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Category: Ankle; Midfoot/Forefoot Introduction/Purpose: Minimally invasive surgical (MIS) techniques have been implemented in various foot and ankle procedures, including joint arthrodesis. While these techniques can be effective in reducing complications and improving outcomes, there remains variability with surgeon learning curves, the type of instruments used, and approach to intraoperative imaging. This study seeks to aid surgeons through more reproducible guidelines by measuring the time needed for joint preparation with an MIS specific burr. Methods: A total of 8 cadaveric limbs (4 left and 4 right feet) were used for the preparation of the 1st metatarsophalangeal (MTP), 1st tarsometatarsal (TMT), talonavicular (TN), subtalar and ankle joints. The active burr use time to debride all cartilage from each joint was recorded. Each joint was prepared with an open approach to precisely determine the amount of time needed for cartilage removal. Descriptive statistics and a Kruskal-Wallis with post-hoc comparisons were used to analyze the data. Results: The 1st MTP was prepared with a mean (SD) time of 54.49 (34.65) seconds; the 1st TMT 51.82 (19.69) seconds; the TN joint 87.89 (43.77) seconds; the subtalar joint 59.46 (37.84) seconds; and the ankle joint 95.59 (54.99) seconds. Only the ankle joint preparation times compared with 1st MTP, 1st TMT and subtalar joints were significantly longer. Conclusion: This study provides burr time metrics for joint debridement in MIS foot and ankle arthrodesis procedures. Although there remains variability in types of burrs used, joint sizes and individual experience with the instruments, the timing of joint preparation can be an objective reference for surgeons to effectively and safely perform minimally invasive techniques. Figure 1. Comparison of joint preparation time across different joints The error bars depict one standard deviation of uncertainty. Asterisk (*) lines indicate a statistically significant difference (P < 0.05) based on unadjusted P values from the Dunn post hoc group comparisons. *Abbreviations: metatarsophalangeal (MTP), tarsometatarsal (TMT), talonavicular (TN).

Category: Ankle; Trauma Introduction/Purpose: Ankle fracture fixation can benefit from minimizing postoperative complications, particularly with wound healing and infection. Less invasive implant options necessitating smaller incisions have emerged, including the fibular intramedullary nail (i.e. Arthrex Fibulock) to minimize incisions and potentially allow earlier mobilization. The purpose of this study is to investigate the efficacy and clinical outcomes of a fibular intramedullary nail (Arthrex Fibulock) in ankle fracture treatment across a diverse patient cohort. Methods: A retrospective chart review from 2018 to 2022 was conducted in order to determine eligible patients. Inclusion criteria included adult patients treated for an ankle fracture with at least 3 months of follow-up and sufficient imaging available. Exclusion criteria included open fractures, other concomitant injuries, pilon and tibial shaft fractures, or previous ankle surgery. Results: A total of 132 patients were consecutively included, 44 in the conventional fixation group (33.33%) and 88 in the fibular nail group (66.67%). 4 out of 88 fibular nail patients (4.55%) and 3 out of 44 conventional patients (6.82%) had a postoperative infection (P = .43). 8 fibular nail (9.09%) and 6 conventional (13.64%) fixation patients underwent hardware removal postoperatively, which was not statistically significantly different (P = .55). Conclusion: This study shows no difference between the fibular nail device and a conventional plate and screw fixation approach in the treatment of ankle fractures when looking at postoperative infection and removal of hardware rates. The rate of postoperative infection and hardware removal trended higher in the conventional fixation patients but did not reach statistical significance. As such, the use of the fibular nail may offer a viable alternative for all patients undergoing ankle fracture operative treatment.

Category: Other; Midfoot/Forefoot Introduction/Purpose: The advent of minimally invasive percutaneous foot and ankle surgery techniques has helped lower certain complication rates, including wound infection and nonunion. The percutaneous burr is the working horse to perform these procedures. One concern with using the burr is that heat generated from prolonged use may induce bone thermal necrosis, affecting healing and outcomes. It is in contention whether further chilling the irrigation fluid may affect postoperative complication rates. Thus, the objective of this study is to assess the impact of chilled vs non-chilled saline during burr use on percutaneous foot surgery. Methods: Data was prospectively collected for 384 consecutive patients undergoing percutaneous foot and ankle surgeries at two separate facilities, treated with either non-chilled saline or chilled saline. Age, sex, complication rates, union rates and time to union data were collected. Categorical and numerical statistical analysis was performed. Results: 384 patients (chilled = 191, non-chilled = 193) were included. The mean age (SD) for all patients was 50.82 (14.28). Time to union took an average (SD) of 9.87 (3.59) weeks for the chilled saline group and 9.27 (2.91) weeks for the non-chilled saline group (P = .07). Union rates were 100% in the chilled saline group and 99.5% in the non-chilled saline group (P = .50). Complication rates were 1.6% in both the chilled and non-chilled saline groups (P = .65). The complications seen in the chilled saline group included one superficial wound dehiscence, and two delayed unions. The non-chilled saline group saw one non-union, one case of sural neuritis and one case of painful hardware removal. Conclusion: Based on the available data, no significant difference could be detected between chilled saline and non-chilled saline groups during burr use for percutaneous foot surgery when comparing union times, union rates and complication rates.

Category: Trauma; Ankle Introduction/Purpose: The modified Charlson Comorbidity Index (mCCI), Elixhauser comorbidity measure (ECM), and 5- factor modified Frailty Index (mFI-5) have been validated for the purpose of outcome prediction in foot and ankle orthopedic care. However, from the perspective of clinical utility, no study has sought to compare the predictive performance of these measures specifically following traumatic ankle fracture. The present study compares the discriminative ability of the mCCI, ECM, and mFI-5, as well as various demographic characteristics, such as age, gender, and race, to predict in-hospital mortality and complications after the surgical management of traumatic ankle fracture. Methods: We performed a retrospective cohort study of adult patients registered in the National Trauma Data Bank (NTDB) 2011-2016 experiencing ankle trauma as malleolar fracture and undergoing surgical management. Patients missing baseline or comorbidity information, dead on arrival, or with a pilon fracture or stress fracture were excluded. Enhanced ICD-9 algorithms were used to calculate mCCI, ECM, and mFI-5 as has been done in prior orthopedic literature. The discriminative ability of the indices for adverse outcomes was assessed using area under the curve analysis from receiver operating characteristic curves. Outcomes included death, severe adverse events (death, deep surgical site infection (SSI), myocardial infarction (MI), cardiac arrest, deep vein thrombosis (DVT), pulmonary embolism (PE), sepsis, stroke, compartment syndrome), minor adverse events (acute kidney injury (AKI), pneumonia, superficial SSI, urinary tract infection (UTI)), infectious events (deep SSI, organ/space SSI, superficial SSI, pneumonia, UTI, catheter-related bloodstream infection, osteomyelitis, sepsis), and any adverse event. Results: In total, 171,097 patients met inclusion criteria. The median age was 50 years and 49% of patients were male. Compared to ECM and mFI-5, mCCI had the largest discriminative ability for the outcome of in-hospital mortality (P=0.02 versus ECM, P

Category: Ankle; Other Introduction/Purpose: Periprosthetic joint infection (PJI) is a devastating complication of arthroplasty. The well known PJI risk factors are useful for identifying high-risk patients but would be even more helpful for clinical decision-making if they are converted to a risk assessment scores. The Mayo Prosthetic Joint Infection Risk Score was based on the data of total hip and knee arthroplasty and has not been validated for application for total ankle arthroplasty. Methods: A series of 398 consecutive cases of total ankle arthroplasty, with minimal follow-up of 6 months, was reviewed for Mayo Periprosthetic Joint Infection Risk Score (Mayo score) and PJI. The patients' Mayo scores and PJI was examined by logistic regression. T-test was performed to compare the Mayo score between the non-infected TAA cases and infected cases. Receiver Operating Characteristic (ROC) was used to identify the critical value of Mayo score for total ankle arthroplasty. Results: There were 12 cases of PJI or 3.0% in the series. Of the 398 patients, the Mayo scores were in the range from -4 to 13 (median 2; interquartile range (IQR) 0-4). Preliminary analysis showed that, by logistic regression, the probability of PJI was increased as increases of the Mayo scores (Fig A). The mean Mayo score of the PJI patients (8.6+-1.8) was significantly greater than the rest of the patients (mean Mayo score 1.9+-3.4; p < .0001). ROC analysis showed that, when a Mayo score was greater than 5, the patient has a high probability of PJI (sensitivity = 100%; specificity = 86.9%; Fig B). Conclusion: This study showed a high correlation between the Mayo score and PJI in total ankle arthroplasty, which is the same trend as in total knee and hip arthroplasty. The preliminary results suggest that strategically focusing on the patients, who have a Mayo score > 5, could be a more efficient approach to prevent PJI after total ankle arthroplasty.

Category: Basic Sciences/Biologics; Hindfoot; Trauma Introduction/Purpose: Three dimensional printing is an actively emerging field within the realm of medical devices. This technology expands therapeutic options and customization of implants to individual patients. The ability to create products that replicate normal bony anatomy has been a significant advancement in the setting of difficult clinical scenarios. 3-D generated, custom implants increase the potential for joint and limb salvage with the goal of improving functional outcomes. We present a technical tip for utilizing 3-D printing technology to create custom, anatomically-matched antibiotic cement spacers for limb- salvage applications. We present two illustrative cases and share our experiences, lessons learned, and a succinct review of the pertinent literature merging 3-D printing and the use of antibiotic cement as temporary and permanent reconstructive solutions. Methods: While the majority of 3-D printing is done for the purpose of generating devices for implantation, we present a technical tip for designing a 3-D printed mold from which to create an antibiotic cement spacer for implantation. Two case illustrations demonstrate comorbid patients presenting with infected implants, osteomyelitis, bone loss, deformity and wound dehiscense. We describe the process of patient selection, implant design, fabrication, and implantation of a custom molded antibiotic cement talus for the purpose of limb salvage. Results: Case illustrations present two successful limb salvage patients while giving a thorough explanation of our technique, learned tips and tricks. This applied technology builds on prior use of antibiotic cement in limb salvage of the lower extremity, most of which is joint sacrificing. 3-D printing the mold for an anatomic talus cement spacer results in a joint sparing limb salvage solution. Conclusion: Utilization of currently available 3-D printing technology as applied to production of anatomic cement spacers should be considered to enhance limb salvage. This innovative application of printing technology is merged with current, pertinent literature regarding antibiotic cement to offer surgeons expanded options for temporary or definitive reconstructive techniques in some of the most challenging patients.

Category: Ankle; Ankle Arthritis; Other Introduction/Purpose: Periprosthetic infection is a devastating complication in total ankle arthroplasty (TAA). Measures that can reduce or eliminate infection occurrence are warranted for further investigation, particularly if they also minimize added costs, operative time or potential adverse effects. There remains insufficient evidence to show definitive benefits or risks associated with use of local antibiotics such as vancomycin for infection prevention. The purpose of this study was to determine the effects of topical vancomycin powder application in TAA and whether it may decrease infection rate in the subacute postoperative period. To our knowledge, this is the first comparative study in a general population undergoing TAA. Methods: A retrospective study was conducted based on a consecutive series of patients who underwent TAA performed by a single senior surgeon. The control group without vancomycin powder was matched to the study group that received application over the implants prior to closure, which was based on when the surgeon transitioned to usage in all patients. Various demographic data for the patients was collected. Only patients with a minimal follow up of 80 days were included in order to capture the perioperative period of infection. Infection rate was based on a definition of deep infection necessitating inpatient hospitalization for IV antibiotics and/or surgical intervention. The associations of various demographic factors and vancomycin application with infection rate were calculated with chi square and odds ratio. Significance level was set to 0.05. Results: A total of 252 patients (n=103 without, and 149 with vancomycin powder) were included in the study. The overall infection rate was 3.2%, which was not correlated with a history of diabetes, BMI, additional concurrent surgery, or age, but was associated with current positive smoking status (p=0.03). The infection rates between the groups that received or did not receive vancomycin powder were not statistically significantly different (2.7% vs 3.9%, respectively, p=0.59). The odds ratio (OR) of infection with vancomycin powder was not statistically significant either, at OR=0.68 (95% CI 0.17-2.81). However, the vancomycin group did have a significantly higher number of patients with previous wound issues (12 vs. 2; p=0.04) and infection (7 vs. 0; p=0.04) as well as concomitant surgeries (81 vs. 41; p=.02). Conclusion: The consequences of periprosthetic TAA infection are substantial, and the risks should be mitigated. Although this study did not detect a statistically significant difference in infection rates between patients who received or did not receive vancomycin powder, there was a trend towards risk reduction by about 30%. In addition, current smoking was found to be significantly associated with higher rates of infection and smoking cessation can serve as another point of intervention. As the complexity of patient factors and indications for performing total ankle arthroplasty expand, vancomycin powder offers a relatively cost-effective, safe, and convenient option to potentially reduce infection.

Category: Ankle; Trauma Introduction/Purpose: Current treatment of ankle fractures is predicated on 1-2 mm of talar shift leading to abnormal contact pressures. Determination of anatomic alignment has conventionally been based on plain radiographs. The ability of x-ray to detect subtle mortise displacement however is unknown. The purpose of this investigation is to determine if CT scan can detect malalignment undetectable utilizing plain radiography when assessing injuries assumed to have anatomic mortise alignment. The findings have implications for utilizing higher resolution diagnostic imaging to assess malalignment and challenging the validity of previous literature in which conclusions of anatomic mortise alignment were determined based on plain radiography. Methods: 24 patients with stress-negative, stable SER-II type ankle fractures were included. Contralateral ankle mortise radiographs were obtained in addition to static and gravity stress radiographs of the injured side. Bilateral CT scans were performed once patients were deemed to have achieved clinical/radiographic healing. Measurements of the medial clear space (MCS) and syndesmosis were performed by two blinded orthopedic surgeons at two different time points. Intraclass correlation coefficients (ICC) were calculated to evaluate the intra- and inter-rater reliability and consistency of measurements. Statistical analyses were performed to determine any differences between x-ray and CT scan measurements to detect discrepancies between the injured and normal ankle measurements. Statistical significance was defined as a two-sided alpha error of less than 0.05 (p < 0.05). Results: Despite plain radiographs demonstrating no statistical side-to-side differences and achieving apparent final anatomic alignment in the majority of the cohort, CT MCS on coronal, axial planes and syndesmosis measurements were significantly different when comparing the injured to the normal contralateral ankle by on average of about 0.5mm. There was also excellent intra and interobserver agreement achieved for the measurements. Conclusion: CT is superior to plain radiography in detecting subtle mortise/syndesmotic displacement and side-to-side differences undetectable by x-ray. These findings challenge conventional assumption of anatomic alignment for SER II injuries and reliance on x-rays to assess anatomic alignment. While injured ankles uniformly demonstrated non-anatomic alignment as compared to the uninjured side, the clinical implications of subtle malalignment are unknown. However, broad reaching implications of this preliminary study include challenging the validity of x-ray to detect possibly clinically-relevant mortise malalignment in patients presenting with isolated lateral malleolus fractures.

Category: Other; Ankle; Arthroscopy; Bunion; Hindfoot; Lesser Toes; Midfoot/Forefoot; Trauma Introduction/Purpose: The COVID-19 pandemic has brought a major increase in telemedicine utilization to conserve resources and maintain social distancing. The rapid transition over a short period of time has exposed challenges and limitations of virtual visits, especially with regards to performing an effective and efficient physical examination. Within months, orthopedic telemedicine guides were published for patient education and facilitating the musculoskeletal examination. These publications, however, included only a short video clip to explain to the patient how to participate in the examination during a telemedicine visit. In the foot and ankle subspecialty, the closely adjacent complex anatomy compared to other areas of the body presents unique challenges for physical exam. Methods: To optimize the efficiency and efficacy of the examination portion of the visit for both patients and providers, we designed and recorded an instructional video that is sent to all patients by email a minimum of 1 week prior to their appointment. This video consists of a step-by-step guide on how to take suitable photos and videos of their feet and ankles for the physical examination portion of their visit. These media files are then directly uploaded by the patients into their EMR or emailed to the physician's office to be uploaded for access by the provider before and during the virtual visit. Along with the video, patients are given a link to test their microphone and camera in advance of the visit to ensure adequate functionality and positioning. Results: Our pre-appointment instructional video has been effective to methodically replicate the most important aspects of an in-person foot and ankle evaluation. Both physicians and patients appear to benefit from the tutorial video by having more time during the telemedicine visit to focus on history, assessment, and plan. Patients are more actively involved in the clinical data collection process because they are educated on what to expect and how to best prepare and participate in telemedicine visits. Moreover, having a set of systematic and detailed photos and recordings of the patient's foot and ankle beforehand better focuses interaction and discussion with the patient during the telemedicine encounter. Additionally, these are saved into the patient's electronic medical record, available for reference and later review. Conclusion: Physical examination plays a critical role in diagnosis and treatment in the orthopedic foot and ankle subspecialty. More research is needed to discern how best to utilize virtual modalities as they become more commonplace, not just from the imposition from the COVID pandemic but also from the standpoint of patient convenience and time efficiency. Here we have described our creation of a pre-visit educational video to guide and engage patients on acquiring invaluable physical examination information for the orthopedic foot and ankle telemedicine encounter.

Category: Trauma Introduction/Purpose: Determining the stability of ankle fractures, particularly for apparent isolated Weber B fibula fractures, can be difficult. While the ultimate goal remains achieving an anatomic mortise, different techniques to predict ankle stability such as stress and weightbearing radiographs have been utilized with variable results. History of injury and the ability to walk after sustaining ankle trauma may be predictive of stability. Therefore, this study seeks to determine whether a patient’s ability to fully weight bear immediately after injury is an effective indicator for ankle stability following ankle fracture. Methods: A prospective review was conducted of patients sustaining isolated, unilateral ankle fractures presenting to two level I trauma centers. Aside from demographic data and fracture characteristics, a patient’s ability or inability to fully weightbear immediately after injury was elicited by interview at their initial assessment. This information was correlated with their ankle radiographs, which were deemed stable or unstable fractures based on commonly used indices to assess ankle stability. Results: 102 consecutive patients sustaining ankle fractures were included. Mean age was 45. When analyzing the entire cohort, patients who were able to ambulate immediately after injury were 10 times more likely to have a stable ankle fracture than those who could not bear weight (odds ratio (OR) 9.9 (P < 0.001). The positive predictive value (PPV) for being able to fully weightbear as it relates to a stable ankle fracture was 77%. Additionally, inability to weightbear was 89% specific for an unstable fracture. When separately analyzing patients with apparent isolated fibula fractures (n=56), the PPV was 75%, specificity was 83%, while the OR was 5.8 (p=0.003) for those who could fully bear weight having a stable ankle fracture. Conclusion: This study demonstrates that patient’s self-reported ability to fully weightbear immediately after injury is a specific and convenient prognostic indicator for ankle stability across a range of ankle fracture subtypes. Future studies can analyze whether initial weightbearing accurately predicts ultimate management and good outcome.