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Category: Ankle; Ankle Arthritis; Trauma Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is a routinely utilized salvage procedure that treats patients with severe talar and subtalar joint disease. Unfortunately, nonunion is a relatively common complication postoperatively which can increase risks and costs for patients. The goal of this study is to review the literature to identify risk factors for nonunion post TTC arthrodesis and stratify them based on strength of evidence. A meta-analysis will be performed on risk factors when appropriate to establish values based on pre-existing studies. Methods: Five databases (CINAHL, Cochrane Library, EMBASE, MEDLINE, and Web of Science) were searched from inception to May 17th, 2020. Two independent reviewers screened abstracts and full-text articles for those that included risk factors predictive of nonunion for TTC arthrodesis. Any disagreements were discussed between the two reviewers and a third reviewer served as the ultimate decision maker if a consensus could not be reached. Relevant data regarding participants’ characteristics, study design, follow-up time, statistical tests and identified risk factors were extracted from the included studies. The two reviewers independently appraised the methodological quality of the studies using the Quality In Prognosis Studies tool. Those risk factors described in multiple studies were included in the meta-analysis. Random effects meta-analyses were summarized as forest plots of individual study and pooled random effect results. Results were reported as odds ratios (OR) with 95% confidence intervals (CI). Results: Database search identified 428 articles, of which 113 were screened for full text. Eight studies involving 607 patients were included and 33 potential risk factors for nonunion were identified. Risk factors were stratified into demographic, preoperative, intraoperative and postoperative. Results of the meta-analysis established two significant risk factors for nonunion following TTC arthrodesis. Strong evidence supports that prior neurological deficits, such as Charcot neuroarthropathy and diabetes neuropathy, are associated with nonunion following surgery (OR: 2.86, 95% CI: 1.56 - 5.23). There was moderate evidence to suggest that preoperative infection was predictive for nonunion (OR: 3.99, 95% CI: 1.26 - 12.68). Although our meta- analysis did not find smoking (OR: 1.75, 95% CI: 0.90 - 3.38) or diabetes (OR: 2.28, 95% CI: 0.98 - 5.34) to be significant risk factors, multiple high quality studies support these as comorbidities that increase the likelihood of nonunion. Conclusion: TTC arthrodesis can be an effective salvage procedure but is associated with high nonunion rates. The results of our meta-analysis suggest that prior neurological deficits, such as Charcot neuroarthropathy or diabetes neuropathy, have strong evidence for failure to achieve union. Although our meta-analysis did not find other statistically significant risk factors, the findings of individual studies in our review suggest that diabetes mellitus and smoking are both factors which can lead to failure of fusion. Surgeons should be cognizant of these risks when performing TTC arthrodesis and carefully monitor patients with the aforementioned comorbidities to achieve successful results.

Category: Trauma Introduction/Purpose: Management of basilar 5th metatarsal fractures remains a controversial topic in orthopaedic surgery. Both operative and non-operative approaches have been described as potentially effective treatment strategies in the clinical setting. Non-operative approach is associated with higher non-union rates and longer times to union; however, operative intervention exposes patients to surgical risks. This confusion has led to non-standardized treatment recommendations for basilar 5th metatarsal fractures. This study was therefore designed to analyze whether or not orthopaedic trainees recommend treatment that differs from the treatments proposed by orthopaedic foot and ankle experts. Our hypothesis is that PGY-level does not improve concordance of treatment recommendation compared with orthopaedic foot and ankle specialists as a reflection of the varied treatment algorithms trainees are exposed to during residency training. Methods: An online survey containing 20 operative cases of proximal 5th metatarsal fractures were distributed to 92 orthopaedic residents in two ACGME-accredited programs. For each case, residents were provided relevant weight-bearing radiographs, patient’s age and gender, and then two questions regarding treatment recommendations. Residents were first asked to decide between operative and non-operative treatment. When the choice was operative, the second question focused on identifying operative reasoning (age, fracture pattern/location, or both). If the respondent chose non-operative treatment, however, the second question instead asked about a recommended weight-bearing status (weight-bearing as tolerated vs. non-weight-bearing). Resident’s recommended treatment was then matched against ultimate treatment by orthopaedic foot and ankle experts, which are all operative. This association was termed the rate of concordant treatment. Pearson’s rho is calculated for associations between the rate of concordant treatment with PGY and trainee foot and ankle experience. Fleiss’ kappa was used to assess the inter-observer agreement. Results: Seventy-two residents returned the survey. The overall concordance rate was 28.33% (32.06% for PGY-1, 32.86% for PGY-2, 31.79% for PGY-3, 19.67% for PGY-4, and 24.58% for PGY-5) with no correlation between agreement rate and PGY-years (Spearman’s r = -0.214, p=0.071). The overall concordance rate for treatment of Jones’ fractures was 34.44% (29.41% for PGY-1, 34.29% for PGY-2, 42.86% for PGY-3, 28% for PGY-4, and 40% for PGY-5) with no correlation between agreement rate and PGY-years (Spearman’s r = 0.073 p=0.540). No difference in agreement rate was observed between residents who had completed their foot and ankle rotation versus those who had not (24.71% vs. 31.58%, p=0.126). There was a slight inter-observer agreement in recommending operative treatment among all residents (? = 0.091, 95% CI 0.055-0.143). Conclusion: Our data demonstrated that there was no significant concordance between resident level in training regarding 5th MT fracture treatment decisions, nor between residents and subspecialty trained foot and ankle surgeons. The inter-observer agreement was in fact minimal amongst residents, suggesting that resident treatment recommendations reflect marked variability in clinical exposure and treatment decision making as trainees. Increased rotations with foot and ankle fellowship-trained surgeons throughout residency may be desirable to improve the quality of residency training.