotomies, 2) hindfoot or midfoot arthrodesis, 3) prior ankle arthrodesis, or 4) revision total ankle arthroplasty. A total of seventy-five patients (TAL, n = 40; GR, n = 35) were included with a control group of seventy-five consecutive patients who underwent TAR without a lengthening procedure. Demographic and clinical data were extracted from the TAR database. Preoperative and postoperative radiographic assessment included a measurement of dorsiflexion and plantarflexion. All measurements were performed by two members of the research team. Results: A total of 150 patients were included in this study: TAL: n = 35, GR: n = 40, Control: n = 75. Dorsiflexion significantly improved by 3.4° (p=0.0053) and by 6.7° (p < 0.0001) in the TAL and GR cohorts respectively with no significant difference in the control group (+1.3°, p=0.0857). Plantarflexion was significantly decreased by 3.6° (p=0.0378) and by 6.6° (p=0.0002) in the TAL and GR cohorts respectively with no significant difference in the control group (+0.3°, p=0.7863). The total arc of motion did not change significantly for any of the three groups postoperative (control 1.63°, GR 0.05°, TAL -0.20°; all p>0.05). There were no significant between-group differences in the change in overall arc of motion between the groups (p=0.3913). Compared to TAL group, GR resulted in a greater increase in dorsiflexion (6.7° versus 3.4°; p=0.0459) with a reciprocal, albeit non-significant, greater decrease in plantarflexion (6.8° versus 3.6°; p=0.1598). Conclusion: Both TAL and GR significantly increased postoperative dorsiflexion; however, this was accompanied by a reciprocal significant loss in plantarflexion. GR resulted in double the improvement in dorsiflexion and loss in plantarflexion compared to TAL. The total arc of motion did not significantly change for the control, GR, or TAL cohorts. Patients should be counselled that their preoperative range of motion (ROM) will dictate their postoperative ROM, and that concomitant procedures performed to achieve an increase in dorsiflexion will do so at the expense of plantarflexion.

Foot and ankle pathology in the adolescent athlete is a growing area of basic science, translational, and clinical research [...]

Osteochondral lesions of the talus (OLTs) are lesions that occur before the physis closes and are frequently associated with acute ankle trauma. These lesions are often difficult to diagnose due to swelling and inflammation that are present after the initial injury. A growing body of literature has assessed the effects of OLTs in the adult population. However, the literature examining these lesions in the juvenile population is sparse. The purpose of this review is to provide a thorough understanding of OLTs, with a specific focus on the juvenile population. We evaluate the recent literature regarding the outcomes of various surgical treatment; modalities in the pediatric patient. While the outcomes after surgical treatment of pediatric OLTs are generally favorable, the paucity of investigation in this demographic is alarming. Further research is needed to better inform practitioners and families regarding these outcomes, as treatment plans are highly dependent on the individual patient in question.

Abstract Background Three dimensional printing has greatly advanced over the past decade and has made an impact in several industries. Within the field of orthopaedic surgery, this technology has vastly improved education and advanced patient care by providing innovating tools to complex clinical problems. Anatomic models are frequently used for physician education and preoperative planning, and custom instrumentation can assist in complex surgical cases. Foot and ankle reconstruction is often complicated by multiplanar deformity and bone loss. 3D printing technology offers solutions to these complex cases with customized implants that conform to anatomy and patient specific instrumentation that enables precise deformity correction. Case presentation The authors present four cases of complex lower extremity reconstruction involving segmental bone loss and deformity – failed total ankle arthroplasty, talus avascular necrosis, ballistic trauma, and nonunion of a tibial osteotomy. Traditional operative management is challenging in these cases and there are high complication rates. Each case presents a unique clinical scenario for which 3D printing technology allows for innovative solutions. Conclusions 3D printing is becoming more widespread within orthopaedic surgery. This technology provides surgeons with tools to better tackle some of the more challenging clinical cases especially within the field of foot and ankle surgery.

Category: Basic Sciences/Biologics; Sports Introduction/Purpose: Tendon healing is a slow and complicated process that results in inferior structural and functional properties compared to healthy tissue. It may be possible to improve outcomes of tendon healing with enhancement of biological repair through the development of tissue engineered medical products (TEMPs). Although many tendons heal with satisfactory outcomes, others do not, leading to pain and additional cost. Current augments for repair lack either native tissue structure or composition, limiting their potential effectiveness. For example, in tendon healing, restoring native organized and dense collagen composition is a primary goal; however, most TEMPs, such as lyophilized collagen or electrospun pure collagen fibers, are mechanically weak and unstable. For optimizing stability and biocompatibility, collagen can be combined with a high-performance co-biopolymer, such as poly(D,L-lactide) (PDLLA). Methods: The purpose of this study was to demonstrate the efficacy of a novel biointegrative construct, composed of type I collagen and PDLLA for Achilles tendon repair. PDLLA is biocompatible, has shown to support cell growth, and degrades to CO2 and H2O in vivo. The electrospun copolymer constructs were post-processed with low-temperature annealing to enhance their porosity and mechanical stability. The constructs were first tested for their ability to absorb blood and platelet-rich-plasma (PRP). Additionally, the constructs were tested in vivo by implantation in a rabbit Achilles tendon injury model by creating a 7 mm midsubstance Achilles defect. For each tendon defect, a copolymer construct was circumferentially wrapped around the defect and sutured into place. Finally, human cadaver testing was performed to assess implant handling and fixation characteristics. Results: Collagen-PDLLA constructs absorbed more than ten times their weight in blood and PRP. Histologically, rabbit tendons showed rapid implant cellularization by 2-8 weeks, along with de novo collagen deposition. By 16 weeks, dense collagenous connective tissue was seen integrating at the tendon-implant interface and throughout the implant. Movin-Bonar scores for the collagen-PDLLA-implanted and sham-operated tendons were identical from 16-72 weeks post-operatively, indicating a return to normal tendon morphology. Overall, surgical application of the collagen-PDLLA constructs demonstrated dense collagenous fibrous connective tissue ingrowth into and around the implant. Moreover, cadaver surgical implantation of the implant in a minimally invasive Achilles tendon repair and arthroscopic rotator cuff repair, allowed easy graft orientation and delivery as well as excellent handleability and suture fixation to the native tendon. Conclusion: Electrospun biointegrative implants were tissue-engineered to enhance cell infiltration for promoting tissue integration and functional remodeling. When implanted in the rabbit Achilles tendon, the implants demonstrated new in situ tissue generation and remodeled into dense, regularly oriented connective tissue at the tendon-implant interface. Collagenous ingrowth may be crucial in tendon protection and significantly progresses towards improving clinical outcomes following tendon injury. Moreover, the implants demonstrated additional clinical utility by absorbing greater than ten times their weight in biologic fluids which demonstrates the potential to combine this novel biointegrative implant with additional fluid based biologic therapies.

Category: Ankle; Ankle Arthritis; Diabetes Introduction/Purpose: Total ankle arthroplasty (TAA) has become increasingly utilized over the past 20 years to treat osteoarthritis of the ankle. The efficacy and safety of this procedure has been previously reported, but relatively few studies have documented the risk of post-operative complications associated with TAA over the past 10 years. Thus, the aim of this study is to provide a current report on the safety of TAA, particularly in association with a number of preoperative risk factors. Methods: A retrospective review of all patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database who underwent TAA between 2012-2018 was performed. A total of 1333 patients were included in this analysis. Penalized logistic regression to consider small numbers of the postoperative complications was used to identify factors associated with incidence of the complications. Results: The rate of readmission and superficial wound infection were found to be 1.4% and 0.6%, respectively. Risk factors associated with a prolonged hospital stay were Black race, Hispanic race, and smoking (Fig. 1). Diabetes was associated with a significantly increased risk of readmission. Age, sex, BMI, and steroid use were not associated with increased risk of postoperative complications. Conclusion: In this study, the rate of surgical site infection and readmission in TAA was found to be relatively low, compared to published data on TKA and THA. Both race and smoking increase the risk of prolonged hospital stay, while diabetes increases the risk of readmission.

Category: Trauma; Ankle Introduction/Purpose: Ankle fractures are common orthopedic injuries with complication rates fixation of up to 40%. Limited evidence exists in the literature regarding complications in the elderly population, and moreover, these studies frequently define elderly arbitrarily at 60-65 years old. The purpose of the present study was to utilize a large, validated database to evaluate whether there is an inflection point of age when postoperative complications after an ankle fracture significantly increase. Methods: A retrospective review of all patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent fixation of an ankle fracture between 2012-2018 was performed. Patients were identified within the database using the Current Procedural Terminology codes. Appropriate statistical analysis was performed with p-value less than 0.05 considered statistically significant. Results: A total of 27,633 fractures were including and comprised of 221 posterior malleolar, 1,567 medial malleolar, 8,495 lateral malleolar, 10,175 bimalleolar, and 7,175 trimalleolar. A total of 1,545 complications were encountered (5.6%). There was a statistically significant association between increasing age and complications (OR=1.03; p

Category: Ankle; Trauma Introduction/Purpose: The impact of time and state regulation on opioid prescribing in orthopaedic trauma is not well known. The purpose of this study is to evaluate the impact of time and state-level opioid legislation on 90-day perioperative opioid prescribing in ankle fracture surgery from 2010 - 2019. Methods: This is a retrospective, cohort study using a national insurance database including commercial insurance, Medicare, Medicaid, and cash pay patients to evaluate 90-day perioperative opioid prescription filling in 40,286 patients ages 18 and older undergoing Current Procedural Terminology codes 27766, 27769, 27792, 27814, 27822, and/or 27823 between 2010 and 2019 in all 50 United States. The primary study outcome was initial and cumulative 90-day perioperative opioid prescription filling and rates of filling and refills. Results: Mean first prescription volume has not changed dramatically from 2010 (37 oxycodone 5-mg pills) to 2019 (33.3 oxycodone 5-mg pills). However, cumulative prescriptions within the 90-day perioperative timeframe have decreased considerably from 2010 (128.5 oxycodone 5-mg pills) to 2019 (70.4 oxycodone 5-mg pills, p

Category: Other; Ankle; Ankle Arthritis; Arthroscopy; Bunion; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports Introduction/Purpose: The opioid epidemic has focused attention on opioid overprescribing. State legislation has been enacted to reduce acute opioid prescribing. However, the impact of this legislation on elective foot and ankle surgery is largely unknown. The purpose of this study was to evaluate the impact of opioid limiting legislation on opioid prescribing in elective foot and ankle surgery. Methods: 90-day perioperative opioid prescription filling in oxycodone 5-mg equivalents was identified in all patients ages 18 and older undergoing non-trauma, non-arthroplasty foot and ankle surgery from 2010 - 2019 using a commercial database. States with and without legislation were identified and opioid prescription filling before and after legislation was tabulated. Unadjusted and adjusted analyses were performed to evaluate the impact of time and state legislation on perioperative opioid prescribing in this patient population. Results: Initial and cumulative opioid prescribing decreased significantly from 2010 to 2019 (39 vs 35.7 initial and 98.1 vs 55.7 cumulative oxycodone 5-mg equivalents, p

Category: Ankle; Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) is an increasingly-utilized treatment for ankle arthritis, and opioids are commonly used as part of perioperative pain control. However, many states have enacted opioid-limiting legislation to reduce perioperative opioid prescribing. The aim of this study was to evaluate the impact of time and state legislation on perioperative opioid prescribing in TAA. Methods: This study is a retrospective, observational review of 90-day perioperative opioid prescribing in 1,829 patients undergoing TAA throughout the United States using a large insurance database. Initial and cumulative volumes and rates of opioid prescription filling were recorded along with baseline patient and operative characteristics. Dates of state legislation enactment were also recorded. Student t-tests, analysis of variance (ANOVA), and multivariable linear and logistic regression were utilized to analyze the impact of time and state legislation on opioid prescription filling. Results: In the 90-day perioperative time period, initial and cumulative opioid prescription filling in oxycodone 5-mg equivalents has decreased significantly from 2010 (63.8 initial and 163.3 cumulative oxycodone 5-mg equivalents filled) to 2019 (41.1 initial and 67.2 cumulative oxycodone 5-mg equivalents filled). States with opioid-limiting legislation saw larger and more significant reductions in initial and cumulative opioid prescription filling pre-act to post-act (63.3 to 50.6 oxycodone 5-mg equivalents filled with legislation vs 61.4 to 51.9 oxycodone 5-mg equivalents filled without legislation initial and 146.4 to 93.3 oxycodone 5-mg equivalents filled with legislation vs 125.1 to 108.6 oxycodone 5-mg equivalents filled without legislation cumulative). Conclusion: This study demonstrates that orthopaedic surgeons in states with opioid-limiting legislation have responded by significantly reducing 90-day perioperative opioid prescribing in TAA. These results encourage states without legislation to enact opioid-specific laws to reduce opioid prescribing.

Category: Ankle; Trauma Introduction/Purpose: Regional anesthesia (RA) is commonly used in ankle and distal tibia surgery. However, the pragmatic effects of this treatment on inpatient and outpatient opioid demand are unclear. The hypothesis was that RA would decrease inpatient opioid consumption and have little effect on outpatient opioid demand in patients undergoing ankle and distal tibia fracture surgery. Methods: All patients ages 18 and older undergoing ankle and distal tibia fracture surgery at a single institution between 7/2013 and 7/2018 were included in this study (n=1,310). Inpatient opioid consumption (0-72 hours post-operative) and outpatient opioid prescribing (1-month pre-operative to 90-days post-operative) were recorded in oxycodone 5-mg equivalents (OE's). Adjusted models were used to evaluate the impact of RA on inpatient and outpatient opioid demand. Results: Adjusted models demonstrated decreased inpatient opioid consumption in patients with RA (12.1 estimated OE's without RA vs 8.8 OE's with RA from 0-24 hours post-op, p

Category: Ankle Introduction/Purpose: The management of large osteochondral lesions of the talar shoulder remains a clinical challenge. Their size, three-dimensional geometry, and subchondral cystic degeneration often preclude treatment with traditional measures such as microfracture and osteochondral autograft transplantation. Structural or bulk osteochondral allograft transplantation has demonstrated efficacy in several retrospective reviews. The purpose of this study was to prospectively evaluate patients who received fresh structural allograft transplantation to the talus. Methods: A prospective evaluation of consecutive patients who underwent fresh structural allograft transplantation for an OLT form 2010 to 2019 was performed under Institutional Review Board approval. All patients failed a minimum of 6 months of conservative management. Preoperative MRI and/or CT, as well as plain radiographs were obtained on all patients. The following patient reported outcomes questionnaires were administered preoperatively and yearly after surgery: 100mm VAS pain scale, AOFAS Ankle-Hindfoot Scale, SF-36, and the Short Musculoskeletal Functional Assessment (SMFA). Pre- and postoperative radiographs were assessed for allograft incorporation and the development of arthritis. Results: 27 patients underwent fresh osteochondral allograft transplantation and were followed for a minimum of 2 years. The mean follow-up was 5 years (range 2-11). The average size of the OLT was 2,269 mm 3 (range 813-8,366) based on CT imaging and 5,797 mm 3 (range 1,136-12,489) based on MRI imaging. There was significant improvement in the VAS pain score, AOFAS Ankle- Hindfoot Scale score, the SF-36 total score, and the SMFA functional and bother indices (Figure 1). Thirteen (48%) of the patients required subsequent surgery. Twelve underwent removal of hardware and joint debridement and one patient underwent isolated joint debridement. At the time of these surgeries, two grafts demonstrated cartilage delamination. One of these patients had continued pain and progression of arthritis without additional surgery and one was converted to an ankle replacement. Therefore, the failure rate was 7%. Conclusion: Significant improvement in pain and function can be achieved with structural allograft transplantation for large OLTs. However, it is important to council patients that painful hardware and stiffness can occur in approximately one-half of patients. An unstable graft and cartilage delamination are indicators of subsequent failure. The use of a structural allograft does not preclude subsequent ankle arthrodesis or arthroplasty.

Category: Ankle; Other Introduction/Purpose: A significant body of literature exists that documents the racial/ethnic disparities in orthopedics. Previous studies have looked at racial disparities in total ankle arthroplasty and have shown concerning TAA utilization rates. One such study detailed a two fold difference in rate per 100,000 of 0.14 in Whites vs. 0.07 in Blacks in 1998, which continued to worsen and by 2011 the utilization rate was 1.17 in Whites vs. 0.33 in Blacks, a 4-fold difference. The purpose of this study was to update the literature and analyze the utilization rates of TAA by race as well as to detect any differences in outcomes between the groups through the most updated data available in the National Surgical Quality Improvement Program (NSQIP) database. Methods: A retrospective cohort study was performed utilizing the National Surgical Quality Improvement Program (NSQIP) database. Patients were identified for inclusion using the Current Procedural Terminology (CPT) codes 27700 and 27702, corresponding to arthroplasty ankle and arthroplasty ankle with implant, respectively. All patient's with known race were included, non-Hispanic White, non-Hispanic Black, Asian, Native American, and Hispanic. A total of 1164 patients met inclusion criteria for this study. Results: A total of 1164 patients with known race undergoing TAA from 2012-2018 were included in this analysis. Of these patients 1051 (90.3%) were non-Hispanic white (White), and 113 (9.7%) were non-Hispanic Black, Asian, Native American, and Hispanic (Non-White). The mean patient age for White patients was 63.7 years, compared to 55.3 years for Non-White patients which was statistically significant. (p-value

The purpose of this study was to report on a small case series of patients undergoing particulated autologous cartilage implantation (PACI) for to treat traumatic displaced OLTs. Four patients underwent PACI procedures at a median time of 16.5 days (range 6 to 26) after the initial trauma. Demographic data, mechanism of injury, OLT characteristics, concomitant procedures, complications, and reoperations were recorded. Postoperative patient-reported outcome measures were collected including the Visual Analog Score (VAS), Short-Form -12 (SF-12), foot and ankle ability measure (FAAM), and American Orthopaedic Foot and Ankle Surgery (AOFAS) hindfoot scores. Postoperative MRI and second-look arthroscopy were assessed for two patients. The mean age of the cohort at the time of the PACI procedure was 23.3 (range 15 to 37) years. At a mean most recent follow-up of 61.8 months (range 33 to 99), the mean postoperative patient-reported outcomes scores were: VAS (0.5; range 0 to 1), PCS SF-12 (45.2; range 34.99 to 54.44), MCS SF-12 (44.1; range 37.75 to 49.2), FAAM ADL (87.5; range 70 to 100), FAAM sporting (71.5; range 29 to 100), and AOFAS hindfoot (86.3; range 77 to 100). The mean time to return to preinjury activity was 7.04to 9 months. There were no graft-related complications. Two of the patients underwent second-look arthroscopy and were found to have intact repairs. The PACI showed promising midterm clinical outcomes and return to preinjury activity level without graft-related complications for irreducible displaced traumatic OLTs. Although our study showed promising outcomes at 61.8 months follow-up, larger cohort studies with standardized surgical protocols are needed to determine whether PACI has favorable outcomes comparted to other restorative and reparative OLT procedures.

Recent developments in robotic technologies in the field of orthopaedic surgery have largely been focused on higher volume arthroplasty procedures, with a paucity of attention paid to robotic potential for foot and ankle surgery. The aim of this paper is to summarize past and present developments foot and ankle robotics and describe outcomes associated with these interventions, with specific emphasis on the following topics: translational and preclinical utilization of robotics, deep learning and artificial intelligence modeling in foot and ankle, current applications for robotics in foot and ankle surgery, and therapeutic and orthotic-related utilizations of robotics related to the foot and ankle. Herein, we describe numerous recent robotic advancements across foot and ankle surgery, geared towards optimizing intra-operative performance, improving detection of foot and ankle pathology, understanding ankle kinematics, and rehabilitating post-surgically. Future research should work to incorporate robotics specifically into surgical procedures as other specialties within orthopaedics have done, and to further individualize machinery to patients, with the ultimate goal to improve perioperative and post-operative outcomes.

Tarsal coalitions are abnormal fibrous or bony connections between the tarsal bones of the foot. While not always symptomatic, coalitions can cause pain, alterations in forefoot and hindfoot morphology, and alterations in foot and ankle biomechanics. Previous research has described the association of tarsal coalitions with fractures of the lower extremity. Multiple reports of acute fracture in the presence of tarsal coalition have been presented, as have reports of stress fractures of the foot and ankle with concomitant coalition, insidious in onset and thought to be related to aberrancies in foot and ankle biomechanics. The purpose of this review is to discuss the biomechanics seen in tarsal coalitions and to describe reports of fracture occurring concomitantly with tarsal coalitions. We will discuss diagnostic options and treatment approaches in the setting of fracture with preexisting tarsal coalition.

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: The utilization of total ankle replacement (TAR) for end-stage ankle osteoarthritis continues to increase in the United States. From 2011-2012, 47.5% of all TAR were covered by Medicare insurance, which represents a large insurance market share for inpatient ankle surgeries. However, there is a growing trend in orthopedics toward performing outpatient surgery. There have been studies that demonstrate the cost benefits and safety of outpatient TAR surgery. However, previous cost studies involve a single implant, small sample size, and lack clinical outcomes. Thus, we aim to compare the costs and clinical outcomes associated with TAR in the outpatient versus inpatient settings. Methods: We performed a retrospective study on 178 consecutive patients undergoing primary inpatient versus short-stay designation TAR during the 2016 and 2017 fiscal years. Patient demographics, concomitant procedures, perioperative complications, patient reported outcomes, and perioperative costs were collected. Results: The mean age of our cohort was 62.5 yo. The implant types were: Infinity (39.3%), Salto (38.2%), INBONE (15.2%), Vantage (7.3%), and STAR (3.4%). 47.8% of patients were covered under managed care and 42.1% under Medicare. There were no significant differences in medical comorbidities (p > 0.05) or concomitant surgeries (p=0.4574) between inpatient and outpatient groups. There was no difference in complications between inpatient and outpatient groups (p= 0.9652). Inpatients had a greater improvement in their SMFA function score compared to outpatients (p=0.0442). Both inpatient and outpatient cohorts significantly improved in all other reported patient reported outcomes at final follow-up (0.05). The total direct cost was higher for the inpatient group ($15,340.1) versus outpatient group ($13,002.6) (p

Category: Basic Sciences/Biologics; Ankle; Trauma Introduction/Purpose Foot and ankle etiologies such as traumatic fractures, Charcot Arthropathy, nonunion after high risk arthrodesis and infectious debridement can result in critical sized bone defect (CSD). CSD is defined as bone loss greater than 1-2 cm in length or greater than 50% loss in circumference of bone. CSD remain a significant challenge in Orthopaedics. Custom 3D printed porous Titanium implants are currently being implemented when allograft is not an option. However, in a subset of cases, Titanium implants need to be removed due to infection or poor osseous integration where surrounding bone does not grow onto or through the scaffold. There is no one clear reason for poor osseous integration. This study explores effects of 3D printed topography on mechanical and biological properties. Methods: Titanium dog bones and discs were printed via laser powder bed fusion. Roughness groups were polished, blasted, as built, sprouts and rough sprouts. Roughness was measured with line measurement using a confocal microscope. To assess mechanical properties, tensile testing of samples from each roughness group produced stress strain curves. MC3T3 preosteoblast were seeded on discs. Samples were analyzed at 0, 2, and 4 weeks. A cell viability assay and confocal florescent microscopy assessed cell growth. Alkaline Phosphatase (ALP) assay and Quantitative Polymerase Chain Reaction (qPCR) examined cell differentiation. Extracellular matrix (ECM) was stained for collagen and calcium. Scanning Electron Microcopy (SEM) was done on sputter coated discs. Results: Rz, maximum peak to valley distance of the sample profile, for the polished, blasted, as built, sprouts and rough sprouts were 2.6, 22.6, 33.0, 41.4 and 65.1 µm respectively. The addition of printed roughness in the sprouts and rough sprouts group significantly diminished ductility resulting in early strain to failure during tensile testing. Cells adhered and proliferated on discs regardless of roughness group. There was no statically difference in ALP activity, but qPCR showed that rough groups (sprouts and rough sprouts) had diminished Osteocalcin gene expression at week 2 and 4. The ECM observed with SEM in the rough groups was more resistant to repeated washes and was more extensive compared to the less rough groups. Conclusion: The addition of 3D printed artificial roughness leads to inferior mechanical properties and confers no clear benefit regarding cellular proliferation. Printed topography increases the initiation of fractures resulting in diminished tensile strength and ductility. Concurrently, the resolution of LBF is not fine enough at this time to create surface features that enhance cell behavior. Therefore, data in this study suggest that artificially printing roughness is not an effective strategy to enhance osseous integration into Titanium implants for critical sized defects.

Category: Midfoot/Forefoot; Other Introduction/Purpose: The prevalence of osteoarthritis of the hallux metatarsophalangeal joint (MTPJ) is estimated to affect 1 in 40 people over the age of 50. Surgical treatment options for MTPJ arthritis include joint preservation, joint resurfacing, and salvage arthrodesis. Arthroplasty of the great toe MTPJ has evolved over the past several decades. The aims of this study were to examine the MAUDE database to determine reported adverse events for hallux MTPJ arthroplasty. Methods: The US Food and Drug Administration’s (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was reviewed from 2010-2018 to determine reported adverse events for approved implants. We recorded and categorized the type of adverse event and excluded duplicate reports and those extracted from already published literature. Results: Among 64 unique hallux MTPJ implant adverse events, the most common modes of failure were component loosening (34%), component fracture (9.4%), inflammation (9.4%), infection (14.1%), and allergic reaction (7.8%). In regards to implant type, synthetic implants (Cartiva) had the highest percentage of adverse events (23.4%), followed by Arthrosurface ToeMotion (20.3%), Ascension MGT (12.5%), Arthrosurface HemiCAP (10.9%), Futura primus (9.4%), and Osteomed Reflexion (6.3%). The number of adverse events reported increased substantially after 2016. Conclusion: Our study of the MAUDE database demonstrated that component loosening and infection are the most common modes of adverse events for hallux MTPJ implants. Cartiva accounted for one-fourth of the implant-related adverse events during our study period, followed by ToeMotion and Ascension MGT implants. Given that the adverse events for hallux MTPJ implants are underreported, improved reporting mechanisms should be utilized to improve our understanding on long-term effects of various hallux MTPJ implants.

Category Ankle; Trauma Introduction/Purpose: Critical Sized Defects (CSD) defined as bone loss greater than 1-2 cm in length or greater than 50% loss in circumference of bone remains a significant challenge in orthopaedic surgery. Patients can acquire these defects through trauma, nonunion post fracture, tumor removal, avascular necrosis, and congenital abnormalities. Custom 3D printed porous Titanium scaffolds are increasingly being used to treat CSD in Foot and Ankle Surgery. Implantation of 3D printed cages is considered a salvage procedure offered after the patient has failed other procedures. Implants fill the space of the defect, provide mechanical strength and provide opportunity for osseous integration. As implementation of this surgical technique is relatively new, further research is needed to assess surgical outcomes and inform future surgical decision making. Methods: This is a retrospective chart review study which examines surgical outcomes after using 3D printed Titanium cages. Patients who received a 3D printed Titanium cage between 1/1/2013 and 11/01/2018 with at least 1 year follow-up were included in this study. Primary outcome is device failure defined as removal of implant for any reason. If applicable, mechanism of failure was recorded for each case. Patient specific factors such as age, gender, race, BMI, diabetes status, Charlson Comorbidity Index, tobacco use, number of foot and ankle surgeries, prior limb infections and laterality of defect were recorded in addition to surgical variables including geometry of implant, duration of surgery, and perioperative antibiotics Results: 18 patients who received custom 3D printed Titanium cages were included in this study. Of the 18 patients, 5 patients (27.8%) had device failure, defined as removal of implant. Of the 5 failures, 2 were removed due to infection while the other 3 were removed due to hardware failure including fractured cage, broken screw and loose fixation. Conclusion: Custom 3D printed Titanium was successfully implemented in 72.2% of patients. Implants were only removed due to infection (2 patients) or mechanical failure of device (3 patients). Future studies need to be powered to determine if certain patient specific factors are associated with device failure. Data from this study and subsequent studies can be used to design better implants, decide who is a good surgical candidate, and create preoperative therapies to improve modifiable risk factors

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 Introduction/Purpose: The term osteochondral lesion of the talus (OLT) refers to any pathology of the talar articular cartilage and corresponding subchondral bone. In general, OLTs can pose a formidable treatment challenge to the orthopaedic surgeon due to the poor intrinsic ability of cartilage to heal as well as the tenuous vascular supply to the talus. Although many treatment options exist, including microfracture, retrograde drilling, autologous chondrocyte implantation (ACI), and osteochondral autograft transfer system (OATS) these options may be inadequate to treat large cartilage lesions. Osteochondral allografts have demonstrated promise as the primary treatment for OLTs with substantial cartilage and bone involvement. To our knowledge, this is the first systematic review of outcomes after fresh osteochondral allograft transplantation for OLTs. Methods: PudMed, the Cochrane Central Register of Controlled Trials, EMBASE, and Medline were searched using PRISMA guidelines. Studies that evaluated outcomes in adult patients after fresh osteochondral allograft transplantation for chondral defects of the talus were included. Operative results, according to standardized scoring systems, such as the AOFAS Ankle/Hindfoot scale and the Visual Analog Scale were compared across various studies. The methodological quality of the included studies was assessed using the Coleman methodology score. Results: There were a total of 12 eligible studies reporting on 191 patients with OLTs with an average follow-up of 56.8 months (range 6-240). The mean age was 37.5 (range 17-74) years and the overall graft survival rate was 86.6%. The AOFAS Ankle/Hindfoot score was obtained pre- and postoperatively in 6 of the 12 studies and had significant improvements in each (P

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) use has increased with newer generation implants. Current reports in the literature regarding complications use data extracted from high-volume centers. The types of complications experienced by less experienced centers may not be reflected in these reports. The purpose of this study was to determine a comprehensive TAA adverse event profile from a mandatory-reporting regulatory database. Methods: The US Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database was reviewed from 2015-2018 to determine reported adverse events for approved implants. We recorded the type of adverse event and excluded duplicate reports and those extracted from already published literature. We categorized the adverse events into infection, intraoperative guide/jig error, component loosening (tibia or talus), cyst formation, component fracture, gutter impingement/heterotopic ossification, iatrogenic fracture, polyethylene wear, component dissociation, malalignment, malalignment recurrence, direct surgeon error, and miscellaneous. The overall percentage distribution of each of the adverse events failure causes was calculated as was the percentage distribution for each total ankle device. Results: Among 408 unique TAA device failures, the modes of failure listed by commonality were component loosening (17.9% [9.6% tibia, 8.3% talus]), intraoperative guide or jig error (15.4%), infection (13.7%), cyst formation (12.7%), gutter impingement/heterotopic ossification (10.3%), component fracture (9.6%), iatrogenic fracture (5.4%), poly wear (3.7%), component dissociation (3.2%), malalignment (2.5%), miscellaneous (2.9%), malalignment recurrence (2.2%), and direct surgeon error (0.5%). These were consistent with some systematic reviews of the literature but in disagreement with others which found high rates of iatrogenic fracture. In addition, the percentage distribution of adverse event failure types differed among implants. Conclusion: The MAUDE database is a publicly available method which requires mandatory reporting of approved device adverse events. Using this report, we found general agreement in types of complications reported in the literature, although there were some differences. In addition, intraoperative guide or jig errors were very common and may not have been previously appreciated. This data may more accurately reflect a comprehensive profile of TAA complications as data was taken from a database of all device users rather than only high-volume centers.

Category: Ankle; Ankle Arthritis; Trauma Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is generally considered a salvage operation for either complex deformity or arthritis about the hindfoot. Several methods can be used to achieve a TTC arthrodesis, including: intramedullary nail fixation, screws, plates, and a fine wire frame. We hypothesized that fibula sparing TTC arthrodesis would improve the union rate and decrease complications in TTC arthrodeses. To best of our knowledge, this is the largest study of TTCs in current literature and no comparative studies have been performed to investigate whether fibular resection influences union and complication rate. Methods: After obtaining approval from the IRB, a retrospective review of the TTC fusions performed at a single academic institution was performed. Orthopaedic surgeons specializing in foot and ankle surgery performed all operations. Eligible patients included those whom underwent a TTC fusion either with or without fibular resection constructs from 2005 to 2017, were 18 years or older at the time of surgery, and had at least two-year follow-up. Patients were excluded if their clinical or radiographic data were unavailable for review. Preoperative diagnosis and indications, fixation methods, clinical success, and complications were obtained from the patient chart and operative reports. 152 patients (155 ankles) underwent TTC arthrodesis, mean age 57.5 years. 94 ankles comprised the fibula-sparing group and 61 comprised the fibular resection group. Statistical analysis was performed using t-Student and Chi-squared test with a p-value of 0.05 defining significance. Results: Common diagnoses included: arthritis (n=66), prior non-union of the ankle or subtalar joint (42), Charcot neuro- arthropathy (25), failed total ankle arthroplasty (TAA) (21) and avascular necrosis of the talus (36). Pre-operative diagnosis of failed TAA was associated with post-operative nonunion (47.6%, p=0.029). In 108 ankles (70%), hindfoot intramedullary arthrodesis nailing was performed, with supplemental plating or screw augmentation in 39 cases. Plating was used in 46 patients (30%). There was no difference in complications (p=0.62) or nonunion (p=0.11) between plating vs nail arthrodesis. There was no difference in non-union rate (26% fibula-resection vs 29% fibula-sparing, p=0.74) or complication rate (49% in fibula-resection vs 53% fibula-sparing, p=0.63) in the fibula-resection compared to the fibula-sparing groups. Most common complications included: non-unions, hardware irritation/failure (17.4%), infection (16.1%), and tibial stress fractures (8.4%). Conclusion: Tibiotalocalcaneal arthrodesis is used primarily as a salvage operation for severe deformity, arthritis of both the ankle and subtalar joints, and situations in which bone loss necessitates a larger fusion procedure. There appears to be no difference in the union rate or complication rates in fibula-sparing or fibula resection during the approach for these fusion operations.

Category: Hindfoot; Trauma Introduction/Purpose: Subtalar distraction arthrodesis (SDA) was developed as a means of treating the symptoms of subtalar arthritis. Despite almost 30 years of research in this field, many controversies still exist regarding SDA. The objectives of this study were (1) to conduct a systematic review of clinical outcomes following SDA, (2) to assess the demographics, indications, and surgical technique used, (3) to assess the clinical and radiographic outcomes of this procedure and its role in improving function, (4) to provide treatment recommendations based on the best available literature, and (5) to identify knowledge deficits that require further investigation. Methods: MEDLINE and EMBASE were queried with an end date of January 1, 2018 using the keywords The keywords used for this search included ‘‘subtalar,’’ ‘‘talar,’’ ‘‘talus,’’ ‘‘bone,’’ ‘‘block,’’ ‘distraction,’ ‘arthrodesis,’ ‘fusion,’ ‘arthritis,’ ‘arthrosis,’ ‘calcaneus,’ ‘calcaneal,’ ‘fracture,’ ‘malunion,’ ‘deformity,’ and ‘‘clinical outcome,’’ alone and in various combinations using the Boolean operator ‘‘AND.’’ Data abstraction was performed by two independent reviewers. Inclusion criteria for the articles were (1) English language, (2) peer-reviewed clinical studies with evidence levels I to IV, (3) with at least five patients, (4) reporting clinical and/or radiographic outcomes of SDA. Data collected included: demographics, operative techniques, radiographic measures, clinical and functional outcomes, and complications. The level of evidence for each study was assessed according to the method described by Wright et al. Methods followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Twenty-five studies matched the inclusion criteria (2 Level III and 23 Level IV studies) including 492 feet in 467 patients. The most common indication for SDA was late complications of calcaneus fractures. Many different operative techniques have been described, and there is no proven superiority of one method over the other. The most commonly reported complications were nonunion, hardware prominence, wound complications, and sural neuralgia. All studies showed both radiographic and clinical improvement at the last follow-up visit compared with the preoperative evaluation. Pooled results (12 studies, 237 patients) demonstrated improved American Orthopaedic Foot & Ankle Society ankle hindfoot scores with a weighted average of 33 points of improvement. Conclusion: Subtalar bone block arthrodesis provides good clinical results at short-term and midterm follow-up, with improvement in ankle function as well as acceptable complication and failure rates. These consistent clinical outcomes throughout the literature, despite different lengths of followup periods, suggest that the functional results do not deteriorate with time. Higher confidence recommendations for SDA require longer follow-up, clear indications and treatment protocols, standardized clinical and radiographic outcome measures, and direct comparison or stratification of results based on graft type and other operative techniques.

Category: Ankle Introduction/Purpose: Poor pre-operative mental health and depression have been shown to negatively impact patient- reported outcomes (PROMs) after a broad array of orthopaedic procedures involving the spine, hip, knee, shoulder, and hand. However, the relationship of mental health and patient-reported outcomes in foot and ankle surgery is less clear. The purpose of this study is to characterize the impact of pre-operative mental health and depression on patient-reported outcomes after total ankle arthroplasty. The study hypothesis is that depression and decreased SF36 MCS will be significantly associated with diminished improvement in PROMs after total ankle arthroplasty. Methods: All patients undergoing primary TAA between January 2007 and December 2016 who were enrolled into a prospective, observational study and who had at least 1 to 2-year minimum study follow-up were included. Patients were separated into 4 groups based on the presence or absence of SF36 MCS=35 and no depression. Patients with MCS=35 and no depression. Patients with MCS>=35 and depression had significantly lower improvement in SF36 MCS (-3.2 points) compared with patients that had MCS>=35 and no depression. Adjusted analyses of minimum 5-year outcomes demonstrated significantly increased improvement in MCS and SMFA function for patients with pre-operative MCS

Category: Ankle Arthritis; Basic Sciences/Biologics Introduction/Purpose: Post-traumatic osteoarthritis (PTOA) is a frequent cause of disability. The most common predisposing factor for ankle PTOA is intra-articular ankle fracture. It has been hypothesized that an early inflammatory response after intra- articular injury could lead to cartilage damage. Our group recently demonstrated significantly elevated inflammatory cytokines in the synovial fluid fracture hematoma (SFFH) immediately after intra-articular ankle fracture. The negative effect that this inflammatory environment has on cartilage is unknown but may be the reason for PTOA development. The purpose of this study was to determine if cartilage occurred when exposed to intra-articular SFFH and if anti-inflammatory agents could attenuate this damage. Methods: SFFH was obtained from 52 intra-articular ankle fractures at the time of surgery. Samples were divided into three groups based on time from fracture: acute (0-2 days), intermediate (3-9 days), late (>=10 days). A biopsy punch was used to create 5mm cartilage discs from the medial and lateral shoulders of fresh human talus cartilage. The cartilage discs were weighed and cultured in standard chondrocyte media (SCM) for 3 days. Next, the discs were randomly assigned to one of 4 groups (n=10 each) and cultured as follows for 6 days: A=control, SCM only; Group B=acute SFFH+SCM; Group C=intermediate SFFH+SCM; Group D=late SFFH+SCM. After 6 days of culture, the discs were rinsed and transferred to new wells and cultured for 3 more days in SCM only, to determine inflammatory cytokine and MMP release from the cartilage discs (cartilage damage). The post SFFH spent culture media was collected. The initial and post SFFH culture spent media were analyzed for inflammatory cytokines, MMPs, CTXII (cartilage breakdown marker), and sGAG. Safranin-O staining was then performed on the discs. The initial and post SFFH media from groups A, B, C, and D were compared to determine if there was a difference in damage caused by SFFH based on time from fracture. Based on the results, Group B (early) was felt to cause the most damage. Therefore, the following treatment groups were created and cultured exactly as before: Group E=same as Group B + IL-1Ra treatment; Group F=same as Group B + doxycycline treatment. Groups B, E, and F were compared to determine if the addition of IL-1Ra or doxycycline (known MMP inhibitor) attenuated the damage. Results: Early, intermediate, and late SFFH all caused some degree of cartilage damage in the form of significantly elevated inflammatory cytokine and MMP production from the cartilage discs ( Figure 1 ). The early SFFH (Group B) was noted to cause significantly elevated production of IL-6, IL-8, CTXII, and decreased safranin-O staining. Therefore, it was chosen to compare with the therapeutic anti-inflammatory agents. The addition of IL-1Ra or doxycycline significantly reduced the production of IL-6, IL-8, CTXII, and MMPs 3, 9, and 10 ( Figure 2 ). Conclusion: This is the first study to show that intra-articular hematoma immediately after ankle fracture causes cartilage damage that can be partially attenuated by current clinically available therapeutic agents. Additionally, further research should be performed regarding the safety and efficacy of anti-inflammatory agents to prevent ankle PTOA.

Osteochondral lesions of the talus (OLTs) are difficult to treat. Arthroscopic microfracture augmented with micronized cartilage (BioCartilage; Arthrex, Naples, FL) and platelet-rich plasma is emerging as a treatment for moderate-sized, well-contained full-thickness OLTs. This treatment may provide superior histologic results and is less technically demanding and yields less morbidity than an open osteochondral allograft or autograft transfer. This technique guide presents the senior author’s preferred strategy for treatment of a moderate-sized OLT with arthroscopic microfracture and placement of micronized cartilage and platelet-rich plasma.

Category: Ankle Arthritis, Hindfoot Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is a common treatment option for hindfoot arthritis, deformity correction and salvage of failed total ankle replacement. However, union can be difficult to achieve in patients with bulk bone defects. Femoral head allograft is commonly used in the setting of TTC fusion with severe bone loss, but recent studies have reported concerns of arthrodesis rates of 50% or worse and graft collapse in these patients. Retrograde intramedullary nail placement through custom 3D spherical implants is a novel option for these patients. The purpose of this study was to compare fusion rates, graft resorption and complication rates between patients undergoing TTC fusion with 3D sphere implants versus femoral head allografts. Methods: All patients who underwent TTC arthrodesis with an intramedullary nail along with a 3D spherical implant or femoral head allograft by the senior author at a single institution from 2013 to 2017 and who had at least one year of follow-up were included in this study. There were 7 patients who received a femoral head allograft and 8 patients who received a 3D printed sphere. Baseline patient and operative characteristics were collected and compared between the 3D sphere and femoral head allograft groups. The rate of successful fusion of the tibia, calcaneus and talar neck to the 3D sphere or femoral head allograft, as determined by radiographs and CT scan, as well as graft resorption and complications were compared between the groups. Results: The rates of union of the tibia (87.5% vs 71.4%), calcaneus (87.5% vs 71.4%), and talar neck (100% vs 42.9%) were higher in the 3D sphere group than in the femoral head allograft group. The rate of union of the talar neck was significantly higher to the 3D sphere implant than to the femoral head allograft (p=0.016). The number of patients achieving successful fusion of all three articulations was higher in the 3D sphere group (75%) than the femoral head allograft group (42.9%), although not statistically significant (p=0.22). The rate of graft resorption was significantly higher in the femoral head allograft group (57.1%) than the 3D sphere group (0%, p=0.016).There were no differences between the groups in terms of complications. Conclusion: These data demonstrate that the use of a custom 3D-printed sphere implant is safe in patients with severe bone loss undergoing TTC arthrodesis with a retrograde intramedullary nail. The rate of successful fusion of all three tibial, calcaneal and talar neck articulations was higher to the 3D sphere than to the femoral head allograft, although not statistically significant. Union of the talar neck was significantly higher to the 3D sphere implants than it was to the femoral head allograft. Subsidence was significantly higher with the femoral head allograft than the 3D sphere.