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Category: Hindfoot; Other Introduction/Purpose: Subtalar fusions have become the standard of care for a variety of pathologies of the hindfoot that have failed non-operative management, both as an isolated procedure or combined as a double or triple arthrodesis. Multiple fixation methods exist for this procedure, although newer technology has introduced the ability for sustained dynamic compression via the use of nitinol. The purpose of this work was to assess a new internal compressing screw on subtalar arthrodesis. Methods: We examined 15 patients who underwent subtalar fusion with a single screw utilizing an internal nitinol device. Serial radiographs were reviewed for migration of the nitinol implant over time, spanning from 3 months to up to a year post operatively. We also assessed for post-operative complications including nonunion, infection, and pulmonary embolism. Results: There was an average of 63% of recovered compression, ranging from 26%-88%. The majority of the recovery was within the first three months post operatively. Our follow up averaged 9.5 months (range, 3 months to 1 year 8 months). There was one patient with a nonunion of the subtalar joint and one patient who suffered a post-operative pulmonary embolus. There were no infections requiring surgical treatment. Conclusion: The nitinol element provides sustained compression to combat bone resorption or settling. While the majority of this is seen in the first three months, it is still possible to have more recovery beyond this time. This small case series demonstrates a low complication rate and high union rate with utilization of this implant. Future studies are needed to compare this fixation method to traditional screws and review differences in union rates and complications. Xrays taken at time of surgery, at 3 months post-op, and 1 year post-op of a 7×80mm screw with an available 3.0mm of post-operative compression. The implant had compressed nearly 50% at 3 months with additional compression noted between 3 months to 1 year post implantation.

Category: Basic Sciences/Biologics; Ankle Arthritis Introduction/Purpose: Arthrodesis stands as the primary method for treating advanced osteoarthritis in the foot and ankle [1]. However, a significant hurdle in this procedure is non-union occurrence, emphasizing the need for adjuncts to enhance osteogenesis and ensure successful fusion. Platelet-Derived Growth Factor (PDGF) emerges as the only clinically approved bone graft substitute for ankle and hindfoot fusion. Bone marrow stimulation, crucial for recruiting cells to aid healing in arthrodesis, is a standard step in all fusions. While preclinical studies on PDGF have mainly focused on human cell lines, the in vitro impact of PDGF on marrow-derived cells, crucial for arthrodesis sites, remains unexplored. This study aims to assess the osteogenic potential of PDGF on heterogeneous marrow-derived cells in both 2D and 3D environments. Methods: Marrow-derived cells (MDCs) from young bovine femoral condyle were utilized without sorting or filtering, to maintain heterogeneity. For 2D assays, MDCs were plated at 10,000 cells per well and cultured in osteogenic media. Both alizarin staining and alkaline phosphatase activity were assessed at 14 days. For 3D assays, we cultured MDCs in fibrin gels at 2M/mL. in osteogenic media for 28 days. For 3D analysis, micro CT and alizarin red staining were performed on fibrin gels. Results: In 2D in vitro analysis, PDGF demonstrated significant increase in alizarin red staining and ALP activity [Figure 1A, 1B]. In 3D analysis, PDGF showed no significant increase in and has trended toward a decrease in alizarin red staining and in micro CT [Figure 1C, 1D]. Conclusion: While many studies have examined the impact of PDGF on human cell lines, this is the first work to analyze the effects of PDGF in a representative distal extremity fusion environment. In our current study, in 2D PDGF demonstrates significant osteoinducton, while in 3D, no increase is seen and a trend towards decreased osteogenic function was observed. Our findings reveal that the differential effects of PDGF in 2D and 3D which may vary depending on the surrounding environment. This work highlights the need for further studies to fully grasp how PDGF functions in an arthrodesis.

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Early detection of Lisfranc instability is critical for improving clinical outcomes, but more subtle instability can be difficult to diagnose. Weightbearing computed tomography (WBCT) provides a unique opportunity to evaluate such injuries in three dimensions (3D) while under physiologic load. This study aimed to assess the utility of one-dimensional, two-dimensional, and three-dimensional measurements on weight-bearing computed tomography (WBCT) to diagnose subtle instability in isolated ligamentous Lisfranc injuries. Methods: Ten cadaveric specimens underwent WBCT evaluation of the Lisfranc joint complex in the intact state and subsequently with sequential sectioning of the dorsal Lisfranc ligament (DLL) and interosseous Lisfranc ligament (IOL) to create subtle Lisfranc instability, and finally after transectioning of plantar Lisfranc ligament (PLL) to create complete Lisfranc instability. Measurements performed on WBCT images included: (1) Lisfranc joint (medial cuneiform-base of second metatarsal) volume, (2) Lisfranc joint area, (3) C1-C2 intercuneiform area, (4) C1-M2 distance, (5) C1-C2 distance, (6) M1-M2 distance, (7) first tarsometatarsal (TMT1) alignment, (8) second tarsometatarsal (TMT2) alignment, (9) TMT1 dorsal step off distance, and (10) TMT2 dorsal step-off distance. Results: In subtle Lisfranc injury state, Lisfranc joint volume and area, C1-M2 distance and M1-M2 distance measurements on WBCT significantly increased, when compared with the intact state (P values 0.001 to 0.014). Additionally, Lisfranc joint volume and area, C1-M2 distance, M1-M2 distance, TMT2 alignment and TMT2 dorsal step off measurements were increased in complete Lisfranc injury state. Of all measurements, C1-M2 had the largest area under the curve (AUC) of 0.96 (sensitivity = 90%; specificity = 90%), followed by Lisfranc volume (AUC = 0.90; sensitivity = 80%; specificity = 80%) and Lisfranc area (AUC = 0.89; sensitivity = 80%; specificity = 100%). Conclusion: WBCT scan can accurately diagnose subtle Lisfranc instability. Among the measurements, C1-M2 distance exhibited the highest level of accuracy. The 2D Joint Area and 3D Joint Volume also proved to be accurate, with 3D volume measurements of the Lisfranc joint displaying the most significant absolute difference between the intact state and increasing severity of Lisfranc instability. These findings suggest that 2D Joint Area and 3D Joint Volume have potential as supplementary measurements to more accurately diagnose subtle Lisfranc injuries.

Category: Basic Sciences/Biologics; Ankle Introduction/Purpose: One of the most common procedures for treating end-stage osteoarthritis of the foot and ankle is arthrodesis [1]. However, a significant complication with arthrodesis is the development of non-union. Thus, identification of adjuvants to enhance osteogenesis are paramount to fusion success. One possible molecule is the immunosuppressant FK506 (Tacrolimus). Previous research [2] demonstrated FK506 as a stand-alone small molecule capable of initiating osteogenesis and bone formation. The purpose of this study was to evaluate the osteogenic potential of FK506 alone and in combination with other bioactive factors to provide a foundation for future in vivo and clinical applications. Methods: Marrow-derived cells (MDCs) were isolated from juvenile bovine femoral condyles, to represent cells present at the ankle fusion site. MDCs (P1) were seeded at 50k cells per well (24-well plate). After 14 days, the wells were stained for calcium deposits using Alizarin Red S, and imaged with brightfield microscopy to visualize calcium deposits. Drug combinations of potentially osteogenic small molecules were tested (simvastatin, platelet derived growth factor [PDGF], tamoxifen, triiodothyronine). The highest alizarin red absorbance values were used to choose the best drug combination. These combinations were further evaluated for gene expression by RT-qPCR [Osteocalcin (OCN), Osteopontin (OPN), and Bone Sialoprotein (IBSP)]. To simulate a 3D osteogenic environment, cells were seeded into fibrin gels (to mimic the “fusion clot”), cultured for 14 days, and sectioned/stained with Alizarin red. Results: FK506 and PDGF produced the highest level of calcium staining compared to other bioactive factors, highlighted via heatmap of alizarin red absorbance values (Figure 1A). Compared to the control, FK506, PDGF, and the combination of both all resulted in enhanced alizarin red staining (Figure 1A/B). Overall, FK506 exhibited an increased expression across all genes. PDGF and the combination of FK506 and PDGF had a more varied expression within the genes queried (Figure 1C). Finally, in a fibrin gel system, variability was observed between gels of the same group. Displaying the best, middle, and worst sections give a comprehensive view of the explained variability. Across the sections, the FK506-PDGF combination showed the densest mineralization, highlighted by the dark maroon regions of the section (Figure 1D). Conclusion: This study confirms that FK506 demonstrates osteogenesis within marrow-derived cells (representative of a fusion site). The combination of FK506 to PDGF may enhance PDGF’s known healing potential within arthrodesis applications. This work provides the foundation for future clinical applications of FK506. Ongoing studies are focused on the effect of FK506, and potentially in combination with PDGF, in an rabbit ankle fusion model to evaluate efficacy and bone formation. The authors thank the American Orthopaedic Foot and Ankle Society (AOFAS) and Emory Department of Orthopaedics for their support and funding. References: [1] Park 2022. [2] Sangadala 2019

Category: Ankle; Other Introduction/Purpose: The rising prevalence of obesity may drastically affect arthroplasty eligibility as Body Mass Index (BMI) remains a commonly used screening criterion. As obesity disproportionately affects Black adults and women, using such a criterion without scientific merit may lead to inequitable access to care. Particularly in total ankle arthroplasty – where weight has been previously attributed to aseptic implant failure – close examination of screening criteria is imperative. The purpose of this study was to evaluate for disparities in patient eligibility for total ankle arthroplasty (TAA) based on race, ethnicity, gender, and age by applying commonly used BMI cutoffs to the American College of Surgeons National Surgical Quality Improvement Program (ACS- NSQIP) database. Methods: Patients in the ACS-NSQIP database who underwent TAA from 2011- 2020 were retrospectively reviewed. BMI cutoffs of < 35, < 40, < 45, and < 50 were applied to the cohort to model the rate of surgical eligibility for TAA. Patients were deemed eligible for surgery if their BMI was less than each modeled BMI cutoff and ineligible if their BMI was equal to or greater than the cutoff. The relative eligibility rate, which was defined as the rate of eligibility minus the rate of ineligibility, was examined for each BMI cutoff. The cohorts were then stratified by race, ethnicity, gender, and age. Independent T-tests, Chi-squared tests, and Fisher’s exact tests were performed to compare differences at an α = 0.05. Results: 65.1% of all TAA patients were included after applying the exclusion criteria. Black patients had disproportionately lower rates of eligibility at the most stringent BMI cutoff of < 35kg/m² (p=0.004). Hispanic patients had generally lower rates of eligibility across all BMI cutoffs. In contrast, Asian American and Pacific Islander patients had higher rates of eligibility at the BMI cutoffs of < 35kg/m² (p=0.033) and < 40kg/m² (p=0.039), and White non-Hispanic patients had higher rates of eligibility across all BMI cutoffs. Females had lower eligibility rates across all BMI cutoffs. Ineligible patients were also younger compared to eligible patients across all BMI cutoffs. Conclusion: Stringent BMI cutoffs may disproportionately disqualify Black, female, and younger patients from receiving total ankle arthroplasty. The data suggests that current eligibility criteria may exacerbate disparity in access to TAA for historically vulnerable populations. While eligibility criteria exist to protect patients from interventions that put them at unacceptable risk, these criteria are not uniformly distributed across populations. Given these data and the rising obesity epidemic, additional highly powered studies are needed to determine the safety of TAA in patients with BMI 35-40 to ensure at-risk populations are not disproportionately excluded from mobility-improving surgery.

Category: Midfoot/Forefoot; Ankle Introduction/Purpose: Venous thromboembolism (VTE) after foot and ankle surgery is a significant concern for patients and surgeons. The absence of guidelines for thromboprophylaxis in elective procedures underscores the importance of understanding risk factors. This study aimed to identify key risk factors of VTE in patients who underwent elective foot and ankle surgery, analyzing the rates based on the anatomical location of the surgery and the post-operative period. Methods: Data was collected from IBM MarketScan Database (2009-2019) for patients >18y without prior VTE who underwent elective foot/ankle surgery. Patients were divided into three groups based on region of surgery (forefoot, mid/hindfoot, lower leg/ankle), and VTE incidence was recorded 30- and 90-days post-surgery. Risk factors for VTE were identified through multivariate logistical regression analysis. Results: Among the 301,256 patients who underwent elective foot and ankle surgeries, the overall incidence of VTE within 90 days was 0.95%. The findings revealed that 31.8% of VTE incidents occurred within the first two weeks after surgery, and 29.2% still occurred after 6 weeks. An analysis of the anatomical region of surgery demonstrated that the lowest rate of VTE was amongst patients undergoing forefoot surgery (0.70%). There was a higher incidence and risk for VTE in patients undergoing midfoot/hindfoot surgery (1.22%, OR = 1.75) and lower leg/ankle surgery (1.76%, OR= 2.53). Additional risk factors for VTE included thrombophilia (OR = 5.06), male sex (OR = 1.43), increasing age (OR > 1.25), and a high Charlson Comorbidity Index (OR < 0.82 for scores < 5). Conclusion: This study identifies the incidence and timing for VTE after elective foot and ankle surgery. Furthermore, this study defines the risk factors associated with increased odds of VTE after elective foot and ankle surgeries. These findings are helpful in educating patients about a continued risk for VTE throughout the 90-day postoperative period. These results can also be utilized to stratify patients who need thromboprophylaxis based on the individual risk level.

Category: Ankle; Other Introduction/Purpose: Chronic ankle instability (CAI) is a common diagnosis among people with previous ankle injuries. Once conservative treatment is exhausted, lateral ankle ligament reconstruction (LALR) is the gold standard surgical treatment for CAI. Previous studies have reported on the impact of race on access to orthopedic procedures in the United States. However, there are few studies evaluating racial disparities in elective foot and ankle surgeries, including LALR. Recognizing and addressing disparities in the access of health resources are imperative in combating systemic care rationing. Thus, our study aims to investigate racial disparities including utilization and perioperative metrics of lateral ankle ligament reconstruction. Methods: A retrospective study was performed using the National Surgical Quality Improvement Program (NSQIP) database. Patients that utilized the Current Procedural Terminology (CPT) code 27698 corresponding to LALR from 2011 to 2020 were included. 61% of these patients had available race/ethnicity data and were included. Designations of race and ethnicity were standardized as White non-Hispanic (WNH), Black non-Hispanic (BNH), Hispanic, Asian American and Pacific Islander (AAPI), and Other. Race/ethnicity stratifications of NSQIP patients were compared to 2010 and 2020 census data from the United States (US) Census Bureau. 30-day postoperative complications and length of hospital stay were also compared between WNH and all other patients combined. Independent T-tests, Chi-squared, and Fisher's exact tests were performed to compare differences including age, gender, and post-operative complications at an α = 0.05. Results: Overall, 1295 patients were included in the study. There were 3.3 times more WNH patients than all other groups who underwent LALR during the study period. This utilization exceeds what would be expected based on population statistics (1.9 times more WNH in the population in 2010 and 1.3 times more WNH in 2020). WNH patients were older with a mean age of 38 years, compared to 36 years for BNH patients (p < 0.05). Amongst the WNH patients, 17.4% smoked which was significantly more than other race/ethnicities. (p=0.012). There were no differences in overall 30-day complication rate or individual types of complications based on race and ethnicity. There were also no significant differences in total length of hospital stay. Conclusion: Our study found that there was increased utilization of LALR amongst White non-Hispanics compared to all other racial/ethnic groups. These numbers do not mimic the current population trends based on the national census data. Despite this discrepancy, no differences in postoperative complications and length of stay based on race and ethnicity were found. These results suggest that there may be systemic barriers for patients to undergo care for LALR and that further research needs to be conducted on racial disparities within orthopedics.

Background: The rising prevalence of obesity among American adults has disproportionately affected Black adults and women. Furthermore, body mass index (BMI) has historically been used as a relative contraindication to many total joint arthroplasty (TJA) procedures, including total ankle arthroplasty. The purpose of this study was to investigate potential disparities in patient eligibility for total ankle arthroplasty based on race, ethnicity, sex, and age by applying commonly used BMI cutoffs to the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Methods: Patients in the ACS-NSQIP database who underwent TAA from 2011 to 2020 were retrospectively reviewed in a cross-sectional analysis. BMI cutoffs of

Background: Limited literature examines the relationship between surgical outcomes in chronic foot and ankle conditions and concurrent psychiatric care. The present study aimed to investigate patient-reported and surgical outcomes of patients treated for a psychiatric disorder undergoing first metatarsophalangeal (MTP) fusion for hallux rigidus. We hypothesized that patients on psychotropic medications would have greater subjective pain preoperatively and less improvement in physical and mental functionality postoperatively when compared with nonmedicated patients. Methods: A single-center, retrospective review of prospectively collected data was conducted on 92 patients undergoing first MTP fusion with a preoperative diagnosis of hallux rigidus from 2015 to 2019. At their preoperative, 6-month postoperative, and 1-year postoperative visits, patients were administered visual analog pain scale (VAS) and 36-Item Short Form Health Survey (SF-36) functionality surveys. Patients were subsequently identified by chronic use of psychotropic medication preoperatively and grouped for analysis (MED, n = 42; NO MED, n = 50). Results: Postoperative mean VAS pain scores were lower for all studied patients at 6 months (VAS = 1.6 ± 2.3) and 1 year postoperatively (VAS = 1.1± 1.8) relative to the preoperative visit (VAS = 4.7 ± 2.8) ( P ≤ .0001 and P ≤ .0001, respectively). No differences in mean VAS pain scores nor SF-36 physical component summary scores were detected at preoperative, 6-month, or 1-year visits between NO MED and MED groups. Mean SF-36 mental component summary scores for those in the MED group were lower at preoperative (NO MED = 83.8, MED = 71.8, P = .006) and 6-month postoperative (NO MED = 86.1, MED = 72.7, P = .037) visits than those in the NO MED group, a trend not observed at the 1-year postoperative mark (NO MED = 84.1, MED = 76.8, P = .228). There were no observed differences in operative time ( P = .219), tourniquet time ( P = .359), nor time to full weightbearing ( P = .512) between MED and NO MED groups. Additionally, no differences in postoperative complication rates were observed between groups. Conclusion: In patients treated with psychotropically active medications with hallux rigidus, MTP Fusion appears to be a reasonable treatment choice with similar outcomes for patients requiring psychotropically active medications to the outcomes of those patients not requiring psychotropically active medications. Level of Evidence: Level III, retrospective comparative study.

Category: Bunion Introduction/Purpose: Arthrodesis of the first metacarpophalangeal joint (MTPJ) is frequently performed for the most common conditions affecting the great toe, hallux rigidus and hallux valgus. However, there is no detailed depiction of the procedural incidence in recent years. We hypothesize that stratified incidences of patients undergoing this procedure in the last decade has risen. Methods: The Truven MarketScan database was queried to identify patients who underwent 1st MTPJ arthrodesis from January 2009 to December 2019 based on CPT coding. Population estimates from the US Census Bureau were used to calculate the annual incidence of 1st MTPJ arthrodesis. Volume and incidence were estimated for annual sums, gender, age subgroups, and four statistical geographical regions of the U.S. Results: In total, 184,016 1st MTPJ arthrodesis procedures were identified in the database from 2009 to 2019. Annual volumes have increased significantly by 70.8%, from 12,125 to 20,710 total procedures nationwide. Procedural incidence reported per 1,000,000 people significantly increased by 58.7%, at 63.8 in 2019. Growth in incidence was demonstrated in males and females of all defined age subgroups. Incidence stratified by region rose in all regions except for the Northeast, where a -0.5% change between 2010 and 2019 was noted, albeit insignificant. Conclusion: The epidemiology of 1st MTPJ arthrodesis has yet to be clarified in recent years. We have found that the annual volumes and incidence of 1st MTP arthrodesis has increased in the past decade. Growth in incidence was demonstrated in both sexes of all age cohorts as well as regionally in the United States. Identifying current trends in procedural incidences can help provide orthopedic surgeons with insight into temporal and quantitative changes in the field.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: First metatarsophalangeal joint (MTPJ) arthrodesis is a commonly performed procedure for patients with various disorders of the first ray including hallux rigidus, severe hallux valgus, failed 1st MTPJ replacement, and failed hallux valgus correction. Outcomes are generally favorable and similar outcomes have been shown in the young and elderly. It is well documented that medical comorbidities have deleterious effects on outcomes in foot and ankle surgery. Obesity - in particular - has been broadly studied among the foot and ankle literature and has been associated with increased complications. Presently, there is a paucity of studies examining obesity's effect on outcomes of 1st MTPJ arthrodesis. This study's purpose was to evaluate outcomes following 1st MTPJ arthrodesis in obese vs non-obese patients. Methods: A retrospective cohort study of 94 patients undergoing first MTPJ fusion over the age of 18 with a diagnosis of hallux valgus or hallux rigidus was performed. Surgical and postoperative outcomes, Visual Analog Pain scale (VAS), and Short Form 36 (SF-36) surveys were examined and stratified into 2 patient groups: BMI < 30 and 3 30, with sub-analyses conducted between Obesity class I (30-34.9) and Obesity class II (35-39.9) patients. Continueous, normally distributed data were compared with independent sample t-tests, while comparisons of categorical data were made using chi-squared tests. Alpha and beta were assumed to be 0.05 and 0.8, respectively. Results: Average overall VAS and SF-36 physical component scores improved significantly at 6 months (P< 0.0001, 0.006) and 1- year postoperative visits (P 30) or non-obese cohorts. Amongst BMI classified subgroups, significantly greater changes in preoperative to 6-month and 1-year postoperative VAS pain were observed in the Obesity class I patients vs. Obsesity class II or greater (P=0.043, 0.022). Conclusion: Our study showed first MTPJ fusion reliably improves pain and physical quality-of-life in arthritic obese and non- obese patients without differences in nonunion, complications, or patient-reported measures. Additionally, we observed that obese patients experienced comparable improvements in VAS pain and SF-36 physical function scores as their non-obese peers. Our findings asset that first MTPJ fusion is an effective procedure for correction of MPTJ pathology in the obese.

Category: Basic Sciences/Biologics; Bunion Introduction/Purpose: Hallux valgus and hallux rigidus are common disorders that can have functional limitations for patients. Although both involve pathology centered around the first metatarsophalangeal joint (MTPJ), the surgical management for both greatly varies. Inflammatory changes in a joint play a critical role in the development of pain and dysfunction. It has been postulated previously that patients with bunion deformity can develop arthritic changes in the long-term. The purpose of this work is to study and compare the synovial tissue inflammation in patients with hallux valgus and hallux rigidus. Methods: A prospective study of patients aged 25 to 75 years undergoing either surgical management of hallux valgus or hallux rigidus between January 2021 and December 2021 was conducted following IRB approval. Tissue samples from the synovium were collected at the time of procedure and sent for processing and histology. The samples were graded in a blinded fashion based on the degree of inflammation. Morphological features of the synovectomy specimens undergoing histopathologic analysis were scored by synovial lining cell layer hyperplasia, the extent of inflammatory synovium infiltration, as well as pannus formation via activation of synovial stroma and resident cells. All parameters were graded from 0 (absent), 1 (slight), 2 (moderate), to 3 (strong). Statistical analysis was conducted to compare the level of inflammation between patients who had hallux valgus and those that had hallux rigidus. Results: A total of twenty-one samples were collected. One sample was excluded as there was inadequate tissue for analysis. There were eight patients with hallux rigidus and twelve patients with hallux valgus. Mean age at the time of sample collection was 59.3 years (SD=11.9). There was no significant difference in the synovium inflammatory scores (M=5.0, SD=2.25) between the two groups, t(18)= 1.704, p=.106, ([CI .95]: -0.388, 3.722). Moreover, Cohen's effect size value (d=0.78) suggests medium to high practical significance. Conclusion: Understanding the intra-articular impact of hallux valgus is important when considering treatment options. The amount of inflammation in the synovial tissue of hallux valgus patients in this study was similar to that of patients with hallux rigidus suggesting that there is intra-articular inflammation in patients with hallux valgus. Further work will need to be performed to determine if this increased inflammation influences outcomes or has an effect on treatment.

Category: Midfoot/Forefoot; Other Introduction/Purpose: It has been well documented in the literature that fractures of the base of the fifth metatarsal are often associated with varus hindfoot alignment. Zone two fractures at the metaphyseal-diaphyseal junction, commonly referred to as Jones fractures, have specifically been noted to have a higher incidence of delayed union and nonunion. This has historically been attributed to the tenuous blood supply in this region. Although it is known that hindfoot varus may predispose to these fractures, there is little information on whether a cavovarus alignment may also contribute to the increased risk of nonunion. The purpose of this study is to determine whether cavovarus foot alignment is associated with delayed union or nonunion in Jones fractures. Methods: We identified patients who sustained a proximal fifth metatarsal fracture between the years 2016-2021 at a single academic institution. Weightbearing foot radiographs were then reviewed to identify zone 2 fractures. Talo-first metatarsal, talonavicular coverage, and talocalcaneal angles were then measured on the AP view and calcaneal pitch, talocalcaneal, and talo- first metatarsal angles were measured on the lateral view to assess foot alignment. The primary outcome measure was the presence of a nonunion or delayed union. T-tests, Mann Whitney U tests, and ANOVA analyses were conducted to assess for differences. Results: We identified a total of 117 patients with 118 zone 2 proximal fifth metatarsal fractures. Of those fractures, there were 23 of which were considered either delayed union (n=8) or nonunion (n=15). Similar rates of nonunion and delayed union were observed between patients undergoing nonoperative and operative management of their Jones fractures (p=0.514, p=0.200, respectively). For all patients with a nonunion or delayed union, no differences in anteroposterior (AP) talo-first metatarsal angle, AP talonavicular coverage angle, AP talocalcaneal angle, lateral calcaneal pitch, lateral talo-first metatarsal angle, or lateral talocalcaneal angle from those with expected healing were observed (p = 0.773, p = 0.084, p = 0.874, p = 0.751, p = 0.471, and p = 0.386 - respectively). Conclusion: Overall, no measured foot alignment values (talo-first metatarsal angle, talonavicular coverage, talocalcaneal angle, or calcaneal pitch) were statistically associated with increased risk of delayed union or non-union among patients with Jones fractures undergoing either operative or non-operative treatment. Furthermore, there was no measured difference in these foot alignment parameters between those patients undergoing operative treatment and those undergoing non-operative treatment. In conclusion, cavovarus alignment is not associated with an increased risk of non-union or delayed union in the operative or non-operative treatment of Jones fractures.

Category: Ankle; Ankle Arthritis; Hindfoot; Trauma Introduction/Purpose: Ankle osteoarthritis accounts for one of the most common ankle joint pathologies. Although total ankle arthrodesis has been the mainstay treatment for degenerative end-stage ankle arthritis, the popularity of total ankle arthroplasty has been on the rise due improved implant design, technologies, and postoperative outcomes. Yet, there remains a paucity of epidemiologic data in recent years on the incidence of total ankle arthroplasty in the United States. We hypothesize that stratified incidences of patients undergoing this procedure in the last decade has risen. Methods: The Truven MarketScan database was queried to identify patients who underwent total ankle arthroplasty from January 2009 to December 2019 based on CPT coding. Population estimates from the US Census Bureau were used to calculate the annual incidence of total ankle arthroplasty. Volume and incidence were estimated for annual sums, gender, age subgroups, and four statistical geographical regions of the U.S. Results: In total, 41,060 total ankle arthroplasty procedures were identified in the database from 2009 to 2019. Annual volumes have increased significantly by 136.1%, from 2,180 to 5,147 total procedures nationwide. Procedural incidence reported per 1,000,000 people significantly increased by 120.8%, at 15.9 in 2019. Significant growth in incidence was demonstrated in males and females below the age of 65 years with the highest annual incidence found in people under the age of 54. Incidence stratified by region rose in all regions of the United States with the South and West seeing the most notable increases. Conclusion: The epidemiology of TAA has yet to be clarified in recent years. We found that annual volumes and incidence of TAA has increased in the past decade. Growth in incidence was demonstrated in both sexes > 54 years as well as in all regions of the US. While ankle arthroplasty succeeds in mitigating certain complications associated with arthrodesis such as impaired ankle motion, gait changes and adjacent joint arthritis, orthopedic surgeons must remain mindful of the significant consequences associated with revision ankle arthroplasty. Describing epidemiology with stratified procedural incidence can help orthopedists adapt to the ever-evolving changes in the field.

Category: Ankle; Trauma Introduction/Purpose: The past 50 years has seen significant development of surgical techniques aimed at treating chronic lateral ankle instability. Surgical procedures currently being performed can be classified as anatomic ligament reconstruction as well as nonanatomic, and more recently, anatomic repair by tenodesis. Anatomic reconstruction is successful at circumventing important shortcomings associated with nonanatomic repair such as impaired ankle kinematics and biomechanics. One variation of the anatomic repairs described in orthopedic literature demonstrating excellent long-term functional outcomes includes the Broström-Gould (BG) modification. However, there is no detailed depiction of the procedural incidence in recent years. We hypothesize that the incidence of this surgical technique has risen in the past decade. Methods: The Truven MarketScan database was queried to identify patients who underwent a BG procedure from January 2009 to December 2019 based on CPT coding. Population estimates from the US Census Bureau were used to calculate the annual incidence of the BG procedure. Volume and incidence were estimated for annual sums, gender, age subgroups, and four statistical geographical regions of the U.S. Results: In total, 160,457 BG procedures were identified in the database from 2009 to 2019. Annual volumes have increased by 89.9%, from 10,441 to 19,829 total procedures nationwide. Procedural incidence reported per 1,000,000 people increased by 76.6%, at 61.1 in 2019. Increased incidence was demonstrated in males and females ≤65 years, with the highest annual incidence found

Category: Ankle; Other Introduction/Purpose: Ankle fractures are a common orthopedic injury observed in a wide variety of patient populations. Prior to being seen by an orthopedic specialist, patients with ankle fractures may have already undergone several procedures in the field or in the emergency department to stabilize or reduce the injured bone. While a paradigm that near-anatomic reduction improves outcomes in non-urgent ankle fractures exists, no study to date has shown objective evidence of this in postoperative patient- reported outcomes. The present study aims to evaluate whether adequate reduction of non-emergent ankle fractures within 24 hours of inciting injury influenced postoperative outcomes. Methods: All non-emergent ankle fractures treated by a single foot and ankle, fellowship-trained surgeon were queried over a period of 5 years and retrospectively evaluated through the electronic medical record. 97 patients over the age of 18 years with traumatic ankle fracture etiologies were considered. Plain film radiographs from initial presentation to the emergency department or first visit to orthopedics clinic were evaluated by the attending physician for adequate reduction based on AP and lateral tibiotalar congruency. Patient demographics and surgical outcomes data were collected from electronic medical record review. In the cases deemed to be dislocated or subluxated on initial injury films, the days until adequate reduction were calculated along with patient-reported VAS and SF-36 scores. Non-continuous data were compared using chi-squared tests, while continuous, non- normally distributed data were compared utilizing a Mann-Whitney U test. Alpha and beta for this study were assumed to be 0.05 and 0.8, respectively. Results: The average age was 46, with 68.9% of the patient population that was female. 51 patients were found to be adequately reduced within 24 hours, while 39 were not. The average time to final PRO follow-up was 12.6 months +- 1.9. No differences in preoperative VAS, SF-36 physical nor mental scores were noted between adequately and inadequately reduced cohorts (p= 0.654, p=0.262, p=0.760 respectively). Similarly, no differences in final postoperative follow up VAS, SF-36 physical nor mental scores were observed (p=0.503, p=0.252, p=0.296 respectively). VAS pain scores in both cohorts also improved to a similar degree over the preoperative to final postoperative follow up time point (p=0.261). Conclusion: These data show no difference in patient-reported pain or physical and mental functioning scores over 1 year after surgical fixation of the ankle, regardless of whether the ankle joint was adequately reduced within 24 hours of injury. We assert that anatomic reduction of the ankle joint following traumatic, non-emergent ankle fracture does not play a significant role in overall patient outcomes over 1 year following surgical correction.

Category: Sports; Ankle; Arthroscopy Introduction/Purpose: The Brostrom-Gould procedure is the gold standard surgical treatment for patients with chronic ankle instability (CAI) whose symptoms are refractory to conservative treatment. The purpose of this study is to investigate the relationship between preoperative radiographic alignment, intraoperative stress testing, concomitant pathology, and postoperative pain scores in patients undergoing Brostrom-Gould procedures. Specific questions included: 1) Is preoperative radiographic alignment predictive of the degree of lateral ankle instability noted intraoperatively? 2) Is the degree of ankle instability associated with the presence of OCD lesions and peroneal tendon pathology? 3) Is the degree of ankle instability associated with postoperative VAS pain? and 4) Does concomitant pathology affect final VAS pain score? Methods: A retrospective study was performed of all patients who underwent lateral ankle ligament reconstruction by a single surgeon from 2002 to 2020. Patients who underwent concomitant hindfoot fusion procedures or ankle arthroplasty were excluded. Demographic and clinical information was recorded from the electronic medical record. Preoperative radiographic measurements were taken using weightbearing ankle films. Intraoperative stress views were evaluated to determine the talar tilt. All data was tested for normality. Parametric and nonparametric univariate statistics were used to determine the relationship between preoperative weightbearing radiographic measurements, preoperative MRI findings, intraoperative talar tilt measurement, and postoperative outcomes. Results: 181 patients with a median follow-up of 1 year were included. Complications included delayed wound healing in 5.6%, superficial infection in 2.8%, and nerve symptoms in 11%. The reoperation rate was 5%, including revision lateral ankle ligament reconstruction (4/181), debridement for infection (1/181), and wound revision (4/181). Increased preoperative anterior distal tibial angle (ADTA) was associated with an increased intraoperative talar tilt (p=0.0073). Increased intraoperative talar tilt was associated with an increased prevalence of osteochondral lesions of the talus (p=0.0176). Mean VAS scores improved from 4.6 preoperatively to 1.9 postoperatively (p

Category: Other; Hindfoot; Midfoot/Forefoot; Trauma Introduction/Purpose: Degenerative conditions of the ankle, hindfoot and midfoot can markedly limit mobility, and functional disability due to bone and joint pathology has been demonstrated to predict mortality, and in some cases, decrease life expectancy by up to 10 years. Optimizing outcomes in surgical treatment of these conditions is therefore essential and requires analysis of both medical interventions and psychosocial factors. Physicians have only recently begun to identify social support to be a key factor in post-operative functional ability, though our understanding of their impact on surgical outcomes is limited. The purpose of this study was to elucidate the link between low social support and postoperative surgical foot and ankle outcomes. Methods: A single-center, prospective study was conducted on patients who underwent elective or non-elective ankle, hindfoot, or midfoot surgery between 2015 and 2019. Patients who were pre-operatively and post-operatively assessed at 6 month or 1 year follow up using the Short Form Health Survey (SF-36), Life-Space Assessment survey (LSA), and/or visual analog scale (VAS) for pain were administered a social support survey scoring the individuals social support system. Patient reported outcomes were compared between low social support patients (score 13). Results: Preoperative baseline and 6 month LSA scores in the low social support group were significantly lower compared to the normal social support group (P = 0.044, P = 0.038), a trend not observed at the 1 year post-operative mark. Low social support pre-operative SF-36 MCS scores (P = 0.015) were significantly lower than the high social support group with no difference detected in pre-operative SF-36 PCS scoring. At 6-month follow-up, the low social support group had significantly lower SF-36 PCS scores (P = 0.031) and SF-36 MCS scores (P = 0.006) compared to the high social support group. At 1 year follow up, these differences in PCS (P = 0.04) and MCS (P= 0.007) persisted. No significant differences in VAS scores were observed. Conclusion: Among adults undergoing foot and ankle surgery, low perceived social support was associated with lower degrees of perceived mental well-being and physical wellbeing up to 1 year postoperatively.

Category: Ankle; Sports; Trauma Introduction/Purpose: Traditionally, open surgical repair has provided improved functional outcomes, reduced re-rupture rates, and quicker recovery and return to activities at the expense of increased wound complications of infection and skin necrosis compared to nonoperative management. Ma and Griffith in 1977 introduced the percutaneous approach, and over the following decades, multiple improved techniques, and modifications thereof, have been described with comparable outcomes to the open repair. The current study aims to provide updated level I evidence comparing the open and minimally invasive (MIS) through a comprehensive search of literature published in English, Spanish, Portuguese, and German while avoiding limitations of previous studies such as heterogeneous study designs and a small number of included studies. Methods: Following the PRISMA guidelines, two independent team members searched several databases to identify randomized controlled trials (RCTs) comparing open and MIS Achilles tendon repairs. The primary outcomes were (1) Sural nerve injury, (2) Skin complications, (3) Infection (deep/superficial), whereas the secondary outcomes were (1) AOFAS/ATRS score, (2) surgical time, (3) re-rupture (4) adhesions (5) ankle range of motion. Population: Achilles tendon rupture Intervention: MIS repair Control: Open repair Outcomes: Primary: (1) Sural nerve injury, (2) Skin complications, (3) Infection (deep/superficial) Secondary: (1) AOFAS/ATRS score, (2) surgical time, (3) re-rupture, (4) adhesions, (5) ankle range of motion (6) other complications. Results: Ten RCTs qualified for the meta-analysis with a total of 522 patients. 260(49.8%) patients had open repair while 262(50.2%) had MIS repair. The mean total complication rate was 15.5% (0-36.4%) in open repair vs. 10.4% (0-45.5%) in MIS repair, with non-significant statistical difference (RR= 1.50,CI=0.87-2.57,p= 0.14;I2=40%). The mean re-rupture rate was 2.5% (0-6.8%) in open repair vs. 1.53% (0-4.6%) with MIS repair, with non-significant statistical difference (RR=1.56,CI=0.42-5.70,p= 0.50;I2=0%). No cases of sural nerve injury were reported in the open repair group. The mean sural nerve injury was 3.4%(0-7.3%) in the MIS group, that was statistically significant (RR= 0.16,CI=0.03-0.46,p=0.02;I2=0%). The mean deep infection rate in the open group was 1.4% (0-5%) while no deep infection was reported in MIS, with no statistically significant difference (RR= 3.24,CI=0.48-20.54,p= 0.23;I2=0%). The mean superficial infection rate was 6.04% (0-18.2%) and 0.40% (0-4.5%) for open and MIS repairs, respectively, with statistically significant difference (RR= 5.70,CI=1.80-18.02,p< 0.001;I2=0%). Conclusion: Open Achilles tendon repair is associated with longer surgical time, higher risk of superficial infection, and ankle stiffness, while MIS repair is associated with a greater risk of temporary sural nerve palsy. Re-rupture rate and functional outcomes are mostly equivalent. We found MIS to be a safe and reliable technique. However, high-quality standardized RCTs are still needed before recommending MIS as the gold standard for the management of Achilles tendon rupture.

Category: Bunion; Midfoot/Forefoot; Other Introduction/Purpose: Hallux rigidus is a mobility limiting disease commonly seen in elderly patient populations. Correction via metatarsophalangeal (MTP) fusion has been shown to be a safe and effective means of treatment in these populations relative to younger cohorts. An increasingly important measure of surgical efficacy is the establishment of patient-reported outcomes for achieving meaningful change through a procedure. Calculation of a minimally clinically important difference (MCID) has been established to illuminate these thresholds. The objective of this study was to calculate MCID thresholds for visual analogue pain (VAS), Short Form 26 Health survey (SF-36), and LifeSpace Mobility Assessment (LSA) following first MTP fusion. Methods: A prospective study of all patients undergoing MTP fusion between August 1, 2015 and July 1, 2018 by a single surgeon was conducted following IRB approval. A total of 143 patients were included in the study. Demographics and surgical data were collected from review of the electronic medical record. Patient reported VAS, SF-36, and LSA scores were collected at routine 6- month and 12-month follow-up clinic appointments, as well as preoperatively. This study utilized a distribution-based approach for calculation of MCID for each of the patient reported outcomes. The MCID was defined as 0.5 times the standard deviation of the pre-operative score, 95% bootstrap confidence intervals were creating using the bias corrected and accelerated method. Results: The average age of patients undergoing first MTP fusion was 63.4 years (SD 10.6). Patient demographics were recorded, 25.9% of patients were current or former smokers, 60.8% had clinically managed hypertension, 9.8% had diabetes, and 31.5% carried a diagnosis of osteoarthritis. The average patient had 1.9 (SD 1.1) toes operated on during the procedure, including their MTP fusion. Mean tourniquet time was 65.6 (SD 24.8) minutes and mean operative time was 89.9 (SD 31.4) minutes. Mean (SD): VAS, 4.7 (2.8); LSA, 86.4 (35.1); SF-36 physical component score, 63.00 (19.9); SF-36 component score, 77.4 (19.8). MCID: VAS, 1.4 (95% CI 1.3 to 1.5); LSA, 17.6 (95% CI 14.4 to 21.4); SF-36 physical component score, 9.9 (95% CI 9.1 to 11.0); SF-36 mental component score, 9.8 (95% CI 8.7 to 11.4). Conclusion: This study identifies the MCID for VAS, SF-36, and LSA following first MTP fusion. The MCID of VAS reveals minimal improvements in pain (>1.5) are clinically significant. Both SF-36 physical and mental component scores reveal narrow 10- point differences have clinically significant changes. In contrast, LSA appears to have a relatively wide MCID value for patients undergoing first MTP fusion, highlighting the need for a large increase in mobility for significant improvement.

Category: Ankle; Trauma Introduction/Purpose: Ankle fractures are a common injury treated by orthopaedic surgeons with a rising incidence. Preoperative depression is a known risk factor for postoperative complications in joint replacement surgery, however its effects on outcomes following ankle fracture surgery is unknown. The purpose of this study was to investigate the relationship between preoperative depression and outcomes following ankle fracture surgery. Methods: In this retrospective study, the Truven MarketScan claims database was used to identify patients who underwent outpatient ankle fracture surgery from January 2009 to December 2018 using Common Procedure Terminology (CPT) codes. Patient characteristics, and medical comorbidities were collected. Patients with and without a diagnosis of preoperative depression were identified based on International Classification of Diseases (ICD) codes. Chi-squared and multivariate analyses were performed to investigate the association between preoperative depression and common postoperative complications following ankle fracture surgery. Results: In total, 107,897 patients were identified for analysis, 13,981 of whom were diagnosed with depression (13%). Preoperative depression was associated with the increased odds for postoperative infection (OR 1.33, CI 1.20-1.46), wound complications (OR 1.13, CI 1.00-1.28), pain-related postoperative emergency department visits (OR 1.58, CI 1.30-19.1), 30-day and 90-day readmissions (OR 1.08, CI 1.03-1.21 and OR 1.13, CI 1.07-1.18), sepsis (OR 1.39, CI 1.12-1.72) and postoperative development of complex regional pain syndrome (OR 1.46, CI 1.18-1.81). Conclusion: Preoperative depression in patients undergoing ankle fracture surgery is common and associated with increased complications following surgery. An understanding of patients' preoperative depression diagnosis can allow providers to modify perioperative and postoperative protocols for these higher risk patients. Further studies are warranted to investigate the degree to which depression is a modifiable risk factor.

Category: Ankle; Hindfoot; Midfoot/Forefoot Introduction/Purpose: Chronic, non-traumatic pathologies of the foot and ankle can be mobility-limiting for patients of all ages. Given increased rates of perioperative comorbidities and the heightened risks of intraoperative complications, physicians may be more inclined to manage elderly patients with longer periods of conservative treatment for similar pathologies. However, previous work has shown that decreased mobility of elderly patients affects longevity and is linked to increased rates of all-cause and non- cancerous morbidity and mortality. Currently, little is known about the effect of elective foot and ankle procedures on mobility in patients of all ages. Therefore, the objective of this study was to compare posteroperative changes in LifeSpace Mobility Assessment (LSA) scores of adult and elderly patients following foot and ankle surgery. Methods: A prospective study of 184 patients undergoing elective ankle, hindfoot, and midfoot procedures conducted by a single surgeon between September 1, 2015 and August 31, 2019 was undertaken following IRB approval. Patient-reported LSA scores were collected at preoperative and routine 6-month and 12-month follow-up clinic appointments. Patient demographic and surgical data were recorded, and they were divided into groups by age over and under 65 years. Demographics and surgical characteristics were compared utilizing an independent sample t-test for continuous, normally distributed data and a chi-squared or Fischer's exact test for categorical data. Alpha and beta were assumed to be 0.05 and 0.8, respectively. Results: The younger (=65) age group (mean age 70.4 years, SD 8.4 (p

Category: Other Introduction/Purpose: Non-union of foot and ankle arthrodesis sites has been associated with revision surgery, morbidity and increased healthcare costs, so many surgeons elect to augment the fusion site with autologous bone grafts to improve union. While iliac crest autografts are considered the historical gold standard, other donor sites distal in the lower extremity such as calcaneus, proximal and distal tibia have been successfully used in foot and ankle surgery. This study aims to report on the safety and donor site morbidity of distal lower extremity (calcaneal, proximal and distal tibial) bone autografts. We summarized the findings in a comprehensive infographic illustration. We are unaware of any similar meta-analyses to date. Methods: Following the PRISMA guidelines, 2 independent investigators searched several databases in December 2020 using the following keywords and their synonyms: ('Bone graft', 'donor site morbidity', 'calcaneal graft', 'Proximal tibia graft', and 'distal tibia graft'). Besides, the reference lists from previous review articles were searched manually for eligible studies. The primary outcomes of interest were (1) Chronic pain, (2) Fracture and (3) infection whereas the secondary outcomes were (1) neurological complications, (2) sensory disturbance and hypertrophic scars, (3) other complications such as shoe-wear difficulties and gait disturbance. Inclusion criteria were: studies on complications and adverse events of lower extremity bone autografts (calcaneal, proximal tibial, and distal tibial bone autografts) reporting at least one desired outcome. Studies not reporting any of the outcomes of interest or if the full text is not available in English were excluded. Studies reporting on bone marrow aspirate or autografts for non-orthopedic indications were also excluded. Results: After removal of duplicates, 5981 studies were identified. After screening, 85 studies remained for full-text assessment, and 15 studies qualified for the meta-analysis with a total of 2296 bone grafts.1557(67.8%) were calcaneal grafts, 625 (27.2%) were proximal tibial grafts, and 114 (5%) were distal tibial grafts. The mean age of all patients was 52.43+-16 [CI=51.77-53.08] years. The mean follow-up duration was 1.86+-1.70[CI=1.79-1.93] years. The primary surgery was reported for 2129 grafts(92.7%).Out of those, foot and ankle procedure represented 97.4% of the procedures. In calcaneal bone grafts, there were 28 cases of chronic pain [1.97%,CI:1.10-2.50%, I2=66%], 5 fractures [0.32%,CI:0.10-0.60%, I2=0%], 20 sural neuritis [1.28%,CI:0.70-1.80%, I2=0%), and no wound infections. In proximal tibial grafts there were 13 cases of chronic pain [2.08%,CI:1.01-3.2%, I2=34.5%], 1 fracture [0.16%,CI:0.10-0.50%, I2= 0%], and 3 superficial wound infections [0.48%,CI:0.10-1.01, I2=0%]. In the distal tibial grafts there were no cases of chronic pain or wound infections, 1 fracture [0.90%,CI:0.80-2.6%,I2=0%], and 5 saphenous neuritis [4.5%,CI: 0.70- 8.40%,I2=65%]. Conclusion: Calcaneal, distal tibial, and proximal tibial bone autografts are safe with a low rate of overall and major complications. We report an overall complication rate of 6.8%, which is less than half of that previously reported for iliac crest grafts. The authors recommend using distal lower extremity grafts for foot and ankle primary surgeries instead of iliac crest grafts when indicated. Clinical trials with large sample sizes are required.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Psychiatric comorbidity has been shown to significantly impact postoperative course, leading to increasingly complicated hospitalizations, increased pain, and worse overall patient outcomes. Achieving adequate pain management is paramount in restoring mobility and ultimately reaching treatment goals, making an understanding of the interplay between psychiatric conditions and orthopedics vitally important. Specifically, deformity of the first MTP joint has been associated with increased psychiatric symptoms preoperatively. However, despite this particular population's vulnerability to depressive symptoms, the effects of surgical correction on mental function outcomes have not been well observed. The purpose of this study was to assess the association of psychotropic medication use in patients with diagnoses of hallux rigidus and hallux valgus undergoing first MTP fusion and differences in patient-reported pain and functionality scores. Methods: A retrospective analysis of prospectively collected patient outcomes for those undergoing MTP fusion for hallux valgus and hallux rigidus between August 1, 2015, and July 1, 2018, was conducted. A total of 95 patients were included in the study. Demographics and surgical data were collected from a review of the electronic medical record, and patients were grouped based on chronic use of psychotropic medications at the time of surgery. Patient-reported VAS, SF-36 Mental Component Scores (MCS), and Physical Component Scores (PCS) scores were collected at preoperative and routine 6-month and 12-month postoperative follow-up clinic appointments. Categorical variables were compared using Pearson's chi-squared test. For normally distributed data outcome scores were compared using the independent sample t-test while non-normal data comparisons were made with the Mann-Whitney U test. For all statistical tests, assumptions of α

Category: Ankle; Hindfoot Introduction/Purpose: Differences between men and women in the perception, incidence, and outcomes of various orthopaedic injuries are well-documented. Recent studies have noted that women display increased ankle ligamentous laxity and double the rate of ankle sprains in relation to their male peers. Current studies indicate that, in general, women and men respond similarly to surgical correction of such pathologies. However, a gender difference in mobility has not been investigated. Given the mobility implications associated with chronic foot and ankle conditions, a need exists to better characterize baseline and postoperative functionality in men and women. The objective of this study was to assess changes in LifeSpace Mobility Assessment (LSA) scores of male and female patients following surgical correction of non-traumatic ankle, hindfoot, and midfoot conditions. Methods: A prospective study of elective ankle, hindfoot, and midfoot procedures conducted by a single surgeon between September 1, 2015 and August 31, 2019 was undertaken following IRB approval. LSA scores on 184 patients - 137 women and 53 men - were collected at preoperative, 3-month, 6-month, and 12-month clinic visits. The electronic medical record was queried for patient demographic and surgical data. Demographics, surgical factors, and patient-reported LSA scores were compared utilizing an independent sample t-test for continuous, normally distributed data. All categorical data was analyzed with a chi- squared or Fischer's exact tests. Alpha and beta were set at 0.05 and 0.8, respectively. Results: The average age of female participants was 51.2 (SD 16.4) years and 48.2 (SD 17.1) years for male participants (p=0.273). There were no significant differences in frequencies of comorbidities (p>0.05). Men and women in this cohort underwent elective foot and ankle surgery for a similar diseases processes, most commonly soft tissue pathology, followed by osteoarthritis (p=0.440). Women had significantly lower LSA scores at preoperative (63.7 [SD 38.1] vs. 84.8 [SD 35.9], p=0.002), 3 month postoperative (52.5 [SD 33.8] vs. 69.9 [SD 34.5], p=0.006), and 1 year postoperative (81.2 [SD 37.2] vs. 105.5 [SD 18.2], p=0.019) timepoints relative to their male peers. No differences in mobility at 6 months postop were observed (p=0.714). Overall, women and men had similar absolute increases in postoperative mobility at 1-year after surgery (17.5 vs. 20.7, p>0.05) as well as similar percentage of increased mobility (27% vs. 24%, p>0.05). Conclusion: The present study provides further evidence of the gender differences in chronic foot and ankle pathologies. Both sexes improved similarly pre to postoperatively, however, women did not reach the same level of absolute mobility as their male counterparts. Prior studies have shown that women characterize a greater degree of limitation with foot and ankle conditions as 'normal' relative to men, making it plausible that they delay treatment until they become more severely symptomatic than men. This persistent deficit highlights the importance of early recognition of mobility impairment in order to preserve function among the sexes in foot and ankle care.

Category: Midfoot/Forefoot; Other Introduction/Purpose: Hallux rigidus is one of the most common toe pathologies in patients greater than 50 years old. While first metatarsophalangeal (MTP) arthrodesis is utilized to improve pain and function, older patients are often considered to be higher risk surgical candidates. There are minimal data on outcomes of MTP arthrodesis and no studies comparing outcomes between geriatric and younger patients. Methods: This is a single center, prospective study of all patients who underwent MTP arthrodesis between August 1, 2015 and July 1, 2018. Patient reported-outcomes were assessed utilizing the Short Form Health survey (SF-36), LifeSpace Assessment survey (LSA), and visual analogue scale (VAS) for pain administered preoperatively as well as 6-months and 1-year postoperatively. Baseline characteristics and surgical outcomes were collected from the electronic medical record. All operations were performed by one foot and ankle fellowship-trained orthopedic surgeon. Clinical and patient-reported outcomes were compared between patients

Category: Bunion; Other Introduction/Purpose: Hallux valgus is one of the most common deformities of the adult foot, and can adversely affect quality of life, with common complaints including pain, footwear restrictions and cosmesis. Minimal Invasive Surgery (MIS) has re-emerged lately, gaining growing popularity as a surgical approach for surgical treatment of HV deformity. Advantages such as short operating time, quicker recovery, and fewer complications have attributed to MIS. However published data are still inconclusive. Methods: The study included 40 feet (33 pts) with hallux valgus treated with MIS technique, between Apr 20016 to March 2018. Patients were included only if pre- and postoperative weightbearing X-rays at final followup (min 6m) were available. The average age was 51.3 years (range, 21 to 77), with average follow-up of 12 months (range, 6 to 24). Patients’ radiographic records were studied to evaluate postoperative change in hallux valgus angle (HVA), intermetatarsal angle (IMA) and DMAA. Clinical outcome was recorded with Patient reported outcome questioners PROMS10 and MOXFQ. Results: Following surgery deformity was corrected with preoperative mean HVA of 29.8° and IMA of 14.4° compared to postoperative mean of 7.1° and 4.7°, respectively. Patient reported outcome measures recorded the efficacy of MIS for HV in terms of pain reduction and function improvement. In six feet surgery for hardware removal was performed. In one case non- union was treated with revision surgery. Conclusion: This study shows that MIS for HV is safe, effective and offers satisfactory surgical and clinical results.

Category: Ankle Arthritis Introduction/Purpose: Total ankle replacement (TAR) is common tool used by the foot and ankle specialist to treat end stage ankle arthritis. Current data about ankle motion following TAR is derived from gait analysis utilizing external markers. Utilizing Xray Reconstruction of Moving Morphology (XROMM), which combines 3-D mapping technology with biplanar fluoroscopy in vivo to visualize true skeletal motion, we can evaluate true motion of TAR implants. Current TAR replacement systems are either mobile bearing or fixed bearing. We hypothesized that subjects implanted with a fixed bearing prosthesis would exhibit less tibiotalar rotation and translation than subjects implanted with a mobile bearing prosthesis. Methods: Six subjects with total ankle replacement at least one-year post implantation gave informed consent before participating (IRB #H16496). Three subjects with a mobile bearing prosthesis with an average age 63.3+-11.1 yrs were compared to three matched subjects with a fixed bearing prosthesis with an average age of 64.7+-1.5 yrs. Utilizing 3D slicer software, lower body CT scans for each subject were evaluated to create 3D models of the foot and ankle bones and implant components. All subjects walked for several trials at a self-selected pace along a walkway while their foot and ankle motions were captured by a high-speed biplanar fluoroscopic x-ray motion analysis (XMA) system. The 3D models were combined with the x-ray images within a 3D animation platform and rotoscoped to resolve accurate kinematic motions at the tibiotalar joint during stance phase of gait. We examined for differences between the two groups using a two-sample t-test (p

Category: Other Introduction/Purpose: The current COVID-19 pandemic has created a unique problem for orthopaedic surgeons by mandating ‘social distancing’ and limiting patient-provider interactions. Centers have reacted to this by implementing Telemedicine as a way to still provide care for patients. We have developed a Telemedicine protocol we believe allows for enough information to be gathered to provide an accurate diagnosis and with high patient satisfaction. Methods: A 12-step standardized protocol was created to be used during foot and ankle Telemedicine visits. This was coupled with pre-visit preparation by the office staff with the patient as well as recommending appropriate follow-up either in person or again via Telemedicine. After implementation of this system in April 2020, we retrospectively reviewed Press-Ganey data collected for provider rating (scale 0-10) with Telemedicine visits and traditional office visits through June 2020. Scores of 9 and 10 out of 10 were grouped together to represent an excellent experience, and all other responses were grouped together as a less than excellent experience. Fischer’s exact test was used to compare samples. Results: A total of 183 patients were surveyed during this time period, 127 from telemedicine visits and 56 from in-office visits. 106/127 (83.4%) patients surveyed after Telehealth visits and 50/56 (89.2%) after in-person visits rated their visit as a 9 or 10 (p=0.37). Conclusion: The COVID-19 pandemic has changed the way that orthopaedic surgeons have needed to deliver care to their patients. Though the transition has had its difficulties, it would be a failure in progress to not recognize and adopt the advances that have been made during this time. Though the adaption of Telemedicine was made out of necessity at our institution, the lessons learned during this trying time has enabled us to provide excellent orthopaedic care through telemedicine that can continue once restrictions have been lifted.

Category: Basic Sciences/Biologics; Trauma; Other Introduction/Purpose: Malnutrition is known to be negatively associated with outcomes after multiple orthopedic procedures. We hypothesized that admission albumin levels, as a maker for malnutrition, would correlate with postoperative outcomes. The purpose of this study is to investigate this relationship following surgery for ankle fracture. Methods: This is a retrospective cohort study of the ACS-NSQIP database. Patients undergoing operative fixation of an ankle fracture were identified. 6,138 patients with albumin available for analysis were identified. Baseline patient information, preoperative serum albumin levels, 30-day postoperative complications, readmission, reoperation, and length of stay data were then collected. Poisson regression with robust error variance was performed to assess the effect of preoperative serum albumin level on postoperative outcomes. Results: 6,138 patients with albumin available for analysis were identified in the database. The mean albumin level was 3.86 g/dl and 20.3% of patients with available albumin levels were hypoalbuminemic. Multivariate analysis revealed that albumin level

Category: Hindfoot; Sports; Trauma Introduction/Purpose: Rupture of the Achilles tendon is a common injury that requires a lengthy duration of recovery and rehabilitation. Patients of various levels of physical activity, ranging from professional high-impact sports to low-impact recreational activities, can be affected by this injury. Often, one of the most important outcomes from the patient’s perspective is the ability to return to the same pre-injury level of sporting activity after recovery. The objective of the current study is to examine the relationship between global ankle strength and the ability to return to previous level of play following surgical repair of an Achilles tendon tear. Methods: Patients aged 18-50 years old at a minimum 1-year post-op from surgical repair of an isolated Achilles tendon rupture were recruited to return for a study visit. Patients reported both pre-injury and current activity level using the 10-point Tegner Activity Level Scale. Isokinetic strength testing was performed and the Isokinetic Strength Score (ISS) was calculated using maximal effort dorsiflexion and plantarflexion strength at 30o/s, 90o/s, and 240o/s comparing the operative and uninvolved extremity. The primary outcome was the patients’ ability to return to same level of play or within 1 Tegner activity level. Logitistic regression analysis was used to determine the relationship between ISS and return to play. Subgroup analysis was performed on patients participating in high level athletic activity (pre-injury Tegner >= 7) an those participating in only recreational or low level activity (pre-injury Tegner = 7), for every 16 point increase in ISS, the odds ratio for return to same level of play was 8.3 (p=0.055) and the OR for return to within 1 Tegner level of play was 6.3 (p=0.043). There was no association between ISS and return to previous activity in the 16 patients with lower pre-injury levels of activity. Conclusion: Improved ankle strength was associated with return to previous level of activity only in patients who participate in high level athletic activity. These results suggest that patients with more strenuous athletic activity prior to injury are more dependent on recovery of ankle strength in the post-operative time period in order to return to their previous high level of play. In contrast, regaining strength may be less important for returning to normal activities for less active patients.

Category: Other; Ankle Introduction/Purpose: Insertional Achilles tendinitis (IAT) is a common cause of chronic posterior heel pain. Non-operative treatment has demonstrated evidence of success, with similar failure rates in both the young and the elderly. Surgical management can reproducibly improve patients’ pain and functional status. Older patients are considered to be at a higher risk for surgical complications due to associated comorbidities when compared to patients under the age of 60. The aim of this study is to investigate the impact of comorbidities and peri-operative variables on functional patient reported outcomes following surgical treatment of IAT in those over and under the age of 60. Methods: Retrospective review of prospectively collected data pertaining to a consecutive series of adult patients who underwent surgical management of IAT by a single surgeon (J.B.). Patients were separated into those 60 years of age and younger, and those above 60. Patients undergoing concomitant surgical procedures or revisions were excluded. Patient demographics, co- morbidities, perioperative variables, and post-operative complications were collected. Visual Analogue Scale (VAS), Short Form Health Survey Physical Component Score (SF-36 PCS), wound infection, and recurrence were assessed with a minimum follow-up of 12 months. Statistics were obtained using linear regression mixed models, and chi-squared analysis. Results: 38 operative cases were identified including 17 patients over and 21 patients under 60 years of age (mean 66.8 +/- 5.1yrs, 49.1 +/- 8.4yrs, respectively). There were no significant differences in demographics, rates of co-morbidities, or post-operative infection between the two groups. Both young and elderly groups experienced improvements in mean VAS pain scores at 6 months (3.3 and 2.7, respectively, P = 0.416) and 12 months (5.0 and 4.1, respectively, P = 0.322) post-operatively. SF-36 PCS improvements were also observed in both young and elderly cohorts at 6 (mean 22.1 and 9.3, respectively, P = 0.122) and 12 months (mean 30.4 and 20.4, respectively, P = 0.158). Linear regression analysis showed no statistical difference between the presence of co-morbidities, or age, on clinical outcomes. Conclusion: None of the co-morbidities nor peri-operative variables assessed were linked to increased risk of failed surgical correction of IAT in elderly patients, suggesting surgical correction of IAT in geriatric populations is an appropriate and reproducible treatment option. Further higher-powered studies, with longer follow-up times would be of use to better elucidate the influence of co-morbidities on recurrence.

Category: Other; Ankle; Hindfoot; Midfoot/Forefoot Introduction/Purpose: A lack of access to care is predictably associated with negative outcomes in foot and ankle surgery. Despite recent advances in telecommunication technologies, the field of orthopaedics has been slow to adopt these resources in offsetting barriers to care. The COVID-19 pandemic has forced departments to change their clinical approach, lending unprecedented opportunity to better understand how telehealth may bridge this care gap in foot and ankle practices. The purpose of this study was to assess patient-reported outcomes of telemedicine encounters, including comfort and patient satisfaction. Our hypothesis was that patients would be significantly less satisfied with telemedicine when compared to in-office appointments for all non-emergent visit types. Methods: Retrospective analysis of patients seen via telemedicine between April 13, 2020, to June 19, 2020, by one surgeon in the Emory Orthopedics Foot and Ankle department was conducted. Patients were contacted by one of the study authors via telephone to complete a questionnaire; satisfaction and other visit characteristics were assessed with a modified Likert scale from 1 to 5. Patients were designated as either ‘New’ or ‘Established’ based on whether or not they had completed an in-office clinic visit within the last year. Anatomy and pathology of disorder were determined by chief complaint and billing code. Patient demographics were recorded, and data were analyzed using paired and independent t-tests for parametric continuous data, Fisher’s exact and chi-square tests for non-continuous data. Results: 338 eligible patients were contacted via telephone, with 216 (63.9%) completing the telemedicine questionnaire. The patient cohort had an average age of 50.6 (19-84) years old and was 73.6% female (n=159). Overall mean satisfaction for telemedicine visits (4.69) was significantly lower than in-office visits (4.86) (p

Category: Ankle; Ankle Arthritis; Other Introduction/Purpose: Total ankle arthroplasty (TAA) is a successful procedure and its incidence is increasing. While a diagnosis of depression is known to effect outcomes following other procedures, its effect on outcomes following TAA are unknown. Therefore, the purpose of this study was to assess the contribution of depression to outcomes following TAA. We hypothesized depression would lead to increased rates of 90-day complications. Methods: This is a retrospective cohort study. Data was collected from the Nationwide Readmission Database (NRD) for all patients undergoing TAA. Patients were screened for a documented preoperative diagnosis of depression. Two cohorts (those with and without depression) were created. Logistic regression was then performed to assess the contribution of a pre-operative diagnosis of depression on rates of 90-day complications, while controlling for patient demographic and comorbid data. Results: Overall 8,047 patients underwent TAA during the study period. Of these, 11.4% (918) had a pre-operative diagnosis of depression. Compared to patients without depression, patients with depression had a 1.61 (95% Confidence Interval [CI]: 1.31- 1.98) times increased odds of non-home discharge and a 34% increased odds (Odds ratio [OR] 1.34, 95%CI 1.15-1.57) of extended LOS (>2 days). In addition, patients were at increased risk of prosthetic complication (OR 1.39, 95%CI 1.10-1.74), wound complication (OR 1.59, 95%CI 1.11-2.29), prosthetic joint infection (OR 1.82, 95%CI 1.06-3.15), superficial surgical site infection (OR 1.62, 95%CI 1.02-2.58), and occurrence of at least one medical complication (OR 1.32, 95%CI 1.03-1.68). Conclusion: Depression in patients undergoing TAA is common and should be recognized by providers. Furthermore, it is associated with increased healthcare utilization and complications following surgery. Further research should be performed to determine if depression is a modifiable risk factor.

Background: Although complications following hammertoe correction surgery are rare, older patients with comorbid conditions are often considered poorer operative candidates compared with younger, healthier patients because of a suspected increased risk of adverse outcomes. The aim of this study was to determine if the presence of multiple comorbidities was associated with increased complications or unsuccessful patient-reported outcomes following operative hammertoe correction in geriatric patients. Methods: Prospectively collected data was reviewed on 78 patients aged 60 years or older who underwent operative correction of hammertoe deformity. Patient demographics, comorbidities, and postoperative complications were recorded. Patient-reported outcomes were assessed using preoperative and postoperative visual analog scale for pain and Short Form Health Survey Physical and Mental Component Summary with 1 year of follow-up. Patients were divided into 2 groups based on number of comorbidities (0 or 1 vs > 2) and then compared. The average age of patients was 69.4 years and the prevalence of comorbidities in the study population was as follows: 11.5% smokers, 25.6% on blood thinners, 15.4% with rheumatoid arthritis, 7.7% with diabetes mellitus, 2.6% with peripheral arterial disease, 6.4% with chronic obstructive pulmonary disease, 11.5% with coronary artery disease, and 23.1% with osteoporosis. Results: Fifty-three patients (67.9%) had 0 or 1 comorbidity and 25 (32.1%) had 2 or more comorbidities. Compared to the 0 or 1 comorbidity group, the presence of multiple comorbidities was associated with an adjusted odds ratio (OR) for superficial wound infection of 4.18 ( P = .045) and deformity recurrence requiring surgery OR of 23.15 ( P = .032). Patient-reported outcomes were similar between comorbidity groups. Conclusions: This study further informs foot and ankle specialists to maintain increased surveillance for postoperative complications and unsuccessful outcomes in patients with multiple comorbidities. Although geriatric patients still report significant improvements in both pain and function, patients with underlying medical conditions should be counseled about their increased risks when pursuing operative hammertoe correction. Level of Evidence: Level III, retrospective comparative series.

Background: Hammertoe deformities can seriously affect activity level and footwear. The use of prescription, mood-altering medications is very common, with some estimates as high as 25% of the population. Mood disorders, especially depression, negatively affect the results of medical and operative treatments. This study assessed the relationship of mood-altering medication use with the outcomes and complications of operative reconstruction of hammertoes. Methods: Data were prospectively collected from 116 patients who underwent hammertoe reconstruction, including demographic information, medical history, the use of mood-altering psychotropic medications (antidepressants, anxiolytics, hypnotics, and mood stabilizers), and postoperative complications. Preoperative patient-reported outcomes were measured using the visual analog scale (VAS) for pain and Short Form Health Survey (SF-36), which were repeated at 1-year follow-up. Results: A total of 36.2% of patients were taking psychotropic medications. Medication and nonmedication groups had similar pain VAS and SF-36 Physical Component Summary (PCS) scores before and after surgery. Compared with nonmedication patients, patients on psychotropic medications had significantly lower SF-36 Mental Component Summary (MCS) scores preoperatively ( P = .001) and postoperatively ( P = .006), but no significant difference in the change in MCS (ΔMCS) from preoperative to postoperative. Psychotropic medication use was associated with superficial wound infections ( P = .048), but not other complications. Conclusions: Patients taking psychotropic medications were equally likely to benefit from forefoot reconstruction as nonmedication patients. Preoperative and postoperative PCS and VAS were not significantly different between medication and nonmedication groups. Although the medication group had lower absolute MCS, they reported the same magnitude of improvement in MCS (ΔMCS) as the nonmedication group. Level of Evidence: Level II, prospective cohort study.

Background: Insertional Achilles tendinopathy (IAT) is a common cause of chronic posterior heel pain. Surgical intervention reproducibly improves patients’ pain and functional status. We hypothesized that patients older than 60 years would have similar improvements in pain and function and low rates of complications after surgery for IAT when compared to a younger cohort. Methods: Retrospective review of adult case series in patients undergoing surgical management of IAT. Patients were stratified into those 60 years and younger and those older than 60 years. Patients with prior or concomitant surgical procedures and revisions were excluded. Visual analog scale (VAS), Short Form–36 Physical Component Summary and Mental Component Summary (SF-36 PCS/MCS) scores, wound infection, and recurrence, defined as a redevelopment of heel pain in the operative extremity within 6 months, were assessed with a minimum follow-up of 12 months. Statistical analysis was performed using linear regression mixed models and χ 2 analysis. Thirty-seven patients were enrolled, with 38 operative heels. The younger cohort had an average age of 49.1 (range, 26-60) years. The older group had an average age of 66.8 (range, 61-76) years. Results: VAS and SF-36 PCS scores for the entire cohort significantly improved at 6 and 12 months postoperatively ( P < .001). Postoperative SF-36 MCS scores for the cohort significantly improved only at 12 months ( P < .001). No significant differences between the young and elderly were seen with regard to improvements in VAS and SF-36 PCS/MCS at 6 or 12 months postoperatively. Multiple linear regression models showed no significant difference between age groups and VAS score, SF-36 PCS/MCS, or change in pain scores after controlling for comorbidities. No significant difference in overall complication rates was seen between the 2 groups (4.9% vs 29.4%, P = .104). There was 1 recurrence of heel pain in the younger group and 4 recurrences of pain in the older group (23.5%) at 6 months, of which 2 resolved at 1 year. There was 1 case of a superficial wound infection requiring antibiotics in the older cohort (5.9%). No patients required surgical revision. Conclusion: Surgical management of IAT in an older population produced similar improvements in clinical results when compared to a younger cohort, with no significant increase in postoperative complications. Level of Evidence: Level III, retrospective comparative series.

Talus fractures continue to represent a challenging and commonly encountered group of injuries. Its near-complete articular cartilage surface, and its role in force transmission between the leg and foot, makes successful treatment of such injuries a mandatory prerequisite to regained function. Familiarity with the complex bony, vascular, and neurologic anatomy is crucial for understanding diagnostic findings, treatment indications, and surgical techniques to maximize the likelihood of anatomic bony union. This review details the structure and function of the talus, a proper diagnostic workup, the treatment algorithm, and post-treatment course in the management of talus fractures. Level of Evidence: Level V, expert opinion.

Ankle fractures are one of the most common injuries treated by orthopedic surgeons worldwide. However, operative indications, techniques, and reported outcomes following operative fixation vary widely in the literature. This evidence-based review focuses on recent advances in the operative management of ankle fractures including arthroscopic-assisted surgery, deltoid ligament complex repair, expanded indications for posterior malleolus fixation, fibula intramedullary nailing, and dynamic syndesmosis repair. Level of Evidence: Level V, expert opinion.

Category: Lesser Toes Introduction/Purpose: Hammertoe deformities are common, often painful deformities of the lesser foot and are known to severely affect physical function. When patients seek surgical management, x-ray imagining is utilized for diagnosis, evaluation for surgical candidacy, and selection of the operative technique. Postoperatively, radiographs are retaken to assess bone health, healing status, and alignment. Despite their frequent use, no previous data support particular X-ray findings as being indicative of clinical presentation nor surgical outcomes. The aim of this study is to identify specific radiographic parameters that are predictive of pain and function outcomes after surgical correction of hammertoe deformity. Methods: Prospectively collected data was reviewed on 116 patients who underwent hammertoe correctional surgery. Patient demographics, comorbidities, and postsurgical complications were recorded from their electronic medical records. Clinical outcomes were assessed utilizing preoperative and postoperative pain Visual Analogue Scale (VAS) and Short Form Health Survey Physical Component (SF-36 PCS) scores with 1-year follow-up. Radiographs were scored by a foot & ankle fellowship-trained orthopaedic surgeon to assess preoperative severity, postoperative joint fusion, and both pre- and postoperative joint instability. Data was examined using chi-squared, t-test, and ANOVA analyses. Results: Preoperatively, 14.7% of patients had a deformity classified radiographically as mild, 37.1% as moderate, and 48.3% as severe. X-rays prior to surgery showed that 65.5% had MTP joint instability, 9.5% had joint dislocation, and 18.1% had joint arthritis. Postoperatively, 78.5% had PIP joint fusion, 38.8% had MTP joint arthritis, and 17.2% had MTP joint instability. A significant association was found between postoperative MTP joint instability and a lower 1-year SF-36 PCS (p=0.0032). There were no associations found between the other radiographic findings and postoperative outcomes, and no parameters were associated with pain VAS scores. Conclusion: After undergoing surgical correction of hammertoe deformity, the postoperative radiographic finding of MTP joint instability was determined to be predictive of physical function. However, neither metatarsophalangeal joint arthritis nor PIP fusion were predictive of outcomes. This work informs foot and ankle specialists that proper joint alignment and stabilization is critical to ensuring success in hammertoe surgery.

Category: Lesser Toes Introduction/Purpose: Hammertoe deformities are common conditions of the lesser toes, known to affect daily activities and cause pain. Following failure of conservative management, surgical correction of these deformities strives to reduce pain and improve physical function. Currently, 1 in 6 Americans are being treated with psychotropic medications. Baseline mental health issues are known to diminish self-perceived overall health and may hamper recovery following surgery. The aim of this study is to assess the impact of psychotropic medication use on the development of complications and reduction of patient reported outcomes following operative hammertoe correction. Methods: Prospectively collected data was reviewed on 116 patients who underwent operative correction of hammertoe deformity following failure of conservative management. Patient demographics, past medical history, and postsurgical complications were recorded from the electronic medical record. Patient-reported outcomes were assessed utilizing preoperative and postoperative Visual Analogue Scale (VAS) and Short Form Health Survey Physical and Mental Component Scores (SF-36 PCS and SF-36 MCS, respectively) with 1-year of follow-up. Data was examined using chi-squared, t-test, and ANOVA analyses. Results: 17.2% of patient were taking only antidepressants, 10.3% other psychotropic medications, and 8.6% both an antidepressant and another psychotropic medication. Wound infections treated with antibiotics occurred in 12.9%. Mean 1-year improvement in VAS, SF-36 PCS, and SF-36 MCS were 2.8 (SE=0.3), 10.8 (SE = 2.0), and 3.1 (SE = 1.3), respectively. A significant association was found between antidepressant use and postoperative superficial wound infection requiring antibiotics (P=0.049). Antidepressant use was also determined to be significantly associated with lower preoperative and postoperative SF-36 MCS (P=0.0023 and P=0.017, respectively). Other psychotropic medication use was significantly associated with lower preoperative SF- 36 MCS (P=0.030) and PCS (P=0.048) as well as postoperative PCS (P=0.023). However, psychotropic medication use was not associated with any reduction in improvement from pre- to postoperatively. Conclusion: Patients receiving psychotropic medications are at an increased risk for developing postoperative infection following hammertoe deformity correction. While these patients at baseline have lower mental and even possible physical component scores, their improvement following hammertoe correction surgery is equivalent to patients not on these medications. Patients treated with psychotropic medications can still benefit from hammertoe correction surgery, but clinicians should recognize the increased risk for complications and expect lower patient-reported outcomes.

Category: Basic Sciences/Biologics Introduction/Purpose: Ankle arthrodesis is performed for a variety of ankle joint pathology with the most common being post traumatic arthritis. It is estimated that there are nearly twenty-five thousand ankle fusions performed annually in the United States. Reported complication rates vary between studies and patient population characteristics and comorbidities. Our understanding of the biology of ankle arthrodesis is based largely upon spine fusion and long bone animal models. However, bony healing and infection is greatly influenced by local soft tissue and vascular anatomy, therefore the application of data from these models may not be entirely accurate. There is currently no small animal ankle fusion model. Accordingly, the purpose of this study is to develop a reliable small animal ankle arthrodesis model. Methods: A total of twenty Lewis rats were included in this study. Ankle arthrodesis was performed on one extremity of fourteen rats with the other ankle serving as an internal control. An anterior approach was used to expose the tibiotalar joint. Careful technique was utilized to protect neurovascular structures. After adequate joint exposure, a power burr and sharp curette was used to remove joint cartilage. A .042 kirschner wire was then passed through the calcaneus and through the subtalar and tibiotalar joint. Six rats served as controls and their procedures did not involve any joint cartilage removal. Radiographs were taken immediately postoperatively and at 8 weeks. Bony healing was assessed in a blinded fashion by a board certified foot and ankle orthopaedic surgeon using a grading system based upon assessment of cortical bridging and joint space. Results: Sixteen rats – eleven fusions and five controls - underwent the procedure without any perioperative complications and were included in analysis. Four rats were excluded due to a perioperative complication and/or death. The most common postoperative complication encountered was a wound complication (n=3). Of the eleven rats in the fusion group, six (55%) were determined to be fused radiographically. Two of the five controls were radiographically fused (40%). Conclusion: This study demonstrates preliminary data from a novel small animal ankle arthrodesis model. Fifty-five percent of the rats in the fusion group fused based on radiographic evaluation at eight weeks postoperatively. Further work involves improving upon the surgical technique for fusion in this small animal model to help increase fusion rates, and using CT scans and biomechanical testing to further assess fusion. The development of a small animal ankle fusion model will enhance our understanding of the biology of ankle arthrodesis and allow for development of novel therapies aimed at increasing fusion rates and decreasing complications.