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Category: Ankle Arthritis; Ankle Introduction/Purpose: Total ankle arthroplasty (TAA) is a common procedure to treat end stage ankle osteoarthritis. Despite recent increase in popularity, there is limited literature assessing clinical and patient-reported outcomes (PROs) in TAA procedures using 5 current generation implants. These measures are an important tool for physicians to better assess patient performance in daily activities. The purpose of this study is to characterize both PROs and clinical outcomes in primary and revision TAA surgeries using current generation prostheses performed by non-design surgeons at a single institution. Methods: Our institution maintains a prospective outcomes registry for patients undergoing TAA at our institution. Patient demographics, relevant case information, PROs and complications are collected. Collected PROs include PROMIS Physical Function (PF), Pain Interference (PI), Depression, Global Physical Health (GPH), Global Mental Health (GMH), and Foot and Ankle SANE. Records are categorized as a primary TAA, or revision involving either a polyethylene only exchange or complete hardware removal and replacement. Differences between groups were determined non-parametrically using Mann-Whitney U tests. In all statistical tests, a p value of less than 0.05 was considered significant. Results: A total of 259 patients were included for analysis; 223 primary and 36 partial or full revision. Average length of stay was 1.6 ± 1 days. There were 18 reoperations (6.95%), with no implant failures within 1 year. Five patients underwent implant revision at an average of 2.5 years. Of these, one was related to delayed infection at year 3, two due to hardware failure in year 2, and 2 polyethylene exchanges in years 2 and 5. All physical health PRO measures showed significant improvements post-operatively (p < 0.0001). Patients reported significant reductions in pain following TAA at 3-months (Figure 1a), and significant improvement of physical function after 6-months (Figure 1b). There were no significant changes in Depression or GMH (Figure 1d). Conclusion: Total ankle arthroplasty is a safe and effective procedure for end-stage ankle arthritis. Patients experience improvement in all physical health PRO metrics at all post-operative time points after 3 months. Complication and early failure rates are lower than that reported in the literature. Long term outcomes and implant longevity will be tracked using the CU Total Ankle Registry. Total ankle arthroplasty improves quality of life in patients suffering from ankle osteoarthritis. Further follow-up and patient enrollment in the CU Total Ankle Registry will help us to identify risk factors for complications and define implant lifespan.

Category: Other Introduction/Purpose: It is often difficult for early career investigators to identify the ideal journal readership for foot and ankle research without knowledge of each journal’s culture and article preferences. Bibliometric analyses have shown the popularity of certain topics can vary widely between similar journals. However, in the foot and ankle literature, there is very little information available regarding the publication preferences of common journals. The goal of this project was to provide a practical table with publishing trends to help investigators identify one or more journals most suitable for a given manuscript. Methods: We examined 43 journals, including both general orthopedic journals and foot and ankle-specific publications. We utilized the National Library of Medicine’s MEDLINE database for general article information, and Web of Science’s (WOS) Journal Citation Report for citation counts. Journals were only included for analysis if they published a minimum of 50 foot and ankle (FA) articles in the past five years, and were indexed in both MEDLINE and WOS. Variables such as publishing nationality, number of authors, and article type were collected using MEDLINE article metadata. Keyword lists were generated by our author team for each topic, and keywords were then searched to calculate the percentage of articles categorized under that topic. To measure the impact factor of a journal, we calculated a 5-year “impact factor” following modified WOS guidelines (total citations in 2020 for articles published 2015-2019 / total publications from 2015-2019). Results: 29 journals met our inclusion criteria for analysis (67%), of which 6 specialized in foot and ankle (Table 1). The popularity of certain article topics varies widely between journals. For example, while the Journal of Foot and Ankle Research publishes more than twice as many sports articles than any other FA publication (25%), it publishes five times less arthroscopy publications (2%). Similarly, we also find notable differences in the type of article published by journals – while only 1% of the total articles published by FAI are case reports, the Journal of Foot and Ankle Surgery published 30% case reports the past five years. We also found the distribution of American first authors can vary widely – ranging from 95% to 0% in different journals. Conclusion: This data set is aimed to provide a practical tool for early investigators to select ideal journals that would be appropriate for their work. Metrics like nationality may help authors intentionally reach out to a more diverse international audience, or an American readership, when appropriate. Likewise, targeting manuscripts that are a topic of interest to journals can save time in the publication process that is spent in initial review. While this data set relies exclusively on publicly available metadata from MEDLINE and WOS, we believe it offers an encouraging start to better understand the foot and ankle publishing landscape.

Category: Ankle Arthritis; Basic Sciences/Biologics Introduction/Purpose: Osteoarthritis (OA) of the ankle is a debilitating condition that impacts millions of people. However, little is known about transcriptomic signatures associated with progression to OA, nor is the synovial contribution to the process established. Our prior work using RNA-sequencing (RNA-seq) has demonstrated unique differences between both ankle and knee OA, as well as ankle OA and non-OA ankles. In these analyses, we have shown visual clustering of ankle OA, ankle non-OA, and knee OA, with subtle transitional regions between each cohort. This study’s objective is to use demographic and patient factors that may contribute to differences in patients within each cohort and evaluate multiple machine learning (ML) clustering methods to better visualize OA subtypes of our complete ankle and knee synovium RNA-seq dataset. Methods: RNA-seq of synovium from ankle OA (n=30), knee OA (n=6), and ankle non-OA (n=30) were analyzed. Differential expression of genes and functional enrichments were determined using the Novomagic online platform (Novogene USA, Sacramento, CA) with DESeq2 software. ML methods were employed on the total gene read counts using Python coding language to perform data i) standardization via unit variance, ii) reduction via principal component analysis, t-distributed stochastic neighbor embedding, and uniform manifold approximation and projection (UMAP) techniques, and iii) clustering via k-means, fuzzy c-means, and gaussian mixture model. The number of principal components and clusters were determined via skree plot and elbow method, respectively. The technique with the highest silhouette score was chosen for subsequent analysis; a higher score indicates better separation of the dataset. Resulting data was plotted and color-coded to visualize the data based on original sample information (surgery, prior injury, sex, and age). Results: RNA-seq analysis of posttraumatic OA ankles compared to primary OA ankles identified decreased enrichment of MMP- 7, metalloproteinase associated with OA and fibrosis, and increased enrichment of IGKV2D-40, a less characterized gene. Significant reactome pathways in primary ankle OA included activation of matrix metalloproteinases, collagen formation and degradation, and extracellular matrix organization (Figure 1A). UMAP reduction with fuzzy C-means clustering (n=8 clusters) best separated the dataset. Qualitatively, the data appears separated by surgery type (ankle OA and ankle non-OA, knee OA), with a transitional region between distinct groupings (Figure 1B); a subtle but crucial difference between knee and ankle OA exists. Increased age appears associated with knee OA and some ankle OA, while patient sex did not display any clear separation in the data. Conclusion: Functional analysis of gene transcription displayed enrichment in genes and pathways related to fibrosis, further indicating ankle OA may be the result of a fibrotic signature. This study additionally demonstrated that ML provides unbiased visualization of multiple groups of RNA-seq data from knee and ankle synovium. A unique transitional group of patients who were deemed non-OA yet clustered with OA samples, suggesting some non-OA synovium that could be displaying signs of early OA progression. Ultimately, exploring the impact of patient demographics using multiple data reduction and ML can help identify unique subtype of patients within the context of OA.

Category: Other Introduction/Purpose: Patient factors such as resilience and mental health play a vital role in perception of pain and surgical outcomes. Increasingly, practices are incorporating psychosocial and mental health patient-reported outcome (PRO) surveys into patient assessment. Individual PROs, such as measures of patient resilience, have been found to correlate with post-surgical outcomes in the orthopaedic population. To date, however, there has been little investigation comparing the efficacy of psychosocial PROs in the foot and ankle population. This study's objective was to evaluate the role of resilience, depression, and global mental health in foot and ankle surgical outcomes and establish the benefits and limitations of each PRO. Methods: Consecutive patients undergoing foot and ankle orthopaedic surgery at a single institution were enrolled in the U- COSMOS platform, an automated outcomes data repository. Patients were included for analysis if they had baseline and minimum 6-month follow-up outcome scores. If more than one follow-up was available, the longest available outcome was used. As measures of physical health, PROMIS Physical Function CAT (PF), PROMIS Pain Interference CAT (PI), Foot and Ankle Single Assessment Numeric Evaluation (FA SANE), and PROMIS Global Physical Health (GPH) were collected. Psychosocial factors were assessed using the Brief Resilience Scale (BRS), PROMIS Depression CAT, and PROMIS Global Mental Health (GMH). Patients lower than, within, and higher than one standard deviation of the average for each psychosocial outcome were divided into three groups. Differences were assessed using ANOVA and corrected for demographics. Results: 725 patients who underwent foot and ankle surgery were included. At longest follow-up, we found that patients reporting higher pre-operative BRS, higher pre-operative GMH, and lower pre-operative Depression report significantly higher follow-up physical health outcomes in all domains (p < 0.05, see Table 1). Importantly, we found stark differences between psychosocial factors when assessing baseline outcomes and post-surgical improvement at longest follow-up. At baseline, GMH and Depression are associated with higher pre-surgical scores in nearly all physical health domains, while BRS is not. Inversely, BRS is associated with higher post-surgical improvement, while GMH and Depression are not. Supporting these findings, baseline Depression and GMH are more strongly correlated with one another (r = 0.67) than with BRS (r = 0.53 and r = 0.46, respectively). Conclusion: We found that patients with higher pre-operative psychosocial PROs reported greater physical health outcomes at follow-up. Patients with high resilience also reported greater improvement in PROs compared to baseline. While global mental health and depression may be associated with physical health scores at a single moment in time, our findings suggest patient resilience plays a larger role in predicting improvement following surgery. Further investigation is warranted to determine the effect resilience scores have on outcomes for specific procedures and conditions. Additionally, interventions to improve patient resilience may be most beneficial for a patient’s long term improvement following surgery.

Category: Hindfoot; Ankle Introduction/Purpose: Both prefabricated and custom-made foot orthoses have long been effective treatment foot and ankle conditions and deformities. Foot orthoses function by replacing the insole of a shoe to redistribute forces during weightbearing activities and can be a cost-effective and noninvasive treatment modality. Custom foot orthoses are created using a 3D scan or weightbearing impression of the patient’s foot and are intended to accommodate a patient’s foot anatomy, whereas prefabricated (off the shelf) orthoses are often prescribed unaltered or minimally modified. Custom orthoses have a much higher cost and are variably covered by insurance. The aim of this study is to compare the effectiveness of custom versus prefabricated foot orthoses for foot and ankle conditions using validated patient-reported outcome scales. Methods: Consecutive patients prescribed custom or prefabricated orthoses at a single institution were retrospectively reviewed. Following IRB approval, a follow-up research survey was distributed to patients to collect patient-reported outcomes. Collected outcome measures included the Foot and Ankle Single Assessment Numeric Evaluation (FA SANE), PROMIS Mobility, PROMIS Pain Interference (PI), and PROMIS Physical Function (PF). All patients with a baseline and minimum three-month follow-up score were included in the final sample. Statistical analysis was conducted using the ANOVA statistical test. In all cases, a p-value of less than 0.05 was considered significant. Results: A total of 238 patient records were included. 152 patients received a custom orthosis, while 86 patients received a prefabricated orthosis. Both groups reported significant improvement from baseline to follow-up in the FA SANE, PROMIS PI and PROMIS PF (p < 0.001). However, assessing PROMIS Mobility, we did not observe a significant difference in improvement from baseline to follow-up in either group. Comparing outcomes between groups, patients receiving custom orthoses reported significantly greater PF at follow-up compared to the prefabricated group (p < 0.05). However, at follow-up there was no significant difference between the custom and prefabricated groups in PI, Mobility, or FA SANE. Mean satisfaction scores were significantly higher for patients with custom orthotics compared to prefabricated orthotics (8.1 vs. 7.5, p < 0.01). Conclusion: Both custom and prefabricated foot orthoses result in improvement in pain and physical function over time. Although the results found in this study lacked definitive evidence in favor of the custom orthoses over prefabricated orthoses, overall patient-reported outcomes were higher for patients receiving custom orthoses. Further research, including longer term follow up, differentiation based on specific clinical diagnoses and deformities, and subsequent need for surgery may ultimately lead to definitive guidelines for custom versus prefabricated orthoses.

Category: Midfoot/Forefoot; Sports Introduction/Purpose: First metatarsophalangeal (MTP) arthrodesis is an effective procedure to alleviate pain and correct deformity. The unique location of our academic center allows us to study an extremely active patient population with high rates of participation in impact sports and particularly alpine specific sports, including Nordic and alpine skiing, snowboarding, hiking, trail running and biking. There is limited literature regarding these specific activities with regards to a 1st MTP arthrodesis. The goal of the study is to better define the ability to return to physical activity, with a focus on alpine and mountain sports. This will help physicians counsel patients appropriately when discussing surgical options. Methods: Patients over 18 years old who underwent MTP arthrodesis with minimum 1 year follow up were identified using CPT code 27850. Patients undergoing concomitant forefoot and hindfoot procedures were excluded. Demographic data and complications were recorded by retrospective chart review. A custom sports questionnaire, PROMIS Physical Function (PF), PROMIS Pain Interference (PI), and Foot and Ankle Ability Measure (FAAM) scores were administered to patients. Postoperative radiographs were analyzed for time to union and fusion position. Results: 96 patients were eligible for analysis. Preliminarily, 34 have completed the follow-up survey. Most common activities were walking, hiking, alpine skiing, biking and running. Compared to preoperatively, patients rated 70.5% of activities as less difficult, 20.5% as the same, and 9.0% as more difficult. 74% of patients returned to their activities by 6 months and 62% of patients reached their maximum level of activity by 9 months postoperatively. Patients who participated in skiing/snowboarding were all able to ski the same level of terrain compared to before surgery, but nearly half (46%) of patients required boot modifications. 43% of patients were able to increase incline when hiking/trail running, and 48% of patients were able to increase their running/walking mileage. Average PROMIS PF was 51.9 (±6.20). Conclusion: Patients are able to participate in a variety of high impact and alpine related sports after 1st MTP arthrodesis. The majority of patients are able to function at similar or increased levels when returning to hiking, walking, skiing and snowboarding. Up to 25% of patients may not reach maximum level of activity until 1 year postoperatively. Additional investigation is required to identify potential risk factors for patients that may experience difficulty returning to activity. Continued survey participation is underway to strengthen these results. Patient counseling on activity participation following hallux MTP arthrodesis is important to optimize outcomes and patient satisfaction.

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: Basic Sciences/Biologics; Ankle Introduction/Purpose: Peroneal tendon disease (PTD) represents a spectrum of pathologies. Current literature focuses on pathoanatomy, but not the microenvironment of the peroneal complex on a histopathological cellular level. This information is crucial to understanding disease progression and future development of therapeutic strategies. This study aims to define the histological microenvironment and transcriptome of tenosynovium in patients with various disease stages. We further propose a classification system for PTD: (Type 0) Normal tenosynovium; (Type 1) Inflammatory tenosynovium with normal appearing tendons; (Type 2) inflammatory or degenerative tenosynovium with tendinosis or split tear involving less than 50% of tendon substance; (Type 3) Inflammatory or degenerative tenosynovium with tendinosis or split tear involving greater than 50% of tendon substance; (Type 4) Complete or near complete degenerative rupture. Methods: Tenosynovium was sampled from patients, classified for PTD, and then processed for RNA sequencing (RNA-seq; n = 3) and histology (n = 7). RNA-seq was performed using the Illumina NovaSeq6000 platform. Differential expression was determined using the R edgeR (3.22.5) package after adjusting via a scaling normalization factor and correcting P-values via the Benjamini Hochberg method. Tenosynovium samples were processed for hematoxylin and eosin (H&E) staining and evaluated using machine learning to classify cell types. Briefly, QuPath software was used to load images of H&E section4-means, fuzzy c-means and gaussian mixture. Cells were assigned to clusters and then quantified and visualized with density plots in QuPath. Results: UMAP with k-means clustering was the best data reduction and clustering technique. Total cellular density increased with type 3 and 4 PTD compared to type 1; cluster 3 cells were the most increased with types 3 and 4 compared to type 1 (Figure 1A). Cluster 3 cells appear in vascular structures and are elongated/oval with dark nuclear staining (Figure 1B). In type 3 and 4, cluster 3 cells appear in and around vascular structures and at the surface lining in type 4. RNA-seq identified 13 genes differentially expressed (p < 0.05; Figure 1B). Significant gene ontology terms include muscle contraction, myofibril assembly, and actin myosin filament sliding (Figure 1C). Significant reactome pathways include muscle contraction, fatty acyl-CoA biosynthesis, and activation of gene expression by SREBF. Conclusion: In this study, RNA-seq and machine learning cell classification in H&E staining yield findings that represent the cellular and molecular disease signature in PTD. Histological analysis demonstrated that in more severe classes of PTD (types 3-4), cell morphologies found in vascular structures and surface lining were increased and suggestive of fibroblasts/ myofibroblasts and smooth muscle cells. RNA-seq demonstrated an increased expression of genes, with muscle contraction and myofibril activity representing significant signatures. Overall, our study demonstrates potentially increased cell and gene pathways consistent with smooth muscle activity and fibrosis. These pathways present targets for better classifying and treating PTD pathology.

Category: Other; Ankle Introduction/ Purpose: Recovery from orthopedic surgery requires a degree of both physical and mental resilience during recovery and rehabilitation. The brief resilience scale (BRS) is a validated and reliable 6-item screening tool that measures resilience as the ability to bounce back or recover from stress. BRS can provide unique and important information about patients coping with health-related stressors. To date, there is little evidence describing the use of BRS as a pre-operative benchmark to evaluate outcomes following foot and ankle orthopedic injuries and procedures. We aim to determine how patient resilience, as measured with BRS, may predict the impact of orthopedic conditions and recovery from foot and ankle surgery. Methods: All patients undergoing foot and ankle orthopedic surgery at a single institution were enrolled in U-COSMOS, a HIPAA-compliant, automated outcomes data repository. All patients undergoing surgery completed BRS pre-operatively. We used a BRS cutoff of < 3 (lower resilience, LR), 3-3.9 (intermediate resilience, IR), and >=4 (high resilience, HR) to create three cohorts. Patients also completed a PROMIS Physical Function (PF) Computer Adaptive Test (CAT), PROMISE Pain Interference (PI) CAT, PROMISE Depression (D) CAT, and Global Health (GH) Short Form pre-operatively as well as 3-, 6-, 12-, and 24- months post-operatively, as applicable. Patients with a minimum follow-up of 180 days were included for analysis, and the longest available follow-up was used. Differences in outcomes between the three BRS groups were determined non-parametrically using a Kruskal–Wallis one-way analysis of variance. Results: A total of 586 patients were included for analysis, with an average follow-up of 389 days. The patients were categorized as low resilience (n=44), intermediate resilience (n=229), and high resilience (n=323). Patients in the high resilience cohort had significantly higher PF and lower PI and Depression scores both pre-operatively (p < 0.05 for all) and post-operatively (p < 0.001 for all). The greatest disparity was found in depression where low resilience patients were greater than 1 SD worse than high resilience patients (Figure 1). Similar trends are observed for physical and mental global health. In addition to having higher absolute baseline and follow-up scores, the change of PF and PI is also significantly higher for high resilience patients (p = 0.02). Conclusion: Patients with high pre-operative resilience demonstrate better pre-operative physical function and pain interference scores compared to lower resilience patients and show greater improvement at 12 months post-op. We also found that lower BRS scores are associated with decreased pre- and post-operative mental health outcomes, including PROMIS Depression. Further analysis of the role of BRS in pre-operative assessment will help guide shared treatment decision-making. Identifying interventions for patients with low resilience will likely lead to improve surgical outcomes.

Category: Other; Ankle; Hindfoot; Midfoot/Forefoot Introduction/Purpose: As digital healthcare systems advance, patient reported outcomes (PRO) platforms offer an effective strategy for clinicians to evaluate patient relevant treatment outcomes. Initiated by AOFAS in 2018, the Orthopaedic Foot and Ankle Outcomes Research (OFAR) Network was a multi-center surgical outcomes registry platform established to collect, aggregate, and report PRO data. OFAR included surgical information, patient demographics, and PRO instruments developed by the National Institutes of Health (NIH) Patient Reported Outcomes Measurement Information System (PROMIS). Due to high costs and competing technologies, OFAR data collection ended in 2020. Although OFAR did not achieve widespread and sustained use, a large number of patients were enrolled over the 2-year period. We hypothesized that each aggregated PRO metric improved at all post-operative time points compared to preoperative values. Methods: From 2018-2020, four sites and 10 orthopedic surgeons were approved and able to contribute patient data to the OFAR database. Enrolled patients completed a pre-operative survey and then post-operative surveys at 3-months, 6-months, and 12-months. Five PROMIS metrics were collected at each survey point, including Physical Function CAT (PF), Pain Intensity Short Form (PI), Pain Interference CAT, Global Health Short Form and Depression CAT. Descriptive statistics were used to summarize the demographics and clinical characteristics of all individuals. Linear mixed models were used to test for differences in patient reported outcomes (PROs) across the study visits. The unstructured covariance structure was used to account for the repeated measures. After the OFAR closed to enrollment, all investigators of the OFAR consortium, including those who were not able to participate as a site, were surveyed to investigate the barriers they faced when launching OFAR at their site. Results: The final OFAR database includes 1,675 procedures performed at four institutions, with 1,126 having complete data for analysis. Ankle impingement (12%), ankle fracture/syndesmosis (11%), ankle arthritis (10%), and hallux valgus (9%) were the most common conditions among 28 unique conditions. The cumulative incidence of post-operative complications was 6.2% and the re- operation rate was 1.5%. Relative to the pre-operative visit, there was significant improvement in all metrics across post-operative time points (Table 1). The majority of OFAR consortium member sites (15 of 19) were unable to enroll patients in OFAR. The most common barriers noted included resistance from institutional EMR/IT or compliance teams, and institutional requirements to collect PROs through another platform. The majority of OFAR members (55%) indicated they would participate in a future low-cost, low-effort multi-center outcomes database. Conclusion: The OFAR database successfully collected patient outcomes data from multiple institutions. The resulting database also provided a comprehensive resource to answer targeted clinical questions about outcome predictors for common interventions. Barriers to participation in a multi-center registry more frequently emanated from the technologic or compliance constraints of hospital systems rather than individual providers. Increasing demand for PROs in practice, combined with the evolving technical landscape of greater automation and EHR interoperability will lead to more sustainable, affordable, and collaborative outcomes platforms. Institutional EMR and compliance barriers remain an important factor in advancing these important initiatives.

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: Sports; Ankle; Trauma; Other Introduction/Purpose: Ligament augmentation repair (LAR) entails supplementing a ligament repair with synthetic material anchored to bone. Purported advantages include increased stability and a more aggressive rehabilitation. In recent years, the literature supporting LAR has grown rapidly, with published techniques and outcomes for many ligament and tendon repairs, including anterior talofibular ligament (ATFL), Achilles tendon, and the spring ligament complex. Despite the increased use of synthetic ligaments reported in literature, there remains a lack of clarity and consensus on the indications and postoperative rehabilitation protocols. The purpose of this study was to survey an international group of orthopedic specialists regarding their current use of LAR techniques and decision-making. Methods: We invited members of several international orthopaedic and sports medicine societies to participate in this survey between January and June 2021. Responding surgeons represented all six continents, and included 319 sports medicine specialists, 179 foot and ankle specialists, and 96 trauma specialists (some reported more than one fellowship). Survey questions fell into three general categories: 1) Surgeon demographics and training, 2) Current LAR use decision-making within respondents' subspecialty, and 3) Outcomes, complications, frequency, and benefits associated with LAR. Chi-square tests of independence were used to assess the likelihood of any dependent relationships between respondent demographics and LAR use our outcome. A p value of less than 0.05 was considered significant. Results: We collected 515 responses total with a 97% completion rate. 75% of all survey respondents report using LAR for some indication. The most frequent use was ATFL repair (69%, Figure 1). LAR is most commonly implemented for additional stability (72%), poor tissue quality (54%), and more rapid return-to-sport/work (47%). LAR users state the greatest limitation is cost (62%), while non-LAR users state their greatest deterrent to LAR is that it is unnecessary for a good outcome (46%). Foot and ankle fellowship trained surgeons are significantly more likely to use LAR (87% use LAR) compared to sports-trained surgeons (67%, p = 0.002) and surgeons without a fellowship (66% use LAR, p = 0.01). Surgeons treating professional/Olympic athletes are significantly more likely to use LAR. Conclusion: While synthetic ligaments are commonly used to supplement ligament repairs, the application, outcomes, and perceived benefit differ for each subspecialty. The reported limitations of LAR differ between LAR users and non-LAR users. For those who do not use LAR, the greatest limitation is perceived benefit, while for those that do, the greatest limitation is cost. Prospective studies of indications, outcomes and accelerated rehabilitation protocols are needed to further elucidate the value and cost-effectiveness of these implants.

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: Midfoot/Forefoot; Sports; Trauma Introduction/Purpose: Fifth metatarsal fractures are a common injury of the foot, however, there remains a lack of consensus regarding the management of Zone I and II fifth metatarsal fractures. The evidence shows varied outcomes between operative management and non-operative interventions. Additionally, there is limited discussion on radiographic outcomes following these fractures, with no established scoring system to assess radiographic healing. The radiographic union scale in tibial (RUST) fractures is an assessment tool designed to standardize radiographic assessment and outcome measures based on cortical bridging. The aim of this study is to assess the functional and radiologic outcomes for patients with base of fifth metatarsal fractures (Zone I-III) utilizing the RUST score as a method for standardized assessment of radiographic healing. Methods: We performed a secondary retrospective chart review of patients with base of fifth metatarsal fractures treated by six orthopedic surgeons at University of Colorado Orthopaedics from 2018-2021. We collected information on treatment modality and the functional, radiographic, and patient reported outcomes. Patients were included who attended minimum two visits and had x-ray available. The x-rays were read by a fellowship trained foot and ankle surgeon, and were assessed based on presence of displacement, resorption, and overall healing. The RUST scoring system was applied when fracture appeared healed and assessed on the four cortices (anterior, posterior, medial, and lateral) of the 5th metatarsal bone by assigning a score from 1 to 3 based on appearance. The scores were combined for a minimum of 4 (not healed) and a maximum of 12 (completely healed). Differences between outcomes were evaluated using an unpaired t-test and figures are reported with standard error. Results: Out of 196 total patients, 109 were excluded due to shaft fracture or insufficient follow-up, leaving 87 non-operative patients with base of fifth metatarsal fractures available for analysis. Radiographically, the average time to resorption was 37 days and average time to healing was 98 days, which was significantly longer than when patients began weight bearing at 44 days (p

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: Other Introduction/Purpose: In recent years, digital publishing and indexing have accelerated the pace of collaboration in foot and ankle (FA) research. As journals become more electronically accessible, authors have greater opportunity to submit to journals that are most appropriate for their work and relevant to the global community. While previous studies have reported general publishing trends in FA research, there is little information available on which topics and authorship practices bring the greatest value to the orthopaedic community. The goal of this study is to investigate global and journal-specific factors associated with high- impact FA research, including sub-topics and collaboration trends. Methods: We examined 43 orthopedic journals, including FA-specific journals, general orthopedic journals, and sports medicine journals. We utilized the National Library of Medicine's MEDLINE database for general article information, and Web of Science's (WOS) Journal Citation Report for citation counts. All 43 journals were indexed in both MEDLINE and WOS. We categorized articles as FA-specific using a keyword search. To measure the impact factor of a journal, we calculated a 5-year 'impact factor' following modified WOS guidelines (Total citations in 2020 for articles published 2015-2019 / total publications from 2015-2019). To measure individual 'article impact', we calculated the average citations/year for that article following publication. Only articles published in the last five years were included for each topic to ensure all article averages are current. Other variables, such as publishing nationality, number of authors, and article type were collected using MEDLINE article metadata and keyword searches. Results: A total of 7,679 FA-specific articles published in 43 journals were included for analysis. Globally, US authors publish the greatest number of first-author FA articles (32%, Figure 1a), followed by the UK (8%), China (6%), and South Korea (5%). Author nation of origin varies considerably by journal; FAI is composed of 53% American first-authors, while 13% of articles from the international journal KSSTA feature American first-authors. Article impact also varies considerably by topic (Figure 1b). Sports- related FA articles, for example, outperform the average FA article in citations/year (2.27 vs. 1.69, p < 0.0001), while deformity- related articles underperform the FA average (1.25, p < 0.0001). The number of authors has a strong positive correlation with article impact (r = 0.88, Figure 1c). Conclusion: A clear understanding of publication trends in the literature allows authors to select the most appropriate journal readership for their work. American authors are global leaders in FA publications, and primarily publish in American journals. We found that many factors, including article sub-topic and authorship group size, influence article impact and journal impact factor. These findings raise opportunities for collaboration, research focus and journal selection. Monitoring publication trends allows authors and journal editors to more accurately predict high-impact areas of research, and to identify potentially under- represented fields needing greater attention and investigation.

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: Sports; Ankle; Trauma Introduction/Purpose: Foot and ankle injuries account for a large percentage of the over one million injuries sustained by high school level athletes. To date, many studies have examined the epidemiology of lower extremity injuries and ankle sprains, but few studies have classified sprains into subtypes across multiple sports. The purpose of this study was to describe the epidemiology of ankle sprain subtypes across 9 common high school sports. Methods: Athlete exposure and injury specific data from 7 seasons (2014 to 2021) were collected using the internet-based High School Reporting Information Online (High School RIO), a national high school sports injury surveillance system, for athletes participating in 1 of 9 sports (boys' and girls' soccer, girls' volleyball, boys' and girls' basketball, boys' baseball, girls' softball, boys' football, boys' wrestling). Incidence and ligament involvement of foot and ankle injuries were examined, with incidence being calculated as 1 injury per 10,000 athlete exposures (AE). Results: Ankle ligament injuries accounted for 89.0% of the 7,321 foot and ankle injuries across the 9 sports (81-94%). Girls and boys' basketball had the highest incidence of sprains, 3.46 and 3.37 respectively. Ankle ligament injuries accounted for 35.9% of all lower extremity injuries in basketball players. 85.0% of the sprains were classified as lateral ligament, 4.0% medial ligament, 11.5% syndesmosis (8.6% partial and 2.9% complete syndesmosis injuries). Football had the highest percentage of syndesmosis injuries at 11.0%, and the highest incidence of both syndesmosis injuries (0.44) and medial ligament injuries (0.17). Surgical intervention was required in 4.3% of complete syndesmosis injuries and 0.7% of lateral ligament injuries. No differences were found in incidence of ankle ligament injuries comparing pre-COVID-19 seasons (2014-2020) to the 2020-2021 season. Conclusion: Ankle sprains account for a large percentage of foot and ankle injuries sustained by high school level athletes. Syndesmosis injuries occur more commonly in football and are 6 times more likely to require early surgical intervention compared to lateral ligament injuries. Identifying sports commonly involved in these injuries and classifying the sprains is the first step in implementing early identification, rehabilitation, and prevention programs. Future studies should examine the efficacy of injury prevention programs and rates of ankle sprains among high school level athletes.

Background: Few studies have examined the causal relationship between transport mode and body mass index (BMI)., Methods: We examined between-person differences and within-person changes in BMI by transport mode over four time points between 2007 and 2013. Data were from the How Areas in Brisbane Influence HealTh and AcTivity project, a population-representative study of persons aged 40-65 in 2007 (baseline) residing in 200 neighbourhoods in Brisbane, Australia. The analytic sample comprised 9931 respondents who reported on their main transport for all travel purposes (work-related and non-work-related). Transport mode was measured as private motor vehicle (PMV), public transport, walking and cycling. Self-reported height and weight were used to derive BMI. Sex-specific analyses were conducted using multilevel hybrid regression before and after adjustment for time-varying and time-invariant confounders., Results: Independent of transport mode and after adjustment for confounders, average BMI increased significantly and linearly across the four time points for both men and women. Men and women who walked or cycled had a significantly lower BMI than their counterparts who used a PMV. BMI was nearly always lower during the time men and women walked or cycled than when they used a PMV; however, few statistically significant differences were observed. For women, BMI was significantly higher during the time they used public transport than when using a PMV., Conclusion: The findings suggest a causal association between transport mode and BMI and support calls from health authorities to promote walking and cycling for transport as a way of incorporating physical activity into everyday life to reduce the risk of chronic disease., Competing Interests: Competing interests: BG-C is supported by an NHMRC Senior Principal Research Fellowship (APP1107672). JNR is supported by an NHMRC Centre of Research Excellence in Healthy, Liveable Communities (APP1061404) on which GT and BG-C are chief investigators., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Competing Interests: Competing interests: Klaus Mönkemüller is a speaker and consultant for Ovesco Germany and Cook Medical USA.

We present a case of primary disseminated herpes simplex virus type 2 (HSV-2) cutaneous disease in a 22-year-old male. We discuss the immune response to HSV-2 infection as well as the extragenital manifestations of HSV-2 observed in immune-competent and immune-suppressed persons.

Introduction and Aims: Individual smokers from disadvantaged backgrounds are less likely to quit, which contributes to widening inequalities in smoking. Residents of disadvantaged neighbourhoods are more likely to smoke, and neighbourhood inequalities in smoking may also be widening because of neighbourhood differences in rates of cessation. This study examined the association between neighbourhood disadvantage and smoking cessation and its relationship with neighbourhood inequalities in smoking., Design and Methods: A multilevel longitudinal study of mid-aged (40-67 years) residents (n = 6915) of Brisbane, Australia, who lived in the same neighbourhoods (n = 200) in 2007 and 2009. Neighbourhood inequalities in cessation and smoking were analysed using multilevel logistic regression and Markov chain Monte Carlo simulation., Results: After adjustment for individual-level socioeconomic factors, the probability of quitting smoking between 2007 and 2009 was lower for residents of disadvantaged neighbourhoods (9.0-12.8%) than their counterparts in more advantaged neighbourhoods (20.7-22.5%). These inequalities in cessation manifested in widening inequalities in smoking: in 2007 the between-neighbourhood variance in rates of smoking was 0.242 (P ≤ 0.001) and in 2009 it was 0.260 (P ≤ 0.001). In 2007, residents of the most disadvantaged neighbourhoods were 88% (OR 1.88, 95% credible intervals (CrI) 1.41-2.49) more likely to smoke than residents in the least disadvantaged neighbourhoods: the corresponding difference in 2009 was 98% (OR 1.98, 95% CrI 1.48-2.66)., Conclusion: Fundamentally, social and economic inequalities at the neighbourhood and individual levels cause smoking and cessation inequalities. Reducing these inequalities will require comprehensive, well-funded and targeted tobacco control efforts and equity-based policies that address the social and economic determinants of smoking., (© 2012 Australasian Professional Society on Alcohol and other Drugs.)