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Background: Percutaneous Zadek osteotomy (ZO) has emerged as a surgical treatment of insertional Achilles tendinopathy (IAT) over the last decade. Existing literature is limited regarding the comparison of this approach with the more established, open ZO technique. This systematic review aims to evaluate and compare the current data on open vs percutaneous ZO approaches to help set evidence-based guidelines. Methods: A systematic literature search was performed using the keywords (Zadek osteotomy) OR (Keck and Kelly osteotomy) OR (dorsal closing wedge calcaneal osteotomy) OR (Haglund Deformity) OR (Haglund Syndrome) OR (Insertional Achilles Tendinopathy) and MeSH terms Osteotomy , Calcaneus , Syndrome , Insertional , Achilles tendon , and Tendinopathy . Our search included the following databases: PubMed, Embase, and the Cochrane Library. The PRISMA protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2009 to 2024 and included the use of open or percutaneous approaches of ZO for the treatment of IAT with at least a 12-month follow-up. The MINORS score criteria were used to evaluate the strength and quality of studies. Results: A total of 17 studies were reviewed, including 611 subjects and 625 ZO procedures. Of these procedures, 81 (11%) subjects had a percutaneous and 544 (89%) subjects had an open ZO. The mean follow-up time was 16.1 months for patients treated with percutaneous ZO and 36.1 months for patients treated with open ZO. Both open and percutaneous studies included in this review showed postoperative improvements in AOFAS, FFI, VISA-A, and VAS scores in patients with IAT. The reported complication rate was 5.8% among patients treated with percutaneous ZO and 10.2% among patients treated with open ZO. Conclusion: Percutaneous ZO is an emerging approach with substantially fewer documented cases compared with the open ZO. Both percutaneous and open ZO appear to be relatively effective treatments for insertional Achilles tendinopathy with Haglund’s deformity. The lower complication rates reported for percutaneous ZO is encouraging. Further investigation with more subjects undergoing percutaneous ZO is clearly needed.

Background: Hallux valgus (HV) is commonly treated with proximal or distal first metatarsal osteotomy. Despite good correction, these procedures have inherent risks such as malunion, nonunion, metatarsal shortening, loss of fixation, and avascular necrosis. Suture button fixation has been used for HV treatment. It avoids the risks of corrective osteotomies while maintaining reduction of the intermetatarsal angle (IMA). The goal of this study was to assess the radiographic and functional outcomes of patients undergoing HV correction with a distal soft tissue procedure and proximal suture button fixation. Methods: The authors retrospectively reviewed the charts and radiographs of 22 patients who had undergone HV correction using a distal soft tissue correction and proximal fixation with a miniature suture button device (Mini TightRope; Arthrex, Inc, Naples, FL). Mean follow-up was 27.7 months. The IMA, hallux valgus angle (HVA), and sesamoid station were measured on radiographs obtained preoperatively as well as in the immediate postoperative period and at final follow-up. Preoperative and postoperative Short Form-36 (SF-36) and Foot and Ankle Ability Measure (FAAM) scores were collected. Postoperative complications, and any additional operative procedures performed were also recorded. Results: The mean preoperative IMA and HVA were 16.9 and 32.6 degrees, respectively. The mean immediate postoperative IMA was 5.2 degrees ( P < .0001) and the mean HVA was 9.8 degrees ( P < .0001). At final follow-up, the mean IMA was 8.2 degrees ( P < .0001) and the mean HVA was 16.7 degrees ( P < .0001). The average change in HVA from preoperative to final follow-up was 16.0 degrees and the average change in IMA from preoperative to final follow-up was 8.6 degrees ( P < .0001). Sesamoid station assessment at the 2-week follow-up showed that 22 patients (100%) were in the normal position group; at final follow-up, 17 patients (77%) had normal position and 5 patients (23%) had displaced position. Although there were no clinically symptomatic recurrences, asymptomatic radiographic recurrence was noted in 5 patients (23%) who had a final HVA >20 degrees. All components of the FAAM and the SF-36 showed improvement from preoperative to final follow-up, although these changes were not statistically significant. Three patients experienced complications, including an intraoperative second metatarsal fracture, a postoperative second metatarsal stress fracture, and a postoperative deep vein thrombosis. Conclusion: The use of a distal soft tissue procedure in conjunction with proximal suture button fixation is a safe and effective procedure for treating symptomatic HV deformity. Our results show that this technique can correct the IMA, HVA, and sesamoid station without the need for osteotomy. Level of evidence: Level IV.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Hallux valgus is one of the most common deformities treated by orthopedic foot and ankle surgeons. Hallux valgus can frequently present with an increased distal metatarsal articular angle (DMAA), which may require correction in addition to treating the hallux valgus deformity. Many surgical procedures can correct hallux valgus with an increased DMAA with varying levels of success. Thus, we investigate the efficacy of the modified Lapidus procedure, a triplanar correction, in correcting the DMAA in hallux valgus surgery. Methods: A retrospective chart review was performed on patients who underwent the hallux valgus reconstruction with a modified Lapidus procedure between April 26th, 2018 and November 19th, 2020. Exclusion criteria included any patient undergoing hallux valgus correction not receiving a modified Lapidus procedure and patients with inadequate follow up. Hallux valgus angle (HVA), intermetatarsal angle (IMA) and DMAA were measured on pre-operative, immediate post-operative and at final follow up weight bearing radiographs. Results: The study included a total of 99 cases of modified Lapidus procedure for hallux valgus on 85 subjects with an average follow up of 5.4 months. On radiologic assessment, the average DMAA decreased from 17.72 +- 6.18 degrees pre-operatively to 9.19 +- 5.19 degrees immediately post-operatively (p < 0.0001) and 9.79 +- 4.62 degrees at the final follow up (p < 0.0001). The average HVA decreased from 31.34 +- 10.39 degrees pre-operatively to 13.34 +- 6.16 degrees immediately post-operatively (p < 0.0001) and 15.05 +- 7.43 degrees at final follow up (p < 0.0001). Lastly, the IMA decreased from 14.99 +- 3.82 pre-operatively (p < 0.0001) to 4.66 +- 2.59 immediately post-operative and 6.62 +- 3.46 degrees at final follow up (p < 0.0001). The rate of recurrence was 3.03%. Conclusion: The modified Lapidus procedure is an effective procedure in correcting the HVA, IMA, and DMAA in hallux valgus surgery without the need for additional distal or proximal metatarsal osteotomies. Surgeons should consider this technique in patients with moderate to severe hallux valgus deformity who may require correction of their DMAA.

Category: Bunion; Other Introduction/Purpose: Orthopedic surgeons frequently prescribe and overprescribe narcotic pain medications during the postoperative period, despite our increased understanding of the opioid crisis. In an effort to minimize narcotic analgesia and its potential side effects, opiate free multimodal pain pathways have been developed with promising results. However, there is a lack of published literature looking at opiate free multimodal pain protocols for elective outpatient foot and ankle surgeries. At our institution we have been implementing a novel opiate free multimodal post-operative pain protocol for elective outpatient foot and ankle surgeries. The purpose of this study was to explore the efficacy, feasibility, outcomes and satisfaction of an opioid-free, multimodal postoperative pathway in patients undergoing elective outpatient foot and ankle surgery. Methods: This study was approved by our IRB and was a prospective study. Data was collected from December 1st, 2020 through February 9th, 2022 for patients who underwent a primary elective outpatient foot and ankle surgery including bunion correction surgery with or without a lesser toe procedure(s). These patients completed a comprehensive opioid-free, multimodal pain management protocol and a follow up with one of two fellowship trained orthopedic foot and ankle surgeons. The multimodal treatment protocol included oral Lyrica, Tylenol, Toradol and flexeril to begin POD#0. Mobic was given to POD #4 once Toradol was completed. All data was collected in a prospective manner. At POD#1, #3, and #8, patients were contacted to collect VAS scores, complications, ED and Urgent care visits, and pain medication needs. At two week follow up these were again collected in addition to overall satisfaction rates. Results: 33 patients enrolled with a mean age of 55 (19-81) years old. The average follow up was 11.5 weeks. On POD#1, #3, #8, and at 2 week follow up our patients’ average VAS pain score was a 4.0, 2.5, 1.6, and 1.4 out of 10, respectively. 18% of patients required narcotics within the first 2 weeks, but by 2 weeks no patients were taking narcotics. No patients visited an ED or urgent care during the first 2 weeks post operatively. Common side effects were drowsiness/tiredness and constipation. Only 4 reported nausea or GI upset at 2 week follow up. Overall, 91% were satisfied with their pain control, 78% would follow the same protocol again, and 82% would recommend this pain management regimen to others. Conclusion: An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing elective outpatient foot and ankle surgery with a very low risk of requiring rescue opioids, having significant side effects, and/or needing an ED or urgent care evaluation within the first 2 week post operative period.

This first of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey the state of scientific knowledge related to incidence, diagnosis, pathologic mechanisms, and injection treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 3, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Part 1 overviews areas of epidemiology and pathophysiology, current approaches in imaging, diagnostic and therapeutic injections, and genetics. Opportunities for future research are discussed. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the needs of patients that suffer from arthritis of foot and ankle. The foot and ankle contain a myriad of interrelated joints and tissues that together provide a critical functionality. When this functionality is compromised by OA, significant disability results, yet the foot and ankle are generally understudied by the research community. Level of Evidence: Level V - Review Article/Expert Opinion.

This second of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey current treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 10, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Topics were chosen by meeting organizers, who then identified and invited the expert speakers. Part 2 overviews the current treatment options, including orthotics, non–joint destructive procedures, as well as arthroscopies and arthroplasties in ankles and feet. Opportunities for future research are also discussed, such as developments in surgical options for ankle and the first metatarsophalangeal joint. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the importance to patients of addressing the foot and ankle with improved basic, translational, and clinical research. Level of Evidence: Level V, review article/expert opinion.

Category: Bunion; Other Introduction/Purpose: More than 200,000 surgeries for hallux valgus correction occur annually in the United States. Due to the post-operative pain associated with the procedure, opioids are often prescribed to help manage pain. Given the lack of objective data on opioid use and the difficulty of addressing a patient's post-operative pain, we sought to quantify, through a prospective analysis, patient's narcotic use after hallux valgus surgery. The purpose of our study was to determine the average quantity and type of post-operative opioids consumed after hallux valgus surgery and to assess potential predictive factors for increased opioid consumption. Methods: Adult patients undergoing primary hallux valgus surgery were recruited from two foot and ankle fellowship trained orthopedic surgeons at a single institution. At the pre-operative visit, patients were consented and completed a demographical questionnaire. Data was collected from the operative and PACU record, as well as the 2, 6, and 12-week post-operative visits. A statistical analysis was performed to determine the average quantity of opioid and non-opioid pain medication consumed post- operatively, as well as any statistically significant correlations. Results: For the 58 subjects who completed treatment and data collection in the PACU, 53 consumed opioids. Initial prescriptions for these patients included Hydrocodone, 39 (73.58%) Oxycodone, 13 (24.52%) and Meperidine, 1 (1.89%). The average number of opioid pills collectively consumed at the two-week and 12-week post-operative visit was 19.99 and 22.52, respectively. At the two-week postoperative visit, only patient BMI showed a statistically significant association with increased opioid use. Conclusion: On average, patients consumed 22-24 narcotic pain pills after hallux valgus reconstruction surgery. If a physician prescribed 24 narcotics pills after surgery to patients that are not currently utilizing narcotic pain medication, there is a 95% chance they will not need additional pain medication during the two-week postoperative period.

Category: Bunion; Other Introduction/Purpose: More than 200,000 surgeries for hallux valgus correction occur annually in the United States. Due to the post-operative pain associated with the procedure, opioids are often prescribed to help manage pain. The opioid epidemic has led to a 78-billion-dollar economic impact. Given the lack of objective data on opioid use and the difficulty of addressing a patient’s post-operative pain, we sought to quantify, through a prospective analysis, patient’s narcotic use after hallux valgus surgery. Objective data may help guide the surgeon in the type and number of opioids utilized after surgery. Methods: Adult patients undergoing primary hallux valgus surgery were recruited from two surgeon’s institution. At the pre- operative visit, patients were consented and completed a demographical questionnaire. Data was collected from the operative and PACU record, as well as the 2-week post-operative visit. A simple statistical analysis was performed to determine average quantity and type of opioid and non-opioid pain medication used in the PACU and for post-operative pain management. Results: 33 subjects were prospectively enrolled and followed. The average time until the first post-operative clinic visit was 13.53 days. The average opioid pain medication consumption during this period was 20.766 (0-66) pills, with a morphine milligram equivalents (MME)/kg of body weight at 1.69. (78.8%) were prescribed hydrocodone/acetaminophen 5/325mg and 7 subjects (21.2%) were prescribed oxycodone/acetaminophen 5/325 for post-operative pain management. 84.8% of subjects (28/33) received a local block, including 2 femoral, 2 ankle, 13 popliteal, 3 sciatic, 3 adductor canal, 4 popliteal and saphenous, and 1 popliteal and adductor canal. 24.2% (8/33) of subjects received opioid pain medication in the PACU post-operatively with a MME/kg of body weight at 0.135 per subject. Conclusion: Based on our prospective study, we recommend an initial prescription of 30 5mg hydro/oxycodone pain pills, as this represents the 3rd quartile of consumption.

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: There is no consensus regarding participation in sports and recreational activities following total ankle replacement (TAR) and ankle arthrodesis (AA). Better understanding on this topic will allow orthopaedic foot and ankle surgeons to set evidence-based goals and expectations with their patients in regards to postoperative activity recommendations and quality of life. We aimed to summarize the evidence on return to sport and activity after surgical management with either TAR or AA for ankle osteoarthritis (OA). Methods: A literature search of PubMed, MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was performed in January 2020. The bibliographies of all relevant publications were searched for further applicable studies. Included studies were required to report sport and activity outcomes in patients undergoing TAR and AA, with primary outcomes being percentage of sport participation and level of sport participation. Excluded studies were non-English and did not assess level of sport activity after TAR or AA. Results: Twelve studies met inclusion criteria for analysis. There were 1,270 ankle procedures, of which 923 TAR and 347 AA were performed. Mean reported patient age was 59.2 years old and mean BMI was 28 kg/m2. Mean follow-up was 43 months. Fifty-four percent of patients were active in sports preoperatively compared to 63.7% postoperatively (Figure 1). Mean preoperative activity participation rate was 41% in the TAR cohort, but improved to 59% after TAR, whereas preoperative activity participation rate of 73% was similar to postoperative rate of 70% in the AA cohort. The most common sports in TAR and AA groups were swimming, hiking, cycling, and skiing. Conclusion: Participation in sports activity is nearly 10% improved after surgical management of ankle OA. The existing literature demonstrated a large improvement in pre-to postoperative activity levels after TAR, with minimal change in activity after AA, however, AA patients were more active at baseline. The most frequent postoperative sports activities after surgical management of ankle OA are: swimming, hiking, cycling, and skiing. Despite preoperative participation in high-impact sports such as tennis, soccer, and running, these were consistently limited after surgery. This review of the literature will equip patients and physicians with the knowledge to appropriately establish realistic expectations for postoperative physical activity and return to sport goals.

Background: Hallux valgus (HV) is commonly treated with proximal or distal first metatarsal osteotomy. Despite good correction, these procedures have inherent risks such as malunion, nonunion, metatarsal shortening, loss of fixation, and avascular necrosis. Suture button fixation has been used for HV treatment. It avoids the risks of corrective osteotomies while maintaining reduction of the intermetatarsal angle (IMA). The goal of this study was to assess the radiographic and functional outcomes of patients undergoing HV correction with a distal soft tissue procedure and proximal suture button fixation. Methods: The authors retrospectively reviewed the charts and radiographs of 22 patients who had undergone HV correction using a distal soft tissue correction and proximal fixation with a miniature suture button device (Mini TightRope; Arthrex, Inc, Naples, FL). Mean follow-up was 27.7 months. The IMA, hallux valgus angle (HVA), and sesamoid station were measured on radiographs obtained preoperatively as well as in the immediate postoperative period and at final follow-up. Preoperative and postoperative Short Form-36 (SF-36) and Foot and Ankle Ability Measure (FAAM) scores were collected. Postoperative complications, and any additional operative procedures performed were also recorded. Results: The mean preoperative IMA and HVA were 16.9 and 32.6 degrees, respectively. The mean immediate postoperative IMA was 5.2 degrees ( P < .0001) and the mean HVA was 9.8 degrees ( P < .0001). At final follow-up, the mean IMA was 8.2 degrees ( P < .0001) and the mean HVA was 16.7 degrees ( P < .0001). The average change in HVA from preoperative to final follow-up was 16.0 degrees and the average change in IMA from preoperative to final follow-up was 8.6 degrees ( P < .0001). Sesamoid station assessment at the 2-week follow-up showed that 22 patients (100%) were in the normal position group; at final follow-up, 17 patients (77%) had normal position and 5 patients (23%) had displaced position. Although there were no clinically symptomatic recurrences, asymptomatic radiographic recurrence was noted in 5 patients (23%) who had a final HVA >20 degrees. All components of the FAAM and the SF-36 showed improvement from preoperative to final follow-up, although these changes were not statistically significant. Three patients experienced complications, including an intraoperative second metatarsal fracture, a postoperative second metatarsal stress fracture, and a postoperative deep vein thrombosis. Conclusion: The use of a distal soft tissue procedure in conjunction with proximal suture button fixation is a safe and effective procedure for treating symptomatic HV deformity. Our results show that this technique can correct the IMA, HVA, and sesamoid station without the need for osteotomy. Level of evidence: Level IV.

Category: Trauma Introduction/Purpose: The determination of stability and ultimate need for operative stabilization of Weber B fibula fractures largely depends on the presence of a competent deltoid ligament. While various radiographic parameters and the application of manual or gravity stress have been proposed to elucidate instability, the prognostic capability of these modalities remains unclear. Given that a recent study found no difference between operative and nonoperative treatment for stress-positive Weber B ankle fractures, the value of stress views is questionable; what may be ultimately more important is the determination of anatomic positioning of the mortise. We propose a novel view, the Gravity Reduction View (GRV), which helps elucidate non-anatomic positioning and reducibility of the mortise. We also propose a treatment algorithm based on the use of the GRV. Methods: To obtain the GRV, the patient is positioned in lateral decubitus with the injured fibula directed upward and elevated with a leg holder. The x-ray cassette is placed posterior to the heel, with the beam angled at 15˚ of internal rotation to obtain a mortise view. Our treatment algorithm is based upon the measurement of the medial clear space (MCS) on the GRV versus the static mortise view. If the MCS on GRV remains wide or decreases, surgery is recommended as the GRV confirms a non- anatomic mortise. If the MCS remains within normal limits on the static and GRV views, a trial of nonoperative treatment with immobilization and repeat radiographs in 1-2 weeks is undertaken. If the MCS is normal on repeat weightbearing x-rays, the patient is treated conservatively; if increased, surgery is recommended. To further assess mortise stability, the MCS is compared to the superior clear space (SCS). Results: 23 patients with Weber B distal fibula fractures were managed according to this treatment algorithm. The mean age was 49.1 years old (range: 18-74). Of these patients, 15 underwent operative treatment and 10 patients were initially treated nonoperatively, although 2 patients demonstrated late displacement and were treated surgically. Using this algorithm, all patients had a final MCS that was less than the SCS (final mean MCS for patients treated operatively or nonoperatively 2.85 mm vs. mean SCS of 3.34), indicating effectiveness of the treatment algorithm. Conclusion: The Gravity Reduction View is a novel radiographic view in which deltoid competency, reducibility and initial anatomic positioning of the mortise are assessed by comparing a static mortise view with the appearance of the mortise on the reduction view (GRV). We have developed a treatment algorithm based on the GRV and have found it to be predictive of mortise alignment and useful in guiding treatment.

Background:. Artificial intelligence (AI) holds potential in improving medical education and healthcare delivery. ChatGPT is a state-of-the-art natural language processing AI model which has shown impressive capabilities, scoring in the top percentiles on numerous standardized examinations, including the Uniform Bar Exam and Scholastic Aptitude Test. The goal of this study was to evaluate ChatGPT performance on the Orthopaedic In-Training Examination (OITE), an assessment of medical knowledge for orthopedic residents. Methods:. OITE 2020, 2021, and 2022 questions without images were inputted into ChatGPT version 3.5 and version 4 (GPT-4) with zero prompting. The performance of ChatGPT was evaluated as a percentage of correct responses and compared with the national average of orthopedic surgery residents at each postgraduate year (PGY) level. ChatGPT was asked to provide a source for its answer, which was categorized as being a journal article, book, or website, and if the source could be verified. Impact factor for the journal cited was also recorded. Results:. ChatGPT answered 196 of 360 answers correctly (54.3%), corresponding to a PGY-1 level. ChatGPT cited a verifiable source in 47.2% of questions, with an average median journal impact factor of 5.4. GPT-4 answered 265 of 360 questions correctly (73.6%), corresponding to the average performance of a PGY-5 and exceeding the corresponding passing score for the American Board of Orthopaedic Surgery Part I Examination of 67%. GPT-4 cited a verifiable source in 87.9% of questions, with an average median journal impact factor of 5.2. Conclusions:. ChatGPT performed above the average PGY-1 level and GPT-4 performed better than the average PGY-5 level, showing major improvement. Further investigation is needed to determine how successive versions of ChatGPT would perform and how to optimize this technology to improve medical education. Clinical Relevance:. AI has the potential to aid in medical education and healthcare delivery.