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Category: Ankle; Arthroscopy Introduction/Purpose: A hypertrophic distal fascicle of the anterior tibiofibular ligament (ATiFLdf) is commonly encountered in patients with anterior ankle impingement. Repetitive snapping of the hypertrophic ATiFLdf has the potential to create osteochondral lesions (OCLs) at the lateral talar dome. However, the clinical manifestations of these OCLs in the setting of a hypertrophic ATiFLdf has not been described to date. The purpose of this retrospective review was to determine the prevalence of OCLs of the lateral talar dome in patients with anterior ankle impingement with an associated hypertrophic ATiFLdf. In addition, we sought to evaluate the anatomy of the ATiFL to fully elucidate its role in creating chondral wear of the talus. Methods: Retrospective chart review identified 40 patients who underwent arthroscopy of the anterior ankle joint for the management of anterior ankle impingement. Pre-operative magnetic resonance imaging (MRI) scans were obtained and correlated with intra-operative arthroscopic findings. Clinical outcomes assessed included: pre- and post-operative foot and ankle outcome score (FAOS), visual analog scale (VAS), complications, failures, secondary surgical procedures, return to work data and return to sport data. Results: Thirty-two patients with a mean follow-up time of 29.3±10.4 months were included. The ATiFLdf was hypertrophic in 29 patients (90.6%), the mean thickness of which was 2.5±0.4 mm. There were 22 OCLs of the lateral talar dome (75.9%) with an associated hypertrophic ATiFLdf visualized during arthroscopy. The international cartilage repair society gradings of the lesions included: 3 (13.6%) grade I lesions, 15 (68.1%) grade II lesions, 3 (13.6%) grade III lesions, and 1 (4.6%) grade IV lesion. There was a statistically significant improvement in mean FAOS and VAS scores from pre-operative to post-operative (p< 0.001). No cases of syndesmotic instability were observed following resection of ATiFLdf. The mean post-operative Likert score was 4.1±0.4. There were 5 failures (15.6%) at a mean time of 9.0±4.7 months. Conclusion: This retrospective case series demonstrated that a hypertrophic ATiFLdf was closely associated with the development of an OCL of the lateral talar dome identified during arthroscopic evaluation. In addition, pre-operative MRI proved to demonstrate poor sensitivity for the detection of these OCLs. Suspicion should be raised for potential lateral talar dome OCLs in patients presenting with anterolateral ankle impingement with a hypertrophic ATiFLdf. Figure 1. (a) Hypertrophic ATiFLdf with associated OCL of the lateral talar dome; (b) Biter resecting hypertrophic ATiFLdf; (c) Resected hypertrophic ATiFLdf; (d) and (e) Hypertrophic ATiFLdf identified on coronal and axial MRI scans

Category: Midfoot/Forefoot; Sports Introduction/Purpose: The purpose of this study was to evaluate outcomes following the use of Platelet-Rich Plasma (PRP) for Plantar Plate Injuries. Methods: Retrospective chart review identified 13 patients who underwent a PRP injection for the treatment of plantar plate injuries. Pre-operative magnetic resonance imaging (MRI) scans were obtained and the grade of the plantar plate injury was recorded. Clinical outcomes assessed included: pre- and post-operative foot and ankle outcome score (FAOS), visual analog scale (VAS), complications, failures, secondary surgical procedures, and return to sport data. Results: Thirteen patients with a mean follow-up time of 22.1±10.4 months were included. There were 6 patients that were grade 1, 4 patients were grade 2 and 3 patients were grade 3. There was a statistically significant improvement in both FAOS (53.1 -> 86.7) and VAS scores (4.5 -> 1.1) following injection of PRP to the plantar plate. No complications were observed. There was 1 failure, which underwent a plantar condylectomy at 8.1 weeks following PRP injection. Ten patients played sport pre-operatively, all of which (100%) returned to sport at a mean time of 5.3 weeks following PRP injection. Conclusion: This retrospective review demonstrated improvement clinical and functional outcomes following injection of PRP for plantar plate injuries. There was a 100% return to sport rate at a mean time of 5.3 weeks. The failure rate was 7.7%. Further comparative studies with longer follow-up are warranted to determine the precise role of PRP for the management of plantar plate injuries.

Category: Other; Ankle Introduction/Purpose: The purpose of this study was to evaluate the efficacy of an Artificial Intelligence Large Language Model (AI-LLM) at improving the readability foot and ankle orthopedic radiology reports. Methods: The radiology reports from 100 foot or ankle X-Rays, 100 computed tomography (CT) scans and 100 magnetic resonance imaging (MRI) scans were randomly sampled from the institution’s database. The following prompt command was inserted into the AI-LLM. “Explain this radiology report to a patient in layman's terms in the second person. [Report Text]”. The mean report length, Flesch reading ease score (FRES) and Flesch-Kincaid reading level (FKRL) were evaluated for both the original radiology report and the AI-LLM generated report. The accuracy of the information contained within the AI-LLM report was assessed via a 5-point Likert scale. Additionally, any “hallucinations” generated by the AI-LLM report were recorded. Results: There was a statistically significant improvement in mean FRES scores in the AI-LLM generated X-Ray report (33.8±6.8 to 72.7±5.4), CT report (27.8±4.6 to 67.5±4.9) and MRI report (20.3±7.2 to 66.9±3.9), p< 0.001. There was also a statistically significant improvement in mean FKRL scores in the AI-LLM generated X-Ray report (12.2±1.1 to 8.5±0.4), CT report (15.4±2.0 to 8.4±0.6) and MRI report (14.1±1.6 to 8.5±0.5), p< 0.001. Superior FRES scores were observed in the AI-LLM generated X-Ray report compared to the AI-LLM generated CT report and MRI report, p< 0.001. The mean Likert score for the AI-LLM generated X-Ray, CT and MRI report was 4.0±0.3, 3.9±0.4, and 3.9±0.4, respectively. The hallucination rate in the AI-LLM generated X-Ray report, CT report and MRI report was 4%, 7% and 6%, respectively. Conclusion: AI-LLM was an efficacious tool for improving the readability of foot and ankle radiological reports across multiple imaging modalities. Superior FRES scores together with superior Likert scores were observed in the X-Ray AI-LLM reports compared to the CT and MRI AI-LLM reports. This study demonstrates the potential use of AI-LLMs as a new patient-centric approach for enhancing patient understanding of their foot and ankle radiology reports.

Category: Sports; Other Introduction/Purpose: The purpose of this study was to assess outcomes following acute Achilles tendon ruptures (AATR) sustained by athletes participating in the National Hockey League (NHL). Methods: Athletes participating in the NHL who sustained an AATR were identified using a publicly available database, match reports and injury reports. The years of inclusion was from 2008-2022. Data collected and analysed: player demographics, player position, if surgical intervention was warranted, rates of return to play, time to return to play, games missed. Pre-injury and post-injury performance outcomes collected and analysed: games played, plus/minus rating, assists, goals, game-winning goals, penalty minutes, power play assists, power play goals, production, points, short-handed assists, short-handed goals, shootout goals, shooting percentage and time on ice per game. Results: Eighteen athletes sustained an AATR in the NHL (0.000481 per 10,000 athlete-exposures). The mean age was 27.9±3.6 years and the mean BMI was 26.3±1.6kg/m 2 . There were 7 (38.9%) AATRs sustained by defenseman, 7 (38.9%) AATRs sustained by centers, 1 (5.6%) AATR sustained by right wings, 1 (5.6%) AATR sustained by left wings, 1(5.6%) AATR sustained by goaltenders and 1 (5.6%) AATR sustained by forwards. Seventeen athletes (94.4%) underwent surgical intervention. The mean number of games played prior to injury was 480.2±240.6. The RTP rate to the NHL was 88.8% at mean time of 4.8 ± 2.5 months. The mean number of games missed due to injury was with 45.1±19.4 games. There was no statistically significant difference in pre-injury performance outcomes compared to post-injury performance outcomes (p>0.05). Conclusion: This current study found that AATRs were an uncommon injury in the NHL with an incidence of 0.000481 per 10,000 athlete-exposures over a 14 year period. Sustaining an AATR was associated with a 88.8% return to play rate to the NHL together at a mean time of 4.8 ± 2.5 months with no deterioration in athletic performance. Although sustaining an AATR in the NHL poses a temporary setback, the findings of this study demonstrate that sustaining an AATR does not have a catastrophic effect on the NHL athlete's career.

Category: Arthroscopy; Other Introduction/Purpose: Posterior Tibial Tendon Insufficiency (PTTI) is a common pathology of the foot and ankle and the leading cause for adult-aquired flatfoot deformity. PTTI typically presents with loss of medial arch of the foot which may progress to hindfoot valgus, forefoot abduction, and development of midfoot osteoarthritis. Following failure of conservative management, tenosynovectomy is indicated in early stage PTTI. However, current tendoscopy techniques lead to significant soft tissue damage. Minimally invasive approaches to these arthroscopic procedures minimize damage to soft-tissue and allow for a much faster recovery. The purpose of this retrospective review is to evaluate the therapeutic and diagnostic potential of In-Office Posterior Tibial Needle Tendoscopy for PTTI. Methods: Chart review was conducted to identify patients who underwent In-Office Posterior Tibial Needle Tendoscopy with a minimum of 1-year follow-up. Data collected and assessed included: patient demographics, pathological characteristics, treatment characteristics, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score, visual analog scale (VAS) scores, return to sport (RTS), and failures. Results: Eleven patients were included at a mean follow-up of 17.4 ± 9.0 months and a mean age of 40.8 ± 14.64 years. Five patients (45.5%) were stage 1 PTTI, 5 patients were stage 2a PTTI and 1 patient was stage 2b PTTI. The mean AOFAS score improved from 45 ± 5.4 preoperatively to 70 ± 18.5 at final follow-up (p< 0.01). The mean VAS improved from 6 ± 0.7 preoperatively to 3.7 ± 1.6 at final follow-up (p< 0.01). The failure rate was 36.3%. All patients with stage 1 PTTI were asymptomatic at final follow-up. Four of the 6 patients (66.7%) with stage 2 PTTI warranted further surgical intervention. Conclusion: This retrospective study demonstrated there is therapeutic and diagnostic potential for In-Office Posterior Tibial Needle Tendoscopy. Patients with early stage PTTI had improved subjective clinical outcomes and rapid return to sport. For moderate to severe PTTI, in-office needle tendoscopy may be less beneficial. Further high quality studies are necessary to determine the optimal role of In-Office Posterior Tibial Needle Tendoscopy in the management of Posterior Tibial Tendon injury.

Category: Ankle Arthritis; Ankle Introduction/Purpose: The TAA was originally introduced in the 1970s and each subsequent generation of implant has been improved upon. Innovative solutions led to second and third generation arthroplasties, which addressed the initial failures and incorporated new designs to improve patients’ lives through significant improvements in pain and function. The Inbone II Total Ankle System was made available in 2009. The successor to the Inbone I, it features pivotal changes to both the tibial stem and talar components. The purpose of this study is to gather intermediate (five or more year follow-up) data on the Inbone II Total Ankle Systems since it's approval in 2009. Methods: The study is retrospective, single-site cohort of patients who have undergone one or multiple surgeries involving the Inbone II Total Ankle System by the senior authors with at least 5 years of follow-up. For patients that are able to be reached, and choose to consent, a prospective clinical visit was conducted. This visit included physical and radiographic assessments, as well as patient-reported outcome measures. Results: Initially, 168 potential patients (77 females and 72 males) and were identified. The average patient was 62.5 years (range: 25 - 88) at surgery. Following retrospective data collection, these post-operative dispositions were noted: (19 (11.3%) declined prospective follow-up, 29 (15.5%) were lost to follow-up, 5 (3%) underwent amputations, 7 (4.2%) were explanted, and 2 (1.2%) expired). Of these, 59 (35%) patients (63 implants) have returned to the office for prospective assessments. Of these, 28 were female, and 31 were male. The mean time from surgery was 7.2 years (6.4 to 10.6). 15 reported complications following the procedure, most commonly noted as residual post-operative swelling (7 patients). Patient satisfaction was noted to be 93% overall, with an average AOFAS score of 84.2% (52 - 100). Conclusion: Preliminary data demonstrates that ankle replacement with the Inbone II device has the equivalent survival rate as that reported in the literature at 5 years post surgery.

Category: Ankle; Other Introduction/Purpose: The purpose of this study was to evaluate the impact on cost effectives with in-office needle arthroscopy (IONA) for the management of anterior ankle pathologies in comparison to anterior ankle arthroscopy performed in a traditional formal operating suite. Methods: Data regarding costs was obtained from the local institution in the following areas: . A Monte Carlo simulation combined with DuPont analysis running 10,000 simulations was conducted to calculate the revenue, expenses and profits between the 2 cohorts. Sensitivity analyses examined the influence of patient preference and revision rates on profit and throughput. Two-sample Student's t test was performed (p < .05). Results: There was a 91.4% reduction in costs in favor of anterior ankle IONA. Sensitivity analysis revealed 4.3% of patients need to select IONA over traditional arthroscopy in an operating suite with the revision rate remaining below 42% for the proposed state profit to be higher than the current state. Conclusion: IONA is a cost-effective alternative to traditional OR arthroscopy in patients undergoing anterior ankle arthroscopy. The next steps are to assess patients' perceptions of IONA as an alternative to traditional OR arthroscopy, and to carry out clinical trials to determine the efficacy, patient-reported outcome metrics, and complications of IONA.

Category: Sports; Other Introduction/Purpose: The purpose of this study was to assess outcomes following acute Achilles tendon ruptures (AATR) sustained by elite rugby union players. Methods: Elite rugby union players who sustained an AATR were identified using a publicly available database, match reports and injury reports. "Elite rugby union" was defined as a player who played professional rugby in the following competitions: United Rugby Championship, Top 14, English Premiership, Super Rugby and international rugby for a top 20 ranked team. The years of inclusion was from 2015-2022. Data collected and analysed: player demographics, player position, if surgical intervention was warranted, rates of return to play (RTP), time to return to play, games missed. Pre-injury and post-injury performance outcomes collected and analysed: games played, tries scored, points scored. Results: Nintety-three elite rugby union players sustained an AATR between 2015-2022 (0.0146 per 10,000 athlete-exposures). The mean age was 27.8±10.1 years and the mean BMI was 30.5±7.6kg/m 2 . There were 61 (65.5%) AATRs sustained by forwards and 32 (34.5%) AATRs sustained by backs. Forty-five (48.3%) of AATRS occurred during the in-season and 48 (51.7%) AATRs occurred during training. All athletes (100%) underwent surgical intervention. The most common mechanism of injury was a non-contact injury (86.4%). The RTP rate was 68.9% at mean time of 8.9±3.9 months. There was a statistically significant decrease in the mean number of games played, tries scored and points scored following RTP. Conclusion: This current study found that AATRs were an uncommon injury in elite rugby union players with an incidence of 0.0146 per 10,000 athlete-exposures. Sustaining an AATR was associated with a 68.9% return to play rate at a mean time of 8.9±3.9 months. There was a statistically significant deterioration in key performance metrics such as mean games played, tries scored and points scored This study reinforces the potentially devastating sequelae following AATR in the elite athletic population.

Category: Sports; Other Introduction/Purpose: The purpose of this study was to assess outcomes following acute Achilles tendon ruptures (AATR) sustained by athletes participating in the Major League Soccer (MLS). Methods: Athletes participating in the MLS who sustained an AATR were identified using a publicly available database, match reports and injury reports. The years of inclusion was from 2008-2022. Data collected and analysed: player demographics, player position, if surgical intervention was warranted, rates of return to play (RTP), time to return to play, games missed. Pre-injury and post-injury performance outcomes collected and analysed: games played, assists, goals, passes, pass %, crosses, shots, shots on target and shot %. Results: Twenty-six athletes sustained an AATR in the MLS (0.008564 per 10,000 athlete-exposures). The mean age was 25.8±8.4 years and the mean BMI was 22.5±6.6kg/m 2 . There were 15 (57.7%) AATRs sustained by defensive players, 5 (19.2%) AATRs sustained by midfield players, 3 (11.6%) AATR sustained by forwards and 3 (11.6%) AATR sustained by goalkeepers. All athletes (100%) underwent surgical intervention. The mean number of games played prior to injury was 164.7±154.9. The RTP rate to the MLS was 73.1% at mean time of 11.1±5.5 months. The mean number of games missed due to injury was with 30.1±11.7 games. There was a statistically significant decrease in the mean number of games played, goals scored and shots taken following RTP. Conclusion: This current study found that AATRs were an uncommon injury in the MLS with an incidence of 0.008564 per 10,000 athlete-exposures. Sustaining an AATR was associated with a 73.1% return to play rate to the MLS at a mean time of 11.1 ± 5.5 months. There was a statistically significant deterioration in key performance metrics such as mean games played, goals scored and shots taken. This study reinforces the potentially devastating sequelae following AATR in the elite athletic population.

Category: Sports; Other Introduction/Purpose: The purpose of this systematic review was to evaluate rates of return to play and levels of performance following acute Achilles tendon ruptures (AATR) in the National Football League (NFL). Additionally, we sought to determine the prevalence rates of AATR and identify any risk factors for the development of AATR. Methods: During November 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following treatment of acute Achilles tendon ruptures (AATR) in the NFL. Twelve studies were included. Results: In total, 676 players (698 Achilles) sustained an AATR in the NFL. The playing positions that sustained the highest rates of AATRs was linebackers (19.0%), wide receivers (11.9%) and running backs (9.0%). 139 AATRs (50.4%) occurred in the preseason, 135 AATRs (48.9%) occurred during the regular season and 2 AATRs (0.7%) occurred during a post-season game. Playing surface was not associated with an increased risk of AATR. The return to play rate was 66.2% at a weighted mean time of 10.9±1.3 months. The mean number of games played per season following AATR was 12.9 games and the weighted mean career length following AATR was 2.2 ± 0.8 seasons. Overall, player performance deteriorated significantly following AATR, as demonstrated by lower power rankings and position specific metrics. Conclusion: This systematic review found was that the proportion of athletes participating in the NFL who returned to play following AATR was 66.2%. Both the mean number of games played per season and the mean number of seasons played decreased significantly following AATR. Overall, player performance deteriorated following AATR, regardless of player position. This study reinforces the potentially devastating sequelae following AATR in the elite athletic population.

Category: Trauma; Ankle Introduction/Purpose: The purpose of this study was to assess outcomes following ankle fractures sustained by elite rugby union players. Methods: Elite rugby union players who sustained an ankle fracture were identified using a publicly available database, match reports and injury reports. "Elite rugby union" was defined as a player who played professional rugby in the following competitions: United Rugby Championship, Top 14, English Premiership, Super Rugby and international rugby for a top 20 ranked team. The years of inclusion was from 2015-2022. Data collected and analysed: player demographics, player position, if surgical intervention was warranted, rates of return to play (RTP), time to return to play, games missed. Pre-injury and post-injury performance outcomes collected and analysed: games played, tries scored, points scored. Results: 107 elite rugby union players sustained an ankle fractures between 2014-2022 (0.0186 per 10,000 athlete-exposures). The mean age was 24.2±9.1 years and the mean BMI was 31.8±8.9kg/m 2 . There were 71 (61.3%) ankle fractures sustained by forwards and 36 (33.6%) ankle fractures sustained by backs. Ninety (84.1%) ankle fractures occurred during the in-season and 17 (15.9%) ankle fractures occurred during training. All athletes (100%) underwent surgical intervention. The most common mechanism of injury was direct trauma to the ankle during a tackle (55.9%). The RTP rate was 78.3% at mean time of 8.9±3.9 months. There was a statistically significant decrease in the mean number of games played, tries scored and points scored following RTP. Conclusion: This current study found that ankle fractures were an uncommon injury in elite rugby union players with an incidence of 0.0186 per 10,000 athlete-exposures. Sustaining an ankle fracture was associated with a RTP rate of 78.3% at mean time of 8.9±3.9 months. There was a statistically significant deterioration in key performance metrics such as mean games played, tries scored and points scored. This study reinforces the potentially devastating sequelae following ankle fractures in the elite athletic population.

Category: Midfoot/Forefoot; Other Introduction/Purpose: The purpose of this systematic review was to evaluate outcomes following surgical intervention for osteochondral lesions of the 1st metatarsal head. Methods: During February 2024, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following surgical intervention for the management of osteochondral lesions of the 1st metatarsal head. Data regarding study characteristics, patient demographics, subjective clinical outcomes, radiological outcomes, complications, and failure rates were extracted and analyzed. In addition, the level of evidence and quality of evidence for each individual study was also assessed. Fifteen studies were included. Results: In total, 324 patients (367 metatarsal) underwent surgical intervention for a 1st metatarsal OCL at a weighted mean follow-up time of 32.1±9.2 months. The mean lesion size was 52.3 ± 8.4 mm2. The most common procedure was osteochondral autograft in 123 cases (19.4%). Other procedures performed included subchondral drilling, particulated juvenile cartilage allograft, osteochondral mosaicplasty, microfracture and anterograde drilling. There were statistically significant improvements in subjective clinical outcomes across all surgical techniques. The overall complication rate was 2.2%, the most common of which was persistent pain (1.5%). There were 29 failures (8.9%) all of which warranted a further surgical procedure. Conclusion: This systematic review demonstrated that osteochondral lesions of the 1st metatarsal head are an uncommon pathology with no consensus regarding the optimal treatment strategy. The most common surgical procedure (osteochondral autograft) restores the osteochondral unit, leading to excellent clinical outcomes at final follow-up. Microfracture destroys the subchondral plate and produces inferior quality fibrocartilage, thus should not be recommended.

Category: Sports; Midfoot/Forefoot Introduction/Purpose: The purpose of this study was to evaluate outcomes following outcomes following plantar condylectomy for the management of plantar plate injuries. Methods: Retrospective chart review identified 20 patients who underwent a PRP injection for the treatment of plantar plate injuries. Pre-operative magnetic resonance imaging (MRI) scans were obtained and the grade of the plantar plate injury was recorded. Clinical outcomes assessed included: pre- and post-operative foot and ankle outcome score (FAOS), visual analog scale (VAS), complications, failures, secondary surgical procedures, and return to sport data. Results: Twenty patients with a mean follow-up time of 32.1±7.8 months were included. There were 0 patients that were grade 1, 5 patients were grade 2 (25.0%) and 15 patients were grade 3 (75.0%). There was a statistically significant improvement in both FAOS (58.1 -> 91.4) and VAS scores (6.5 -> 1.8) following plantar condylectomy for the management of plantar plate injuries. No complications were observed. There was 1 failure, which underwent a scorpion procedure at 15.6 months following plantar condylectomy. 15 patients played sport pre-operatively, all of which (100%) returned to sport at a mean time of 7.5 weeks following plantar condylectomy. Conclusion: This retrospective review demonstrated improvement clinical and functional outcomes following plantar condylectomy for plantar plate injuries. There was a 100% return to sport rate at a mean time of 7.5 weeks. The failure rate was 5.0%. Further comparative studies with longer follow-up are warranted to determine the precise role of plantar condylectomy for the management of plantar plate injuries.

Category: Ankle; Sports Introduction/Purpose: The purpose of this study was to evaluate outcomes following autologous osteochondral transplantation (AOT) for the treatment of osteochondral lesions of the talus (OLT) at a minimum of 10-year follow-up. Methods: Retrospective chart review identified patients who underwent AOT for the treatment of OLT. Pre-operative magnetic resonance imaging (MRI) scans were obtained in all patients. Clinical outcomes assessed included: pre- and post-operative foot and ankle outcome score (FAOS), visual analog scale (VAS), patient satisfaction, complications, failures and secondary surgical procedures. Results: Thirty-nine patients with a mean lesion size was 122.3±64.1 mm 2 and mean follow-up time of 138.9±16.9months were included. The mean FAOS scores improved from a preoperative score of 51.9±16.0 to 75.3±21.9 (p < 0.001). Increasing lesion size was variable associated with inferior FAOS scores (R2=0.2228). There was statistically significant higher mean T2 relaxation values at the superficial layer at the site of the AOT graft (42.9±5.2ms) compared to the superficial layer of the adjacent native cartilage (35.8±3.8ms) (p < 0.001). Seventeen complications (43.6%) were observed, the most common of which was anterior ankle impingement (25.6%). There were 2 failures (5.1%), both of which had a history of prior bone marrow stimulation via microfracture and post-operative cysts identified on MRI. Conclusion: This retrospective review found that AOT for the treatment of large OLTs produced a 94.9% survival rate at a minimum of 10-year follow-up. Increasing lesion size was associated with inferior clinical outcomes. The findings of this study indicates that AOT is a viable long-term surgical strategy for the treatment of large OLTs.

Category: Arthroscopy; Sports Introduction/Purpose: The purpose of this retrospective review is to evaluate the clinical and radiological outcomes following In-Office peroneal Needle Tendoscopy for peroneal tendon dysfunction. Methods: Chart review was conducted to identify patients who underwent In-Office Peroneal Needle Tendoscopy with a minimum of 1-year follow-up. Data collected and assessed included: patient demographics, pathological characteristics, treatment characteristics, American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, visual analog scale (VAS) scores, return to sport (RTS), and failures. Results: Ten cases were included. The mean follow-up was 30±6.3 months and the mean age was 45.27±22.15 years. There were 6 men and 4 women. IONT identified 5 tears that were not identified on pre-operative MRI. The mean AOFAS improvement was not statistically significant from 49.3 ± 8.3 preoperatively to 53.2±19.7 at final follow-up (p=0.45). There was no change in mean VAS at 5.4±2.2 preoperatively to 4.6±2.7 at final follow-up (p=.27). All patients returned to work at an average time of 3 days, however only 2 patients reported returning to their sport at the same level following in-office needle tendoscopy. The complication rate was 50% and the failure rate at final follow-up was 80%. The mean time to failure was 8 months. Conclusion: This retrospective study found that IONT is an effective modality in the management of peroneal tendon dysfunction. In particular, IONT identified peroneal tears that were not captured on pre-operative MRI and thus required treatment in an operating suite. The exact role of IONT for the management of peroneal tendon disorders remains unclear, thus further research is warranted.

Category: Midfoot/Forefoot Introduction/Purpose: The purpose of this systematic review was to evaluate the clinical and radiological outcomes at short-term follow-up following suture button fixation for the management of ligamentous Lisfranc injuries. Methods: During January 2024, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following suture button fixation for the management of ligamentous Lisfranc injuries. Data regarding patient demographics, pathological characteristics, subjective clinical outcomes, radiological outcomes, complications and failure rates were extracted and analysed. Results: Ten studies were included. In total, 100 patients (100 feet) underwent suture button fixation for the management of ligamentous Lisfranc injuries at a weighted mean follow-up of 30.5±10.3 months. The AOFAS score improved from a weighted mean pre-operative score of 52.9±11.8 to a weighted mean post-operative score of 89.0±5.4. The VAS score improved from a weighted mean pre-operative score of 7.7±0.6 to a weighted mean post-operative score of 2.1±0.4. In total, 100% of patients returned to sport at a mean time of 22.3±4.8 weeks. The complication rate was 13.5%, the most common of which was residual midfoot stiffness (3.0%). No failures nor secondary surgical procedures were recorded. Conclusion: This systematic review demonstrated improvement in subjective clinical with a moderate complication rate at short-term follow-up following suture button fixation for the management of ligamentous Lisfranc injuries. No failures nor secondary surgical procedures were recorded. Further high quality comparative studies are warranted to determine the optimal role of suture button fixation in the management of ligamentous Lisfranc injuries.

Category: Midfoot/Forefoot; Other Introduction/Purpose: Cheilectomy of the 1st metatarsophalangeal joint is one of the most common procedures for the management of hallux rigidus. However, there is no consensus regarding outcomes following minimally invasive dorsal cheilectomy (MIDC) for the management of hallux rigidus. The purpose of this systematic review was to evaluate outcomes following MIDC for the management of hallux rigidus. Methods: : During November 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following MIDC for the management of hallux rigidus. In total, 6 studies were included. Results: In total, 348 patients (370 feet) underwent MIDC for hallux rigidus at a weighted mean follow-up of 37.9 ± 16.5 months. The distribution of patients by Coughlin and Shurna's classification was as follows: I (58 patients,27.1%), II (112 patients,52.3%), III (44 patients,20.6%). Three studies performed an additional 1st MTPJ arthroscopy and debridement following MIDC. Retained intra-articular bone debris was observed in 100% of patients in 1 study. The weighted mean AOFAS score improved from a preoperative score of 68.9±3.2 to a postoperative score of 87.1. The complication rate was 8.4%, the most common of which was persistent 1st MTPJ pain and stiffness. Thirty-two failures(8.7%) were observed. Thirty-three secondary procedures(8.9%) were performed at a weighted mean time of 8.6±3.2 months following the index procedure. Conclusion: This systematic review demonstrated improvements in subjective clinical outcomes together with a moderate complication rate following MIDC for the management of hallux rigidus at short-term follow-up. A moderate re-operation rate at short-term follow-up was recorded. The marked heterogeneity between included studies and paucity of high quality comparative studies limits the generation of any robust conclusions.

ABSTRACT Genetic mixing aims to increase the genetic diversity of small or isolated populations, by mitigating genetic drift and inbreeding depression, either by maximally increasing genetic diversity, or minimising the prevalence of recessive, deleterious alleles. However, few studies investigate this beyond a single generation of mixing. Here, we model genetic mixing using captive, low‐diversity recipient population of the threatened Southern brown bandicoot (Isoodon obesulus) over 50 generations and compare wild populations across south‐eastern Australia as candidate source populations. We first assess genetic differentiation between 12 populations, including the first genomic assessment of three mainland Australian and three Tasmanian populations. We assess genetic diversity in the 12 populations using an individualised autosomal heterozygosity pipeline, using these results to identify a candidate recipient population for genetic mixing simulations. We found that populations fell into four major groups of genetic similarity: Adelaide Hills, western Victoria, eastern Victoria, and Tasmania, but populations within these groups were also distinct, and additional substructure was observed in some populations. Our autosomal heterozygosity pipeline indicated significant variability in mean heterozygosity between populations, identifying one extremely genetically degraded population on Inner Sister Island, Tasmania. Genetic mixing simulations of a low heterozygosity captive population in Victoria suggested the greatest increase in heterozygosity would be reached by using highly differentiated populations as mixing sources. However, when removing populations that may represent taxonomically discrete lineages, neither metrics of differentiation nor heterozygosity was strongly correlated with modelled heterozygosity increase, indicating the value of simulation‐based approaches when selecting source populations for population mixing.

Category: Ankle; Sports Introduction/Purpose: The purpose of this prospective study was to evaluate the quality of the reparative cartilage during second-look needle arthroscopy following talar osteoperiostic grafting from the iliac crest (TOPIC) and autologous osteochondral transplantation (AOT) procedures for the management of large osteochondral lesions (OCLs) of the talus. Methods: Patients who underwent second-look needle arthroscopy following either TOPIC or AOT procedure were prospectively recruited. The primary outcome was the assessment of the quality of the reparative cartilage via second-look needle arthroscopy scored by the International Cartilage Repair Society (ICRS) score. The secondary outcomes were the number and nature of ad-hoc needle arthroscopy interventions and complications associated with these interventions. Results: Five patients underwent second-look needle arthroscopy following TOPIC procedure and 11 patients underwent second-look in-office needle arthroscopy following AOT. The mean ICRS in the TOPIC cohort was 9.4 ± 1.0 at a mean time of 24.4 months following the index procedure. The mean ICRS in the AOT cohort was 10.6 ± 1.3 at a mean time of 58.8 months following the index procedure. No complications were observed in either cohort. Conclusion: This study demonstrated that AOT and TOPIC lead to high-quality reparative cartilage at short-term to mid-term follow-ups, but further studies with larger patient cohorts and longer follow-ups are warranted. Furthermore, second-look needle arthroscopy is a safe and viable minimally invasive procedure that can effectively evaluate the quality of reparative cartilage following surgical intervention for OCLs of the talus. In addition to arthroscopic evaluation of the reparative cartilage, this procedure has therapeutic capabilities and can resect bony and soft tissue sources of anterior ankle impingement.

Category: Ankle Arthritis; Ankle Introduction/Purpose: Social determinants of health (SDOH) encompass environmental, institutional, and intrinsic conditions that can influence an individual's access to and utilization of healthcare over their lifespan. While SDOH effects are linked to disparities in patient-reported outcomes post hip and knee arthroplasty, their impact on total ankle arthroplasty (TAA) remains unclear. This study sought to examine how SDOH factors affect access to appropriate orthopedic treatment and their repercussions on patient-reported outcomes following TAA. Methods: In January 2024, a systematic review of the PubMed, Embase and the Cochrane Library was conducted to identify studies reporting at least 1 SDOH and its effect on access to health care, clinical outcomes, or patient-reported outcomes following TAA. Results: Fifty-eight studies, involving 212,944 patients, were analyzed. The INBONE system emerged as the most utilized Total Ankle Arthroplasty (TAA) system. Factors contributing to healthcare access delays included female gender, advanced age, worker's compensation claims, comorbidities, tobacco use, federally subsidized insurance, lower education, racial/ethnic minority status, low-income residence, low-volume surgery regions, unemployment, and preoperative narcotic use. Black patients experienced significantly worse postoperative clinical and patient-reported outcomes, along with heightened pain following TAA. Lower education level independently predicted poor surgical and patient-reported outcomes, increased pain, and lower patient satisfaction. Moreover, patients with federally subsidized insurance demonstrated significantly worse postoperative clinical and patient-reported outcomes. Conclusion: The impediments created by SDOH lead to worse clinical and patient-reported outcomes following TAA including increased risk of postoperative complications, TAA failure, higher rates of revision surgery, and decreased ability to return to work. Orthopedic surgeons, policy makers, and insurers should be aware of the aforementioned SDOH as markers for characteristics that may predispose to inferior outcomes following RCR.

Category: Sports; Arthroscopy Introduction/Purpose: Graft transplantation is a widely used treatment for large osteochondral lesions of the talus. However, cyst formation surrounding the graft is of concern. The primary purpose was to assess and compare cystic occurrence after autografting, allografting and osteoperiosteal grafting for osteochondral lesions of the talus. Our secondary aim was to assess correlation of clinical outcomes with the presence of postoperative cysts. Methods: A literature search was performed up to October 2023 through PubMed, Embase (Ovid), and Cochrane Library. The primary outcome was the postoperative cystic occurrence rate. A random effects model with moderator analysis was used to calculate differences in occurrence rates between treatment groups. The relationship between the presence of cysts and clinical outcomes was additionally described. Results: Thirteen studies were included with 382 ankles that were radiologically assessed at follow-up after osteochondral autograft, allograft, and osteoperiosteal transplantation. The rates of cystic occurrence for the osteochondral autograft transplantation group, the allograft transplantation group, and the osteoperiosteal transplantation group were 42% (95% CI 24-61), 58% (95% CI 40-74), and 34% (95% CI 12-67), respectively, without any significant differences noted between these treatment groups. Six studies studied the relationship between the presence of cysts and clinical outcomes: none of these studies found a significant relationship between these two variables. Conclusion: Postoperative cystic occurrence is common after osteochondral autograft transplantation (42%), allograft transplantation (58%), and osteoperiosteal transplantation (34%) in osteochondral lesions of the talus – without significant intertreatment differences. The postoperative presence of cysts was not correlated with clinical outcomes.

Background: To demonstrate the safety and performance of the Arrow EZ-IO Intraosseous Vascular Access System, particularly in the pediatric patient population, a retrospective observational study was conducted in 2021 and 2022. Methods: Following study design, IRB approval, and investigator selection, data were collected for all patients needing intraosseous access—adult and pediatric. The primary endpoint was the success rate for achieving intraosseous access; the secondary endpoint was the rate of adverse events. Following initial data collection, additional data were collected and a sub-set analysis was conducted to demonstrate the same in pediatric patients only, which is the focus of this report. Results: Data for 106 pediatric cases were collected. The success rate for achieving intraosseous access and infusion was 96.2%. There were three adverse events in two patients (1.9%); none serious or previously unreported. The mean duration of device use was 60 h (SD = 46). For 46 patients, the device was used for up to 48 h, and for another 45 patients, the device was used for a longer duration. Conclusions: This report is the first characterization of the safety and performance of the Arrow EZ-IO Intraosseous Vascular Access System when used in the pediatric population for longer dwell times (>24 h), with no serious complications reported. Performance and safety objectives were met. The results of this real-world evidence study are in alignment with findings from the clinical literature concluding that, for pediatric patients, the Arrow EZ-IO Intraosseous Vascular Access System is safe and effective for providing vascular access in urgent, emergent, and medically necessary situations, in which intravenous access is difficult or impossible to obtain. In addition, this study supports the use of intraosseous access for dwell times greater than 24 h.

Background Diabetic retinopathy is a major cause of sight loss in people with diabetes. The most severe form, proliferative diabetic retinopathy, carries a high risk of vision loss, vitreous haemorrhage, macular oedema and other harms. Panretinal photocoagulation is the primary treatment for proliferative diabetic retinopathy. Anti-vascular endothelial growth factor drugs are used to treat various eye conditions and may be beneficial for people with diabetic retinopathy. Objective To investigate the efficacy and safety of anti-vascular endothelial growth factor therapy for the treatment of diabetic retinopathy when compared to panretinal photocoagulation. Methods A systematic review and network meta-analysis of all published randomised controlled trials comparing anti-vascular endothelial growth factor (alone or in combination with panretinal photocoagulation) to panretinal photocoagulation in people with diabetic retinopathy. The database searches were updated in May 2023. Trials where the primary focus was treatment of macular oedema or vitreous haemorrhage were excluded. Results A total of 14 trials were included: 3 of aflibercept, 5 of bevacizumab and 6 of ranibizumab. Two trials were of patients with non-proliferative diabetic retinopathy; all others were in proliferative diabetic retinopathy. Overall, anti-vascular endothelial growth factor was slightly better than panretinal photocoagulation at preventing vision loss, measured as best corrected visual acuity, at up to 2 years follow-up [mean difference in the logarithm of the minimum angle of resolution −0.089 (or 3.6 Early Treatment Diabetic Retinopathy Study letters), 95% confidence interval −0.180 to −0.019]. There was no clear evidence of any difference between the anti-vascular endothelial growth factors, but the potential for bias complicated the comparison. One trial found no benefit of anti-vascular endothelial growth factor over panretinal photocoagulation after 5 years. Anti-vascular endothelial growth factor was superior to panretinal photocoagulation at preventing macular oedema (relative risk 0.29, 95% confidence interval 0.18 to 0.49) and vitreous haemorrhage (relative risk 0.77, 95% confidence interval 0.61 to 0.99). There was no clear evidence that the effectiveness of anti-vascular endothelial growth factor varied over time. Conclusions Anti-vascular endothelial growth factor injections reduce vision loss when compared to panretinal photocoagulation, but the benefit is small and unlikely to be clinically meaningful. Anti-vascular endothelial growth factor may have greater benefits for preventing complications such as macular oedema. Observational studies extending follow-up beyond the 1-year duration of most trials are needed to investigate the longer-term effects of repeated anti-vascular endothelial growth factor injections. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR132948. Plain language summary People with diabetes are at risk of gradually losing their sight. This is because blood vessels in the part of the eye called the retina may become damaged, leading to sight loss. This condition is called diabetic retinopathy. People with a more severe type of retinopathy, called proliferative diabetic retinopathy, are usually offered laser treatment to reduce the risk of further sight loss. Recently, drugs called anti-vascular endothelial growth factor drugs, which are injected directly into the eye, have been used to treat other eye conditions, and might be useful to treat retinopathy. This project investigated whether anti-vascular endothelial growth factor therapy is effective by identifying and re-analysing all the clinical trials that used the three main anti-vascular endothelial growth factor drugs (called aflibercept, bevacizumab and ranibizumab) to treat diabetic retinopathy. We identified 14 relevant clinical trials, including approximately 1800 persons. Our analyses found that anti-vascular endothelial growth factor injections were slightly better than laser therapy at maintaining vision. After 1 year, people with proliferative retinopathy who received anti-vascular endothelial growth factor injections could, on average, read three or four more letters on a standard eye test chart than people who had received laser therapy. This difference may be too small to make anti-vascular endothelial growth factor injections worthwhile. People with less severe forms of retinopathy saw no benefit in vision after receiving anti-vascular endothelial growth factor therapy. We did find that people who received anti-vascular endothelial growth factor injections were substantially less likely to experience some of the more severe consequences of vision loss, including where vision is lost in the centre of the eye (called diabetic macular oedema), and where blood leaks into the eye (called vitreous haemorrhage). Most of the trials lasted for 1 year or less, so the long-term impact of using anti-vascular endothelial growth factor injections is still not well understood. This long-term impact of anti-vascular endothelial growth factor use requires further clinical research.

Background: Despite extensive theoretical debate, empirical research on medical aid in dying (MAID) largely has disregarded broader, contextual factors as potential correlates of attitudes in hospice clinicians. Objective: Informed by institutional theory and neofunctional attitude theory, the objective of the current study was to quantitatively examine hospice clinicians’ attitudes toward MAID as functions of institutional characteristics relating to (Aim 1) individual adherence to hospice values and (Aim 2) state law. Design: We used a cross-sectional design. Methods: A national convenience sample of interdisciplinary hospice clinicians recruited through US professional membership associations self-administered an online survey. Measures included attitudes toward MAID, attitudes toward the hospice philosophy of care, attitudes toward the principle that hospice care should not hasten death, orientation toward patient-centeredness, professional exposure to working in a state where MAID is legal, and demographic characteristics. Data were analyzed via a partial proportional odds model. Results: The sample ( N = 450) comprised hospice physicians (227 [50.4%]), nurses (64 [14.2%]), social workers (74 [16.4%]), and 85 chaplains (85 [18.9%]). Results of the partial proportional odds model indicated that professional exposure to working in a state where MAID is legal was significantly associated with over twice the cumulative odds of MAID support. Although neither orientation toward patient-centered care nor attitudes toward the hospice philosophy of care was significantly associated with attitudes toward MAID, results showed that disagreement with the narrower principle that hospice care should not hasten death was significantly associated with 6-to-7 times the cumulative odds of MAID support. Conclusion: Findings suggest that contextual factors—namely, the environments in which hospice clinicians practice—may shape attitudes toward MAID. Unanticipated results indicating that hospice professionals’ adherence to hospice values was not significantly associated with attitudes toward MAID underscore the need for further research on these complex associations, given previous theoretical and empirical support.

Summary: Background: There is a significant association between low vitamin D levels at diagnosis of indolent B-cell lymphomas and inferior overall survival (OS). To determine whether supplemental vitamin D improves event-free survival (EFS) in these patients, we conducted a comparative double-blind study of vitamin D3 vs. placebo. Methods: In this phase 3, randomized, double-blind, placebo-controlled trial, patients with low tumor burden follicular, marginal zone or small lymphocytic lymphoma, age 18 or older, with stage two or greater disease and no prior systemic treatment were enrolled at 7 academic cancer centers. Patients were stratified by histology and FLIPI (Follicular Lymphoma International Prognostic Index) score and randomized 2:1 to receive 2000 IU vitamin D3 or placebo daily beginning on day one with rituximab 375 mg/m2 administered weekly times four. 257 patients were assessed for participation: 24 were not eligible and 22 refused. Patients with stable disease or disease progression at week 13 counted as events; responding patients continued treatment with vitamin D or placebo until progression for up to three years. The primary endpoint was EFS, defined as the time from randomization to lack of response at week 13, initiation of a new treatment, disease progression or death. Secondary endpoints included week 13 response and OS. This trial is registered at clinicaltrials.gov, NCT03078855. Findings: 206 evaluable patients (135 on vitamin D and 71 on placebo) were enrolled between September 2017 and March 2022 with a median EFS follow-up of 19.6 months (IQR, 9.3–33.5). The median age was 62 years (IQR, 54–70); 118 (57%) female; 182 (89%) white. At week 13 the mean vitamin D level increased to 41.6 ng/mL (SD 10.1) in the vitamin D arm vs. remaining stable (31.3 ng/mL, SD 11.2) in the placebo arm. There was insufficient evidence of a difference in EFS between the two arms (P = 0.26): three-year EFS in the vitamin D arm was 47.7% (95% CI, 39.0–58.4) compared to 49.5% (95% CI, 37.6–65.0) in the placebo arm. There was no difference in week 13 response between the arms (both 84%). Adverse events associated with vitamin D supplementation were rare. The median OS follow-up was 35.1 months (IQR, 22.9–45.1), overall survival was 96.6% (95% CI, 93.1–98.6) and there was no significant difference between the vitamin D and placebo arms (P = 0.47). Interpretation: As tested in this study, there is no benefit to routine vitamin D supplementation in patients with indolent lymphoma treated with rituximab. These results have implications for ongoing and planned studies of vitamin D supplementation in other malignancies. Funding: This study was funded by the National Institutes of Health, National Cancer Institute grant R01CA214890.

Background Adolescence is a critical period for the maturation of complex cognitive functions like reward, motivation, and behavioural control. (1) This period is also characterized by the maturation of the [...], Background: Critical adolescent neural refinement is controlled by the DCC (deleted in colorectal cancer) protein, a receptor for the netrin-1 guidance cue. We sought to describe the effects of reduced DCC on neuroanatomy in the adolescent and adult mouse brain. Methods: We examined neuronal connectivity, structural covariance, and molecular processes in a DCC-haploinsufficient mouse model, compared with wild-type mice, using new, custom analytical tools designed to leverage publicly available databases from the Allen Institute. Results: We included 11 DCC-haploinsufficient mice and 16 wild-type littermates. Neuroanatomical effects of DCC haploinsufficiency were more severe in adolescence than adulthood and were largely restricted to the mesocorticolimbic dopamine system. The latter finding was consistent whether we identified the regions of the mesocorticolimbic dopamine system a priori or used connectivity data from the Allen Brain Atlas to determine de novo where these dopamine axons terminated. Covariance analyses found that DCC haploinsufficiency disrupted the coordinated development of the brain regions that make up the mesocorticolimbic dopamine system. Gene expression maps pointed to molecular processes involving the expression of DCC, UNC5C (encoding DCC&apos;s co- receptor), and NTN1 (encoding its ligand, netrin-1) as underlying our structural findings. Limitations: Our study involved a single sex (males) at only 2 ages. Conclusion: The neuroanatomical phenotype of DCC haploinsufficiency described in mice parallels that observed in DCC- haploinsufficient humans. It is critical to understand the DCChaploinsufficient mouse as a clinically relevant model system.

BackgroundWe aimed to identify factors associated with a significant reduction in SLE disease activity over 12 months assessed by the BILAG Index.MethodsIn an international SLE cohort, we studied patients from their 'inception enrolment' visit. We also defined an 'active disease' cohort of patients who had active disease similar to that needed for enrolment into clinical trials. Outcomes at 12 months were; Major Clinical Response (MCR: reduction to classic BILAG C in all domains, steroid dose of ≤7.5 mg and SLEDAI ≤ 4) and 'Improvement' (reduction to ≤1B score in previously active organs; no new BILAG A/B; stable or reduced steroid dose; no increase in SLEDAI). Univariate and multivariate logistic regression with Least Absolute Shrinkage and Selection Operator (LASSO) and cross-validation in randomly split samples were used to build prediction models.Results'Inception enrolment' (n = 1492) and 'active disease' (n = 924) patients were studied. Models for MCR performed well (ROC AUC = .777 and .732 in the inception enrolment and active disease cohorts, respectively). Models for Improvement performed poorly (ROC AUC = .574 in the active disease cohort). MCR in both cohorts was associated with anti-malarial use and inversely associated with active disease at baseline (BILAG or SLEDAI) scores, BILAG haematological A/B scores, higher steroid dose and immunosuppressive use.ConclusionBaseline predictors of response in SLE can help identify patients in clinic who are less likely to respond to standard therapy. They are also important as stratification factors when designing clinical trials in order to better standardize overall usual care response rates.

Studies of voluntary visual spatial attention have used attention-directing cues, such as arrows, to induce or instruct observers to focus selective attention on relevant locations in visual space to detect or discriminate subsequent target stimuli. In everyday vision, however, voluntary attention is influenced by a host of factors, most of which are quite different from the laboratory paradigms that use attention-directing cues. These factors include priming, experience, reward, meaning, motivations, and high-level behavioral goals. Attention that is endogenously directed in the absence of external attention-directing cues has been referred to as "self-initiated attention" or, as in our prior work, as "willed attention" where volunteers decide where to attend in response to a prompt to do so. Here, we used a novel paradigm that eliminated external influences (i.e., attention-directing cues and prompts) about where and/or when spatial attention should be directed. Using machine learning decoding methods, we showed that the well known lateralization of EEG alpha power during spatial attention was also present during purely self-generated attention. By eliminating explicit cues or prompts that affect the allocation of voluntary attention, this work advances our understanding of the neural correlates of attentional control and provides steps toward the development of EEG-based brain-computer interfaces that tap into human intentions.