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Background: Manuscripts discussing return to play (RTP) following ankle surgery are common. However, the definition for RTP and the method by which it is determined remains unclear. The purpose of this scoping review was to clarify how RTP is defined following ankle surgery in physically active patients, to identify key factors informing RTP decision making (such as objective clinical measures), and make recommendations for future research. Methods: A scoping literature review was performed in April 2021 using PubMed, EMBASE, and Nursing and Allied Health databases. Thirty studies met inclusion criteria: original research following ankle surgery reporting at least 1 objective clinical test and documentation of RTP. Data were extracted for study methods and outcomes (RTP definition, RTP outcomes, and objective clinical tests). Results: The scoping review found studies on 5 ankle pathologies: Achilles tendon rupture, chronic lateral ankle instability, anterior ankle impingement, peroneal tendon dislocation, and ankle fracture. RTP criteria were not provided in the majority of studies (18/30 studies). In the studies that provided them, the RTP criteria were primarily based on time postsurgery (8/12) rather than validated criteria. Objective clinical outcome measures and patient-reported outcome measures (PROMs) were documented for each surgery when available. Both clinical outcomes and PROMs were typically measured >1 year postsurgery. Conclusion: In physically active patients who have had ankle surgery, RTP remains largely undefined and is not consistently based on prospective objective criteria nor PROMS. We recommend standardization of RTP terminology, adoption of prospective criteria for both clinical measures and PROMs to guide RTP decision making, and enhanced reporting of patient data at the time of RTP to develop normative values and determine when the decision to RTP is not safe. Level of Evidence: Level IV, scoping review.

Category: Ankle Arthritis; Ankle Introduction/Purpose: Previous studies have documented improvement in patient-reported outcomes (PROs) following primary total ankle arthroplasty (TAA) with mean two-year postoperative Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) scores reported as >80 (Norvell et al. JBJS 2019). As TAAs become more common, complications including chronic prosthetic joint infections (PJIs) will be encountered more frequently. Although well-documented in the hip and knee arthroplasty literature, no studies have reported on PROs following a two-stage revision procedure for a chronic PJI after a TAA. The primary purpose of this study was to investigate clinical outcomes at a minimum of two-years postoperatively following a two-stage revision TAA for a chronic PJI. Secondary outcomes were to identify the need for soft-tissue coverage and postoperative complications following the revision. Methods: Patients who underwent a two-stage revision TAA for a chronic PJI (>4 weeks after a primary TAA) between January 2010 and December 2019 were eligible to be included in this study. Chronic PJI was defined as a sinus tract that directly communicated with the prosthesis or the same organism identified in 2 synovial fluid samples. Patients were excluded if they did not have at least two-year postoperative Foot and Ankle Ability Measure (FAAM) scores, which are validated patient-reported outcome tools. Twelve patients were eligible to be included in this study. One patient died prior to two-year follow-up, which left 11 patients available for analysis. All eleven patients underwent reimplantation with a stemmed tibial implant and flat-cut talus. Patients were contacted to determine if they had any additional reoperations since their last office note. The data was found not to be normally distributed; therefore, medians and interquartile ranges (IQRs) are reported. Results: The median time from primary TAA to resection was 17 months (IQR 2-24 months). Seven of 10 patients required a free flap for soft-tissue coverage prior to reimplantation. At a median of 3.0 years (IQR 2.0-4.0 years) following the second stage of their revision arthroplasty, the median FAAM ADL, Sports, Current Function, and Current Sports Level scores were 60.7 (IQR 52.4, 79.8), 31.3 (IQR 9.4, 40.6), 70 (IQR 25.0, 90.0), and 10 (IQR 0.0, 75.0) (Figure 1). Patients rated their current level of function as 'Severely Abnormal' in 3 patients, 'Abnormal' in 4 patients, 'Nearly Normal' in 3 patients, and 'Normal' in 1 patient. Six patients required a reoperation including three patients who underwent a subsequent irrigation and debridement, one patient who had a below knee amputation, one patient who required a dorsiflexion first metatarsal osteotomy, and one patient who had a subtalar and talonavicular arthrodesis. Conclusion: Our study suggests that a two-stage revision TAA is a viable option for patients with a chronic PJI with 90.9% of patients retaining their metal components at a minimum two-year follow-up. However, patients who undergo a two-stage revision TAA for a chronic PJI have lower than previously published two-year FAAM scores and a high rate of flap coverage and reoperation. Only 36.4% of patients rated their function as 'Normal' or 'Near Normal.' This data may be used to help counsel patients about the expected outcome following a two-stage revision TAA for a chronic PJI.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Treatment for symptomatic hallux valgus encompasses a spectrum of surgical options to appropriately address the degree of deformity. The modified Lapidus has emerged as a powerful surgical option to address moderate to severe deformity as well as hallux valgus with 1st ray hypermobility. Unlike metatarsal osteotomies, the literature is lacking in clinical and radiographic outcomes. Previous retrospective series have reported recurrence rates less than 15%, but our experience found a higher recurrence rate. We aimed to evaluate the effect of radiographic recurrence on patient reported outcome measures and satisfaction. Methods: After obtaining institutional board review approval, patients were identified by procedural billing codes from 2012- 2016. Only primary Lapidus surgeries were included. All patients were contacted and invited to return to obtain patient reported outcome scores (AOFAS, FAAM) and assess satisfaction. HVA>=20 at final follow-up was used to define recurrence. Data was analyzed utilizing statistical analysis software (SAS v9.4).328 surgeries were identified with 255 eligible and contacted for follow-up. 77 surveys were completed in person and 50 were completed over the phone or via email with total response rate of 50%. Results: Average follow-up was 59 months. 38% had radiographic recurrence (48/127), 24% perceived recurrence (30/125), and 9.5% had reoperation for recurrence (12/126). AOFAS scores were lower with radiographic recurrence (p=0.01) and perceived recurrence (p=0.003). FAAM-ADL scores were not different in radiographic recurrence (p=0.79) but were lower in perceived recurrence (p=0.001). Overall, satisfaction was good-excellent in 74% and fair-poor in 26%. For radiographic (p=0.03) and perceived recurrence (pConclusion: Despite a high radiographic recurrence rate (38%), only a portion perceived a recurrence (24%) and an even smaller proportion (9.5%) had a reoperation for the recurrence. Nonetheless, these results suggest radiographic and clinical outcomes are not as high as previously reported for the modified Lapidus procedure.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Treatment for symptomatic hallux valgus encompasses a spectrum of surgical options to appropriately address the degree of deformity. The modified Lapidus has emerged as a powerful surgical option to address moderate to severe deformity as well as hallux valgus with 1st ray hypermobility. Unlike metatarsal osteotomies, the literature is lacking in clinical and radiographic outcomes. Previous retrospective series have reported recurrence rates less than 15%, but our experience suggested recurrence rates were higher. Methods: After obtaining institutional board review approval, patients were identified by procedural billing codes from 2012- 2016. Only patients who underwent a primary Lapidus surgery with greater than 1 year radiographic follow-up were included. Larger midfoot fusions and flatfoot reconstructions were excluded. Charts were reviewed to identify complications and reoperations. Radiographs were reviewed and HVA, IMA, sesamoid position (0-4), and Meary’s angle measured on preoperative, 1st weigh-bearing post-operative, and final follow-up radiographs. Data was analyzed utilizing statistical analysis software (SAS v9.4). Results: 114 patients were identified with 12 undergoing bilateral surgery (126 surgeries). There were 106 females and 8 males, and median age was 57.5 years at time of surgery. Median follow-up from index surgery was 2.9 years. Using HVA>=20 as cutoff for recurrence, 58 (46%) recurrences were identified, but only 15 (12%) underwent revision surgery. There were 32 total reoperations, including 8 nonunions ( table 1A ). Median preoperative HVA was greater in group with recurrence than group without recurrence (38 vs 30, p=30 with an AUC of 0.75. That indicated that in 75% of cases, preoperative HVA>=30 predicted recurrence. We identified that HVAConclusion: As has been determined in other hallux valgus series evaluating metatarsal osteotomies, increased HVA>=30 is a risk factor for recurrence. Despite being acknowledged as a powerful operation for hallux valgus correction, the modified Lapidus still had a high rate (46%) of radiographic recurrence when used to treat severe deformity. However, only 12% underwent revision surgery in our series. This is important when counseling patients before surgery as the modified Lapidus operation does not obviate the risk of recurrence as has been previously suggested, but the lower revision rate suggests radiographic outcomes alone do not drive satisfaction. Further outcome measures are needed on this cohort to better identify surgical variables associated with maintained correction, other risk factors for recurrence, as well as patient reported outcomes.

Category: Ankle Arthritis, Diabetes, Hindfoot Introduction/Purpose: Charcot neuropathy of the ankle and hindfoot is a progressive and destructive process that can lead to instability and ulceration resulting in significant morbidity which can end with amputation. The foot and ankle surgeon’s aim is to reconstruct the high risk foot with the creation of a stable plantigrade foot, while reducing the risk of ulceration and allowing the patient to mobilize in commercially available footwear. There are numerous techniques for the reconstruction of the neuropathic hindfoot, but the most utilized of these include multiplanar external fixation or internal fixation with a plate or intramedullary nail. It is our goal to further elucidate outcomes of Charcot patients undergoing corrective ankle and hindfoot fusion comparing internal versus external fixation. Methods: We retrospectively collected 377 patients undergoing hindfoot and ankle arthrodesis at our institution from 2006- 2017. 77 patients were identified that underwent arthrodesis for Charcot arthropathy, 56 of which met our inclusion and exclusion criteria. This included 47 who had internal fixation as their primary procedure and 9 patients who underwent external fixation with a multi-planar external fixator. Our median follow up time was 3.4 years (IQR .5 to 12.9). Preoperatively we collected basic demographic variables, reasons for neuropathy, and ulcer status. Postoperatively we collected complications including infection, hardware failure, ulceration, recurrent deformity, and radiographic outcomes including union and hardware backout. Reoperation numbers and indications were also collected. Our primary outcome was limb salvage at final follow up. Secondarily, we collected final ambulatory and footwear status. Results: The limb salvage rate was 82% with 10 patients undergoing amputation, which did not vary between groups (p=.99). The primary reasons for amputation were persistent infection (4 of 10) and nonunion (4 of 10). Thirteen (24%) patients developed an infection. The median number of reoperations per patient was 1 (IQR 0-2) with the patients who underwent amputation undergoing a median of 2 (IQR 2-4) reoperations. The rate of union was 54%, occurring at a median of 26.5 (IQR 12-47) months. 44% (4/9) of patients in the external fixation group had a preoperative ulceration versus 19% (9/47) of the patients in the internal fixation group (p=.19). Preoperative ulceration was not a risk factor for amputation. Forty-two (75%) patients were ambulatory at final follow up. Conclusion: We report on the single largest series of Charcot patients undergoing hindfoot and ankle arthrodesis. The surgical management of this population has a high rate of complications with infection and reoperation being common. Despite a high nonunion rate most patients are able to ambulate in a brace or orthotic. Limb salvage can be expected with either internal or external fixation techniques.

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) has been shown to be a viable option in the treatment of end stage ankle arthritis (ESAA). Early reports demonstrated good results with intramedullary fixation implants. Third generation implants of this kind added a central sulcus to the talar component. This is a report of clinical follow up data from a prospectively collected database at a single US institution using a third generation fixed bearing total ankle arthroplasty implant with a stemmed tibial component and a talar component with a central sulcus. To our knowledge, this is the first report of 5 year follow up data for this implant. Methods: Patients undergoing primary TAA at a single institution by one of four fellowship trained orthopedic foot and ankle surgeons with a third generation fixed bearing implant consisting of an intramedullary stemmed tibial component and a sulcus talus that were at least 5 years postoperative were reviewed from a prospectively collected database. These patients were followed at regular intervals with history, physical examination and radiographs; multiple patient reported outcomes (PRO) measures were obtained. Primary outcomes included implant survivability and PRO scores. Secondary outcomes included coronal plane radiographic alignment (Medial distal tibial articular angle (MDTA) and talar tilt angle (TTA)), evaluation for osteolysis, and failure mode when applicable. All reoperation events were recorded using the Canadian Orthopedic Foot and Ankle Society (COFAS) Reoperations Coding System (CROCS). Results: 121 TAA with this implant were performed in 119 patients between 2010 and 2013; 64 met inclusion criteria. The mean age at surgery was 61.3 ± 10.0 years (range 38.7-84.3). The mean duration of follow up for living patients that retained both initial components at final follow-up was 6.1 ± 0.9 years (range 4.7 – 8.1 years). 26.6% of ankles had a preoperative MDTA and/or TTA greater than 10 degrees. There were 6 (9.4%) failures that occurred at a mean 2.0 ± 1.4 years postoperative. Two failures were due to deep infection. Only one failure was related to tibial component subsidence. One patient is currently scheduled for revision due to talar component subsidence. Conclusion: This cohort of TAA patients with minimum 5 year follow up using a third generation fixed bearing implant demonstrates acceptable implant survival, improved patient reported outcomes scores and maintenance of coronal plane alignment. These data also suggest tolerance of a larger preoperative deformity with improved implant design. To our knowledge, this is the first report with 5 year data on this implant. Continued follow up and reporting is needed to ensure that these favorable outcomes are maintained. Additionally, further investigation on acceptable coronal plane alignment correction with TAA is needed to determine the possible limitations of this procedure.

Category: Ankle Arthritis, Hindfoot Introduction/Purpose: Triple arthrodesis is a commonly performed surgical treatment for hindfoot arthritis and deformity. No study has clearly delineated correlates of both clinical and radiographic outcomes in a sample size this large. The purpose of this study is to explore predictive and demographic outcome measures with long-term followup after triple arthrodesis. Methods: With IRB approval, an institutional radiology database was queried for patients undergoing triple arthrodesis between 2004 and 2016, by a single surgeon at a single institution. A total of 465 cases were identified. Pre- and post-operative clinical and radiographic data was collected retrospectively. Demographic and predictive data included: age, Body Mass Index (BMI), American Society of Anesthesiologists Score (ASA), Charleston Comorbidity Index (CCI), diabetic status, osteoporosis, hypothyroidism, and neuromuscular disease status. Clinical outcomes including infection rate, reoperation rate and clinical nonunion were recorded. Unintended return to the operating room defined clinical failure. Radiographic data including non-union rate, pre- and post- operative ankle degenerative joint disease was also recorded. Statistical analysis was then performed to evaluate the relationship between predictive measures and various outcomes including reoperation, infection, and non-union rates. 23 cases were lost to follow-up. Results: A total of 442 feet (397 patients) were analyzed. The average age was 54 years (14 to 85) with the majority of cases being female (60%). Average follow up was 593 days (40 to 4079). Overall failure rate was 13.7% with clinical nonunion rate of 4.5%. Infection rate was 5.9%. Mortality rate was 0% at 2 years post-operatively. Predictors of failure included: increased BMI, elevated ASA, history of diabetes, underlying neuromuscular disorder (Figure 1). We found no significant difference between pre and post-operative degenerative joint disease rates in the midfoot (9.4%, 12.5%) and ankle (11.7%,13.7%), respectively. Conclusion: Triple arthrodesis is a highly effective procedure for treating hindfoot arthritis. Certain predictive measures including BMI, ASA score, diabetic status and underlying neuromuscular disorders significantly correlate with radiographic union. Additionally, diabetic status significantly correlates with infection status postoperatively. An understanding of these predictive measures may help surgeons in their preoperative planning to improve their clinical and radiographic success rates.

Category: Bunion, Midfoot/Forefoot, Sesamoid Introduction/Purpose: Potential etiologies of sesamoid related pain include repetitive stresses, fracture, cartilage lesions, arthrosis, and/or osteonecrosis. When patients fail to respond to conservative treatment, surgical intervention may be indicated in the form of sesamoid bone grafting, shaving/debridement, and/or sesamoid excision. Minimal published literature exists regarding the long-term safety and efficacy of fibular sesamoidectomy. The purpose of this study was to evaluate patients following isolated, complete fibular sesamoidectomy for long-term pain relief, functional outcome, and changes in hallux alignment. Methods: A query of a tertiary referral center administrative database was performed using the CPT code 28135 for sesamoidectomy between 10/1/2005 and 9/1/2016. Patients who underwent an isolated fibular sesamoidectomy were identified and contacted by their treating physicians with a recruitment letter, phone call, or e-mail to return for an office visit. The primary outcome measure was preoperative to final postoperative change in ten-point visual analog scale pain score. Secondary measures included satisfaction, hallux flexion strength, change in hallux alignment, and final post-operative functional outcome scores. Patients who met the 2-year clinical or radiographic follow-up minimum were included. Patients who underwent concomitant joint realignment procedures or had a medical history of either diabetes or peripheral neuropathy were excluded. Results: Ninety-three fibular sesamoidectomies were identified. Thirty-six sesamoidectomies (35 patients) met inclusion criteria (median follow-up 60 months). The average patient was 36-years-old with a BMI of 24.7 kg/m2 and underwent sesamoidectomy a mean 1.1 years after initial diagnosis. Median VAS scores improved 5 (6 to 1) points at final follow-up (pConclusion: Fibular sesamoidectomy effectively provides long-term pain relief for patients with sesamoiditis, fracture, nonunion, osteonecrosis, and arthritis at long-term follow-up (median 5 years). Potential long-term sequelae, including hallux flexion weakness, change in hallux alignment, and deterioration of patient satisfaction/function were not encountered.

Category: Basic Sciences/Biologics; Other Introduction/Purpose: Arthritis of the first MTP joint (hallux rigidus) is the most common form of osteoarthritis affecting the foot. Even with advances in interpositional techniques and devices, dorsal cheilectomy remains part of the treatment algorithm after failed conservative treatment of hallux rigidus. Cheilectomy aims to alleviate dorsal impingement and improve pain and function as well as range of motion. However, prospective data on outcomes following this procedure is lacking.Cryopreserved amniotic membrane-umbilical cord (AM-UC) allograft has been shown to mitigate inflammation and decrease scar formation. This has theoretical benefit for improving outcomes following cheilectomy. In the first prospective randomized and blinded cheilectomy study reported, we aimed to compare outcomes between patients undergoing cheilectomy alone and cheilectomy with cryopreserved amniotic membrane-umbilical cord allograft. Methods: After obtaining institutional board review approval, patients were randomized to cheilectomy alone (CA) or cheilectomy with cryopreserved amniotic membrane-umbilical cord (AM-UC). Surgeries were performed by fellowship trained surgeons. Cheilectomy was performed utilizing fluoroscopy to remove ˜25% dorsal articular surface. Cryopreserved AM-UC was applied to cheilectomy site and secured inside capsule with absorbable ‘stay-stitch.’Patients were followed with AOFAS MTP- IP, Foot Function Index (FFI), and VAS-pain (walking, waking, and end of day) outcomes collected preoperatively and at 6 months and 1 year postoperatively. In addition, radiographic range of motion data was collected (maximal dorsiflexion and plantarflexion) utilizing stress radiographs. Power analysis determined 27 patients per group was needed to detect a difference between AOFAS scores of 95 (AM-UC) and 85 (CA). Data was analyzed utilizing statistical analysis software (SAS v9.4). AOFAS, FFI, and VAS scores were analyzed using Wilcoxon signed-rank test. Range of motion data was analyzed using two-way ANOVA with Tukey adjusted least square means test. Results: 51 patients (26 AM-UC, 25 CA) completed the study. There were 5 bilateral surgeries in AM-UC group and 2 in CA group, totaling 31 and 27 feet respectively. Postoperatively, the AM-UC group had improved AOFAS and FFI scores at 1 year compared to CA group but there was no difference at 6 months. There was no difference between groups for VAS-pain scores (walking, waking, or end of day) at any time point, but overall VAS-pain improved in both groups from preoperative values. There was no difference seen in range of motion (total arc) between groups. In addition, changes in range of motion (total arc) in both groups from preoperative to 1 year postoperative were small. Conclusion: We present the results of the first randomized and blinded prospective study of cheilectomy surgery patients. There was improvement in pain, AOFAS MTP-IP, and FFI scores in all patients with statistically significant improvement at 1 year in AOFAS and FFI scores in the cryopreserved amniotic membrane-umbilical cord group compared to cheilectomy alone group. This was despite minimal change in range of motion in both groups. When appropriately selected, cheilectomy remains a good option for patients with symptomatic hallux rigidus. Cryopreserved amniotic membrane-umbilical cord is a potential adjuvant to cheilectomy to modulate inflammation and scarring with 1 year results showing improvements in functional outcome scores. [Table: see text]

Category: Ankle Arthritis, Arthroscopy Introduction/Purpose: Tibiotalar arthrodesis is a reliable option in the treatment of end-stage ankle arthritis and both open and arthroscopically assisted techniques are well described. When compared head to head, multiple studies have demonstrated advantages of arthroscopic arthrodesis over open fusions including decreased morbidity, and shorter hospital stays while achieving equivalent or increased rates of fusion. It is unclear why arthroscopic fusion may be favorable to open surgery, however, it is hypothesized that patient selection and soft tissue trauma may play a role. No study, however, has evaluated the extent of articular debridement afforded by each technique. The purpose of this study was to evaluate the amount of articular cartilage denuded via open arthrodesis and via arthroscopic arthrodesis with time of procedure evaluated as a secondary measure. Methods: Six matched sets of fresh frozen cadaver lower extremities were acquired for study. One limb from each set was randomly assigned to open articular debridement while the other limb was assigned to arthroscopic debridement. The duration of each procedure was timed. The tibiotalar joints were disarticulated following debridement and the talus was dissected free of all soft tissue attachments. Photographs of the weight bearing portion of the articular surfaces were then taken and residual cartilage was mapped using ImageJ software. The percentage of the joint debrided was determined by the area of denuded bone divided by the total area of the articular surface to allow for comparison across specimens. The mapping process was blinded to the type of debridement undertaken. Repeated measurements were taken to determine intra- and inter-reliability of the measurements. Student t-tests were used to compare the percentage of joint debrided and differences in time of the procedure. Results: The average percentage of cartilage debrided in the arthroscopic procedure was 88.99+11.19% for the tibial plafond and 88.84.08+5.45% for the talar dome. For the open procedure, 82.93+6.91% of the tibial plafond was debrided and 84.08+5.45% of the talar dome was debrided. There were no significant differences of the tibia or talus between the open and arthroscopic procedures (p>0.05). Inter- and intra-reliability were calculated for all measurements with r>.8. There was a significant difference in the time of the procedure with the arthroscopic debridement taking 50.17+5.57 minutes to complete while the open debridement took 30.67+5.16 minutes to complete (pConclusion: There were no differences in the percentage of articular surface debrided when comparing arthroscopic versus open arthrodesis of the ankle joint in cadaver specimens. The arthroscopic debridement took significantly longer, however this difference may be offset by a decrease in time required for wound closure. Furthermore, an increased time of debridement may be warranted if it results in decreased wound complications and pain. The results of this study support previous clinical findings that arthroscopic debridement can yield fusion rates comparable to, or better, than open debridement of the ankle joint.

Category: Midfoot/Forefoot Introduction/Purpose: Arthritis of the first MTP joint (hallux rigidus) is the most common form of osteoarthritis affecting the foot. Despite advances in interpositional techniques and devices, dorsal cheilectomy remains part of the treatment algorithm after failed conservative treatment of hallux rigidus. Dorsal cheilectomy aims to surgically remove dorsal impingement and improve pain and function as well as range of motion. However, prospective data on outcomes following this procedure is lacking. Cryopreserved umbilical cord (UC) allografts have been shown to mitigate inflammation and decrease scar formation. This has theoretical benefit for recovery and disease progression following dorsal cheilectomy. In the first prospective randomized and blinded cheilectomy trial reported, we aimed to compare outcomes of patients undergoing dorsal cheilectomy alone and dorsal cheilectomy with cryopreserved umbilical cord. Methods: After obtaining institutional board review approval, patients were randomized to cheilectomy alone(CA) or cheilectomy with cryopreserved UC. Surgeries were performed by fellowship trained surgeons. Dorsal cheilectomy was performed utilizing fluoroscopy to remove ˜25% articular surface. UC was applied to cheilectomy site and secured inside capsule with absorbable “stay-stitch.” Patients were followed for 1 year with AOFAS MTP-IP, Foot Function Index (FFI), and VAS-pain (walking, waking, and end of day) outcomes collected preoperatively and at 6 months and 1 year. In addition, radiographic range of motion data was collected (maximal dorsiflexion and plantarflexion). Power analysis determined 27 patients per group was needed to detect a significant difference between AOFAS scores of 95(UC) and 85(control). Data was analyzed utilizing statistical analysis software(SAS v9.4). AOFAS MTP-IP, FFI, and VAS scores were analyzed using Wilcoxon signed-rank test. Range of motion data was analyzed using two-way ANOVA with Tukey adjusted least square means test. Results: 51 patients (26 UC, 25 CA) completed the study. There were 5 bilateral surgeries in UC group and 2 in CA group, totaling 31 and 27 feet respectively. Post-operatively, UC group had significantly improved AOFAS and FFI scores at 1 year compared to CA group. There was no difference between groups for VAS-pain scores (walking, waking, or end of day at any time point), but overall VAS-pain improved in both groups from preoperative values. There was no difference seen in range of motion between groups. However, there was an overall improvement in maximal plantarflexion at 6 months and 1 year and maximal dorsiflexion at 6 months in both groups. Conclusion: We present the results of the first randomized and blinded prospective study of cheilectomy surgery patients. There was improvement in range of motion, pain, AOFAS, and FFI scores in all patients with statistically significant improvement at 1 year in AOFAS and FFI scores in the UC group compared to CA group. When appropriately selected, cheilectomy remains a good option for patients with symptomatic hallux rigidus. Cryopreserved umbilical cord is a potential adjuvant to cheilectomy to modulate inflammation and scarring with early 1 year results showing improvements in functional outcome scores.

Category: Midfoot/Forefoot Introduction/Purpose: Postoperative pain is often difficult to control with oral medications, often times requiring large doses of opioid analgesia. The purpose of this study is to compare the analgesic effects of an ankle block (AB) to a single shot popliteal fossa block (PFB) for patients undergoing orthopaedic forefoot procedures. Our hypothesis is that a PFB would have fewer conversions to general anesthesia, less pain medication requirements and better pain control in the immediate postoperative period. Methods: Patients having elective outpatient orthopaedic foot and ankle procedures were invited to participate. Patients with Diabetes, peripheral neuropathy, bilateral procedures, allergy to local anesthetics and procedures proximal to chopart’s joint were excluded. Patients were randomized to either an ultrasound guided AB or PFB by an anesthesiologist pre-operatively. Intraoperative conversion to general anesthesia and PACU opioid requirements were converted to mg of Morphine and then recorded. Postoperative pain was assessed using the visual analog scale (VAS) at regular time intervals until postoperative day (POD) 2. Patients rated their block experience on a 1-5 scale, with 5 being very effective. Results: A total of 167 patients participated in the study with 88 patients (53%) receiving an AB and 79 (47%) receiving a single shot PFB. No difference in the conversion to general anesthesia was seen between the two groups (12 patients in AB v. 10 in PFB, p>0.05), with the most common reason being movement without pain in both groups. PACU morphine requirements were significantly reduced in the PFB group (p=0.004). The VAS was significantly lower for the PFB patients for all time points 24 hrs after surgery (p < 0.01). Individual and combined complication rates were similar between both groups (AB 11.4% v PFB 10.1%, p>0.05). The PFB lasted longer (14.5 hrs v 20.9 hrs, p < 0.001). Both groups felt their block was effective (AB 4.79/5 v PFB 4.82/5, p=0.68) Conclusion: Regional anesthesia can be a safe and reliable adjunct to perioperative pain management with high patient satisfaction in patients undergoing elective forefoot procedures. However, better pain management and decreased opioid requirements in the immediate perioperative period was seen in patients having a popliteal fossa block when compared to an ankle block.

Category: Ankle Introduction/Purpose: Ankle fusion and total ankle arthroplasty (TAA) are common surgical procedures used to treat ankle morbidity. Little is known about the comparative rates of in-hospital complications between patients treated with ankle fusion and TAA. Methods: Data from the 2002-2013 Nationwide Inpatient Sample releases were analyzed. 4,451 TAA patients and 16,277 ankle fusion patients were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) 81.11 and 81.56 procedure codes, respectively. ICD-9-CM diagnosis codes were utilized to classify major or minor in-hospital complications. Fusion and TAA patients were exact matched on age, gender, race, hospital type, geographical region, comorbidities, and diabetes status. Minor and major in-hospital complications, including mortality were compared using chi-square and multivariate logistic regression. Results: Exact matches were identified for 4,174 (93.8%) TAA patients, with a mean age of 62.2 years. The major in-hospital complication rate for ankle fusion patients was 14.7% (615 of 4,174) versus 6.4% (269 of 4,174) for TAA patients (p< .01). The minor complication rate for ankle fusion was 3.9% (169 of 4,174) compared to 4.6% (167 of 4,174) for TAA (p=0.91). Fewer than 10 patients in either group died (p=0.59). After adjusting for case-mix, ankle fusion patients were 2.46 times more likely to experience major complications (OR: 2.46, 95% CI 2.11-2.88) than TAA patients. Conclusion: Compared to a matched cohort of ankle fusion patients, TAA patients are less likely to experience major in-hospital complications. These findings suggest that TAA may be a safer surgery than ankle fusion.

Category: Patient Reported Outcomes Introduction/Purpose: Patient-reported outcomes are advancing clinical care by improving patient satisfaction and engagement. A recent publication reported preoperative PROMIS scores to be highly predictive in selecting patients who would and would not benefit from foot and ankle (F/A) surgery. Although this publication used the data from 5 fellowship trained foot and ankle surgeons at one institution, the generalizability to other patient populations and geographic areas is unknown. This validation study assesses the pre-operative PROMIS physical function (PF) and pain interference (PI) t-scores as a predictor of post-operative success from a separate geographic area. Methods: Prospective consecutive patient visits to a multi-surgeon tertiary F/A clinic were obtained between 1/2014-11/2016 resulting in 18,565 unique visits and 1,408 new patients. Patients undergoing elective operative intervention for F/A were identified by ICD-9/10; CPT code. PROMIS PF and PI were assessed at initial and follow-up visits (minimum 6 months, mean 7.8 months). Two-way ANOVA was used to determine differences in PROMIS PF and PI from pre to post surgery with age and gender as co- variates. The distributive method of estimating a minimal clinical important difference (MCID) was used. Receiver operator curve (ROC) analysis was used to determine cut offs for achieving and failing to achieve MCID. To determine the validity of previously published cut offs, 1) they were compared to cut offs for this data set and 2) the percentage of patients achieving and failing to achieve MCID based on previous cut offs were evaluated using a chi-square analysis. Results: There were significant improvements in PROMIS PF scores (mean=6.0; sd=11.6; p41.1 versus previous study=>42) were comparable (Figure 1). Of the patients identified as unlikely to achieve MCID, a significant proportion (88.9%) failed to achieve an MCID ((Chi square=4.7; p=0.03). Of the patients identified as likely to achieve MCID, a significant proportion (84.2%) achieved MCID ((Chi square=17.8; pConclusion: PROMIS PF cut offs from published data were successful in classifying patients who would improve in PF with surgery from a different geographic area and academic institution with a broad unique array of surgical procedures, diagnoses, and a diverse patient population. This study provides validation evidence to support using the PROMIS PF as a potential tool for surgical selection to help identify patients who would benefit from surgery as well as those who would not. This can allow for appropriate utilization of healthcare dollars and manpower resources to benefit our patients.

Category: Midfoot/Forefoot Introduction/Purpose: Postoperative pain is often difficult to control with oral medications, often times requiring large doses of opioid analgesia. The purpose of this study is to compare the analgesic effects of an ankle block (AB) to a single shot popliteal fossa block (PFB) for patients undergoing orthopaedic forefoot procedures. Our hypothesis is that a PFB would have fewer conversions to general anesthesia, less pain medication requirements and better pain control in the immediate postoperative period. Methods: Patients having elective outpatient orthopaedic foot and ankle procedures were invited to participate. Patients with Diabetes, peripheral neuropathy, bilateral procedures, allergy to local anesthetics and procedures proximal to chopart’s joint were excluded. Patients were randomized to either an ultrasound guided AB or PFB by an anesthesiologist pre-operatively. Intraoperative conversion to general anesthesia and PACU opioid requirements were converted to mg of Morphine and then recorded. Postoperative pain was assessed using the visual analog scale (VAS) at regular time intervals until postoperative day (POD) 2. Patients rated their block experience on a 1-5 scale, with 5 being very effective. Results: A total of 167 patients participated in the study with 88 patients (53%) receiving an AB and 79 (47%) receiving a single shot PFB. No difference in the conversion to general anesthesia was seen between the two groups (12 patients in AB v. 10 in PFB, p>0.05), with the most common reason being movement without pain in both groups. PACU morphine requirements were significantly reduced in the PFB group (p=0.004). The VAS was significantly lower for the PFB patients for all time points 24 hrs after surgery (p < 0.01). Individual and combined complication rates were similar between both groups (AB 11.4% v PFB 10.1%, p>0.05). The PFB lasted longer (14.5 hrs v 20.9 hrs, p < 0.001). Both groups felt their block was effective (AB 4.79/5 v PFB 4.82/5, p=0.68) Conclusion: Regional anesthesia can be a safe and reliable adjunct to perioperative pain management with high patient satisfaction in patients undergoing elective forefoot procedures. However, better pain management and decreased opioid requirements in the immediate perioperative period was seen in patients having a popliteal fossa block when compared to an ankle block.

Category: Hindfoot Introduction/Purpose: Tarsal coalition can be a common underlying cause of painful flatfoot deformity in adolescent and adult patient populations. When conservative options fail, surgical resection becomes the mainstay of treatment. Adequate resection leaves a void, often filled with bone wax, fat graft or adjacent muscle or tendon. Interposition grafting is designed to provide a physical barrier between the ends of the excised segment and deter recurrence or bony overgrowth. No definitive graft choice has been shown to be superior to another. The goal of this study was to evaluate the use commercially available umbilical cord plus amniotic membrane tissues as an interposition graft with functional and radiological outcomes at one year follow-up. Methods: Retrospective review was performed of patients who had resection of tarsal coalition at our institution. Patients who had interposition of umbilical cord plus amniotic membrane tissues (Amniox Medical, Atlanta GA) at the site of the resection were included in this review. Postoperative data collection included VAS scores, Foot Function index scores, and radiographic review. Radiographic review included postoperative CT scans in all patients. Assessment of hindfoot ROM was noted on physical examination at last follow up visit. Results: Fourteen patients (8 male and 6 female; median age 28.5 years at time of evaluation) were enrolled in the study. Of these patients, 7 were calcaneonavicular coalitions and 7 were talonavicular coalitions. Average follow up occurred at 18 months (range 9-32 months). Interposition of umbilical cord plus amniotic membrane tissues was performed at the site of the resection. Median improvement in pain visual analog score (VAS) was 89.75%, with no post-operative infection or wound complications. Post-operative CT scan review demonstrated evidence of osteoarthritis in two patients (one at talonavicular and one subtalar joint). Four of 14 patients (29%) were found to have recurrence at follow-up. The median post-operative Foot Function Index score was 46 (range 30-110) and 64% of patients had improvement in range of motion. Conclusion: Based on radiological and functional outcomes at an average 19 month follow up, the interposition of umbilical cord plus amniotic membrane tissues after tarsal coalition resection appears to be a viable option in treating these patients. No adverse reactions were found and recurrence rate was noted to be 29%.

Category: Ankle Introduction/Purpose: Nearly 40% of patients undergoing ambulatory orthopedic surgery experience moderate-to-severe pain at home in spite of analgesic medication.As a result, a multimodal approach consisting of oral opioid agents and regional analgesics are recommended.Regional anesthesia is considered the primary anesthetic modality and adjunct to post-operative pain control following foot and ankle surgery, however it is not without potential complication.An ideal analgesic would provide long-term pain relief without resulting in a transiently weak or insensate limb. Extended-release liposomal bupivacaine-based analgesics as been approved by the FDA for anesthetic injection and have been shown to provide extended pain relief and decrease opioid use after bunionectomy, compared with placebo. This prospective study has been designed to evaluate the effect of surgeon applied liposomal bupivacaine on post-operative pain in patients undergoing major ankle and hindfoot surgery. Methods: 28 patients who were scheduled to undergo ankle arthrodesis, a tibiotalocalcaneal arthrodesis, hindfoot arthrodesis including, or a flatfoot procedure were enrolled prospectively. Prior to surgerypatients received a single shot popliteal block and at the conclusion of the case received 20cc of liposomal bupivacaine mixed with 10cc of normal saline injected at the surgical site. VAS pain scale at PACU admission and discharge, narcotic use, anti-emetic use, length of time in PACU and any complications were documented. A take home questionnaire documenting oral narcotic use, VAS pain scales at different intervals throughout the day, patient satisfaction with post surgical pain relief, as well as any complications for the day of surgery up to post op day 3 was completed. Patient satisfaction with post surgical pain relief and complications were also recorded at the patient’s first post- operative visit. Results: 28 total patients were enrolled ( Average age 55.6, Range 20-80). Post operatively 18/28 patients (64%) rated their satisfaction as >4 (on a five-point scale). Greatest increase in VAS pain scores was seen from DOS to POD1 at 4:00 PM. Satisfaction with pain control was most strongly associated on POD3 at midday with a negative correlation (R= -0.68). Patients took the least amount of pain medications on DOS (28.83 mg) with an average total morphine equivalents consumed from DOS to POD3 of 236.68 mg. There were no complications associated with application of liposomal bupivacaine, this included postoperative wound complications, skin necrosis and persistent paresthesias. Conclusion: Extended-release liposomal bupivacaine-based analgesics when utilizedduring major ankle or hindfoot surgery did not provide complete pain relief as demonstrated by the sharp rise in pain scores seen after the resolution of the analgesic effect of the popliteal block. However it seemed that the effect of liposomal bupivacaine did contribute to lower pain scores at the conclusion of the period of efficacy, as there was no further rise in pain complaints after POD1 and lowest pain scores were seen on POD3. Application of liposomal bupivacaine appears to be safe without an increase in complications, wound problems or adverse reactions.