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Category: Ankle; Other Introduction/Purpose: Portable fluoroscopy devices provide point-of-care imaging in emergency and out-patient clinics. In patients suffering from ankle syndesmosis injuries, imaging under physiologic load can lead to more accurate diagnosis, particularly in subtle cases. In this study, we compared weightbearing images obtained using a novel lightweight portable battery-powered fluoroscopy device with a conventional radiography device regarding syndesmosis examination measurements. Methods: In this prospective study, eleven healthy participants underwent bilateral three-view weightbearing imaging of both ankles using a radiography (X-ray group) device and a portable fluoroscopy system (Smart-C group). Radiographic measurements were done by two observers on anteroposterior, mortise, and lateral views were compared between the two techniques. These measurements included talar tilt, tibiofibular clear space, tibiofibular overlap, plafond malleolar angle, medial distal tibial angle, medial clear space, lateral distal tibial angle, anterior and posterior tibiofibular distance were measured using the appropriate view. Data were compared between the two techniques; the interobserver agreement was calculated within each group. P

Category: Ankle Introduction/Purpose: The lateral fibular stress test (LFST), also known as the hook or Cotton test, is commonly performed to assess syndesmotic instability intraoperatively. Several studies have determined that 100 Newtons (N) is the required force applied when performing the LFST to detect syndesmotic instability. We hypothesize that surgeons do not uniformly nor consistently apply 100N of force when performing the LFST and that substantial variation exists. Fundamentally, this could lead to under-detection of syndesmotic instability as surgeons may not be applying the requisite force in a consistent manner. Methods: A biomechanical SawBones lower leg model including simulated soft tissue envelope (SawBones inc., Vashon Island, Washington) was mounted to a board and a 1cm diameter hole was drilled across the tibia and fibula in the area of the syndesmosis. An industrial force gauge (Nidec-Shimpo, Kyoto, Japan) was then mounted. A metal extension piece was passed from the force gauge through the hole and positioned so that the tip was exposed on the lateral side of the model. A commonly utilized reduction clamp was affixed to the force gauge. Orthopaedic attending surgeons and trainees were asked to perform a series of LFSTs and to simulate the force they typically apply intra-operatively and this force was recorded in Newtons (N). Basic demographic data was collected on each participant. Results: 33 surgeons participated in the study, including 18 trainees. The median (IQR) force applied during the LFST was 96.42(71.42-126.33), 87.49 (69.19-117.40), 99.99(79.91-137.49), for the pooled group, attendings, and trainees respectively. Over half (54.5%) of all trials were less than 100N (57.8% of surgeons, 51.8% trainees). The distribution of pulls is shown in Figure 1. Intraobserver correlation was excellent within the overall cohort (0.92, p

Category: Other; Ankle; Hindfoot; Lesser Toes; Midfoot/Forefoot Introduction/Purpose: Minimally invasive surgery (MIS) is growing in the field of foot and ankle surgery, and the MIS burr is an emerging tool. While commonly used to perform osteotomies, the burr can also be utilized for arthrodesis joint preparation that traditionally would be performed through open incisions. To date, there is no study comparing the quality of joint preparation between using a fluoroscopy-guided MIS technique compared to traditional open techniques. The goal of this cadaveric study is to compare the percentage of joint surfaces prepared between MIS and open techniques, for the most common joints that are fused in foot and ankle surgery. Methods: Open joint preparation was performed under direct visualization with open incisions. MIS joint preparation was performed percutaneously using fluoroscopic guidance alone, without arthroscopy. After joint preparation, cadaveric samples were disarticulated, and joint surfaces were analyzed for percentage of cartilaginous surface removed. The percentage of joint surface prepared was compared between the open and MIS techniques. Results: Ten cadaveric samples were used for the MIS technique, and five samples for the open technique. Percentage of joint surface prepared was not statistically different for 15/17 joint surfaces. The MIS technique demonstrated statistically significant (p=0.048) better preparation than open in the talar head and the cuboid at the CC joint. Qualitative inspection of these two joints suggested the open technique frequently missed the most plantar surface of the talar head and the medial side of the CC joint, whereas the MIS technique performed better in these areas. Conclusion: The MIS technique provides similar percentages of surface area prepared compared to traditional open techniques. In certain joints with greater depth, the MIS technique may provide better joint preparation. This study suggests that MIS joint preparation is a reasonable, and possibly advantageous, alternative to open preparation in arthrodesis surgery when performed by experienced MIS surgeons.

Category: Ankle; Sports; Trauma Introduction/Purpose: While the lateral hook test (LHT) has been widely used to arthroscopically evaluate syndesmotic instability in the coronal plane, it is unclear whether the angulation of the applied force has any impact on the degree of instability. The aim of this study was to determine if changing the direction of the force applied while performing the LHT impacts the amount of coronal diastasis observed in purely ligamentous syndesmotic injuries. Methods: In 10 cadaveric specimens, arthroscopic evaluation of the distal tibiofibular joint in the coronal plane was performed. Anterior and posterior third coronal plane diastasis were assessed in the intact state and repeated after sequential transection of the, 1) anterior inferior tibiofibular ligament (AITFL), 2) the interosseous ligament (IOL) and the 3) posterior inferior tibiofibular ligament (PITFL). In all scenarios, the lateral hook test (LHT) was performed under 100N of laterally directed force. Additionally, LHT was also performed under 1) anterior inclination of 15 degrees and 2) posterior inclination of 15 degrees in the intact and AITFL+IOL deficient state. One-way ANOVA with post hoc Tukey HSD was used to test for significant differences in coronal plane measurements between each stage of ligament transection, and to determine the effect of different directions of force application on coronal space measurements in the intact and AITFL+IOL transected states. Results: Compared to the intact state, the distal tibiofibular joint remained stable after transection of AITFL under laterally directed force with no angulation. However, after additional transection of the IOL, the syndesmosis became unstable in the coronal plane (p = 0.029 and 0.025 for anterior and posterior third diastasis, respectively). This instability worsened further with subsequent transection of the PITFL (p =

Background: Assessment of mortise stability is paramount in determining appropriate management of ankle fractures. Although instability is readily apparent in bimalleolar or trimalleolar ankle fractures, determination of instability in the isolated Weber B fibula fracture often requires further investigation. Prior authors have demonstrated poor predictive value of physical examination findings such as tenderness, ecchymosis, and swelling with instability. The goal of this study is to test the validity of a new clinical examination maneuver, the lateral drawer test, against the gravity stress view (GSV) in a cohort of patients with Weber B fibula fractures. Secondary goals included assessing pain tolerability of the lateral drawer test, as well as testing interobserver reliability. Methods: Sixty-two patients presenting with isolated fibula fractures were prospectively identified by an orthopaedic nurse practitioner or resident. Three nonweightbearing radiographic views of the ankle as well as a GSV were obtained. Radiographs were not visualized before conducting the lateral drawer test. Two foot and ankle fellowship–trained orthopaedic surgeons performed and graded the lateral drawer test. Radiographs were then examined and medial clear space (MCS) was measured. Visual analog scale (VAS) pain scores were obtained before and after testing. The results of the lateral drawer test were compared with radiographic measurements of MCS on GSV. A cadaveric experiment was devised to assess interobserver reliability of the lateral drawer test. Results: Thirty (48%) of 62 consecutively enrolled patients demonstrated radiographic instability with widening of the MCS ≥5 mm on GSV. When correlated with MCS measurement, the lateral drawer test demonstrated a sensitivity of 83%, specificity of 97%, positive predictive value (PPV) of 96%, and negative predictive value (NPV) of 86%. There was a strong correlation between the lateral drawer test grade and amount of MCS widening (Spearman correlation ρ = 0.82, P < .005). Patients tolerated the maneuver well with an average increase of 0.7 on the VAS pain scale. Testing of 2 observers utilizing the cadaveric model demonstrated a Cohen’s Kappa coefficient of 0.7 indicating moderate interobserver agreement. Conclusion: The lateral drawer test demonstrates high sensitivity, specificity, PPV, and NPV with moderate interobserver reliability compared with the MCS on GSV in patients presenting with Weber B fibula fractures. Although further external validation is required, the lateral drawer test may offer an adjunct tool via physical examination to help determine mortise stability. Level of Evidence: Level II, Prospective Cohort Study.

Category: Ankle; Arthroscopy; Basic Sciences/Biologics Introduction/Purpose: The lateral hook test is considered the gold standard for the diagnosis of coronal plane syndesmotic instability during arthroscopy. The amount of distal tibiofibular space is directly related to the amount of lateral directed applied force. This study aims to determine the optimal amount of forced needed during a lateral hook test to evaluate syndesmotic instability in the coronal plane. The secondary aim was to determine the amount of displacement variation that occurs when the lateral force is angled anteriorly or posteriorly. Methods: Ten fresh-frozen above-knee amputated cadaveric specimens underwent arthroscopic evaluation of the distal tibiofibular joint. The assessment was done first with all syndesmotic and ankle ligaments intact and subsequently with transection of the anterior inferior tibiofibular ligament (AITFL) and the interosseous ligament (IOL). In all scenarios, a lateral hook test was performed under increasing force from 0N to 120N of direct force, with increments of 20N. The lateral hook test was performed in: 1) the neutral position (no angulation), 2) anterior inclination of 15 degrees, and 3) posterior inclination of 15 degrees under the aforementioned force. Anterior and posterior coronal plane distal tibiofibular space were arthroscopically measured. Descriptive statistics were employed to determine the force and the most sensitive method to pull during arthroscopic evaluation to detect syndesmotic instability. Results: Among the specimens, after transection of AITFL and IOL, the anterior and posterior coronal plane space increased with increment in force until 60N and then displayed no change in these measurements despite the increase in force. In the intact state, there was an increase in syndesmosis coronal space with increase in force. Of the three methods of force application, the posteriorly directed force has the largest absolute value for the anterior and posterior coronal space, suggesting it is the most sensitive in distinguishing between stable and unstable syndesmotic injury. Conclusion: Arthroscopic coronal plane evaluation under 60N of direct force is best suited to distinguish stable from an unstable syndesmosis. Syndesmosis anterior and posterior coronal plane space measurement demonstrate the largest absolute difference when subjected to posteriorly directed force, suggesting that this new method of assessment has the highest potential for diagnosing even subtle syndesmotic instability, along with a lower propensity for error.

Category: Trauma; Ankle; Sports Introduction/Purpose: Acute Achilles tendon rupture repair has undergone several changes in the past decade, aiming to minimize complications while maximizing clinical outcomes. Less invasive approaches have been associated with comparable results and decreased infection risk compared with traditional open techniques. Patient positioning during surgery also influences outcomes; prone positioning is associated with increased operative times as well as risk of neuropraxia and ophthalmologic injuries as compared to supine positioning. The Medial Mini-Open Supine (MMOS) Achilles Repair technique combines the benefits of supine positioning and mini-open techniques. This study compares 1-year clinical outcomes, operative times, and complication rates of patients undergoing repair with this novel technique to those treated with an open or mini-open approach with prone positioning. Methods: Patients undergoing operative acute Achilles rupture repair at our institution after February 2015 were included in this study. Patients were grouped by technique used: 1) open repair with prone positioning, 2) mini-open repair with prone positioning, or 3) the medial mini-open repair with supine positioning. Patients were followed for a minimum of 1 year postoperatively. Primary outcome measures include Patient-Reported Outcomes Measurement Information System (PROMIS) scores (Physical Function, Pain Interference and Depression), Foot and Ankle Ability Measure (FAAM) assessments (ADLs and Sport) and Visual Analog Scale (VAS) pain scores. Secondary outcome measures include intraoperative times and complication rates. Statistical analysis to assess for significant differences between the groups was conducted using the Kruskal-Wallis test, Nemenyi test, ANOVA with posthoc Tukey test and chi-square test as was appropriate. Results: A total of 56 patients (Group 1: n=18, Group 2: n=14, Group 3: n=24) were included in this study. Average 1-year PROMIS Physical Function scores were 59.57 (+-12.9), 64.29 (+-13.96) and 63.03 (+-11.69) for Groups 1, 2 and 3 respectively. Average Pain Interference scores were 46.05 (+-17.65), 42.12 (+-8.75) and 42.48 (+-7.11). Depression score averages were 40.79 (+-7.61), 36.87 (+-9.35) and 39.81 (+-9.48) for Groups 1, 2 and 3, respectively. Differences between groups were not significant (p >0.05). Group 3 had statistically significant differences in total OR time compared to both Groups 1 and 2. The median difference was 33 min between Groups 1 and 3, and 35 min between Groups 2 and 3 (p

Category: Ankle; Trauma Introduction/Purpose: Assessment of mortise stability is paramount in determining appropriate management of ankle fractures. While instability is readily apparent in bimalleolar or trimalleolar ankle fractures, determination of instability in the apparent isolated Weber B fibula fracture often requires further investigations such as stress radiography. While several authors have previously demonstrated poor predictive value of physical examination findings such as tenderness, ecchymosis and swelling with instability, no previous investigation has examined the ability of a translational test to determine deltoid ligament injury. The goal of this study is to test the validity of a novel clinical test, the lateral drawer test, in determining mortise instability in a cohort of patients with Weber B fibula fractures. Methods: Patients presenting with isolated fibula fractures were prospectively identified by an orthopaedic nurse practitioner or resident. Three views of the ankle as well as gravity stress views (GSV) were obtained. Prior to examining radiographs, two foot & ankle fellowship-trained orthopaedic surgeons (JYK, CPM) performed and graded the lateral drawer test. (Grade 0: no instability/symmetric to contralateral ankle, Grade I: translation < 5mm, Grade II: translation >= 5mm) While the surgeons were made aware of the presence of a Weber B fibula fracture, radiographs were not visualized prior to conducting the drawer test. Medial clear space (MCS) was measured. VAS pain scores were obtained before and after testing. The results of the lateral drawer test results were compared with radiographic measurements of MCS. Results: The study has thus far prospectively enrolled 14 consecutive patients with Weber B ankle fractures. Six (43%) patients demonstrated radiographic instability with widening of the medial clear space >= 5 mm on GSV. When correlated with MCS measurement, the lateral drawer test demonstrated a sensitivity of 83.3%, specificity of 100%, positive predictive value (PPV) of 100% and negative predictive value (NPV) of 88.9% for determining instability. There was a strong correlation between the lateral drawer test grade and amount of MCS widening (⍴=0.82, p=0.0003). Patients tolerated the lateral drawer test well with an average increase of 1.6 on the VAS pain scale after testing. Conclusion: The lateral drawer test demonstrates high sensitivity, specificity, PPV and NPV for detecting instability in patients presenting with Weber B fibula fractures. While further validation is required in a larger cohort of patients, the lateral drawer test may offer an adjunct tool via physical examination to predict mortise stability.

Purpose: Collagenase Clostridium histolyticum (CCH) has increasingly been used to treat Dupuytren contracture since its Food and Drug Administration approval in 2010. One concern among practitioners is the learning curve of this new technique. This study characterizes success and complication rates for surgeons with no prior experience with CCH treatment. Methods: We recruited 10 hand and upper-extremity surgeons for this study. Retrospective clinical records were reviewed for the first 10 CCH injections by each surgeon. Preinjection, postmanipulation, and 30- to 90-day follow-up measurements were recorded, along with any complications. Finally, provider opinions regarding CCH for Dupuytren contracture were collected. Results: There were 100 CCH injections in 100 fingers: 42 with isolated metacarpophalangeal contractures, 24 with isolated proximal interphalangeal contractures, and 34 with both metacarpophalangeal and proximal interphalangeal contractures. At 30- to 90-day follow-up, 61.4% of primary joints demonstrated improvement of contracture to within 0° to 5° degrees from full extension, 85.2% showed greater than 50% reduction in contracture, and 12 patients were lost to follow-up. Trend analysis suggested a flat initial learning curve. Complications occurred in 33 cases and included skin tears (31) and lymphadenopathy (4). No tendon ruptures were observed. All surgeons were either satisfied or extremely satisfied with CCH and continued using it in their practices. Conclusions: Clinical results achieved from practitioners’ early injections mirrored success and surgeon satisfaction rates previously reported in the literature. However, complication rates were higher than those in initial clinical trials but similar to later studies that used local anesthesia during manipulation. Trends in clinical outcomes among the first 10 injections suggest an initially flat learning curve for CCH. Practitioners’ opinions of CCH remained favorable after early use. Type of study/level of evidence: Therapeutic III. Key words: collagenase, Dupuytren, initial learning phase