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Category: Ankle; Basic Sciences/Biologics Introduction/Purpose: Peroneal tendon disease (PTD) represents a spectrum of pathologies often misdiagnosed as an ankle sprain. PTD encompasses a spectrum of peroneal tendon pathologies (e.g., tendinosis, tenosynovitis, tears, and instability), resulting in inflammation and/or degeneration of the peroneal tendon and surrounding tenosynovium. While the microenvironment of inflamed joints and tendons has been described for other parts of the human body, this has not been well investigated for patients with PTD. Furthermore, limited consensus exists on the classification of PTD, challenging accurate diagnosis and targeted therapeutic strategies. We aimed to develop a clinically meaningful classification system for PTD incorporating detailed analysis of molecular, cellular, and tissue changes of the tenosynovium surrounding the peroneal tendon. Methods: Patients undergoing surgery for PTD (IRB-approved) were classified using our 5-type classification system (Fig 1A). After classifying PTD, tenosynovium was processed for bulk RNA sequencing (RNA-seq; PTD0 vs PTD1-4; n = 7 for PTD0 and n = 3-7 for PTD1-4), and digital histopathology (DH; n = 1-7/PTD). For RNA-seq, standard Gene Ontology (GO) analysis was used to identify enriched gene pathways. For DH, tenosynovium was paraffin-embedded, sectioned, stained with hematoxylin/eosin, imaged using a slide scanner, and imported into QuPath software for quantification (n = 3 sections/tenosynovium). Briefly, tenosynovium was manually traced, and cellular density (cell numbers/tissue area) was quantified and averaged for each patient’s tenosynovium. A qualitative assessment evaluated the cell spatial distribution relative to tissue structures (e.g., fat, fibrous tissue, and vascularity). Kruskal Wallis with Dunn’s post-hoc was used to detect differences in cellular density between PTD1-4 vs PTD0. Results: We observed distinct transcriptomic signatures between the tenosynovium graded by our classification system (Fig 1D). GO term analysis highlighted increased gene expression associated with biological and molecular pathways related to inflammatory leukocyte and neutrophil activation/migration in PTD1 (Fig 1E). PTD2 was associated with decreased pathways related to glucose and fatty acid metabolism. PTD3 showed increased hemoglobin expression, gas transport, and detoxification (Fig 1E). PTD4 was associated with increased leukocyte activation and chemotaxis (Fig 1E). DH revealed increased cellular density (i.e., hypercellularity) with PTD4 (Figure 1B, C). Qualitatively, cells appeared spatially around vascular/nerve structures and non-fatty-like tissue (Fig 1B). Conclusion: Our novel classification system created to define PTD better demonstrates unique cellular and molecular signatures in each PTD type. Tissue level analysis showed increased cell density around vascular structures with increased PTD type. RNA-seq revealed an increase in inflammation-related gene pathways at PTD types 1 and 2, while pathways related to energy metabolism and detoxification were significantly altered at PTD types 2 and 3. Improved clarity in biological pathways and cellular characterization of the tenosynovium in each classification of PTD will help optimize surgical strategies and allow for personalized therapeutic intervention for PTD.

Category: Ankle; Trauma Introduction/Purpose: Achilles tendon ruptures are a common ankle injury, predominantly affecting young, active, and athletic populations. Surgical repair is often favored in healthy and active individuals due to decreased re-rupture rates. Both open and minimally invasive percutaneous techniques have been described with excellent outcomes and reduced rates of re-rupture compared to non-surgical treatment. However, little research has focused on the impact of time-to-surgery on complications, re- rupture rates, and patient reported outcomes (PROs). The purpose of this study was to investigate outcomes following Achilles repair with respect to time-to-surgery and surgical technique. Outcomes were established both clinically and functionally, as indicated by complication rates and patient-reported outcomes, respectively. Methods: Patient records from a single institution were retrospectively reviewed from October 2016 to March 2022. Patients with an acute Achilles tendon rupture surgically treated within 6 weeks from injury and a minimum follow up of 3 months ± 14 days were eligible for inclusion. Injury and surgical variables included mechanism of injury, rupture grade and location, time-to- surgery, surgical technique, and operative time. Postoperative complications included deep vein thrombosis (DVT), major and minor wound complication, re-rupture, sural nerve injury, and postoperative neuropathic pain. PROs included PROMIS Physical Function CAT (PF), Pain Interference CAT, and Foot and Ankle SANE. Patients were stratified based both by operative technique and time-to-surgery (0-6 days, 7-13 days, and 14-42 days). Categorical variables were compared using Fischer exact tests, while numerical variables were evaluated using an unpaired t-test and ANOVA, depending on the number of groups compared. Results: 327 patients (79% male, mean age 40.4) were included. PRO data was available for 154 (47%). Average clinical and PRO follow-up was 155 days and 575 days, respectively. 149 were treated open, while 178 were percutaneously repaired. No significant differences were observed in complications between treatment groups; however, percutaneous repairs recorded shorter operative times (55.3 vs 65.8 minutes, p< 0.001). Stratifying by timepoints, follow-up physical function scores were significantly higher in patients repaired within 0-6 days (p < 0.05, Figure). There were 11 re-ruptures (3.3%), with 10/11 occurring within 3 months of surgery. Most re-ruptures were attributed to falls (4) and non-compliance (3), while 4 occurred following prescribed protocols. When stratified by time-to-surgery, the fewest re-ruptures (0) were observed for repairs performed 7-13 days following rupture. Conclusion: While no significant differences were observed in PROs or complications rates between open and percutaneous groups, our data suggests that time-to-surgery may play an important role in long-term patient reported physical function. Stratified by surgical timing, we also found significantly lower rates of re-rupture when surgical intervention occurred 7-13 days following injury. However, nearly all re-ruptures occurred within 3-months, with most occurring following postoperative falls or documented patient non-compliance with immobilization or protected weight-bearing instructions. The significance of surgical timing and re-rupture rates therefore requires additional investigation given the low failure rates and mechanisms of re-rupture.

Category: Ankle Arthritis; Arthroscopy; Basic Sciences/Biologics; Trauma Introduction/Purpose: Post-traumatic Osteoarthritis (OA) of the ankle is a debilitating condition that impacts millions of people. However, little is known about the genetic and epigenetic risk factors for progression to OA following injury. In order to better understand these factors, a thorough knowledge of the molecular signature in ankle OA relative to non-arthritic ankles is critical. The objective of this study was to perform RNA-sequencing of ankle joint synovial samples from OA and non-OA ankles to better characterize the synovial transcriptome. We compared synovial gene expression patterns in patients with end-stage OA with ankle synovium from non-OA ankles to investigate the unique biological pathways altered in ankle OA. Methods: Patients undergoing total ankle arthroplasty or ankle arthrodesis for end stage OA and patients undergoing ankle arthroscopic surgery for non-arthritic conditions (negative control), were consented for participation. Patients with immune disorders or inflammatory arthropathies were excluded. Patient demographics and medical history were collected. Synovial samples were harvested during surgery and RNA was isolated. Bulk 150 bp, paired-end RNA seq was performed using the Illumina NovaSeq6000 platform. Differential expression was determined using the edgeR (v3.16.5) package for R, after adjustment using a scaling normalization factor and P-values were corrected using the Benjamini Hochberg method. Similarities between samples were determined using Spearman Correlation and degree of similarity was visualized considering the first three Principal Components. Gene Ontology terms were identified to classify gene properties. Results: A total of 8 synovial samples from total ankle OA and 24 synovial samples from ankle non-OA were available for analysis. We found 808 genes uniquely expressed in OA synovium and another 786 different genes expressed in synovium from the control group. GO enrichment term analysis revealed an upregulation in endomembrane system organization, ubiquitin system/proteasomal degradation, and membrane transport processes including cytoskeletal, endosomal, and vacuolar in ankle OA samples compared to controls (Figure 1). These signatures differ from those previously identified in knee OA. Reactome analysis revealed pathways to those previously identified in OA of other joints, including TGF-beta signaling modulation. However, several signatures unique to ankle OA included extracellular matrix organization, integrin signaling, and AKT signaling modulation, among others. In addition, unlike in knee OA, reactome analyses of ankle OA synovium did not present with an inflammatory component associated with M1 macrophage infiltration. Conclusion: Ankle synovium in patients with end-stage ankle OA exhibit a transcriptomic signature distinct from ankle synovium collected from non-OA patients. More intriguing, we find that the ankle OA synovial transcriptome signature is distinct from previously published datasets studying synovium from patients with OA in other joints, particularly the knee. GO term and Reactome analyses identified signatures in bulk membrane transport, proteasome, matrix organization, integrin signaling, and AKT signaling, which are different from phenotypes previously reported in the knee. We conclude that development of effective disease modifying treatments for OA require attention to joint-specific biology and disease progression.

Category: Ankle; Sports; Trauma Introduction/Purpose: Symptomatic osteochondral lesions of the talus (OLT) are challenging to treat, and large lesions (>10mm) with concomitant subchondral bony defects are particularly challenging. Standard treatments such as bone stimulation are limited and are often restricted to smaller lesions. Particulate and fragmented chondral allograft techniques face limitations with uncontained lesions. Structural allograft/autograft techniques often require removal of regions of native, uninjured bone and may encounter donor issues. Postoperatively, ensuring reliable osseous and cartilaginous healing responses can be difficult. Articular Regional Reconstruction (ARR) is a novel technique combining viable osteochondral allograft with morselized autograft bone to address large OLT lesions with bony defects, whether contained or uncontained. We describe a consecutive series of patients undergoing ARR here. Methods: Patients indicated for the ARR procedure had preoperative MRI and CT imaging identifying large (>10mm), unstable osteochondral lesions with bony defects; 11 consecutive patients that had undergone ARR were identified. OLT lesions were initially inspected arthroscopically, and then converted to open debridement. Medial malleolar osteotomies were used for access when necessary. A stable bony base and viable cartilage rim was established, removing all damaged cartilage and nonstructural material from the OLT and bony defect. Talar body structure and morphology was restored using iliac crest or tibial morselized autograft bone placed in the bony defect. Viable osteochondral allograft (Cartiform) was shaped and then secured over the autograft using suture anchors placed at the lesion periphery. Patient Reported Outcome (PRO) measures included PROMIS- physical function (PROMIS-PF), PROMIS-pain interference (PROMIS-PI), and single assessment numeric evaluation (SANE). Three patients without PRO data were excluded, leaving eight patients with preoperative and postoperative PRO data for analysis. Results: The ARR patients averaged 40 years old (range 28-60) with a mean follow up of 19 months (range 10-38). The lesion surface areas averaged 1.95 cm 2 (range 1.17-2.99 cm 2 ) with a depth of 7.25mm (range 5-9mm). Four were uncontained corner lesions. Postoperative PROMIS-PF improved from 41 to 47 (p = 0.036), and PROMIS- PI improved from 60 to 53 (p = 0.093). Average SANE scores improved from 60 to 69 (p = 0.148). No complications occurred. No revision OLT surgeries were required, though three patients returned to the OR (Two for osteotomy screw removal, one for anterior impingement of opposite corner). During these 'second looks', the implanted cartilage layer was found intact. In a recent survey, all patients indicated they would undergo the procedure again. Conclusion: Articular Regional Reconstruction (ARR) is a reproducible procedure with demonstrated potential for improvement in pain and physical function among patients with symptomatic, large osteochondral lesions of the talus with bony defects, whether 'contained' or 'uncontained'. It has particular utility as an alternative to bulk structural graft salvage procedures among patients who have failed prior procedures, as 5 of the 8 patients had undergone unsuccessful prior surgical intervention for their OLT by outside providers. Further studies on ARR of the talus are necessary to elucidate the prognosis of this procedure, establish indication boundaries, and strengthen long-term outcome data.

Category: Arthroscopy; Ankle; Hindfoot; Sports Introduction/Purpose: Haglund's syndrome is a common cause of posterior heel pain and can be associated with retrocalcaneal bursitis and degenerative Achilles tendinosis. Open approaches for resection of the Haglund's lesion have long been employed in patients that fail to improve with conservative treatment. This often involves partial elevation of the Achilles insertion with reattachment. More recently, endoscopic surgical techniques have evolved, enabling more rapid rehabilitation with less tendon disruption. The decision on the surgical approach is influenced by the degree of insertional Achilles tendinosis with endoscopic techniques preferred in the absence of insertional pathology. The primary objective of this investigation was to report on a large series of patients treated surgically for symptomatic Haglund's lesions. Methods: We reviewed the outcomes of Haglund's syndrome surgical cases at our institution over a five-year period. We included cases with insertional Achilles tendinosis and retrocalcaneal bursitis related to the Haglund's lesion, but excluded revisions and cases involving flexor hallucis longus tendon transfers. We recorded patient demographics, sport and activity level, comorbidities, BMI, duration of symptoms, surgical technique, tourniquet time, rehabilitation protocol, postoperative complications, and duration of postoperative follow-up. We also reviewed relevant preoperative imaging and recorded the presence of Achilles insertional degenerative calcification or an insertional calcaneal enthesophyte on radiographs. We then prospectively administered questionnaires regarding return to sport and patient-reported outcome measures including the SANE, PASS, VISA-A and PROMIS (Physical Function, Pain Interference and Global Health domains). Results: In total, 17 of the 77 (22%) included cases were performed with the endoscopic surgical technique. Six patients underwent bilateral Haglund surgeries during the study period, accounting for 12 of the 77 cases. The open Haglund resection group had a higher rate of concomitant Achilles insertional degenerative calcification on radiographs and MRI (72%). In addition, the open group was older than the endoscopic group (average age 54 vs 45), had a higher rate of comorbidities, higher rate of postoperative complications, and a higher rate of return to the operating room for revision surgery (11% vs 0% for endoscopic). Seventeen patients were elite distance running athletes and were preferentially treated by endoscopic techniques (11/17, 64%). At 24-month follow-up, the majority of patients report return to baseline activity. Conclusion: Patients treated surgically for Haglund's syndrome and insertional Achilles tendinopathy generally have good outcomes. Outcomes are better for endoscopically treated patients compared to open treatment, although these patients tend to be younger, healthier, and have less Achilles tendons disease. Still, some degree of Achilles tendinopathy and limited intrasubstance calcification can be successfully addressed with the endoscopic technique. We are endeavoring to better define indications for, and limitations of, the endoscopic technique for insertional Haglund's disease.

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: Total ankle replacement (TAR) is an effective procedure to help patients with end-stage osteoarthritis regain mobility and function. While previous studies have suggested that pre-operative factors such as stress or depression may influence the success of TAR, there is limited literature investigating this relationship. The goal of this study is to evaluate differences in functional and pain outcomes following TAR from patients with high and average PROMIS depression scores. Methods: Patients enrolled in the Orthopaedic Foot and Ankle Outcomes Research (OFAR) platform who underwent total ankle replacement were retrospectively analyzed. Patients were included if they had PROMIS outcomes collected both pre- and 12- months post-operatively. Patients were grouped as 'no/low depression' if they scored below 60 on the PROMIS depression scale, and 'high depression' if they scored greater than or equal to 60 (one standard deviation from the population mean). Statistical differences were evaluated non-parametrically using Wilcoxon rank tests and Mann-Whitney U tests. Results: 36 patients who underwent TAR met inclusion criteria for analysis. Based on pre-operative PROMIS depression scores, 28 patients were categorized 'no/low depression' (ND), and 8 were categorized as 'high depression' (HD). Both groups showed significant improvement in PROMIS physical function and PROMIS pain interference at 12-months. While the HD group had a significantly higher baseline PROMIS pain interference (65.8) compared to the ND group (58.4, p < 0.05), there was no significant difference between the two groups at 12-months (50.5 vs. 47.6, respectively). Similarly, while there was a significant difference in PROMIS depression score pre-operatively between HD and ND (62.5 vs. 48.3, p < 0.05), there was no significant difference 12- months post-operatively (52.5 vs. 45.8). Conclusion: Our data suggests that patients with high pre-operative PROMIS depression scores may have worse baseline physical function and pain interference compared to other patients but see greater overall improvement after total ankle arthroplasty. Patients in the 'high depression' group also showed a significant improvement in PROMIS depression score 12- months post-operatively. Additional investigation of large, non-commercial outcomes databases, such as OFAR, may also help determine which surgical interventions impact mental health outcomes.

Category: Other; Ankle; Hindfoot; Lesser Toes; Midfoot/Forefoot Introduction/Purpose: The automation and integration of patient reported outcomes (PROs) into standard of care practice and electronic health systems is becoming increasingly viable. While often collected as a quality assurance measure for a practice and surgical decision-making, PROs are also valuable to assess the relative treatment outcomes. In order for physicians to gain the most insight from PROs, more baseline outcomes are needed to serve as a benchmark of anticipated patient improvement following surgical interventions. The goal of this study is to evaluate differences in patient improvement among validated physical and mental health PROs in a foot and ankle surgery practice. Methods: Consecutive patients undergoing foot and ankle surgery were enrolled into the U-COSMOS pathway. All PROs are automatically distributed and tracked through a secure, HIPAA-compliant, online PRO data capture tool. All patients are invited to complete the PROMIS Physical Function (PF) Computer Adaptive Test (CAT), PROMIS Pain Interference CAT (PI), Foot and Ankle Single Assessment Numeric Evaluation (SANE), PROMIS Global Physical Health (GPH), PROMIS Global Mental Health (GMH), PROMIS Depression, and a brief resiliency scale (BRS). PROs are collected pre-operatively, and post-operatively at 3- months, 6-months, 12-months, and 24-months. In this study, differences between pre- and post-operative scores for each PRO are evaluated using an unpaired Mann-Whitney U Test. Results: To date, 3154 patients have been enrolled into the U-COSMOS foot and ankle surgery pathway. Overall survey compliance was 77%. A significant improvement was seen in PF, PI, SANE, and GPH at 6-months, 12-months, and 24-months (p < 0.0001, see Table 1). There was no significant improvement in PF or GPH at the 3-month mark, supporting reduction of pain interference may be observed before return of physical function. All PROs measuring changes in mental health or resilience (Depression, GMH, BRS) did not significantly change at any post-operative visit relative to baseline. We found a mild positive correlation between BRS and improved 12-month PF and PI outcomes and a mild inverse correlation between pre-operative depression and 12-month PI and PF scores. Conclusion: Our data suggests that foot and ankle surgery leads to significant improvement in physical outcomes such as function or pain interference, but mental health and resilience outcomes remain somewhat unchanged throughout treatment on average. Within physical outcomes, we also find significant improvement in pain interference precedes functional and general measures. Early findings from the U-COSMOS outcomes pathway demonstrates greater overall improvement in physical health PROs, and a sustained improvement up to 24 months post-op. Future investigation of outcomes specific to procedures and conditions within the U-COSMOS pathway will help elucidate anticipated variation from general trends.

Category: Trauma; Ankle; Hindfoot; Sports Introduction/Purpose: Achilles tendon ruptures are challenging injuries and complications following Achilles repair surgery can lead to poor patient outcomes. The objective of this study was to determine if time to surgery and an open versus closed surgical technique were related to postoperative complications. We hypothesized that an increased time to surgery and an open surgical technique would correlate with an increase in complications. Methods: One hundred ninety-four patients at a single institution who underwent Achilles rupture repair surgery between October 2016 and November 2020 were included. All patients had a minimum follow-up of 3 months +- 14 days. A retrospective review was performed collecting data which included injury and treatment timepoints, surgical technique (open or percutaneous), and complications. Patients were separated into 3 categories based on time to surgery: acute (6 weeks). Complications were categorized as minor (wounds and/or infections that resolved with outpatient care), major (wounds and/or infections requiring operative intervention), re-rupture, DVT, and all other complications. A Fisher's exact test was used to determine if there was a statistically significant relationship between time to surgery and post-surgical complications as well as surgical technique and post-surgical complications. Results: In total, 194 patients were included for analysis: 134 with an acute rupture (69%), 36 sub-acute (18.6%), and 24 chronic (12.4%). 45 complications were observed in 37 patients (19.0% of patients); 8 patients had a minor complication (4.1%), 8 major (4.1%), 7 re-ruptures (3.6%), 12 DVTs (6.2%), and 8 others (4.1%). 25 acute ruptures had complications (18.7%), 6 sub-acute (16.7%), and 6 chronic (25%). No statistical differences were determined between time to surgery or surgical technique and complications among groups. There was an increase in complications in the chronic group, the most notable being Achilles tendon re-rupture (P = 0.06). The mean re-rupture time from the date of original injury to surgery was 47 days (range 3-131 days), and mean time from surgery to re-rupture was 49 days (range 7-133 days). Conclusion: This study did not demonstrate any statistically significant relationship between time to surgery or open versus percutaneous surgical technique and post-surgical complications following operative treatment of Achilles ruptures. Though not statistically significant, complications and re-ruptures were more frequent in patients undergoing surgery >6 weeks following injury. These results suggest increased time to surgery may be a predictor of increased risk for postoperative complications following Achilles repair surgery, however further research including studies with larger patient populations is needed to support this determination.

Category: Midfoot/Forefoot; Other Introduction/Purpose: Hallux rigidus is a common condition estimated to affect 1 in 40 adults older than 60 years old. Patients experience functional limitations secondary to progressive pain and stiffness of the 1st metatarsophalangeal (MTP) joint. Historically, 1st MTP arthrodesis has been considered the gold-standard treatment for end-stage hallux rigidus. In 2016, the US Food and Drug Administration (FDA) approved the use of a synthetic cartilage implant (SCI) for the treatment of hallux rigidus grades 2-4 with an aim to improve pain and preserve range of motion at the 1st MTP joint. Studies evaluating patient satisfaction and need for reoperation have varied considerably (4-20%). We aim to evaluate outcomes, complication rate, revision rate, and overall satisfaction for patients undergoing primary SCI for hallux rigidus. Methods: In a single-institution retrospective study, we evaluated patients undergoing primary SCI for hallux rigidus between August 2016 to May 2020 by three fellowship-trained foot and ankle surgeons. Preoperatively, patient demographics, age at the time of surgery, laterality, body mass index (BMI), hallux rigidus grade, hallux valgus angle, and first-second intermetatarsal angle were collected. Operative reports were reviewed for concomitant procedures and implant size. Postoperatively, we recorded all additional treatments for continued pain or stiffness and need for revision surgery or conversion to arthrodesis. Patients were surveyed via email or telephone by an author not previously involved in their care administering patient reported outcomes (PROs): PROMIS physical function (PF), and pain interference (PI) surveys, foot and ankle SANE score, and a satisfaction survey. Results: A total of 59 feet in 56 patients underwent a primary SCI procedure for hallux rigidus. Patients were classified as grade 2 (32%), 3 (59%), or 4 (2%). Nineteen (34%) patients underwent additional procedures, and 8 (14%) had a history of prior surgery to the MTP joint. Forty-five patients (80%) completed surveys at an average of 19.5-month follow-up. The majority (58%) considered surgery a success and 42% reported being unsatisfied or very unsatisfied. Mean (+-SD) post-operative foot and ankle SANE, PROMIS PF and PI scores were 57 (+-27), 48 (+-7) and 54 (+-9), respectively. The overall revision rate was 11% (6/56) with 3 patients undergoing conversion to arthrodesis. The majority of patients (61%) stated they would undergo the procedure again. Conclusion: Consistent with existing literature, we found that the majority of patients undergoing the procedure were satisfied and would undergo the procedure again. Further, post-operative PRO scores were favorable, even when factoring in patients who were less satisfied. While our revision rate (11%) is consistent with early studies of the implant, 42% reported being unsatisfied or very unsatisfied with their procedure. These findings emphasize the importance of preoperative patient counseling regarding post- operative limitations, risks, satisfaction, and revisions rates. Further investigation into factors that may predict successful outcomes is needed to inform surgical decision-making and appropriate patient selection for this procedure.

Category: Ankle; Ankle Arthritis; Basic Sciences/Biologics; Other Introduction/Purpose: Total ankle arthroplasty through the anterior approach (TAR-AA) is an increasingly popular treatment for ankle arthritis. This approach carries significant risk for wound complications. Several products have been investigated to mitigate this risk, but these are either costly or invasive. Noninvasive skin expansion strips (NSESs) have two nonelastic adhesive strips, one on either side of the incision, with an elastic band connecting them. These were designed to induce new skin growth at the edges of the strips for plastic surgery applications. In the postoperative setting, the NSES functions to transfer tension away from the site of the incision to the edge of the strips. We hypothesize that postoperative application of NSESs will decrease unplanned clinic visits and wound complications after TAR-AA. Methods: This is a prospective cohort study with retrospectively identified historical controls designed to evaluate the effectiveness of NSESs. Prospectively enrolled patients undergoing TAR-AA at a single institution (3 surgeons) received application of NSESs in the operating room after routine wound closure. At their two-week postoperative visit, each wound was assessed and new NSESs were applied. No other changes were made to the surgeons' wound closure technique, immobilization, follow-up cadence, or rehabilitation protocols. Patients following up with providers outside the institution were excluded. Thirty five consecutive historical controls were identified for comparison. Primary outcomes included (1) Additional clinic visit required for wound assessment or suture removal, (2) superficial wound complication before 8 weeks, and (3) deep infection before 8 weeks. Z-score test was used to calculate statistically significant (p

Category: Ankle; Sports Introduction/Purpose: There exists little consensus regarding optimal treatment protocols for syndesmotic injuries. Orthopedic clinicians have implemented a variety of treatment strategies, ranging from immobilization to screw fixation to new flexible fixation devices. While the body of literature is growing with regard to both the biomechanics and clinical outcomes for various constructs and rehabilitation protocols, there is little consensus on the optimal treatment and return to sport strategy for these injuries. We endeavored to assess current approaches to syndesmotic injuries by orthopedic foot and ankle specialists around the world in six athlete scenarios with increasing degrees of injury. Commensurate with the lack of available data to guide treatments, we hypothesize that there will be great variability in the treatment and management of syndesmotic injuries. Methods: A REDcap survey was created with 27 questions, including respondent demographics, indications for treatment of syndesmotic injuries, preferred treatment, preferred technique for repairing the syndesmosis, and post-operative management. Respondents were asked to choose their preferred fixation device and post-operative return to play protocols in six different athlete scenarios (moderate impact, high impact, and very high impact and each with/without complete deltoid injury). The survey was disseminated among the memberships of 18 North American and International medical societies. Society members were surveyed via three emails distributed two weeks apart. Frequencies and percentages were calculated for all categorical responses. Results: A total of 596 providers responded to the survey, including 337 American surgeons and 259 members of various international societies. There was a 70% survey completion rate with a wide geographic distribution among respondents. Flexible devices were the preferred fixation construct (48%), followed by screws (27%), hybrid fixation (19%) and other (6%). There was a higher preference for flexible devices among sports medicine trained providers (58%) relative to non-sports medicine trained providers (44%). 62% of respondents noted that their rehabilitation protocols would not change for each athlete scenario. Considerable variability was present in anticipated full return to sport, ranging from immediately following injury to six months post-op. 33% stated that they would repair the deltoid ‘greater than 50%’ of the time if injured. Conclusion: There is a wide variety of indications and treatment constructs employed by orthopedic surgeons for athletes with ligamentous syndesmotic injuries requiring fixation. Although flexible fixation devices are the preferred choice among all respondents, there was considerable variability in device choices. Fellowship training also appears to affect the preferred fixation method. There was no overall difference between device preference between North American and International respondents (Fig1). There also exists substantial variability in expected return to play for every athlete scenario. The diversity in approaches and post-operative recommendations underscores the need for evidence-based guidelines regarding the management of syndesmotic injuries.

Category: Arthroscopy; Ankle; Trauma Introduction/Purpose: Ankle fractures are one of the most common types of fractures, yet there is currently no consensus about how best to treat these patients. The treatment approach typically includes open reduction-internal fixation (ORIF), but not all patients have a good clinical outcome. Intra-articular injuries have been suggested as one potential cause of these sub-optimal outcomes. Use of arthroscopy at the time of surgery is useful in identifying intra-articular lesions in acute ankle fractures, however, there is no evidence that arthroscopic intervention changes the patient’s outcome. Ankle arthroscopy increases the duration and potential complications of anesthesia administration and also increases cost. Our study assesses the clinical impact of arthroscopy accompanying an ankle fracture ORIF, which is essential to promote positive outcomes, while decreasing unnecessary complications and costs. Methods: This is a retrospective chart review. We queried all patients that underwent operative fixation of a bimalleolar or trimalleolar ankle fracture at our institution from January 1, 2014 through November 1, 2018. From this list, we excluded patients less than 18 years old and patients that had concomitant injuries to other body parts that required surgery. In addition, we only included Weber B and Weber C fibula fracture to homogenize the data. We then performed a chart review to extract all demographic data, fracture pattern, surgical procedures performed, tourniquet times, any revision surgeries, arthroscopic findings and any interventions performed due to the arthroscopic portion of the procedure. We then conducted a phone and email survey utilizing the Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Short Form and the two question Patient Acceptable Symptom State (PASS). Results: Our study included 213 total patients (142 traditional ORIF, 71 ORIF plus arthroscopy) with an average age of 40 (standard deviation 14.2). The average follow up was 32.4 (13.1) months with a survey follow up rate of 50.7%. The demographic information between the two cohorts was statistically similar. The average tourniquet time for the arthroscopy cohort is 10 minutes longer (89 minutes versus 79 minutes). During the arthroscopy, there was a 28.2% rate of full thickness osteochondral lesions, 33.8% rate of loose bodies, and a 49.2% rate of small cartilage injury not requiring intervention. The mean PROMIS physical function score amongst Weber B fibula fractures was 45.8 and 42.3 in the arthroscopy and non-arthroscopy groups respectively (P value 0.012). In addition, the patient satisfaction rate in Weber B fibula fractures was higher in those patients that underwent arthroscopy as compared to ORIF alone (93.1% versus 75.5%, P value of 0.05). Patients that suffered a tibiotalar joint dislocation at the time of the ankle fracture had a significantly higher PROMIS physical function score (46.6 versus 40.2, P value 0.005) when their surgery included arthroscopy. Conclusion: Ankle arthroscopy at the time of ORIF led to higher mean patient reported outcomes for every tested metric but this reached statistical significance only when looking at the Weber B fibula fractures and ankle dislocations. There was no increase in complication rate and the arthroscopy took only 10 minutes longer on average.