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One of the genetic mutations most associated with the onset of amyotrophic lateral sclerosis, both in sporadic and familial cases, is the expansion of the C9orf72 gene. The presence of more than 30 repeats (GGGGCC) correlates with uncertain ALS symptomatology. Here we collected a dermal biopsy from a subject carrying 36 hexanucleotide repeats and reprogrammed it into an induced pluripotent stem cell line. Despite the number of repeat elements, the subject had no symptoms at the age of the biopsy (76 years), thus resulting in a healthy carrier of the mutation.

Introduction: Morton's interdigital neuroma (MN) is a common compression neuropathy of an interdigital nerve in the foot. We present retrospective treatment outcomes with a novel modification of the de Prado technique for distal minimally invasive metatarsal osteotomy (DMMO)., Methods: We retrospectively reviewed 25 consecutive patients (25 neuromas) with MRI- or US-confirmed MN who underwent DMMO of only the 4th metatarsal with deep transverse intermetatarsal ligament release with a minimum one-year follow-up after the failure of non-operative treatment. Patient-reported outcome measures (PROMs) were assessed using the Visual Analog Scale (VAS) and the Foot Function Index (FFI). Statistical analysis was performed to assess for differences among sub-groups., Results: A significant decrease is reported post-operatively in all PROMs evaluated. Pre- and post-intervention mean VAS scores were 7.35 and 0.41, respectively (p < 0.001). Pre- and post-intervention FFI Total scores were 57.5 and 17.2, respectively (p < 0.001). All pre- and post-intervention FFI sub-scores were found to be significantly reduced (P < 0.001). There was one case of prolonged serous (non-infected) drainage, which resolved by three weeks postoperatively., Conclusions: The data presented demonstrates that our novel operative technique significantly improved patient-reported outcomes irrespective of initial neuroma size, patient sex, or comorbidities., Level of Evidence: IV., Competing Interests: Declarations. Ethical approval: Ethical approval for this study was obtained from the Institutional Review Board Mt Sinai: OR76593. Informed consent: The informed consent requirement for this study was waived by the Institutional Review Board (IRB) because it involved a retrospective chart review. The study posed minimal risk to participants and did not involve any direct patient interaction, making it impracticable to obtain informed consent from all subjects included in the study. Conflict of interest: Ettore Vulcano is a consultant for Vilex and Novastep. Mariano de Prado has no disclosures. Alirio J. deMeireles has no disclosures. Jamie Confino has no disclosures. Mahant Malempati has no disclosures., (© 2025. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: In the case of end-stage hallux rigidus, first metatarsophalangeal (MTP) joint arthrodesis is the gold-standard and is traditionally performed via an open approach. However, complications such as nonunion have been reported to be as high as 30%. Recently, there have been reports demonstrating a percutaneous approach to be effective and safe., Methods: Forty-nine patients with end-stage hallux rigidus underwent percutaneous first MTP joint arthrodesis with calcaneus autograft performed by a single surgeon. Each patient underwent a minimum of 24 month clinical and radiographic follow up, including 3 month post operative computed tomography scans. Clinical outcomes were assessed using the Visual Analog Scale (VAS) and Foot Function Index (FFI) preoperatively and at final follow-up., Results: Mean follow-up was 27.3 months. Bone union was observed in 46 patients (93.9%). Mean time to union was 3.1 months. Nonunion rate was 6.1%. Overall complication rate was 12.2%. Mean pre- and postoperative VAS scores were 7.5 and 0.2, respectively (P < .0001). Mean pre- and postoperative total FFI values were 56.3 and 15.7 (P < .0001), respectively. Patient satisfaction after the procedure was 93.9%., Conclusion: Observed union rate is comparable to the average fusion rate previously reported for open and minimally invasive procedure union rates. Mean time to union was observed to be comparable to open procedures union time. Observed overall complication rate is similar to those reported for open techniques as well. Patient reported outcomes demonstrated a significant reduction in postoperative VAS and FFI for the percutaneous metatarsophalangeal arthrodesis with calcaneus bone autograft. Patient satisfaction rates compared favorably to those reported following open surgery., Competing Interests: Declarations. Conflict of interest: Ettore Vulcano is a consultant for Vilex and Novastep. Marco Minelli has no disclosures. Alirio J. deMeireles has no disclosures. Gerard F. Marciano has no disclosures. Bonnie Y. Chien has no disclosures. Mahant Malempati has no disclosures. Ethical approval Ethical approval for this study was obtained from the Institutional Review Board of Columbia University (FWA00000176). Informed consent: The informed consent requirement for this study was waived by the Institutional Review Board (IRB) because it involved a retrospective chart review. The study posed minimal risk to participants and did not involve any direct patient interaction, making it impracticable to obtain informed consent from all subjects included in the study., (© 2025. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Smith-Magenis syndrome (SMS) is a complex neurodevelopmental disorder with a birth incidence of 1:25,000. SMS is caused by haploinsufficiency of the retinoic acid-induced retinoic acid1 (RAI1) gene, determined by an interstitial deletion of ∼ 3.7 Mb (17p11.2, including the RAI1 gene) in 90 % of cases and a mutation on the RAI1 gene in only 10 % of cases. We generated and characterized a human pluripotent stem cell line (hIPSCs) derived from primary fibroblasts of a 17-year-old woman carrying a 17p11.2 deletion including the RAI1 gene., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background/objectives: Surgical management of chronic lateral ankle instability has traditionally been performed using an open technique. Arthroscopic-assisted and all-arthroscopic techniques have gained popularity as they have achieved strong clinical outcomes. However, they rely on the surgeon's arthroscopic skills and familiarity with arthroscopic anatomy. Recently, a minimally invasive percutaneous technique without arthroscopic assistance has been developed that incorporates the benefits of arthroscopy, such as minimal soft tissue disruption, without the additional requirements of performing an arthroscopic technique. The aim of the current study is to describe the minimally invasive percutaneous technique for chronic lateral ankle instability and report on its clinical outcomes., Methods: Fifty-four consecutive patients without intra-articular ankle pathology underwent lateral ligament repair for chronic ankle instability with a percutaneous technique at a single institution by a fellowship-trained foot and ankle surgeon. Foot Function Index (FFI) score was recorded pre-operatively and post-operatively at final follow-up. All patients had a minimum follow-up of 12 months. Post-operative complications and patient satisfaction were also recorded., Results: A significant improvement ( p < 0.001) in FFI compared to pre-operative values (from 55, SD 4.1, to 10, SD 1.9) was observed. A single patient required a return to the operating room for open revision with allograft reconstruction following a fall 2.5 months post-operatively. There were no other complications including infection or nerve injury. The overall rate of satisfaction after surgery was 98.1%, with one patient dissatisfied due to excessive ankle stiffness., Conclusions: The described minimally invasive percutaneous Brostrom procedure is safe and effective for the treatment of chronic lateral ankle instability without intra-articular ankle pathology.

Foot drop due to peroneal nerve palsy is a complex condition stemming from multiple etiologies. It can result from central or peripheral injuries, leading to a variable spectrum of deformities and weakness in the ankle and a "foot drop," which can be either flexible or fixed. As a result, there is no universal approach with which to treat patients. This article presents and reviews the most common surgical procedures used to address foot drop, with emphasis on peripheral etiology., Competing Interests: The authors declare that they have no conflict of interest.

Background: Surgical treatment of insertional Achilles tendinopathy (IAT) historically consists of Achilles tendon debridement with reattachment and excision of the posterosuperior calcaneal prominence with or without a gastrocnemius recession. Zadek osteotomy (ZO) is an alternative to an open midline splitting approach. The purpose of this study was to analyze patient-reported outcomes and complications after percutaneously performed ZO with minimum 2 years' follow-up., Methods: One hundred eight cases treated with percutaneous ZO with a minimum 2-year follow-up were retrospectively reviewed. Postoperative complications and patient satisfaction were evaluated. Foot Function Index (FFI) and visual analog scale (VAS) scores were recorded at preoperative and follow-up appointments to measure patients' functional outcomes and pain, respectively., Results: Mean follow-up was 41.2 months (range, 24-65). Mean age was 51.8 years (range, 28-81). The mean FFI score improved from 56.1 (range, 47-88) to 11.0 (range, 7-59) postoperatively ( P < .001). The mean VAS score improved from 7.7 (range, 5-10) to 0.4 (range, 0-7) postoperatively ( P < .001). The overall complication rate was 3.8% (n = 4). Of 104 cases, 98.1% of patients said they were satisfied with their procedure (n = 102) when asked if they were satisfied with their ZO and recovery., Conclusion: We found the percutaneous ZO to be a safe and effective intervention for treatment of IAT. At a minimum of 2-year follow-up, this intervention is associated with minimal complications, improved function, reduced pain, and a high rate of patient satisfaction., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Oliver N. Schiper, MD reports royalties or licenses and consulting fees from Treasce Medical Concepts, Vilex, Exactech, and Enovis. Jonathan R. M. Kaplan, MD, reports royalties or licenses and consulting fees from Artelon, Edge Surgical, Exactech, Surgebright, and Enovis. A. Holly Johnson, MD, reports royalties or licenses from Novastep and Treace Medical Concepts. Tyler A. Gonzalez, MD, MBA, reports royalties or licenses and consulting fees from Treace Medical Concepts, Surgical Fusion Technologies, Vilex; consulting fees from Stryker, Surgebright, and Enovis. Ettore Vulcano, MD, reports royalties or licenses and consulting fees from Novastep, Vilex, and Treace Medical Concepts. Disclosure forms for all authors are available online.

Introduction: The Zadek Osteotomy has been described as an effective technique for the treatment of insertional Achilles tendinopathy. Recently, this strategy has been modified using minimally invasive techniques. A learning curve has been observed in many minimally invasive procedures in foot and ankle surgery. This retrospective study first intended to evaluate if there is a learning curve associated with the percutaneous Zadek Osteotomy. Further, if a learning curve was observed, we planned to assess the data for associated changes in complications and postoperative outcomes., Methods: A retrospective analysis of 98 patients who underwent percutaneous Zadek Osteotomy was performed. Patient charts were reviewed for operative times, complications, union rates, and Foot Function Index (FFI) and Visual Analogue Scale (VAS) scores. Analysis of variance was utilized to assess for differences between groups of cases., Results: Patients included 61 females and 37 males. Mean age was 51.28 ± 11.12 (range 28-81) years. Mean follow-up time was 42.07 ± 12.99 (range 24-65) months. Significant increases in operative times were observed in cases 1-14 when compared to cases 15-98 (p < 0.001). Improvements in FFI and VAS scores were observed at final follow-up within each case group (p < 0.001); there were no differences detected in FFI or VAS scores between groups of cases. There was no difference detected in number of complications between intervals of cases., Conclusion: A learning curve was observed for the percutaneous Zadek Osteotomy, which was overcome around case 14. This learning curve was only observed in terms of procedure length. A surgeon's level of inexperience with the technique does not appear to affect functional outcomes, nonunion, or need for revision., Level of Evidence Iv: Data will not be deposited in a repository., (© 2024. The Author(s).)

Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Jonathan R. M. Kaplan, MD, reports royalties or licenses and consulting fees from Enovis and Novastep. Oliver N. Schipper, MD, reports royalties or licenses and consulting fees from Enovis. Ettore Vulcano, MD, reports royalties or licenses and consulting fees from Novastep. Tyler A. Gonzalez, MD, MBA, reports consulting fees from Enovis. Disclosure forms for all authors are available online.

Background: Percutaneous Zadek osteotomy (ZO) has emerged as a surgical treatment of insertional Achilles tendinopathy (IAT) over the last decade. Existing literature is limited regarding the comparison of this approach with the more established, open ZO technique. This systematic review aims to evaluate and compare the current data on open vs percutaneous ZO approaches to help set evidence-based guidelines., Methods: A systematic literature search was performed using the keywords (Zadek osteotomy) OR (Keck and Kelly osteotomy) OR (dorsal closing wedge calcaneal osteotomy) OR (Haglund Deformity) OR (Haglund Syndrome) OR (Insertional Achilles Tendinopathy) and MeSH terms Osteotomy , Calcaneus , Syndrome , Insertional , Achilles tendon , and Tendinopathy . Our search included the following databases: PubMed, Embase, and the Cochrane Library. The PRISMA protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2009 to 2024 and included the use of open or percutaneous approaches of ZO for the treatment of IAT with at least a 12-month follow-up. The MINORS score criteria were used to evaluate the strength and quality of studies., Results: A total of 17 studies were reviewed, including 611 subjects and 625 ZO procedures. Of these procedures, 81 (11%) subjects had a percutaneous and 544 (89%) subjects had an open ZO. The mean follow-up time was 16.1 months for patients treated with percutaneous ZO and 36.1 months for patients treated with open ZO. Both open and percutaneous studies included in this review showed postoperative improvements in AOFAS, FFI, VISA-A, and VAS scores in patients with IAT. The reported complication rate was 5.8% among patients treated with percutaneous ZO and 10.2% among patients treated with open ZO., Conclusion: Percutaneous ZO is an emerging approach with substantially fewer documented cases compared with the open ZO. Both percutaneous and open ZO appear to be relatively effective treatments for insertional Achilles tendinopathy with Haglund's deformity. The lower complication rates reported for percutaneous ZO is encouraging. Further investigation with more subjects undergoing percutaneous ZO is clearly needed., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: A. Holly Johnson, MD, reports royalties or licenses from Novastep and Treace. Oliver Schipper, MD, reports royalties or licenses and consulting fees from Treace Medical Concepts, Vilex, Exactech, and Enovis. Ettore Vulcano, MD, reports royalties or licenses and consulting fees from Treace Medical Concepts and Vilex; consulting fees from Surgebright, and Novastep. Jonathan R.M. Kaplan, MD, reports royalties or licenses and consulting fees from Surgical Fusion Technologies, Enovis, Treace Medical Concepts, Vilex; consulting fees from Artelon, Edge Surgical, Exactech, and Surgebright. Tyler A. Gonzalez, MD, MBA, reports royalties or liceses and consulting fees from Treace Medical Concepts, Surgical Fusion Technologies, Vilex; consulting fees from Stryker, Surgebright and Enovis. Disclosure forms for all authors are available online., (© The Author(s) 2024.)

Background: Syndesmotic injuries are frequently stabilized using syndesmotic screws. Traditionally, these screws were routinely removed during the postoperative period, however recent literature has brought into question the necessity of routine removal, citing no change in functional outcomes and the inherent risks of a second surgery. Our study aimed to compare outcomes of patients undergoing routine syndesmotic screw removal versus those undergoing an on-demand approach to removal., Methods: A systematic search of studies comparing routine syndesmotic screw removal to on-demand screw removal following an acute ankle fracture, or an isolated syndesmotic injury was conducted across seven databases. Only Prospective randomized controlled trials were eligible for inclusion. Data reported on by at least 2 studies was pooled for analysis., Results: Three studies were identified that met inclusion and exclusion criteria. No significant difference in Olerud-Molander Ankle Score (MD -2.36, 95% CI -6.50 to 1.78, p = 0.26), American Orthopedic Foot and Ankle Hindfoot Score (MD -0.45, 95% CI -1.59 to .69, p = 0.44), or dorsiflexion (MD 2.20, 95% CI -0.50 to 4.89, p = 0.11) was found between the routine removal group and on-demand removal group at 1-year postoperatively. Routine removal was associated with a significantly higher rate of complications than on-demand removal (RR 3.02, 95% CI 1.64 to 5.54, p = 0.0004). None of the included studies found significant differences in pain scores or range of motion by 1-year postoperatively., Conclusion: Given the increased risk of complications with routine syndesmotic screw removal and the comparable outcomes when screws are retained, an as-needed approach to syndesmotic screw removal should be considered., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Daniel Acevedo reports was provided by Nova Southeastern University. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Background: Readmission rate after surgery is an important outcome measure in revealing disparities. This study aimed to examine how 30-day readmission rates and causes of readmission differ by race and specific injury areas within orthopaedic surgery., Methods: The American College of Surgeon-National Surgical Quality Improvement Program database was queried for orthopaedic procedures from 2015 to 2019. Patients were stratified by self-reported race. Procedures were stratified using current procedural terminology codes corresponding to given injury areas. Multiple logistic regression was done to evaluate associations between race and all-cause readmission risk, and risk of readmission due to specific causes., Results: Of 780,043 orthopaedic patients, the overall 30-day readmission rate was 4.18%. Black and Asian patients were at greater (OR = 1.18, P < 0.01) and lesser (OR = 0.76, P < 0.01) risk for readmission than White patients, respectively. Black patients were more likely to be readmitted for deep surgical site infection (OR = 1.25, P = 0.03), PE (OR = 1.64, P < 0.01), or wound disruption (OR = 1.45, P < 0.01). For all races, all-cause readmission was highest after spine procedures and lowest after hand/wrist procedures., Conclusions: Black patients were at greater risk for overall, spine, shoulder/elbow, hand/wrist, and hip/knee all-cause readmission. Asian patients were at lower risk for overall, spine, hand/wrist, and hip/knee surgery all-cause readmission. Our findings can identify complications that should be more carefully monitored in certain patient populations., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: Bunionette deformity (BD) is a painful condition of the fifth metatarsal characterized by an osseous prominence and fifth toe varus deformity. The purpose of this study is to assess the clinical, functional, and radiographic outcomes of percutaneous distal metatarsal metaphyseal osteotomy (DMMO) without fixation or postoperative strapping of the foot., Methods: A retrospective case series was performed on 111 patients (132 feet) with symptomatic BD who underwent percutaneous DMMO of the fifth metatarsal from September 2020 to January 2022 by an experienced minimally invasive surgeon. According to the Shimobayashi classification, we treated 1 type I deformity, 37 type II deformities, 52 type III deformities, 42 feet with type IV deformity, and no patient with a type V deformity. Ninety patients (81%) underwent unilateral osteotomy, and 21 (19%) had bilateral osteotomies. Most cases included other procedures including treatment of 114 associated deformities of the same feet: 68 bunions, 12 lesser metatarsal osteotomies (2-3-4 metatarsals), and 34 hammertoes (20 second hammertoes, 10 third hammertoes, 1 fourth hammertoes, 2 fifth hammertoes). Patient-reported clinical outcome measures, including the Foot Function Index (FFI) questionnaire, the visual analog score (VAS), and overall satisfaction were collected. Fourth-to-fifth intermetatarsal angle (IMA) correction, time to bone union, and complication rates were assessed in all patients., Results: Mean follow-up was 24.1 months (range, 14-39 months). Both radiographic parameters and patient-reported outcome measures significantly improved after DMMO procedure. The average fourth-to-fifth IMA improved from 12.2 degrees, preoperatively, to 4.4 degrees, postoperatively ( P  < .001). Patient outcomes reflect the overall outcomes of the combined surgeries on a per-patient basis. Preoperatively, patients had a mean VAS score of 7.6, which improved to 0.6 at the last follow-up ( P  < .001). Furthermore, the average FFI significantly decreased from pre- to postoperation from 19.2 to 4.4, respectively ( P  < .001). Overall, 108 of 111 patients reported being satisfied with the outcomes of the procedure. Average bone union was achieved at 12.6 weeks postoperation, with a minimum of 12 and a maximum of 25 weeks. The complication rate was 1.5%, including 1 case of an asymptomatic cock-up deformity and 1 case of lateral fifth metatarsal shaft bone overhang pain, which resolved with an exostectomy., Conclusion: The results of this study of patients who had minimally invasive surgery from an experienced surgeon suggest that percutaneous DMMO of the fifth metatarsal without internal fixation or postoperative immobilization or strapping can be effective at improving radiographic alignment, pain, function, and overall satisfaction with minimal rates of complication., Level of Evidence: Level IV, case series., Competing Interests: Ethical ApprovalEthical approval for this study was obtained from ICAHN School of medicine Institutional Review Board at Mount Sinai. Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Ettore Vulcano, MD, reports grants or contracts from Novastep as a paid consultant. ICMJE forms for all authors are available online.

Background: Intraoperative fracture of the lateral cortex is common during Akin osteotomy. In a recent study, lateral cortex fracture did not impede healing or result in loss of correction in a combined cohort of open and percutaneous osteotomies stabilized by K-wire fixation. We hypothesize that undesired lateral cortex fracture will not affect radiographic correction and patient-reported outcomes in a percutaneous cohort stabilized by permanent, rigid screw fixation., Methods: Consecutive patients with hallux valgus who underwent first metatarsal osteotomy and percutaneous Akin osteotomy stabilized by permanent, rigid screw fixation between May 2020 and January 2022 were retrospectively reviewed. Patients were stratified based on fractured lateral cortex (FC) or its absence (nonfractured cortex [NFC]). Visual analog scale (VAS) and Foot Function Index (FFI) were used to assess pain and patient-reported outcomes at 1-year follow-up. Patients were polled for satisfaction at 1-year follow-up by yes/no survey., Results: Ninety-eight patients (89% female) were reviewed (98 feet; 43 NFC, 55 FC). Mean age was 48.3 years (range, 18-83 years). Mean preoperative VAS score was 7.5 and 7.7 in NFC and FC groups, which significantly decreased to 0.6 ( P  < .01) and 0.6 ( P  < .01), respectively. Mean total FFI was 53.9 and 54.2 and decreased to 17.9 ( P  < .01) and 17.2 ( P  < .01) in the NFC group and FC group, respectively. Overall, 97.8% of the NFC group and 96.4% of the FC group reported satisfaction.Mean HVA improved from 27.2 (16-42) degrees to 10.7 degrees (4-12) postoperatively in the NFC group. And in the FC group, HVA improved from 29.3 (19-39) degrees to 7.1 (4-12) degrees postoperatively. Postoperative HVA was significantly lower in the FC group ( P  < .05)., Conclusion: In an exclusively percutaneous surgical cohort with correction maintained by rigid screw fixation, fracture of the lateral cortex is associated with improved postoperative radiologic alignment without detriment to patient-reported outcomes., Level of Evidence: Level III, retrospective cohort study., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online.

Background: Percutaneous ankle fusion is an emerging technique with minimal published outcome data. The goal of the present study is to retrospectively review clinical and radiographic outcomes following percutaneous ankle fusion and provide technique tips to perform percutaneous ankle fusion., Methods: Patients >18 years of age, treated by a single surgeon, from February 2018 to June 2021, who underwent primary isolated percutaneous ankle fusion supplemented with platelet-derived growth factor B (rhPDGF-BB) and beta-tricalcium phosphate, with at least 1-year follow-up were included. Surgical technique consisted of percutaneous ankle preparation followed by fixation with 3 headless compression screws. Pre- and postoperative visual analog scale (VAS) and Foot Function Index (FFI) were compared using paired t tests. Fusion was assessed radiographically by the surgeon on postoperative radiographs and computed tomography (CT) at 3 months postoperatively., Results: Twenty-seven consecutive adult patients were included in the study. Mean follow-up was 21 months. Mean age was 59.8 years. Mean preoperative and postoperative VAS scores were 7.4 and 0.2, respectively ( P  < .01). Mean preoperative FFI pain domain, disability domain, activity restriction domain, and total score were 20.9, 16.7, 18.5, and 56.4, respectively. Mean postoperative FFI pain domain, disability domain, activity restriction domain, and total score were 4.3, 4.7, 6.7, and 15.8, respectively ( P  < .01). Fusion was achieved in 26 of 27 patients (96.3%) at 3 months. Four patients (14.8%) had complications., Conclusion: We found in this cohort with surgery performed by a surgeon highly experienced in minimally invasive surgery that percutaneous ankle fusion augmented with a bone graft supplement achieved a high rate of fusion (96.3%) and a significant improvement in pain and function postoperatively while associated with minimal complications., Level of Evidence: Level IV, case series., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Ettore Vulcano, MD, reports royalties or licenses from Novastep. ICMJE forms for all authors are available online., (© The Author(s) 2023.)

Background: Achilles tendon rupture (ATR) is a common injury with a growing incidence rate. Treatment is either operative or nonoperative. However, evidence is lacking on the cost comparison between these modalities. The objective of this study is to investigate the cost differences between operative and nonoperative treatment of ATR using a large national database., Methods: Patients who received treatment for an ATR were abstracted from the large national commercial insurance claims database, Marketscan Commercial Claims and Encounters Database (n = 100 825) and divided into nonoperative (n = 75 731) and operative (n = 25 094) cohorts. Demographics, location, and health care charges were compared using multivariable regression analysis. Subanalysis of costs for medical services including clinic visits, imaging studies, opioid usage, and physical therapy were conducted. Patients who underwent secondary repair were excluded., Results: Operative treatment was associated with increased net and total payments, coinsurance, copayment, deductible, coordination of benefits (COB) / savings, greater number of clinic visits, radiographs, magnetic resonance imaging (MRI) scans, and physical therapy (PT) sessions, and with higher net costs due to clinic visits, radiographs, MRIs, and PT ( P  < .001). Operative repair at an ambulatory surgical center was associated with a lower net and total payment, and a significantly higher deductible compared to in-hospital settings ( P  < .001). Both cohorts received similar numbers of opioid prescriptions during the study period. Yet, operative patients had a significantly shorter duration of opioid use. After controlling for confounders, operative repair was also independently associated with lower net costs due to opioid prescriptions., Conclusion: Compared with nonoperatively managed ATR, surgical repair is associated with greater costs partially because of greater utilization of clinic visits, imaging, and physical therapy sessions. However, surgical costs may be reduced when procedures are performed in ambulatory surgery centers vs hospital facilities. Nonoperative treatment is associated with higher prescription costs secondary to longer duration of opioid use., Level of Evidence: Level III, retrospective cohort study., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2023.)

Background: Nonunion is a postoperative complication after ankle arthrodesis (AA), which leads to increased morbidity and revision rates. Previous studies have identified risk factors for nonunion following AA, but no meta-analysis has been performed to stratify risk factors based on strength of evidence., Methods: Abstracts and full-text articles were screened by 2 independent reviewers. Relevant data were extracted from the included studies. Random effects meta-analyses were summarized as forest plots of individual study and pooled random effect results., Results: Database search yielded 13 studies involving 987 patients were included, and 37 potential risk factors for nonunion. Meta-analysis found 5 significant risk factors for nonunion post-AA. Strong evidence supports male gender (OR: 1.96; 95% CI: 1.13-3.41), smoking (OR: 2.89; 95% CI: 1.23-6.76), and history of operative site infection prior to arthrodesis (OR: 2.40; 95% CI: 1.13-5.09) as predictors for nonunion following AA. There was moderate evidence supporting history of open injury (OR: 5.95; 95% CI: 2.31-15.38) and limited evidence for preoperative avascular necrosis (OR: 13.16; 95% CI: 2.17-79.61) as possible risk factors for nonunion., Conclusion: The results of our meta-analysis suggest that male gender, smoking, and history of operative site infection have strong evidence and that history of open injury and avascular necrosis also have evidence as risk factors for nonunion. Surgeons should be cognizant of these risks when performing AA and closely follow up with patients with the aforementioned risk factors to ensure postoperative success., Levels of Evidence: Level V: Systematic review of cohort and case-control studies.

Background: Plantar fasciitis (PF) is the most common cause of heel pain and can be a source of extensive physical disability and financial burden. Platelet-rich plasma (PRP) offers a potentially definitive, regenerative treatment modality that, if effective, could change the current paradigm of PF care. However, randomized controlled trials (RCTs) on the clinical benefits of PRP for refractory PF offer inconsistent conclusions, potentially because of the broader limitations of using P value thresholds to declare statistical and clinical significance. In this study, we use the Continuous Fragility Index (CFI) and Quotient (CFQ) to appraise the statistical robustness of data from RCTs evaluating PRP for treatment of PF., Methods: RCTs comparing outcomes after PRP injection vs alternative treatment in patients with chronic PF were evaluated. Representative simulated data sets were generated for each reported outcome event using summary statistics. The CFI was determined by manipulating each data set until reversal of significance (α=0.05) was achieved. The corresponding CFQ was calculated by dividing the CFI by the sample size., Results: Of 259 studies screened, 20 studies (59 outcome events) were included in this analysis. From these simulations, the median CFI for all events was 9, suggesting that varying the treatment of 9 patients would be required to reverse trial significance. The corresponding CFQ was 0.177. Studies with reported P value <.05 were more statistically fragile (CFI=10, CFQ=0.122) than studies with reported P value >.05 (CFI=5, CFQ=0.179). Of 36 outcome events reporting lost to follow-up data, 10 events (27.8%) lost ≥9 patients., Conclusion: Our findings suggest that, on average, the statistical fragility of RCTs evaluating PRP for nonoperative PF therapy is at least comparable to that of the sports medicine literature. However, several included studies had concerningly low simulated fragility scores. Orthopaedic surgeons may benefit from preferentially relying on studies with higher CFI and CFQ values when evaluating the utility of PRP for chronic PF in their own clinical practice. Given the importance of RCT data in clinical decision making, fragility indices could help give context to the stability of statistical findings., Level of Evidence: Level I, systematic review., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2022.)

Background: The demand for total ankle arthroplasty (TAA) and ankle arthrodesis surgery is increasing. Findings from other orthopaedic populations suggest an increasing comorbidity burden among those planned for surgery, however, data on TAA and ankle arthrodesis is limited. The goal of this study is to study the comorbidity burden for TAA and ankle arthrodesis., Hypothesis: Comorbidity burden is associated with higher resource utilization for both TAA and ankle arthrodesis., Patients and Methods: This retrospective cohort study utilized data from the nationwide Premier Healthcare Database (2006-2016) which contains inpatient claims on n=10,085 ankle arthrodesis and n=4,977 TAA procedures. Patients were categorized into Deyo-Charlson comorbidity index (DCCI) groups. Outcomes were cost of hospitalization, length of stay (LOS), total opioid utilization, discharge to a skilled nursing facility (SNF), and 30-day readmission. Mixed-effects models estimated associations between DCCI and outcomes. We report odds ratios (OR, or % change for continuous outcomes) and 95% confidence intervals (CI)., Results: In the TAA group, 67.9% of patients were in DCCI category 0 while 22.4%, 6.6%, and 3.1% were in the 1, 2, and >2 DCCI categories, respectively. This was 61.3%, 18.1%, 9.8% and 10.9% in the ankle arthrodesis group. The most common comorbidities were obesity, diabetes mellitus, and chronic pulmonary disease. Particularly in the ankle arthrodesis group, the proportion of patients with comorbidities has increased over time. After adjustment for relevant covariates, patients in the DCCI group >2 (compared to '0') were associated with stepwise effects of up to 77.1% (CI 70.9%; 83.6%) longer length of stay and up to 48.5% (CI 44.0%; 53.2%) higher cost of hospitalization., Discussions: Comorbidity burden is increasing among patients undergoing ankle arthrodesis where it is associated with significantly increased resource utilization. Our data demonstrate the potential impact of patient selection, which may be crucial in optimizing preoperative status., Level of Evidence: III., (Copyright © 2021. Published by Elsevier Masson SAS.)

Background: Closed wound drainage has been extensively studied in the hip and knee arthroplasty literature with equivocal results on its clinical benefits. Although also used in orthopaedic surgeries like ankle arthrodesis and ankle arthroplasty, large-scale data are currently lacking on utilization patterns and real-world effectiveness. We, therefore, aimed to address this research gap in this distinct surgical cohort using national claims data., Methods: Using the Premier Healthcare claims database from 2006 to 2016, ankle arthrodesis (n=10,085) and ankle arthroplasty (n=4,977) procedures were included. The main effect was drain use, defined by detailed billing descriptions. Outcomes included blood transfusion, 90-day readmission, and length and cost of hospitalization. Mixed-effects models measured associations between drain use and outcomes. Odds ratios (OR, or % change), 95% CIs, and P values are reported., Results: Overall, drains were used in 11% (n=1,074) and 15% (n=755) of ankle arthrodesis and ankle arthroplasty procedures, respectively. Drain use dramatically decreased over the years in both surgery types: from 14% to 6% and 24% to 7% between 2006 and 2016, for arthrodesis and ankle arthroplasty procedures, respectively. After adjustment for relevant covariates, drain use was associated with increased odds of blood transfusion in ankle arthrodesis surgery (OR 1.4, CI 1.1-1.8, P = .0168), whereas differences that were statistically but not clinically significant were seen in cost and length of stay. In total ankle arthroplasty, no statistically significant associations were observed between drain use and the selected outcomes., Conclusion: This is the first national study on drain use in ankle surgery. We found a decrease in use over time. Drain use was associated with higher odds of blood transfusion in ankle arthrodesis patients. Although this negative effect may be mitigated by the rapidly decreasing use of drains, future studies are needed to discern drivers of drain use in this distinct surgical population., Level of Evidence: Level III, retrospective cohort study., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2022.)

Background: Randomized controlled trial (RCT) outcomes reaching statistical significance, frequently determined by P <.05, are often used to guide decision making. Noted lack of reproducibility of some RCTs has brought special attention to the limitations of this approach. In this meta-analysis, we assessed the robustness of RCTs evaluating platelet-rich plasma (PRP) for the treatment of chronic noninsertional Achilles tendinopathy (AT) by using fragility indices., Methods: The present study was a systematic review and meta-analysis of RCTs comparing outcomes after PRP injection vs alternative treatment in patients with AT. Representative data sets were generated for each reported continuous outcome event using summary statistics. Fragility indices refer to the minimal number of patients whose status would have to change from a nonevent to an event to turn a statistically significant result into a nonsignificant result, or vice versa. The fragility index (FI) and continuous FI (CFI) were determined for dichotomous and continuous outcomes, respectively, by manipulating each data set until reversal of significance (a=0.05) was achieved. The corresponding fragility quotient (FQ) and continuous FQ (CFQ) were calculated by dividing FI/CFI by sample size., Results: Of 432 studies screened, 8 studies (52 outcome events) were included in this analysis. The 12 dichotomous outcomes had a median FI of 4.5 (FQ: 0.111), and the 40 continuous outcomes had a median CFI of 5 (CFQ: 0.154). All 52 outcome events included lost-to-follow-up data, and 12 (23.1%) indicated a greater number of patients lost to follow-up than the FI or CFI., Conclusion: Our findings suggest that RCTs evaluating PRP for AT therapy lack statistical robustness, because changing only a small number of events may alter outcome significance., Level of Evidence: Level II, therapeutic study., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2022.)

Background: Open hindfoot surgery is associated with a relatively high rate of complications, including neurovascular injuries and wound healing problems compared with percutaneous techniques. However, there is a scarcity of literature describing the outcomes of these percutaneous techniques given their relatively recent adoption. The present study aims to assess the rate of postoperative complications for 3 commonly performed percutaneous calcaneal osteotomies., Methods: One hundred eighteen patients (unilateral feet) were treated with one of 3 common percutaneous calcaneal osteotomies. Sixty-five patients (55.1%) were treated with a medializing calcaneal osteotomy for hindfoot valgus, 32 patients with a Zadek osteotomy (27.1%) for insertional Achilles tendinopathy, and 21 patients (17.8%) with a modified Dwyer osteotomy for hindfoot varus. Fisher exact test was used to assess for associations between categorical variables., Results: The mean age was 46.2 years and there was a mean follow-up of 16.1 months. The overall rate of postoperative complications was 3.4% (n = 4), and no significant differences were found between the different osteotomy types. Complications included 2 cases (1.7%) of transient neuritis, 1 case of prolonged wound drainage (0.8%), and 1 nonunion (0.8%). None of the complications were associated with any recorded preoperative comorbidity., Discussion: In this series, we found that percutaneous calcaneal osteotomies are a safe alternative method for the treatment of conditions involving the hindfoot. The rate of postoperative complications may be less when compared to the reported rates of open hindfoot correction and should be considered in patients with a traditionally high risk of developing a postoperative complication., Level of Evidence: Level IV, retrospective analysis., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Ettore Vulcano, MD, is a consultant for Novastep. ICMJE forms for all authors are available online., (© The Author(s) 2022.)

Background: Extensor mechanism injuries involving the quadriceps tendon, patella, or patellar tendon can be a devastating setback for athletes. Despite the potential severity and relative frequency with which these injuries occur, large-scale epidemiological data on collegiate-level athletes are lacking., Study Design: Descriptive epidemiology study., Level of Evidence: Level 4., Methods: Knee extensor mechanism injuries across 16 sports among National Collegiate Athletic Association (NCAA) men and women during the 2004-2005 to 2013-2014 academic years were analyzed using the NCAA Injury Surveillance Program (NCAA-ISP). Extensor mechanism injuries per 100,000 athlete-exposures (AEs), operative rate, annual injury and reinjury rates, in-season status (pre-/regular/postseason), and time lost were compiled and calculated., Results: A total of 11,778,265 AEs were identified and included in the study. Overall, 1,748 extensor mechanism injuries were identified, with an injury rate (IR) of 14.84 (per 100,000 AEs). N = 114 (6.5%) injuries were classified as severe injuries with a relatively higher median time loss (44 days) and operative risk (18.42%). Male athletes had higher risk of season-ending injuries in both all (3.20% vs 0.89%, P < 0.01) and severe (41.54% vs 16.33%, P < 0.01) extensor mechanism injuries. Similarly, contact injuries were more frequently season-ending injuries (4.44% vs 1.69%, P = 0.01). Women's soccer (IR = 2.59), women's field hockey (IR = 2.15), and women's cross country (IR = 2.14) were the sports with the highest rate of severe extensor mechanism injuries., Conclusion: Extensor mechanism injuries in collegiate athletes represent a significant set of injuries both in terms of volume and potentially to their athletic careers. Male athletes and contact injuries appear to have a greater risk of severe injuries. Injuries defined as severe had a higher risk of operative intervention and greater amount of missed playing time., Clinical Relevance: Knowledge of the epidemiology of extensor mechanism injuries may help clinicians guide their athlete patients in sports-related injury prevention and management.

Ankle distraction arthroplasty (DA) is a joint-preserving option for the treatment of ankle osteoarthritis. The ideal patient is a young, active person who is compliant with follow-up and understands that clinical improvements may not be fully evident until 1 year after surgery. The procedure promotes cartilage healing and regeneration by removing mechanical stress at the joint surface through the application of a joint-spanning external fixator. There is an array of adjuvant procedures commonly performed to optimize healing potential-including microfracture, osteophyte removal, osteotomies, and soft tissue balancing procedures. Short- and intermediate-term studies have been promising, though there is a wide variance in reported failure and complication rates., Competing Interests: Disclosure E. Vulcano is a consultant for Vilex and Novastep. A.J. deMeireles has no disclosures., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Hallux valgus is a common cause of pain and dysfunction of the foot, sometimes requiring surgical correction when conservative measures fail. Although there are many methods of correction, one of the newer techniques is minimally invasive chevron-Akin (MICA). The aim of the current study is to evaluate clinical and radiographic effectiveness of MICA and narcotic use in a large patient cohort., Methods: All patients in this retrospective study were treated by a single fellowship-trained foot and ankle orthopaedic surgeon. Patient demographics were collected for all cases. Preoperative and postoperative intermetatarsal angle (IMA) and hallux valgus angle (HVA) were measured in all patients on weightbearing 3-views radiographs. The Foot Function Index (FFI) was obtained pre- and postoperatively at each visit. All patients were prescribed regular use of ibuprofen for 3 days with acetaminophen and oxycodone reserved for breakthrough pain. Use of narcotic pain medication was recorded., Results: A total of 274 feet in 248 patients were included in the study. Overall, 87.9% were female and 12.1% were male. The mean preoperative IMA and HVA were 13.4 and 29.1 degrees, respectively. The postoperative IMA and HVA were 4.9 and 8.9 degrees, respectively. The mean FFI score part A was 92 preoperatively and 43 postoperatively. Patient satisfaction was 91.6%. The mean postoperative 5 mg oxycodone pill consumption was 2.2., Conclusion: MICA is good method to correct hallux valgus deformity with low postoperative narcotic use., Level of Evidence: Level III, restrospective cohort study of a single surgeon practice.

Background: The goal of this study is to review the literature to identify risk factors for nonunion after tibiotalocalcaneal arthrodesis (TTCA) and stratify them based on strength of evidence., Methods: Five databases were searched from inception to May 17th, 2020. Abstracts and full-text articles were screened for those that included risk factors predictive of nonunion following TTCA., Results: Eight studies involving 624 patients were included and 33 potential risk factors for nonunion were identified. Strong evidence supported prior peripheral neuropathic conditions as risk factors for nonunion following surgery (OR: 2.86, 95% CI: 1.56-5.23)., Conclusion: TTCA is an effective salvage procedure but is associated with high nonunion rates. The results of our meta-analysis suggest that prior peripheral neuropathic conditions have strong evidence for failure to achieve union. Surgeons should be cognizant of these risks when performing TTCA and carefully monitor patients with the aforementioned comorbidity to achieve successful results., (Copyright © 2021. Published by Elsevier Ltd.)

Purpose: Ankle arthrodesis and total ankle arthroplasty (TAA) are often associated with significant postoperative pain. While this may be mitigated by the use of peripheral nerve blocks (PNB), large-scale data are lacking. Using national data, we aimed to evaluate PNB utilization pattern and its impact on outcomes., Methods: This retrospective cohort study utilized data from the nationwide database (2006-2016) on TAA (n = 5,290) and ankle arthrodesis (n = 14,709) procedures. PNB use was defined from billing; outcomes included opioid utilization, length and cost of stay, discharge to a skilled nurse facility, and opioid-related complications. Mixed-effects models estimated the association between PNB use and outcomes, separate by procedure type and inpatient/outpatient setting. We report odds ratios and 95% confidence intervals (CI)., Results: Overall, PNB was utilized in 8.7% of TAA and 9.9% of ankle arthrodesis procedures, with increased utilization from 2006 to 2016 of 2.6% to 11.3% and 5.2% to 12.0%, respectively. After adjustment for relevant covariates, PNB use was significantly associated with decreased total opioid utilization specifically in the inpatient setting in TAA ( - 16.9% CI  - 23.9%;  - 9.1%) and ankle arthrodesis procedures ( - 18.9% CI  - 24.4;  - 13.0%), this was particularly driven by a decrease in opioid utilization on the day of surgery. No clinically relevant effects were observed for other outcomes., Conclusion: PNB utilization is associated with substantial reductions in opioid utilization, particularly in the inpatient setting. Our study is in support of a wider use of this analgesic technique, which may translate into more benefits in terms of clinical outcomes and resource utilization., Level of Evidence: III., (© 2021. Japanese Society of Anesthesiologists.)

Study Objective: TXA is an antifibrinolytic medication widely used to reduce perioperative blood loss, but it has been seldom used during foot and ankle surgery. Our study evaluates the impact of TXA use on blood loss, post-operative pain, peri-operative opioid consumption, and wound healing in ambulatory outpatient foot and ankle procedures., Design: Prospective, triple-blinded, randomized controlled trial., Setting: Peri-operative environment of a major academic health centre in New York City., Patients: A total of 100 participants who were scheduled for ambulatory foot and ankle surgery with a single surgeon., Interventions: Patients receive either 10 mg/kg TXA (TXA group) or 10 ml/kg of normal saline (placebo group) intravenously prior to skin incision., Measurements: Primary outcome was intra-operative blood loss. Secondary outcomes were peri-operative opioid consumption and wound complications between post-operative days 14 and 21., Main Results: We found no difference between TXA and placebo groups in terms of intra-operative blood loss, p value 0.71, 95% CI (63.13-19.80). There was no difference between the two groups in terms of post-operative morphine milliequivalents (MME). The incidence of wound complications was 16.3% in the TXA group compared to 15.7% in the placebo group with OR 1.04, p value 0.93, 95% CI (0.32-2.77). No adverse events associated with TXA were reported., Conclusions: The use of TXA during foot and ankle surgery was not associated with any benefits in perioperative outcomes in our outpatient ambulatory surgical population. Considering potential risks, we do not support the routine use of TXA in this surgical model., (© 2021. SICOT aisbl.)

Background: With the development of the COVID-19 pandemic, elective foot and ankle surgeries were delayed throughout the United States to divert health care resources and limit exposure. Little is known about the impact of COVID-19 on patient's willingness to proceed with elective procedures once restrictions are lifted and factors contributing to such decision., Methods: Patients across 6 US orthopedic institutions who had their elective foot and ankle surgeries cancelled secondary to the pandemic were given a questionnaire. Specifically, patients were asked about their willingness to move forward with surgery once restrictions were lifted and if not why. Pain-level and pain medication use were also assessed. Univariate analysis was used to identify factors that contribute to patient's decisions., Results: A total of 150 patients participated in this study. Twenty-one (14%) opted not to proceed with surgery once restrictions were lifted. Forty-three percent (n = 9) listed concern for COVID infection as the reason; however, 14% of them would proceed if procedures were performed in surgery center. Twenty-nine (19% of the total cohort) patients had increased pain and 11% of patients were taking more pain meds because of the delay to their procedure. Patients who decided not to proceed with surgery reported pain reduction (3% vs 14%) and lower increase in pain medication used (5% vs 12%)., Conclusion: COVID-19 has made a significant impact on the health care system. Delay of elective foot and ankle procedures impact patient quality of life and outcomes. Access to surgery centers may provide a partial solution during the pandemic., Level of Evidence: Level III., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2021.)

Background: Ankle fractures are common and may require open reduction and internal fixation (ORIF). Literature is scarce evaluating the associations of opioid use disorder (OUD) with ORIF postoperative outcomes. This study investigates whether OUD patients have increased (1) costs of care, (2) emergency room visits, and (3) readmission rates., Methods: ORIF patients with a 90-day history of OUD were identified using an administrative claims database. OUD patients were matched (1:4) to controls by age, sex, and medical comorbidities. The Welch t-test determined the significance of cost of care. Logistic regression yielded odds ratios (ORs) for emergency room visits and 90-day readmission rates., Results: A total of 2183 patients underwent ORIF (n = 485 with OUD vs n = 1698 without OUD). OUD patients incurred significantly higher costs of care compared with controls ($5921.59 vs $5128.22, P < .0001). OUD patients had a higher incidence and odds of emergency room visits compared with controls (3.50% vs 0.64%; OR = 5.57, 95% CI = 2.59-11.97, P < .0001). The 90-day readmission rates were not significantly different between patients with and without OUD (8.65% vs 7.30%; OR = 1.20, 95% CI = 0.83-1.73, P = .320)., Conclusion: OUD patients have greater costs of care and odds of emergency room visits within 90 days following ORIF. Levels of Evidence: Level III: Retrospective cohort study.

Background: The effects of foot injuries on collegiate athletes in the United States are of interest because of the short 5-year eligibility period in the National Collegiate Athletic Association (NCAA)., Purpose: To discuss the epidemiology of severe NCAA foot injuries sustained over 10 years in 25 sports., Study Design: Descriptive epidemiology study., Methods: We utilized the NCAA Injury Surveillance System, which prospectively collects deidentified injury data for collegiate athletes. Severe injuries were classified as season- or career-ending injuries, injuries with >30-day time loss, or injuries requiring operative treatment. Injury rates (IRs) were analyzed per 100,000 athlete-exposures., Results: Of 3607 total foot injuries, 18.71% (n = 675) were classified as severe, with an IR of 5.73 per 100,000 athletic-exposures. For all severe injuries, the operative rate was 24.3%, the season-ending rate 37.0%, and the career-ending rate 4.4%. The proportion of recurrent injuries was 13.9%. Men's sports with the highest severe foot IRs were basketball (IR = 10.71), indoor track (IR = 7.16), and football (IR = 7.08). Women's sports with the highest severe foot IRs were cross-country (IR = 17.15), gymnastics (IR = 14.76), and outdoor track (IR = 14.65). Among all severe foot injuries, the most common was a fifth metatarsal fracture. The highest contact/noncontact injury ratios were phalangeal fracture, turf toe, and Lisfranc injury. The severe injuries with the highest operative rates were Lisfranc injuries, fifth metatarsal fractures, and midfoot fractures. The severe injuries associated with the highest season-ending IRs were Lisfranc injury, midfoot fracture, and general metatarsal fractures. Severe flexor/extensor injuries had the highest career-ending IRs, followed by turf toe. Severe injuries with the highest median time loss were sesamoidal fractures, calcaneal fractures, and plantar fascial injuries., Conclusion: Of all collegiate foot injuries sustained over a 10-year period, 18.7% were characterized as severe, and 24.3% of severe injuries required surgery. Basketball was the men's sport with the highest severe IR, and cross-country was the women's sport with the highest severe IR. Overall, female athletes experienced slightly higher severe foot IRs as compared with male athletes., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: E.V. has received consulting fees from Wright Medical and education payments from Arthrex and Gotham Surgical. A.A. has received education payments from Arthrex; consulting fees from Arthrex, Medshape, and Medline Industries; nonconsulting fees from Arthrex and Medline Industries; honoraria from Paragon 28; and royalties from Elsevier. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)

A 73-year-old woman with significant medical comorbidities presented with a grade I open left ankle fracture dislocation. Distraction arthroplasty was used as a definitive treatment for this injury. The patient tolerated the procedure and had no postoperative complications. The external fixator was removed at 6 months. The patient maintained good ankle function at the 1-year postoperative visit. Distraction arthroplasty is a viable acute and definitive treatment option for ankle fracture in patients with significant medical comorbidities. [Orthopedics. 2021;44(1):e148-e150.]., (Copyright 2020, SLACK Incorporated.)

Background: Insertional Achilles tendinopathy (IAT) is a challenging common lower extremity disorder, despite several treatment options described in literature. Open dorsal closing wedge calcaneal osteotomy or Zadek Osteotomy (ZO), for the treatment of the IAT has good clinical results but a high rate of postoperative complications. The purpose of this study is to describe percutaneous ZO for the treatment of the IAT and to evaluate its impact on the clinical and functional postoperative outcomes., Methods: Twenty-six consecutive patients presenting with unilateral IAT refractory to nonoperative measures were treated with percutaneous ZO. Visual Analogue Scale (VAS) and Foot Function Index Score (FFI) were recorded preoperatively and at final follow-up visit (12±3) months. Postoperative complications, satisfaction, and relief of the pain were also recorded., Results: The percutaneous ZO showed a significant improvement (p<0.0001) in preoperative to postoperative FFI (from 65±9 to 8±12) and VAS (from 9±1 to 1±2). Two postoperative complications (8%) were observed: a case of symptomatic non-union and hardware pain, both in healthy patients. The overall rate of satisfaction after surgery was (92%). The relief from pain was achieved after an average period of 12 weeks., Conclusions: ZO is a safe and effective procedure for the treatment of IAT. The use of a minimally invasive surgical approach is associated with excellent pain reduction (VAS score) and improved clinical function (FFI score). When compared to the open surgical approach, the percutaneous ZO may decrease recovery time and postoperative complications., Level of Evidence: III, retrospective case series., (Copyright © 2019 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Recreational athletes are susceptible to experiencing pain in the Achilles tendon, affecting their ability to complete daily activities. Achilles tendinosis is a degenerative process of the tendon without histologic or clinical signs of intratendinous inflammation, which can be categorized by location into insertional and noninsertional tendinosis. This condition is one that can be treated conservatively with great success or surgically for refractory cases. Currently, there is a lack of consensus regarding the best treatment options. This review aims to explore both conservative and operative treatment options for Achilles tendinopathy and Achilles tendon rupture., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the applicability of an MRI-compatible foot stressor device in patients with image-proven or clinically suspected Lisfranc joint injuries., Method: This prospective study evaluated Lisfranc joint injury by utilizing a joint-specific, stress device that was engineered to replicate weightbearing and physical examination maneuvers. Sixteen patients with either clinically suspected or image-proven Lisfranc joint injuries were recruited from September 2018 to November 2019 (9 men, 7 women; mean age, 39.3 years; age range, 14-68 years). Resting and stressed MR sequences of the injured and non-injured feet were obtained. Measured values for Lisfranc interval widths, dorsal tarsometatarsal subluxations, and lambda-angles were subtracted between the stressed and resting images to calculate net stress-induced changes. A graded injury schema was used to measure significance., Results: The foot stressor device reliably generated stress-induced changes in the Lisfranc joint during dynamic MRI examination. All morphologically abnormal ligaments on resting images demonstrated stress-induced changes, whereas all morphologically normal ligaments lacked evidence of instability. More severely injured Lisfranc ligaments allowed greater Lisfranc joint widening (IOL, p < 0.001; PCL, p < 0.001; DCL, p < 0.001). More highly graded DCL injuries allowed greater dorsal TMT subluxation when present (p < 0.001). Angular gain in the midfoot (lambda-angle) correlated with the graded IOL score (p < 0.001). Acute-to-subacute injuries demonstrated greater inducible changes than chronic injuries (p = 0.047). Seven patients underwent surgery and nine patients received physical therapy., Conclusions: Stress-induced changes in the midfoot provided information on the degree of ligament pathology and associated joint instability in Lisfranc joint injuries., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Surgeries involving the foot and ankle are painful procedures, with many patients unwilling to discontinue prescribed narcotics at 3 months postoperatively. Percutaneous techniques allow for smaller incisions and minimal soft tissue disruption. Fifty consecutive patients underwent outpatient percutaneous foot surgery. Data were collected on pain medication taken and time to return to work. A mean of 3.3 tablets of oxycodone were consumed during the first 2 weeks. No patient was taking narcotics after 2 weeks. Mean time to return to work was 18.9 days. Percutaneous foot and ankle surgery led to a significant reduction in narcotic consumption. [Orthopedics. 2020;43(4):e334-e337.]., (Copyright 2020, SLACK Incorporated.)

Background: Management of proximal 5th metatarsal fractures remains a controversial topic in orthopaedic surgery. Both operative and non-operative approaches have been described in the clinical setting. This confusion has led to non-standardized treatment recommendations for proximal 5th metatarsal fractures. This study was designed to analyze concordance rate of treatment recommendations between orthopaedic trainees and orthopaedic foot and ankle experts., Methods: An online survey containing 14 cases of proximal 5th metatarsal fractures were distributed to 92 orthopaedic residents in two ACGME-accredited programs. Relevant weight-bearing radiographs, patient's age and gender were provided, and two questions regarding treatment recommendations were surveyed. Resident's recommended treatment was then matched against ultimate treatment by orthopaedic foot and ankle experts. ANOVA and T-test are used for associations between the rate of concordant treatment with PGY and trainee foot and ankle experience. Fleiss' kappa was used to assess the inter-observer agreement., Results: Seventy-two residents returned the survey. The overall concordance rate was 43.98% with no correlation between agreement rate and PGY-years. No difference in agreement rate was observed between residents who had completed their foot and ankle rotation versus those who had not. There was a slight inter-observer agreement in recommending treatment among all residents (κ=0.117, 95% CI: 0.071-0.184)., Conclusions: Our data demonstrated no significant concordance between resident level in training regarding proximal 5th metatarsal fracture treatment decisions, nor between residents and subspecialty-trained foot and ankle surgeons. Increased rotations with foot and ankle fellowship-trained surgeons throughout residency may be desirable to improve the quality of residency training., Level of Evidence: III., (Copyright © 2019 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Achilles injuries are devastating injuries, especially for competitive athletes. No studies have examined the outcomes of Achilles injuries in NCAA athletes. Therefore, a better characterization and understanding of the epidemiology is crucial., Methods: Achilles injuries across 16 sports among NCAA men and women during the 2004-2005 to 2013-2014 academic years were analyzed using the NCAA Injury Surveillance Program (NCAA-ISP). Achilles tendon injury rate (IR) per 100,000 athlete-exposures (AEs), operative rate, annual injury rate trends, reinjury rates, mechanism of injury, in-season status (pre/regular/post season), and time loss distributions were compiled and calculated. A sub-analysis of comparing gender and injury mechanism was also performed for both all injuries and severe injuries., Results: Overall, N = 255 Achilles injuries were identified with an injury rate (IR) of 2.17 (per 100,000 AEs). These injuries occurred most often in women's gymnastics (IR = 16.73), men's basketball (IR = 4.26), and women's basketball (IR = 3.32), respectively. N = 52 injuries were classified as severe injuries which have higher median time loss (48 days) and higher operative rate (65.4%). For severe Achilles injuries, female athletes had higher operative (77.8% vs. 58.8%) and higher time loss compared to male athletes (96 days vs. 48 days). Contact mechanisms were associated with a higher season-ending injury rate., Conclusion: Overall, 20.4% of Achilles injuries were considered severe with 65.6% operative rate. About 73.1% were season-ending injuries, and the remaining athletes have a median time loss of 48 days. Severe Achilles injuries create significant impact on playing time and career for NCAA athletes.

Resection arthroplasty for metatarsalgia is a selective procedure primarily indicated for patients with rheumatoid arthritis. These patients present with significant forefoot deformities, poor bone quality, and loss of soft tissue integrity. Resection of the metatarsal heads and correction of lesser toe deformities improve pain and decrease transfer metatarsalgia. Patients with concurrent hallux valgus may benefit from a lapidus procedure or hallux metatarsophalangeal fusion in an effort to improve outcomes and decrease incidence of recurrent hallux valgus. In rare cases, diabetics with neuropathy may require resection arthroplasty in the setting of forefoot deformities recalcitrant to other modalities., (Copyright © 2019 Elsevier Inc. All rights reserved.)