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Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Primary arthrodesis of Lisfranc and midfoot fracture-dislocations is a reliable treatment option, yet concerns remain about nonunion and dorsiflexion malunion. The use of a new generation of nitinol staples has proliferated in midfoot arthrodesis. The purpose of this study is to examine the use of nitinol staples in primary arthrodesis of acute Lisfranc fracture-dislocations, comparing outcomes to traditional plate and screw fixation. The primary hypothesis is that nonunion rates are lower with constructs that include nitinol staples than those with plates and screws alone. Secondary hypotheses are: 1. Total operative and tourniquet time are shorter using nitinol staples. 2. Reoperation rates are lower using nitinol staples. 3. Dorsiflexion malunion rates are lower using nitinol staples. 4. Functional outcome scores will indicate comparable post-arthrodesis disability. Methods: Midfoot fracture-dislocations treated with primary arthrodesis by seven foot and ankle orthopaedic surgeons at a tertiary referral center from 1/1/2012 to 8/1/2021 were reviewed. Patients with open fractures, fractures managed with external fixation, Charcot arthropathy, neuropathy, previous midfoot surgery, or concomitant hindfoot/ankle fractures were excluded. Of the 160 eligible patients, 121 met the required 4-month minimum radiographic follow-up. Preoperative imaging and operative records were reviewed, evaluating for associated metatarsal and cuneiform fractures, operative and tourniquet time, joints included, and fixation construct. Patients and individual joints (303 total) were categorized as either staples alone (47 patients), staples plus plates and screws (hybrid) (47), or plates and screws alone (35). Postoperative radiographs at last follow-up were then analyzed for union and malunion at each joint fused. CT scans were used, when available (41 patients), to assess for union. Medical records were reviewed for postoperative complications. FAAM, VR-12, and NPRS were collected. Results: When assessed at the individual joint level, the nonunion rate was higher (8%, 9/101) among joints fixed with plate and screw constructs than with hybrid (2.4%, 1/41) or staple only constructs (1.3%, 2/152) (P = 0.015). Of the 12 nonunions in the study, 6 had either a metatarsal or cuneiform fracture. Median OR and tourniquet time were both shorter for hybrid (92 & 83 minutes) and staple only (67 & 63 minutes) constructs than plate and screw only fixation (107 & 96 minutes) (P = 0.0002 & 0.0009). There were 17 (14%) reoperations including 10 hardware removals, 3 nonunion revisions, and 1 malunion revision. There was no difference in reoperation, malunion (14 total, 12%), or patient reported outcome measure between fixation types. Conclusion: Nitinol staples are effective in achieving bony fusion when used alone or in combination with plates and screws. With lower rates of nonunion and shorter tourniquet and operative time compared to traditional plate and screw fixation, their use should be considered for primary arthrodesis of Lisfranc and midfoot fracture-dislocations. Further studies are needed to determine if staples decrease the risk for dorsiflexion malunion and improve patient reported outcomes.

Category: Ankle; Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) is a common treatment for ankle arthritis, but many challenges exist when attempting to correct and balance coronal plane deformity. Varus ankle arthritis tends to be stiffer and often leads to a more stable TAA, but valgus ankle arthritis tends to have more laxity especially in the setting of a progressive collapsing foot deformity. Failure to achieve appropriate deformity correction and soft tissue balance can result in recurrence of the deformity with valgus drift. The purpose of this study was to evaluate the longitudinal coronal plane alignment as well as outcomes in patients treated with TAA with resultant valgus drift. Methods: 98 patients who underwent TAA for valgus ankle arthritis were identified through a prospectively collected database. All patients had a minimum of 2 year follow-up. The tibiotalar angle was measured on preoperative radiographs to include patients with valgus ankle arthritis five degrees or greater. Radiographic alignment in the postoperative period was compared to the alignment at final follow-up. Complications, failures, revisions, and reoperations were recorded. Patients were categorized by severity of preoperative valgus deformity into 3 groups: 5-10 degrees, 11-20 degrees, and greater than 20 degrees. Valgus drift was defined as greater than 5 degrees of valgus shift at final follow-up when compared to the postoperative alignment. Median follow- up was 49.2 (37.2-68.3 inner quartile) months. Results: Patients with greater than 20 degrees of preoperative valgus deformity had an initial postoperative alignment of 2 degrees of valgus and ended with an average of 5.5 degrees of valgus at final follow-up. The groups of patients with 5-10 degrees as well as 11-20 degrees of valgus were corrected to neutral (0 degrees) in the initial post-op period and ended with a final postoperative valgus alignment of 2.5 degrees and 2 degrees, respectively. Overall, 16 patients (18%) had greater than 5 degrees of valgus drift after their surgery, of which 2 failed and were revised (13%) and 5 had reoperations (31%). Conclusion: All groups of preoperative valgus deformity severity had some valgus shift overall at final follow-up. The most severe preoperative valgus deformities were least likely to be corrected to neutral with the index procedure and also on average drifted back to over 5 degrees of valgus. Patients with valgus drift after TAA can still have a good result but should be monitored closely. Overall, they did not have a high failure rate. This study emphasizes the necessity of correcting both the ankle and foot deformity when performing TAA for valgus ankle arthritis in order to maintain deformity correction.

Category: Ankle; Ankle Arthritis Introduction/Purpose: Coronal plane deformity is an important consideration in the treatment of ankle arthritis, and valgus alignment presents its own unique challenges. Ankle fusions were previously considered the gold standard, but advancements in total ankle arthroplasty (TAA) implant design and surgical technique have increased its popularity in the treatment of even large coronal plane deformities. Although many studies have compared fusion to arthroplasty, no studies have directly compared these two treatments in the treatment of valgus ankle arthritis. The purpose of this study was to evaluate and compare clinical and radiographic outcomes of TAA to ankle fusion in the treatment of valgus ankle arthritis. Methods: 137 patients with valgus ankle arthritis who underwent either TAA or ankle fusion were identified through a prospectively collected database. Minimum clinic follow-up was two years. Preoperative radiographs were measured for tibiotalar angle to include patients with valgus ankle arthritis five degrees or greater. Axial alignment views were also analyzed for preoperative hindfoot alignment. Patients who underwent tibiotalocalcaneal fusion or had previous ankle corrective osteotomy were excluded. Complications, failures, revisions, and reoperations were recorded. Failures were defined by explant of a metal component. Reoperations included any additional related ankle/hindfoot surgery including subtalar fusion. Patients were categorized by severity of preoperative valgus deformity into 4 groups: 5-10 degrees, 11-15 degrees, 16-20 degrees, and greater than 20 degrees. Outcomes were compared across these groups between TAA and ankle fusion. There were 98 patients who underwent TAA and 39 patients who underwent ankle fusion. Median follow-up was 50.4 months (inner quartile 37.4-74.1). Results: Patients who underwent TAA with greater than 15 degrees of preoperative valgus deformity had higher rates of failures, revisions, and reoperations compared to those who underwent fusion with the same deformity severity. Overall, 44% of patients (60/137) had major or minor complications. There were 6 failures (6%) in the TAA cohort and 5 failures (13%) in the fusion cohort. 36% of fusions (14/39) underwent reoperation which was a higher rate compared to 18% of TAAs (18/98) (p=0.03). Combined fusion and TAR cohorts had less complications, failures/revisions, and reoperation rates as the severity of deformity increased (p

Category: Midfoot/Forefoot; Diabetes; Other Introduction/Purpose: Non-traumatic lower extremity amputations (LEA), especially those performed in dysvascular and diabetic patients, are known to have poor long-term prognosis. Perioperative mortality has been reported at between 4 and 10%, and the 1 and 5 year mortality rates range between 22-33% and 39-69%, respectively. While poor outcomes in these patients have been described, there is no consensus as to the predictors of mortality. The purpose of the study is to determine the percentage of patients who had a complication following transmetatarsal amputation (TMA) and identify associated risk factors for complications and mortality. Methods: We queried our institution’s administrative database to identify 247 TMA procedures performed in 229 patients between January, 2002 and December, 2016. Electronic health records were reviewed to document complications defined as reoperation, amputation and mortality. Mortality was also verified using the National Death Index. Additionally, we recorded risk factors including diabetes, A1c level, end stage renal disease (ESRD), cardiovascular disease (CVD), peripheral vascular disease (PVD), history of revascularization, contralateral amputation, and neuropathy. The majority of the study patients were males (157, 69%) and the average age was 57 years (range 24-91). The median BMI was 28 (range 16-58) and 29% of the study patients were obese with a BMI ≥ 30. Fishers Exact tests were used to compare categorical variables. Kruskal-Wallis and Independent T-tests were used to compare numeric data. All data were analyzed using SAS/STAT software version 9.4 (Carey, NC) and a 0.05 level of significance was defined apriori. Results: The conversion rate to below (BKA) or above knee amputation (AKA) was 26% (64 of 247). Males (p=.0274), diabetics (p=.0139), patients in ESRD (p=.019), and patients with a history of CVD (p=.0247) or perioperative revascularization (p=.022) were more likely to undergo further amputation following an index TMA. BMI was significantly higher in patients requiring BKA/AKA (p=.0305). There were no significant differences in age (p=.2723) or A1c levels (p=.4219). The overall mortality rate was 35% (84 of 229). Diabetes (p=.0272), ESRD (p=.0031), history of CVD (p

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.

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: 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.