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Abstract The organosulfur compound dimethylsulfoniopropionate (DMSP) has key roles in stress protection, global carbon and sulfur cycling, chemotaxis, and is a major source of climate-active gases. Saltmarshes are global hotspots for DMSP cycling due to Spartina cordgrasses that produce exceptionally high concentrations of DMSP. Here, in Spartina anglica, we identify the plant genes that underpin high-level DMSP synthesis: methionine S-methyltransferase (MMT), S-methylmethionine decarboxylase (SDC) and DMSP-amine oxidase (DOX). Homologs of these enzymes are common in plants, but differences in expression and catalytic efficiency explain why S. anglica accumulates such high DMSP concentrations and other plants only accumulate low concentrations. Furthermore, DMSP accumulation in S. anglica is consistent with DMSP having a role in oxidative and osmotic stress protection. Importantly, administration of DMSP by root uptake or over-expression of Spartina DMSP synthesis genes confers plant tolerance to salinity and drought offering a route for future bioengineering for sustainable crop production.

Category: Ankle; Other Introduction/Purpose: Corticosteroid injections are commonly used in the clinical setting for the treatment of foot and ankle tendinopathy, although there is limited research into their efficacy and rate of complications. The purpose of this study is to examine the patient-reported outcomes and complications, specifically tendon rupture, associated with ultrasound-guided corticosteroid injections for foot and ankle tendinopathy. Methods: A retrospective review was conducted of patients who underwent corticosteroid injection into the extensor hallucis longus, extensor digitorum longus, flexor digitorum longus, posterior tibial, anterior tibial, peroneal, or Achilles tendons for the treatment of foot and ankle tendinopathy between June 2020 and September 2022. Demographic information, incidence of complications, incidence of surgical intervention, and patient-reported outcomes were recorded. A total of 131 patients were included in the study population, with 73 (55.7%) patients receiving a posterior tibial tendon injection, 53 (40.6%) receiving a peroneal tendon injection, and 6 (4.6%) receiving an injection of a different tendon. The average follow-up was 27.8 weeks (range: 3.4 to 111.3). Continuous and categorical data were expressed as a mean and percentage, respectively. Paired Student’s t-test was utilized to compare pre- and post-procedure patient-reported outcomes. Multivariable analysis was utilized to control for confounding variables. All p< 0.05 were considered statistically significant. Results: There were 2 (1.6%) reported ruptures, both of which involved the peroneal tendon, and 22 (16.8%) patients who required surgical treatment of their affected tendons following their injection. Multivariable analysis demonstrated no specific patient or procedure factors were significantly associated with an increase in the tendon rupture rate. Overall, patients who received a corticosteroid injection had significant improvements in their pain interference (63.3 vs 58.7, p< 0.001), physical function (38.9 vs 41.3, p=0.032), and mobility (37 vs 39.7, p=0.006) scores. There was no significant difference in the amount of improvement between those receiving a posterior tibial tendon and peroneal tendon injection regarding pain interference (4.6 vs 4.9, p=0.805), physical function (3.2 vs 1.9, p=0.294), and mobility (3.4 vs 3.1, p=0.865) scores. Conclusion: There is a lack of efficacy and safety data surrounding corticosteroid injections for use in foot and ankle pathology. This study demonstrates patients receiving a corticosteroid injection for the treatment of foot and ankle tendinopathy had significant improvements in their patient-reported outcomes with a 1.6% tendon rupture rate. These results demonstrate corticosteroid injections are an effective treatment for foot and ankle tendinopathy, but further research is necessary to fully categorize the safety of this procedure.

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Nitinol is a metal alloy with high elastic flexibility and shape memory characteristics, making it effective in orthopedic surgery. Although nitinol staples have shown similar efficacy to traditional implants for foot and ankle surgery, the literature is limited regarding nitinol screws. The purpose of this study is to determine whether there is a difference in outcomes and complications between nitinol screws and traditional screws used for foot and ankle surgery. Methods: A multicenter retrospective cohort study was conducted for patients who underwent a foot and ankle procedure utilizing traditional compression screws or nitinol compression screws, between February 1st, 2021, and July 1st, 2023. Demographic factors, type of implant, and outcomes were recorded. Student’s t-test and Wilcoxon rank sum test were used to compare continuous variables, while the chi-squared test was used to compare categorical variables. Results: A total of 163 patients were included in the study, with 106 patients treated with traditional screws and 58 treated with nitinol screws. There was no significant difference between those treated with nitinol screws and those treated with traditional screws in complication rate (8.6% vs 11.3%, P=0.78), non-union rate (5.2% vs 8.5%, P=0.54), revision surgeries (1.7% vs 2.8%, P=1), hardware removal (3.4% vs 11.3%, P=0.14), or 90-day hospital readmissions (0% vs 2.8%, P=0.55) for foot and ankle surgery. Conclusion: Our study found no difference in terms of complications or postoperative outcomes between those treated with nitinol screws and those treated with traditional screws for elective foot and ankle procedures. Our findings suggest that nitinol screws appear to be safe and effective for foot and ankle surgery with positive postoperative outcomes and a trend in lower complication and non-union rates. However further investigation is warranted to assess if faster time to union and quicker weight bearing may be possible with this type of fixation.

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Patient-reported outcome metrics are useful in determining a patient’s clinical response to a given intervention. Despite their usefulness, few studies have identified the potential prognostic value of patient-reported outcome metrics. This study looks to evaluate whether preoperative PROMIS scores can predict time to surgery and improvement in postoperative PROMIS scores in those undergoing hallux valgus correction surgery. Methods: A retrospective review was conducted of patients undergoing surgical intervention for hallux valgus at a single academic institution between June 2020 and June 2023. Demographic information, time to surgery, PROMIS scores, and preoperative radiographic measurements were collected. The minimal clinically important difference (MCID) in PROMIS scores was defined as half of the standard deviation of the change in PROMIS scores. A total of 209 patients were included in the study. Categorical and continuous data were compared using the Chi-squared test and Student’s T-test, respectively. Multivariable logistic regression analysis was utilized to control for confounding variables. All p< 0.05 were considered statistically significant. Results: Higher preoperative pain interference (PI) (OR=1.3, p< 0.001), mobility (OR=1.22, p=0.003), and global health-physical (OR=1.14, p=0.043) scores were independent predictors for increased odds of achieving an MCID in PI score. Lower preoperative physical function (PF) (OR=1.18, p=0.007) scores and higher preoperative PI (OF=1.16, p=0.005) and global health-physical (OR=1.22, p=0.001) scores were independent predictors for increased odds of achieving an MCID in PF scores. No factors were independently associated with achieving an MCID in mobility scores. Finally, being seen first by an MD (OR=3.7, p=0.034) and being unmarried (OR=34.3, p=0.032) were both independent predictors for having surgery within 6 months of presentation. Hallux valgus and Intermetatarsal angles at presentation did not significantly influence either the ability to achieve an MCID in PROMIS scores or time to surgery. Conclusion: Worse preoperative PI and PF scores were independently associated with an increased likelihood of achieving an MCID in those respective scores when controlling for confounding variables. Additionally, the severity of a patient’s hallux valgus, based upon their radiographic measurements at presentation, did not significantly influence a patient’s postoperative outcomes or time to surgery. These results suggest that patients with more severe hallux valgus symptoms, but not necessarily more severe hallux valgus radiographic findings, are most likely to clinically improve following surgical intervention.

Category: Hindfoot; Ankle Introduction/Purpose: Minimally Invasive Zadek osteotomy (MIS ZO) has been demonstrated to be a safe and effective surgical intervention for patients with Insertional Achilles Tendinopathy (IAT) and Haglund’s deformity. However, there is limited literature to guide surgeons one which patients may be the best candidates for MIS ZO. Severity of IAT on preoperative MRI may correlate with post operative functional outcomes and help guide patient selection for treatment with MIS ZO. The current study evaluated the postoperative outcomes of MIS ZO in patients with various grades of Achilles tendinopathy on preoperative MRI, to determine if severity of disease on preoperative MRI could be predictive of improved functional outcomes after MIS ZO. Methods: Patients who underwent MIS ZO for IAT and Haglund’s deformity were identified and retrospectively analyzed at a mean of 15.59 months follow-up. Achilles pathology was graded as previously described by Nicholson et al. on preoperative MRI. Grade 1 describes anteroposterior diameter of 6-8 mm and nonuniform degeneration; grade 2 describes diameter >8 mm and < 50% uniform tendon degeneration; grade 3 describes tendon diameter >8 mm and uniform degeneration of >50% tendon width. Fourteen patients met our inclusion criteria. Four patients exhibited grade 1 pathology preoperatively, 3 patients exhibited grade 2 pathology preoperatively, and 7 patients exhibited grade 3 pathology preoperatively. Preoperative and postoperative Patient Reported Outcome Measurement Information System (PROMIS) scores, complications, and revisions were recorded for each patient. PROMIS scores were compared using a paired t-test. All other continuous data was compared by Analysis of Variance (ANOVA); all categorical data was compared using Chi-squared analysis. P< 0.05 were considered significant. Results: PROMIS pain score improved postoperatively in patients with grade 1 66.75±5.50 to 59.00±7.75, p=0.036) and grade 3 (69.86±6.17 to 55.71±10.44, p=0.011) Achilles tendinopathy on preoperative MRI. Meanwhile, in patients with grade 2 pathology, PROMIS physical function (38.33±8.50 to 43.67±9.07, p=0.02) improved postoperatively. In the grade three group, 1/7 (14.29%) patients experienced transient neuritis that resolved at 3 months without further treatment and 1/7 (14.29%) patients required revision surgery to an open midline splitting Haglund’s resection. Meanwhile no patients in either the grade one or grade two groups required reoperation, rehospitalization, or complications. 13/14 (93%) patients were very satisfied with their procedure and wound undergo it again. Conclusion: These early data suggest that patients with IAT, regardless of severity, improve after MIS ZO. Therefore, ZO may be a reasonable first line option for all patients presenting with IAT. In our small retrospective study, we were able to demonstrate significant improvement in pain and/or function following ZO in all grades of IAT tendinous pathology on preoperative MRI. This study may help guide surgeons when deciding between MIS ZO and other surgical options for IAT and Haglund’s deformity. Further, large prospective studies are warranted to further investigate outcomes and indications of MIS ZO in patients with IAT and Haglund’s deformity

Category: Hindfoot; Ankle Introduction/Purpose: The Zadek osteotomy (ZO) has been demonstrated to be an effective treatment for patients with Haglund deformity and Insertional Achilles Tendinopathy (IAT). Radiographic measurements are one method of diagnostic criteria that have been utilized to define a more specific patient cohort that is a superior candidate for Zadek intervention. Tourné et al. most recently proposed an X/Y < 2.5 to define candidates that will benefit from the Zadek. However, many clinicians do not consider radiographic measurements to define efficacy of ZO. Additionally, current literature is lacking a direct comparison of ZO efficacy in patients with preoperative X/Y ratios above and below Tourné’s criteria. The current study tested the hypothesis: patients with IAT, regardless of X/Y ratio, would improve in pain and physical function after ZO. Methods: This was a retrospective, multi-center study. Patients underwent ZO at two different institutions, by three different fellowship trained orthopedic foot and ankle surgeons. 48 cases in 46 patients treated with Zadek osteotomy were included in our retrospective analysis. There were 34 cases with preoperative X/Y < 2.5 and 14 cases with preoperative radiographs measuring an X/Y > 2.5. All patients had a minimum of one-year follow-up (mean 23.24±4.82). Pain, function, and mobility PROMIS scores, VAS scores, complications, X/Y ratio measurements, and calcaneal pitch angle measurement were collected preoperatively and at final follow-up appointment. Cases were placed in cohorts based on preoperative X/Y above or below 2.5). T-tests were used to determine statistical differences following ZO. Similarly, chi-squared analysis was used to compare differences in categorical data between our groups. Results: A summary of preoperative and postoperative PROMIS scores, VAS scores, calcaneal pitch measurements, and X/Y ratios can be found in Table 1. Patients with X/Y < 2.5 demonstrated significant improvement in PROMIS pain, function, mobility scores, VAS score, calcaneal pitch angle, and X/Y ratio following ZO intervention (p< 0.05). In comparison, following ZO, patients with X/Y > 2.5 demonstrated significant improvement in PROMIS pain, VAS, and X/Y ratio (p< 0.05). However, in patients with X/Y > 2.5, preoperative VAS scores were higher (p=0.014) and improved to a significantly larger degree (p=0.006). There was one case of minor neuropathy (X/Y > 2.5); there was one patient that required revision to open debridement and repair (X/Y < 2.5). We observed a 98% rate of satisfaction overall following ZO intervention. Conclusion: Zadek osteotomy demonstrated improvement in patients’ pain and excellent patient satisfaction, regardless of their preoperative X/Y ratio on radiograph. However, patients with X/Y ratio < 2.5 did demonstrate significant improvement in patient reported function and mobility scores. Overall, a 98% satisfaction was observed following ZO in all patients. Preoperative X/Y ratio did not seem to determine success of ZO in the treatment of IAT, however, further clinical correlation is needed. to better understand differences if PROMIS physical function and mobility in terms of long-term success of the ZO.

Category: Ankle; Trauma Introduction/Purpose: Flexible syndesmotic devices have been associated with a reduction in hardware complications, syndesmotic diastasis, and rehabilitation time. Current guidelines suggest syndesmotic devices should be placed specifically 1.5-3.0 cm above the tibiotalar joint, however some may argue that this precise guideline is not necessary. In many syndesmotic injuries, a fibula fracture can occur at this landmark, which may increase the risk of fracture displacement and entrapment of the non-absorbable suture within the fracture itself. The goal of placing a flexible syndesmotic device is to help the fibula “find its home” in the incisura. Therefore, specific proximity to the tibial plafond may be negligible. The current study compared outcomes, union rate, and complications associated with flexible syndesmotic device placement at varied distances from the tibial plafond. Methods: Flexible syndesmotic devices, were placed in patients with a confirmed fracture-associated syndesmotic injury on CT scan. Cases were retrospectively analyzed at a minimum one-year follow-up. 24 patients met our inclusion criteria for this study. 14/24 devices were placed between 1.5-3.0 cm from the tibial plafond (mean 2.26±0.35cm), while the other 10/24 were placed outside of this guideline (mean 4.30±0.64cm). On postoperative radiographs, the placement of each syndesmotic device was measured as a proximal distance from the tibial plafond. Cases were placed into cohorts, defined by device placement within or outside of the 1.5-3.0 cm guideline. Incidences of postoperative complication, revision surgery, radiographic nonunion, and hardware failure were recorded. Patient Reported Outcome Measurement System (PROMIS) pain, function, and mobility scores were recorded. Outcome measures of each study cohort were compared by t-test. Categorical data was compared by Chi-squared analysis. Results: Flexible syndesmotic device placement within current guidelines demonstrated improvement in PROMIS function (p=0.044), pain (p=0.032), and mobility (p=0.035) scores at postoperative follow-up. Similarly, device placement outside of the 1.5-3.0 cm guidelines demonstrated improvement in PROMIS function (p=0.010), pain (p=0.026), and mobility (p< 0.001) scores. There was one patient with a flexible syndesmotic device placed at 1.5-3.0 cm who experienced a traumatic break and wound infection secondary to noncompliance with non-weightbearing status. This patient required debridement, hardware removal, and eventually a below knee amputation. Amongst cases with devices placed outside current guidelines, there was one case of painful hardware, requiring removal (10.00%). There was no statistical difference noted in PROMIS pain scores or complications between the two cohorts. Conclusion: Current guidelines suggest the placement of flexible syndesmotic devices should be limited to 1.5-3.0 cm proximal to the tibiotalar joint. However, these guidelines may be outdated. The current study presents novel evidence that alternative placement of syndesmotic devices may lead to improvement in patient reported function, pain, and mobility, with a low complication rate. There was no evidence of nonunion in any patient in the current study; all cases maintained their syndesmotic reduction. This study may serve to better inform the scope of flexible syndesmotic device application in cases of ankle fractures requiring fixation of the syndesmosis.

Category: Lesser Toes; Other Introduction/Purpose: A Flexor Tenotomy (FT) is a procedure that can be performed in a minimally invasive fashion for the treatment of a symptomatic flexible hammertoe or diabetic ulcers on the tip of the toe or dorsally over the PIP joint. Today, there is conflicting data regarding its complication rate and limited data for patient-reported outcomes following the procedure. Additionally, the safety of this procedure has not been rigorously studied in the in-hospital vs the in-office location of service. Our study looks to evaluate the rate of acute complications, recurrences, revisions, and patient-reported outcomes for both in-hospital and in-office FT procedures. Methods: A retrospective review was conducted for patients who had undergone FT procedure at Prisma Health – Midlands between February 1st, 2021, and April 31st, 2023. Data collected included demographic data, complications, revision rates, hospital readmission, and PROMIS scores preoperatively and at 3 and 6 months postoperatively. Rates of complications, revisions, readmissions, and differences between preoperative and postoperative PROMIS scores were calculated and compared between in-hospital and in-office clinical settings. Results: A total of 130 patients were evaluated. There was found to be no significant difference in the rate of complications, revisions, or readmission between the in-hospital and in-office groups (P=0.277, 0.327, 0.837, respectively). Additionally, there was a significant decrease in Pain Interference PROMIS scores at 3 and 6 months in the in-patient group and a significant increase in Physical Function PROMIS scores at 3 months in the in-office group (P=0.001, 0.028, 0.041, respectively). Finally, there was no significant difference in the change of PI, PF, or mobility PROMIS scores between the in-hospital and in-office groups at 3 (P=0.194, 0.379, 0.734, respectively) or 6 months postoperatively (P=0.364, 0.598, 0.25). Conclusion: We found similar rates of complications, revision procedures, readmissions, and change in patient-reported outcomes between FT performed in either an in-hospital or in-office setting. These findings suggest that FT is a safe and effective procedure, regardless of the clinical setting in which it is performed.

Category: Hindfoot; Ankle Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is commonly performed for complex deformity, arthritis, or unstable Charcot about the hindfoot. Due to this complexity, these procedures are often associated with increased morbidity and postoperative complications. There is limited data analyzing the prevalence of various preoperative diagnoses and comorbidities, as well as treatment modalities on the outcomes of TTC arthrodesis. As such, this study aims to investigate how various preoperative and intraoperative factors affect the outcomes of patients undergoing TTC arthrodesis. Methods: A multi-center retrospective review was conducted on the TTC fusions performed from 2016-2023 by one of four fellowship trained foot and ankle surgeon at an academic medical center. 74 ankles (75 patients) underwent TTC arthrodesis. Preoperative diagnosis and indications, fixation method, clinical success, and complications were obtained from the patients’ charts. Surgical indications included arthritis (n=39), Charcot neuropathy (n=23), post-traumatic (n=14), and cavovarus (n=10), osteomyelitis (n=4), and foot drop (n=3). Patients were excluded if their clinical or radiographic data were unavailable for review, or if they had less than 6 months of follow-up. Mean age was 58.2 (range 31-81) years and mean follow-up was 1.7 (range .50-5.17) years. Statistical analysis was performed using t-Student and Chi-squared tests with a p-value of 0.05 defining significance. Midline tibiotalar angle (MTA) was measured before and after surgery to assess position of fusion. Thirteen (17.3%) patients had preoperative ulcers at the time of surgery. Results: Of the 74 subjects in the study, 32 (43.2%) experienced postoperative complications, 14 (18.9%) had postoperative infection, 17 (23.0%) underwent reoperation for hardware removal, 10 (13.5%) experienced wound breakdown, 8 (10.8%) experienced nonunion, and 4 (5.4%) underwent below knee amputation. There was no statistical association between any surgical indication and adverse postoperative outcome, including patients with Charcot neuropathy. Majority of patients received a TTC nail (n=68, 94.4%) as opposed to plate (n=4; 5.6%), with plate configurations experiencing higher rates of overall complication (plate=100%, nail=39.7%; p=.031) and hardware removal (plate=75%, nail=20.6%; p=.039). There was no statistically significant difference in rates of any adverse outcomes when stratifying by use of combined external fixation and internal fixation (n=12;16.7%), 3D printed cage implant (n=7;9.5%), or use of graft (n=63;85.1%). Conclusion: TTC arthrodesis continues to have high rates of postoperative complications and adverse outcomes. The present study found increase rates of complication in patients receiving patients receiving a plate construction. There was no difference in rates of adverse outcomes when considering preoperative indication, including Charcot neuropathy, nor use of graft, 3D printed cage, or both external and internal fixation. Further studies with larger sample size are needed to confirm these findings and further identify factors which place patients at increased risk for adverse postoperative complications.

Category: Hindfoot; Ankle Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is commonly performed for complex deformity, arthritis, or unstable Charcot about the hindfoot. Due to this complexity, these procedures are often associated with increased morbidity and postoperative complications. There is limited data analyzing the prevalence of various preoperative diagnoses and comorbidities, as well as treatment modalities on the outcomes of TTC arthrodesis. As such, this study aims to investigate how various preoperative and intraoperative factors affect the outcomes of patients undergoing TTC arthrodesis. Methods: A multi-center retrospective review was conducted on the TTC fusions performed from 2016-2023 by one of four fellowship trained foot and ankle surgeon at an academic medical center. 74 ankles (75 patients) underwent TTC arthrodesis. Preoperative diagnosis and indications, fixation method, clinical success, and complications were obtained from the patients’ charts. Surgical indications included arthritis (n=39), Charcot neuropathy (n=23), post-traumatic (n=14), and cavovarus (n=10), osteomyelitis (n=4), and foot drop (n=3). Patients were excluded if their clinical or radiographic data were unavailable for review, or if they had less than 6 months of follow-up. Mean age was 58.2 (range 31-81) years and mean follow-up was 1.7 (range .50-5.17) years. Statistical analysis was performed using t-Student and Chi-squared tests with a p-value of 0.05 defining significance. Midline tibiotalar angle (MTA) was measured before and after surgery to assess position of fusion. Thirteen patients had preoperative ulcers at the time of surgery. Results: The most common surgical approach was lateral (n=47), then anterior (n=21) and posterior (n=7). Patients undergoing a lateral and posterior approach had statistically significantly higher rates of overall postoperative complication (lateral=51.1%, posterior=57.1%, anterior=19.0%; p=.029), although this was not specific to any single complication. Patients undergoing concomitant fibular osteotomy (n=41, 55%) experienced significantly higher rates of postoperative complications (osteotomy=61.0%, no osteotomy=21.2%; p

Category: Midfoot/Forefoot; Hindfoot Introduction/Purpose: Plantar fasciitis is one of the most common causes of foot pain among the United States’ population. There are several treatment options including both nonoperative and operative approaches. Recently, minimally invasive (MIS) percutaneous plantar fasciotomy has come on the market with anecdotally good patient outcomes but limited published literature. This study aimed to review the patient outcomes, complications, and revision rates in patients undergoing MIS ultrasound-guided percutaneous plantar fasciotomy for the treatment of chronic plantar fasciitis. Methods: A multicenter retrospective chart review of patients undergoing MIS ultrasound-guided percutaneous fasciotomy using the Tenex device (Trice Medical, Lake Forest California) from January 2020 to December 2022 was performed. The main data points collected were patient-reported outcomes, follow-up times, revision surgery, and complications. Continuous variables were defined as a mean and were compared using Paired Student’s T-Test. Multivariable linear regression analysis was utilized to determine specific factors that influenced outcomes when controlling for confounding variables. All P< 0.05 were considered significant. Results: There were 56 (42 female/14 male) patients that underwent 60 procedures. The average age and BMI were 48.6 years (range 19–80), and 33.2 kg/m 2 (range 19.7–58.6), respectively. There were two (3.3%) complications of wound-healing delays and one (1.7%) complication of nerve damage noted. There were two (3.3%) revisions. The average follow-up was 27 months (range 13.3–48.6). The average improvement in pain, physical function, and mobility Patient-Reported Outcomes Measurement Information System (PROMIS) scores were 5.2 (range: -5.1–25.8), P< 0.01), 3.6 (range -7–30.7, P=0.01), and 3.1 (range -6–25, P=0.01). Overall, over 90% of patients had no to minimal pain at the final follow-up. No specific demographic factors were significantly associated with an improvement in PROMIS scores or overall pain at final follow-up. Conclusion: MIS ultrasound-guided plantar fasciotomy appears to be a reliable surgical treatment option for chronic plantar fasciitis with high patient satisfaction, minimal complications, and low revision rates.

Category: Ankle; Hindfoot Introduction/Purpose: Surgical options for Insertional Achilles Tendinopathy (IAT) and Haglund‘s deformity include the open midline Achilles tendon splitting approach with Haglund’s resection and Achilles debridement and repair. However, many have cited high rates of complications with this approach such as wound dehiscence, infections, and persistent postoperative pain. Alternative surgical management of IAT and Haglund’s deformity includes the Zadek osteotomy (ZO). ZO can be accomplished percutaneously, reducing potential wound complications, pain, and infections. The current study compared outcomes and complications of the open midline Achilles tendon splitting approach with the percutaneous ZO in patients with IAT and Haglund’s deformity. We hypothesized that the percutaneous ZO would allow for improvement in patient reported outcomes, yet less complications in comparison to the traditional, open midline Achilles tendon splitting approach. Methods: Patients who received an open midline Achilles tendon splitting procedure or percutaneous ZO for IAT and Haglund’s deformity were identified and retrospectively analyzed at a minimum of one-year follow-up. 21 patients treated with percutaneous ZO and 45 patients treated with open midline Achilles tendon splitting procedure for IAT and Haglund’s deformity met our inclusion criteria. Patients had average follow up of 23.65±6.87 months. Preoperative Patient Reported Outcome Measurement Information System (PROMIS) scores, postoperative PROMIS scores, complications, and revisions were recorded for each patient. Preoperative and postoperative PROMIS scores were compared using a paired t-test. All other continuous data was compared by t-test; all categorical data was compared using Chi-squared analysis. All p< 0.05 were considered significant. Results: In patients who underwent percutaneous ZO or an open midline Achilles tendon splitting Haglund’s resection, PROMIS function (p< 0.01), pain (p< 0.01), and mobility (p< 0.01) scores improved at 12-month minimum follow-up. In the ZO group, 1/21 (4.6%) patients experienced nerve injury and 1/21 (4.6%) patients required revision surgery to an open midline splitting Haglund’s resection. Meanwhile, 3/45 (6.67%) patients who underwent an open midline Achilles tendon splitting procedure experienced significant postoperative pain, 3/45 (6.67%) wound dehiscence, 3/45 (6.67%) wound infection, and 1/45 (2.22%) nerve injury. 4/45 (8.89%) patients who underwent the open midline Achilles tendon splitting approach required revision. Additionally, 1/45 required hardware removal and 1/45 required incision and debridement. All cause complication were found to be higher in the open midline Achilles tendon splitting approach (p=0.02). Conclusion: There are several surgical treatment options for IAT and Haglund‘s deformity, yet IAT remains a challenging lower extremity disorder to treat. In the current study, both the open, midline Achilles tendon splitting Haglund’s resection and percutaneous ZO led to significant improvement in patient reported outcomes. However, our study demonstrated a significant lower complication and revision in the ZO group. Data presented in this study may guide surgeons’ decision making when choosing suitable treatment options for patients with IAT and Haglund deformity.

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Both Primary Arthrodesis (PA) and Open Reduction and Internal Fixation (ORIF) have been shown to effectively treat Lisfranc injuries, however, debate remains regarding the complication rate for each procedure, and the data is limited regarding patient-reported outcomes. The purpose of this study is to evaluate the rate of acute complications, reoperations, patient-reported outcomes through the Patient Reported Outcome Instrumentation System (PROMIS), and postoperative radiographic data for PA versus ORIF for acute Lisfranc injuries. Methods: A retrospective review was conducted of patients who underwent PA or ORIF for the treatment of Lisfranc injuries at Prisma Health – Midlands between January 1st, 2020 - December 31st, 2022 with at least 6 months of postoperative data. Data collected included demographic data, postoperative outcomes, and Pain Interference (PI), Physical Function (PF) and Mobility PROMIS scores both preoperatively and at the most recent postoperative follow-up. Continuous variables were compared between PA and ORIF using the Student’s T-Test and Wilcoxon Rank Sum test for continuous variables and the Chi-Squared test for categorical variables. Results: A total of 56 patients were included in the study with an average follow-up time of 51.1 weeks (range: 27 to 121). Patients treated with ORIF were younger (30 vs 46.6, p=0.002) and were more likely to suffer a Myerson Classification type B1 injury (87.8% vs 28.6%, p=0.002) compared to those treated with PA. ORIF patients had greater improvements in PI (13.1 vs 9.7, p=0.508), PF (15.7 vs 7.2, p=0.343), and mobility (18.2 vs 10.3, p=0.203) compared to PA patients, although these improvements were not statistically significant. Finally, there was no significant difference in the rate of complications (p=1), reoperations (p=1), or evidence of radiographic hardware failure (p=0.423) between PA and ORIF. Conclusion: Patients treated with ORIF had greater improvements in patient-reported outcomes than those treated with PA, although these improvements were not statistically significant and there were potential confounding factors present. Both procedures demonstrated similar rates of complications, reoperations, and radiographic hardware failure. Our findings suggest that ORIF and PA are both effective in improving patient-reported outcomes and treating Lisfranc injuries in certain patient populations.

Abstract When children are discharged from the hospital after surgery, their caregivers often rely on subjective assessments (e.g., appetite, fatigue) to monitor postoperative recovery as objective assessment tools are scarce at home. Such imprecise and one-dimensional evaluations can result in unwarranted emergency department visits or delayed care. To address this gap in postoperative monitoring, we evaluated the ability of a consumer-grade wearable device, Fitbit, which records multimodal data about daily physical activity, heart rate, and sleep, in detecting abnormal recovery early in children recovering after appendectomy. One hundred and sixty-two children, ages 3–17 years old, who underwent an appendectomy (86 complicated and 76 simple cases of appendicitis) wore a Fitbit device on their wrist for 21 days postoperatively. Abnormal recovery events (i.e., abnormal symptoms or confirmed postoperative complications) that arose during this period were gathered from medical records and patient reports. Fitbit-derived measures, as well as demographic and clinical characteristics, were used to train machine learning models to retrospectively detect abnormal recovery in the two days leading up to the event for patients with complicated and simple appendicitis. A balanced random forest classifier accurately detected 83% of these abnormal recovery days in complicated appendicitis and 70% of abnormal recovery days in simple appendicitis prior to the true report of a symptom/complication. These results support the development of machine learning algorithms to predict onset of abnormal symptoms and complications in children undergoing surgery, and the use of consumer wearables as monitoring tools for early detection of postoperative events.

Introduction/Purpose: The modified Lapidus procedure (MLP) or a minimally invasive surgery distal transverse osteotomy (MISDTO) are acceptable surgical treatment options for hallux valgus. The current literature is evolving when comparing the effects of each procedure on patient reported outcomes and post-operative complications. The purpose of this study is to compare postoperative outcomes, time to weight bear, and patient reported outcomes using the Patient Reported Outcome Instrumentation System (PROMIS) for the MLP and MISDTO. Methods: This study retrospectively reviewed patients who underwent a MLP or MISDTO for hallux valgus correction at Prisma Health Midlands between February 2020 – February 2022. Data collected included: demographic data, postoperative outcomes, time to weight bear, and PROMIS scores, including Pain Interference (PI), Physical Function (PF), and Mobility scores. Paired Student’s T-Test and Wilcoxon Rank Sum test were used to compare continuous variables and Chi-Squared test for categorical variables. Results: A total of 81 patients undergoing MLP and 78 undergoing MISDTO were included in the study. Average follow-up for MLP and MISDTO patients was 53.7 and 43.4 weeks, respectively. MLP demonstrated significant improvement in PI (52.5 vs 56.8, P< 0.001) and Mobility (46.3 vs 43.4, P=0.044) scores, while MISDTO demonstrated a significant improvement in PI (48.8 vs 57.1, P< 0.001), PF (50.2 vs 44.9, P< 0.001), and Mobility (49 vs 42.8, P< 0.001) scores. MISDTO patients had significantly larger improvements in PI (7.6 vs 4.5, P=0.008), PF (5.3 vs 2.2, P=0.026), and Mobility (5.5 vs 2.9, P=0.02) compared to MLP patients. MISDTO patients had a significantly lower non-union rate (13.6% vs 2.6%, P=0.025), hardware failure rate (0% vs 9.9%, P=0.007), and time to weight-bear (2.2 vs 7.8 weeks, P< 0.001). Conclusion: Both MLP and MISDTO procedures are effective treatments for improving the pain and mobility issues associated with hallux valgus while maintaining patients’ function. MISDTO was found to improve patient reported outcomes significantly more than MLP, with a lower non-union rate, lower hardware failure rate, and shorter time to weight-bear. These findings suggest MISDTO is superior to MLP in improving patient reported outcomes and postoperative outcomes in the treatment of hallux valgus. Further study multicenter and long term outcome studies could be useful further evaluate these short term findings.

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.

Introduction/Purpose: Minimally invasive surgical (MIS) treatment of hallux valgus (HV) deformity is increasing in popularity. A 2mm-diameter burr is used to create a distal first metatarsal osteotomy prior to capital fragment translation and fixation. The metatarsal will shorten by the burr’s diameter (2mm). Plantar or dorsal capital fragment displacement may also cause load transference and possibly transfer metatarsalgia. In this study, we examine the effect of MIS HV on forefoot loading mechanics with respect to metatarsal shortening and sagittal plane displacement. Methods: Four lower-limb cadaveric specimens were studied. A pedobarography pressure-sensing mat was used to record forefoot plantar pressure in a controlled weightbearing stance position.10 Control and post-osteotomy measurements were obtained with the capital fragment fixated in 3 possible positions: 0mm, 5mm dorsal, and 5mm plantar displacement. Pedobarography data yielded pressure data within measurable graphical depictions. Raw mean contact pressure measurements were taken under the first and fifth metatarsal heads to establish medial and lateral forefoot loading pressure ratios. A priori power analysis was performed based on previous peer-reviewed pedobarographic data and our study was adequately powered. Results: 40 measurements were recorded and ratios of medial-to-lateral forefoot loading were constructed. Medial forefoot pressure change control versus 0mm displacement, and control versus dorsal displacement was not found to be statistically significant (p=0.525, p=0.55 respectively). Significant medial pressure increase was identified comparing control versus plantar displacement (p=0.006). Lateral pressure increased significantly with dorsal displacement of the osteotomy (p=0.013). Conclusion: MIS hallux valgus correction does not appear to cause increase in lateral forefoot pressure loading when sagittal plane displacements are controlled. Plantar displacement increases medial loading, and dorsal displacement increases lateral loading. The clinician must consider metatarsal head position post-osteotomy, as decrease in medial loading and subsequent increase in lateral loading may lead to lateral forefoot pain and transfer metatarsalgia.

Introduction/Purpose: Minimally invasive dorsal cheilectomy (MIDC) has become a popular alternative to an open approach for treating Hallux Rigidus, although the current literature is divided on its effectiveness regarding complications and patient reported outcomes. To combat a portion of the complications related to the MIDC approach, a first metatarsophalangeal (MTP) joint arthroscopy can often be added to the procedure. The combined procedure has been demonstrated to be effective at improving patient reported outcomes without increasing the complication rate relative to an open procedure. This study looks to examine the effectiveness of the MIDC with first MTP arthroscopy procedure in patients with hallux rigidus with minimum 1 year follow up. Methods: This was a multicenter retrospective review was conducted for adult patients treated with MIDC and first MTP arthroscopy between 3/1/2020 and 8/1/2022, with at least one year of postoperative follow-up data. Patient charts were reviewed for demographic information, operative time, pre and postoperative first MTP range of motion (ROM), visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOXFQ), and EQ5DLD scores. Continuous data was expressed as a mean and standard deviation, categorical data was expressed as a percentage. Wilcoxon Rank Sum test was used to compare continuous variables. All P < 0.05 was considered significant. Results: A total of 31 patients were included in the study with an average follow-up time of 16.5 months (range: 12 to 26.2). There was 1 (3.2%) complication of an underservice EHL tendon tear, 2 (6.5%) patients were converted to a MTP fusion, and 1 (3.2%) patient underwent revision cheilectomy and capsular release for MTP joint contracture. There was a significant improvement in patient’s ROM in dorsiflexion (50 vs 89.6 degrees, P=0.002), but not in plantarflexion (11.3 vs 18.6 degrees, P=0.07). There was a significant improvement in patient’s postoperative VAS pain scores (6.4 vs 2.1, P< 0.001), MOXFQ pain scores (58.1 vs 30.7, P=0.001), MOXFQ Walking/Standing scores (56.6 vs 20.6, P=0.001), MOXFQ Social Interaction scores (47.3 vs 19.36, P=0.002), and MOXFQ Index scores (54.7 vs 22.4, P< 0.001). Conclusion: We found that MIDC with first MTP arthroscopy was effective at improving patient reported outcomes, specifically patient’s pain scores, at one year with low complication and revision rates. These results demonstrate MIDC and first MTP arthroscopy’s is an effective treatment for early-stage hallux rigidus and may be considered as an alternative to an open approach.

Introduction/Purpose: Many patients use the internet as a source for medical information regarding their medical condition. However, the accuracy and reliability of the information is variable. The recent release of general population facing artificial intelligence (AI) chatbot programs has created a potential alternative medical information source for patients. Our study examined the accuracy of the information provided by ChatGPT for total ankle arthroplasty (TAA), as determined by four fellowship-trained foot and ankle orthopedic surgeons. Methods: GPT-4, the latest ChatGPT model, was asked the 12 of the most common questions patients have regarding TAA. Its responses were recorded and evaluated by four fellowship-trained foot and ankle orthopedic surgeons on a scale of 1 – 4, with 1 representing an excellent response not requiring clarification and 4 representing an unsatisfactory response requiring significant clarification. Averages of scores for each question were recorded and an average of every score was used to develop an overall accuracy score. Results: The overall accuracy score of GPT-4 was 1.35. The responses by GPT-4 received a score of 1 for 32 of 48 (66.7%) responses. There was found to be no significant difference in scores for any of GPT-4’s responses. Conclusion: Our study found that GPT-4 performed well in providing accurate and near complete information to commonly questions asked to physicians by patients regarding TAA. Our results suggest that AI models, like GPT-4, may be an effective alternative source of medical information for patients. Further study with subsequent AI models and direct patient interaction may shed further light on the utility of this potential patient education modality. ChatGPT Response Accuracy Score Accuracy scores for ChatGPT, as determined by four foot and ankle fellowship-trained orthopedic surgeons

Background: Hindfoot fusion procedures are common for the treatment of end-stage arthritis or deformity. Surgical treatments for these conditions include talonavicular joint (single) arthrodesis, talonavicular and subtalar (double) arthrodesis, or talonavicular, subtalar, and calcaneocuboid (triple) arthrodesis. This study evaluated the complication rate, revision surgery rate, and hardware removal rate for those treated with either single, double, or triple arthrodesis. Methods: A retrospective review was conducted for patients who underwent single ( Current Procedural Terminology [ CPT ] code 28740), double ( CPT 28725 and 28740), or triple ( CPT 28715) arthrodesis to treat hindfoot arthritis/deformity ( International Classification of Diseases, Ninth Revision [ ICD-9 ] code: 734, International Classification of Diseases, Tenth Revision [ ICD-10 ] codes: M76821, M76822, and M76829) from 2005 to 2022 using the South Carolina Revenue and Fiscal Affairs databank. Data collected included demographics, comorbidities, procedure data, and postoperative outcomes within 1 year of principal surgery. Student t test, chi-squared test, and multivariable logistic regression analysis were utilized during data analysis. Results: A total of 433 patients were identified, with 248 undergoing single arthrodesis, 67 undergoing double arthrodesis, and 118 undergoing triple arthrodesis. There was no significant difference between single, double, and triple arthrodesis in the rate of complications, hardware removals, revision surgeries, or 30-day readmission when controlling for confounding variables. However, a decrease in Charlson Comorbidity Index (CCI) was found to be predictive of an increase in the revision surgery rate (OR = 0.46, 95% CI 0.22-0.85, P = .02). Conclusion: We found no difference in the rate of complications, hardware removals, or revision surgeries in those undergoing single, double, or triple arthrodesis. Surprisingly we found that a lower Charlson Comorbidity Index, indicating a healthier patient had a significant relationship with a higher rate of revision surgery. Further study including radiographic indications for surgery or the impact of overall health status on revision surgery rates may further elucidate the other components of this relationship. Level of Evidence: Level III, cohort study.

Abstract Converging, cross-species evidence indicates that memory for time is supported by hippocampal area CA1 and entorhinal cortex. However, limited evidence characterizes how these regions preserve temporal memories over long timescales (e.g., months). At long timescales, memoranda may be encountered in multiple temporal contexts, potentially creating interference. Here, using 7T fMRI, we measured CA1 and entorhinal activity patterns as human participants viewed thousands of natural scene images distributed, and repeated, across many months. We show that memory for an image’s original temporal context was predicted by the degree to which CA1/entorhinal activity patterns from the first encounter with an image were re-expressed during re-encounters occurring minutes to months later. Critically, temporal memory signals were dissociable from predictors of recognition confidence, which were carried by distinct medial temporal lobe expressions. These findings suggest that CA1 and entorhinal cortex preserve temporal memories across long timescales by coding for and reinstating temporal context information.

Manual monitoring of vital signs, which often fails to capture the onset of deterioration, is the main monitoring modality in most Ghanaian hospitals due to the high cost and inadequate supply of patient bedside monitors. Consumer wearable devices (CWDs) are emerging, relatively low-cost technologies for continuous monitoring of physiological status; however, their validity has not been established in low-resource clinical settings. We aimed to (1) investigate the validity of the heart rate (HR) and oxygen saturation (SpO2) data from two widely used CWDs, the Fitbit Versa 2 and Xiaomi Mi Smart Band 6, against gold standard bedside monitors in one Ghanaian hospital and (2) develop a web application to capture and display CWD data in a clinician-friendly way. A healthy volunteer simultaneously wore both CWDs and blood pressure cuffs to measure HR and SpO2. To test for concordance, we conducted the Bland-Altman and mean absolute percentage error analyses. We also developed a web application that retrieves and displays CWD data in near real time as text and graphical trends. Compared to gold standards (patient monitor and manual), the Fitbit Versa 2 had 96.87% and 96.67% measurement accuracies for HR, and the Xiaomi Mi Smart Band 6 had 94.24% and 93.21% measurement accuracies for HR. The Xiaomi Mi Smart Band 6 had 98.79% measurement accuracy for SpO2. The strong concordance between CWD and gold standards supports the potential implementation of these devices as a novel method of vital sign monitoring to replace manual monitoring, thus saving costs and improving patient outcomes. Further studies are needed for confirmation.

Category: Midfoot/Forefoot; Basic Sciences/Biologics Introduction/Purpose: Traditional hardware for first MTP arthrodesis procedures are typically made from stainless steel or titanium. While postoperative non-weightbearing protocols have enabled successful results with these devices, they are still prone to permanent deformation and associated plantar gapping/joint misalignment following excessive prefusion loading (e.g., patient falling). By leveraging the material properties of NiTiNOL, sustained dynamic compression (SDC) staples have been designed to recover their initial shape after large loading events. As such, implementation of these SDC staples may produce first MTP arthrodesis constructs more robust to early loading events, potentially decreasing patient immobility times and reducing incidences of postoperative joint misalignment. The goal of this study was to characterize the biomechanical performance of first MTP. Methods: Solid foam MTP replicas underwent simulated arthrodesis using one of eight constructs (N=6 replicates within each group). Groups consisted of: (1) double 2-leg staple, (2) 4-leg inline staple, (3) 4-leg Y staple, (4) 4-leg inline staple & screw, (5) 4- leg Y staple & screw, (6) double screw, (7) locking plate, and (8) locking plate & screw (Figure A-C). Simulated loading was applied to the samples 23mm distal to the joint line in the dorsiflexion direction. Samples underwent 1,000 nondestructive cycles of loading between 5-15N (replicative of postoperative walking in a recovery boot), followed by simulated overloading (destructive test) that applied 10mm of displacement at the loading point. Plantar gapping was measured using photogrammetry techniques throughout the entire testing protocol. Data were analyzed using a one-way ANOVA (α=0.05) with Dunnett’s post hoc test using the ubiquitous plate and screw group as the control. Results: Plantar gapping at simulated walking revealed significantly increased plantar gapping in the locking plate (P=.001) and double 2-leg staple (P .75, Figure D). The double screw and Y staple & screw groups exhibited significantly decreased gapping at 10mm extension as compared to the locking plate & screw group (P=.030 and .049, respectively). All SDC NiTiNOL constructs (both with and without static devices) recovered plantar gapping post-failure, with plantar gaps ≤ 0.29 mm, whereas the locking plate & screw construct group had a mean post-failure plantar gap of 0.85 mm (P