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

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

Background: It is not known how peroneal tendon exploration influences results after modified Broström for lateral ankle instability. We propose peroneal exploration at the time of modified Broström will have similar outcomes as no peroneal exploration. Methods: A retrospective analysis was performed of patients undergoing modified Broström with and without peroneal exploration. Foot and Ankle Outcome scores and data regarding military retention were gathered and compared. Results: Seventeen patients were identified in the modified Broström only cohort and 24 in the peroneal exploration cohort. Patients had mean follow-up of 5 years in both cohorts. The mean FAOS in the modified Broström only cohort was 68 and 72 in the cohort with peroneal exploration (P = .541). When each FAOS subcategory was analyzed, no difference was identified in any subcategory. Eight of 17 patients (47%) in the modified Broström only cohort remained active duty compared with 8 of 24 patients (33%) in the modified Broström with peroneal exploration cohort (P = .518). One patient medically discharged in the modified Broström only cohort versus 6 in peroneal exploration cohort (P = .109). Overall satisfaction with the procedure was 12 of 17 (71%) in the modified Broström only cohort and 19 of 24 (79%) in the peroneal exploration cohort (P = .529). Conclusions: No significant difference was identified between patients undergoing modified Broström alone or modified Broström with peroneal exploration. There was no significant difference in return to duty, medical discharge or patient satisfaction. Levels of Evidence: Level III: retrospective case-control study with prospectively collected data

A retrospective review of consecutive patients diagnosed with insertional Achilles tendinopathy (IAT) was performed. Outcomes included Visual Analog Scale (VAS) pain scores, return to run rates, and return to military duty rates. Our data analysis included 113 patients; 58 (55%) patients required surgery. Mean duration of follow-up was 42 months (range, 12-143). Mean age at the time of surgery was 37.2 years (range, 21-54). VAS scores significantly improved from 5.4 at the preoperative visit to 2.9 at 24 months. There was no significant improvement in VAS scores after the 3-month postoperative visit. Mean return to run time was 9 months (range, 4.5-16). At 1 year, 80% (46/58) of patients returned to military duty. Complications requiring return to the operating room were observed in 6 patients (9%). The high rate of return to duty and significant improvement in pain scores demonstrate that the surgical management of IAT is a viable treatment option for patients who could not otherwise remain on active duty. With that said, the complication rate of 27% is high. Patients and providers should consider the risks, benefits, and duration of therapy during their shared decision-making process. Level of Evidence: Level IV

Background: This study is a retrospective review of prospectively gathered data determining the postoperative outcomes of patients who underwent operative treatment to address chronic syndesmotic instability. Methods: The cohort is composed of 19 individuals who elected to undergo operative treatment of chronic syndesmotic instability. The operative repair consisted of arthroscopic debridement in all cases with reduction and suture button fixation of those patients who had greater than 4 mm of syndesmotic diastasis on arthroscopic evaluation. All patients had a minimum of 24 months follow-up. This study retrospectively examined the prospectively gathered preoperative and postoperative outcome scores to include a Visual Analog Scale (VAS) pain score and an American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. In addition, patients were questioned on their ability to return to their preinjury level of activity and their ability to continue running sports. Fourteen patients returned their postoperative surveys. Results: Mean AOFAS scores improved significantly from 48 to 82.7 ( P = .014). Mean VAS scores improved from 6.1 to 1.0 ( P = .002). Overall, 86% (12/14) of patients were able to return to running and 79% (11/14) of patients were able to return to their preinjury level of sport. Preoperative and postoperative weight-bearing ankle radiographs were reviewed to evaluate the tibiofibular clear space and overlap. The clear space measured on anteroposterior (AP) radiographs decreased from 5.4 mm to 4.6 mm ( P = .005), the clear space evaluated on the mortise radiograph decreased from 4.5 mm to 3.6 mm ( P = .006), and the overlap measured on the AP radiograph increased from 5.7 mm to 6.9 mm ( P = .019). All radiographs were measured by a board-certified musculoskeletal radiologist. Conclusion: This study presents a treatment method that can be instituted at the time of diagnosis for syndesmotic injuries with greater than 4 mm of diastasis that were treated with debridement and stabilization. The results of this treatment technique are promising, with significant improvements in subjective outcome scores and a high rate of return to running sports. Level of Evidence: Level IV, retrospective case series.

Background: Osteochondral lesions of the talus (OLTs) are common injuries in young, active patients. Microfracture is an effective treatment for lesions less than 150 mm2 in size. Most commonly employed postoperative protocols involve delaying weightbearing for 6 to 8 weeks (DWB), though one study suggests that early weightbearing (EWB) may not be detrimental to patient outcomes. The goal of this research is to compare outcomes following EWB and DWB protocols after microfracture for OLTs. Methods: We performed a prospective, randomized, multicenter clinical trial of subjects with unilateral, primary, unifocal OLTs treated with microfracture. Thirty-eight subjects were randomized into EWB (18 subjects) and DWB (20 subjects) at their first postsurgical visit. The EWB group began unrestricted WB at that time, whereas the DWB group were instructed to remain strictly nonweightbearing for an additional 4 weeks. Primary outcome measures were the American Academy of Orthopaedic Surgery (AAOS) Foot and Ankle score and numeric rating scale (NRS) pain score. Results: The EWB group demonstrated significant improvement in AAOS Foot and Ankle Questionnaire scores at the 6-week follow-up appointment as compared to the DWB group (83.1 ± 13.5 vs 68.7 ± 15.8, P = .017). Following this point, there were no significant differences in AAOS scores between groups. At no point were NRS pain scores significantly different between the groups. Conclusions: EWB after microfracture for OLTs was associated with improved AAOS scores in the short term. Thereafter and through 2 years’ follow-up, no statistically significant differences were seen between EWB and DWB groups. Level of Evidence: Level II, prospective randomized trial.

Background: The treatment of osteochondral lesions of the talus (OLTs) with a juvenile cartilage allograft is a relatively new procedure. Although other treatment options exist for large OLTs, the potential advantage of a particulated juvenile allograft is the ability to perform the procedure arthroscopically or through a minimal approach. No previous studies have looked at the results of an arthroscopic approach, nor have any compared an arthroscopic technique with an open approach. Purpose: To compare the outcomes of an arthroscopic transfer technique with the previously published open technique. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 34 patients (mean age, 33 years) underwent treatment of talar cartilage lesions with a DeNovo NT Natural Tissue Graft. Of these treatments, 20 were performed arthroscopically and 14 were performed with open arthrotomy. There was no statistically significant difference between the groups with respect to age, lesion width, lesion depth, lesion length, or operative time. The mean lesion area was 107 mm2. The scores from 6 different validated outcome measures were recorded for patients in each group preoperatively and subsequently at 6 months, 1 year, 18 months, and 2 years. Results: Comparing outcome scores at each time point to baseline, there were no statistically significant postoperative differences found between open and arthroscopic approaches with regard to the visual analog scale (VAS) for pain ( P = .09), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale ( P = .17), Foot and Ankle Ability Measure (FAAM)–sports subscale ( P = .73), Short Form–12 (SF-12) physical health summary ( P = .85), SF-12 mental health summary ( P = .91), or FAAM–activities of daily living subscale ( P = .76). Conclusion: The treatment of talar articular cartilage lesions with a DeNovo NT Natural Tissue Graft demonstrated no significant differences in outcome at 2 years regardless of whether the graft was inserted with an arthroscopic or open technique. Clinical Relevance: Our analysis demonstrated no significant difference between an arthroscopic versus open approach at any time point for the first 2 years after implantation of a juvenile particulated cartilage allograft for large OLTs. With that said, both groups demonstrated improvement from baseline. These findings indicate that surgeons with different levels of comfort utilizing arthroscopic techniques can offer this treatment modality to their patients without altering their planned surgical approach. In addition, this will be particularly helpful in counseling patients for surgery when the extent of the defect will be evaluated intraoperatively. Patients can be counseled that they will likely have the same incisions regardless of whether they require debridement, microfracture, or implantation of a particulated allograft.

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

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

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

Category: Ankle Introduction/Purpose: Ankle sprains are a common sports related injury and typically treated conservatively. Chronic ankle instability, however, may require surgical management when non-operative measures fail. The Brostrom procedure with Gould modification is the most frequently employed operation for chronic ankle instability with a record of good to excellent treatment outcomes. The purpose of our study was to evaluate the clinical outcomes of this procedure in an active duty population. Methods: A retrospective review of our electronic surgery records for a cohort of active duty patients aged 18-45 who were indicated for operative treatment of chronic ankle instability and who underwent surgical repair consisting of a standard Brostrom procedure with Gould modification at Madigan Army Medical Center between January 1,2010 through April 30, 2014 was performed. All patients were treated by a single surgeon and had a minimum of one year follow-up. The electronic medical record was reviewed for each patient to determine their ability to remain on active duty status as well as their permanent lower extremity activity restrictions. Results: 127 total patients who met the inclusion criteria underwent Brostrom procedures with Gould modification during the study period. 23 out of 127 (18.1%) underwent Medical Evaluation Board (MEB) and separation from active duty for reasons related to their ankle. Another 11 patients underwent military separation for reasons unrelated to their ankle. 67 patients (52.7%) currently have permanent lower extremity profiles in the electronic record. 38 patients with permanent profiles have been able to meet retention standards and remain on active duty status. Of the 93 patients who were able to remain on active duty status, only 2 individuals changed their military occupational specialty (MOS). The remainder of patients remain on active duty status in their current MOS, completed their active duty obligation or reached planned retirement. Conclusion: Chronic ankle instability in active duty service members can be severely limiting. Brostrom procedure with Gould modification can provide significant improvement in symptoms and allow patients to remain on active duty status. However, in our high demand population approximately 50% of patients required some form of permanent activity restriction with nearly 20% requiring military separation. This is important information when counseling an active patient population about the expectations from surgical intervention for chronic ankle instability.