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Category: Ankle; Ankle Arthritis Introduction/Purpose: Anchors are frequently used in reconstructive orthopedic surgery to achieve fixation of soft tissue to bone. Anchors vary with respect to material composition, configuration, and methods of fixation at the site of attachment. The fixation component of anchoring devices has generally evolved from metal-fabricated implants to various types of bioresorbable anchors. The SonicAnchor TM (Stryker, Kalamazoo, MI USA) polymer implant provides a unique form of anchor fixation using SonicFusion TM technology to achieve interdigitation within cancellous bone while being radiolucent and providing a small footprint. Methods: During a four-year period, 116 patients underwent a reconstructive orthopedic foot and ankle surgical procedure with the use of at least one bioresorbable polymer anchor (SonicAnchor implant). There were 59 males and 57 females, with an average age of 42 years (range: 12-83 years). Results: A total of 233 bioresorbable anchor (SonicAnchor) implants were used in 116 patients. Of the 116 patients, 108 (93.1%) achieved successful clinical healing of their surgery at their most recent follow-up. The average follow-up duration was 309 days (range: 14-1,429 days). Eight (6.9%) patients were lost to follow-up prior to clinical healing. Two (1.7%) patients underwent reoperation. Also, 65 (56%) patients had at least six months of follow-up and 36 (31%) had at least one year of follow-up. Conclusion: This preliminary clinical trial of patients undergoing soft tissue repair or reconstruction with a bioresorbable polymer appears to perform comparably to other commercially available devices. The lack of adverse events, mechanical failures, or infections further supports the safety of this device.

Category: Ankle Introduction/Purpose: When performing surgical fixation of bimalleolar equivalent ankle fractures, there has been considerable debate regarding fixation of the deltoid ligament. Many surgeons would agree that deltoid ligament repair should be undertaken if there is radiographic evidence of medial interposition of the deep deltoid. The incidence of deltoid ligament interposition has not been addressed in current literature. This study aims to assess the incidence of deltoid interposition in bimalleolar equivalent ankle fractures to provide further guidance on the importance of acute deltoid ligament repair. Methods: Over a five year time frame, 49 bimalleolar equivalent ankle fractures were repaired in 30 males and 19 females with a mean age, 37 (15-73) years. There was no exclusion criteria and patients were consecutively enrolled if they sustained a bimalleolar equivalent ankle fracture. Results: During this time frame, 49 patients who sustained a bimalleolar equivalent ankle fracture underwent surgical fixation with routine repair of the deltoid ligament. 18 patients (36.73%) had deltoid interposed within the medial gutter. 13 patients (26.53%) had an osteochondral defect. Conclusion: The incidence of deltoid interposition seen with medial exploration within this cohort was 37%. While the benefits of deltoid ligament repair are still controversial, persistent medial gutter soft tissue interposition could lead to symptoms of impingement or even result in persistent medial widening. This study supports increased scrutiny to the relationship of the medial gutter and deltoid ligament in acute bimalleolar equivalent ankle fractures.

Category: Ankle; Sports; Trauma Introduction/Purpose: Non-operative treatment is regarded as the standard of care for the management of acute, uncomplicated lateral ankle sprains. As diagnostic and treatment options evolve, there is intermittently renewed interest in early surgical treatment of these acute injuries. Wider availability of magnetic resonance imaging (MRI) has made advanced imaging of acute ankle sprains more commonplace. One entity commonly seen on MRI is the ‘bone marrow lesion’ (BML). Recently, a procedure termed ‘Subchondroplasty’ (Zimmer, Warsaw, Indiana) has been developed to address chronic bone marrow lesions that have failed conservative management. We present a series of five cases referred from outside institutions in which patients developed rapid osteonecrosis of their tali after undergoing acute lateral ligament reconstruction with talar Subchondroplasty. Methods: We retrospectively evaluated the charts and available imaging of five patients who had developed osteonecrosis after undergoing a Subchondroplasty procedure in the setting of acute lateral ligament injury at outside institutions. Outside radiology reports, x-rays and magnetic resonance images, clinic notes, and operative reports were collected and analyzed. Patient demographics, comorbidities, and secondary interventions (after the index procedure) were recorded. Results: Average patient age was 23 (range 16-31). All patients were healthy. The patients were taken care of by different outside providers. All patients had pre-operative MRI demonstrating ATFL signal changes and bony edema within the talus in a distribution expected after ankle sprain. All patients were taken to the OR within 4 weeks of injury. Three underwent isolated talar Subchondroplasty; two underwent Subchondroplasty and an open Broström procedure. Within 6 months, radiographs and MRI in all patients demonstrated diffuse sclerosis of the tali, and diffuse talar hyperintensity on MRI scans, consistent with osteonecrosis. Two patients additionally had talar fragmentation and collapse. Currently, one patient has subsequently undergone total ankle replacement, two have had arthroscopy with bone marrow stimulation, and two are considering arthrodesis. Conclusion: We present 5 cases from outside institutions in which patients with acute ankle sprains and associated acute talar bone marrow lesions developed osteonecrosis after Subchondroplasty with or without lateral ligament repair. Although Subchondroplasty was likely not well-indicated in these acute cases, it raises a question of whether Subchondroplasty may be harmful to the talar blood supply. There is currently a lack of evidence to support Subchondroplasty for use in the foot and ankle. Practitioners should exercise caution when performing Subchondroplasy for the talus.

Category: Lesser Toes; Midfoot/Forefoot; Other Introduction/Purpose: There is no consensus as to which skin antiseptic technique is most effective at reducing bacterial load prior to orthopaedic foot and ankle procedures. The purpose of this study is to determine if the addition of a dilute betadine soak and scrub to a standard preparation with alcohol and chlorhexidine decreases positive bacterial culture rates from the hallux nailfold. Methods: In this prospective, randomized controlled trial, 242 subjects were randomized to one of two groups. The control group received only a standard skin antiseptic preparation with alcohol and chlorhexidine, while the intervention group received a three-minute dilute betadine soak and scrub followed by the standard preparation with alcohol and chlorohexidine (Figure 1). Immediately before skin incision, culture swabs were taken from the hallux nailfold of both groups. Results: Of the 257 subjects enrolled and randomized, 242 (94.2%) completed the study, satisfying the a priori sample size requirement of 242 subjects. There were no crossovers between groups. There were no differences in baseline characteristics between groups (p>0.05 for each). There was no difference in the bacterial growth rate between groups (26.8% growth in the intervention group versus 26.9% growth in the control group, p=0.991). Conclusion: The hallux nailfold is one of the most difficult to sterilize areas prior to orthopaedic foot and ankle surgery. This randomized controlled trail found no benefit to adding a three-minute dilute betadine soak and scrub to a standard skin preparation with alcohol and chlorohexidine.

Category: Ankle Introduction/Purpose: The current standard of care for management of an unstable ankle fracture that includes an oblique Weber B fibula fracture is open reduction and internal fixation (ORIF) using a plate and screws to anatomically reduce and compress the fractured fibula. The most popular first-line techniques include either a lag screw with neutralization plate or an anti- glide plate with or without a lag screw through the plate. However, these techniques can be technically challenging in osteoporotic bone or within fibulas of smaller diameter, and in some cases can result in fragmentation at the fracture site. The purpose of this study is to examine an alternative first-line method for routine treatment of Weber B fibula fractures. Methods: Fifty-two patients undergoing ORIF of a Weber B fibula fracture by a single surgeon were included in this retrospective study. In every case, reduction and clamping of the fracture was attempted. If successful, a lateral locking plate was slid underneath the clamp(s) and applied with cortical screws proximally and locking screws distally. If clamping was unsuccessful, length/alignment/rotation was achieved by alternative methods (i.e. push-pull technique, use of plate to reduce fracture, etc.), and a lateral locking plate was ultimately applied in a similar manner. No screw crossed the fracture in any case. Per published precedent, nonunion was defined as either a gap of >3mm between fracture surfaces >6 months postoperatively or a fracture line >2-3 mm wide and sclerosing of the fracture surfaces >6 months postoperatively. Similarly, malunion was defined as >=1 of the following: talar tilt >2 degrees, talar subluxation >2 mm, or tibiofibular clear space >=5 mm. Results: The mean (+- standard deviation) age of the 52 included patients was 44.2 +- 16.2 years, the mean body mass index was 27.7 +- 6.6 kg/m2, and 63.5% of patients identified themselves as female. The mean follow-up was 6.2 +- 4.4 months. In addition to undergoing fixation of the lateral malleolus, 21 patients also underwent fixation of the posterior malleolus, 27 underwent fixation of the medial malleolus, 29 underwent fixation across the syndesmosis, and seven underwent repair of the deltoid. In all patients, bony anatomic union of the fibula and congruence of the mortise were achieved, with no cases of malunion or nonunion. Conclusion: Routine fixation of Weber B fibula fractures with a lateral locking plate and no lag screw is an alternative method to treat Weber B fibula fractures with excellent radiographic results.

Category: Bunion; Lesser Toes; Midfoot/Forefoot Introduction/Purpose: Shortening and dorsiflexion of the first metatarsal are a known side effect of metatarsal osteotomies for hallux valgus (HV) deformity with the potential to cause transfer metatarsalgia. We compared the effect of the first tarsometatarsal joint arthrodesis (Lapidus), proximal lateral closing wedge osteotomy (PLCWO), and intermetatarsal suture button fixation procedures on the length and dorsiflexion of the first ray. Methods: We retrospectively evaluated 123 feet in 115 patients. The average age was 54. There were 106 females. Eighty-four feet had a Lapidus procedure, 14 had a PLCWO, and 24 had intermetatarsal suture button fixation. Digital radiographic measurements were made for pre- and postoperative hallux valgus angle (HVA) and intermetatarsal angle (IMA), absolute and relative shortening of the first ray, and dorsiflexion. Results: Preoperative HVA and IMA did not differ between treatment groups (p>0.05 for each). Similar corrections of HVA (30.1 to 12.3 degrees) and IMA (14.7 to 7.0 degrees) were achieved in all three groups (p>0.05). There were significant differences in absolute first-cuneiform-metatarsal length (FCML) between Lapidus (-1.5mm), PLCWO (-2.5mm), and intermetatarsal suture button fixation (+1.1mm) (p

Category: Other Introduction/Purpose: Surgeon prescription of narcotic medications has been identified as a contributor to the nation’s devastating opioid epidemic. The purpose of this study is to identify risk factors for postoperative opioid dependence following orthopaedic foot and ankle surgery. Methods: Four hundred and forty-eight patients undergoing orthopaedic foot and ankle surgery at a single institution over a 6- month period were identified. The Illinois Prescription Monitoring Program was used to track opioid prescriptions filled in the preoperative, perioperative, and postoperative periods. Preoperative use was defined as the filling of a prescription during the six months prior to the procedure, excluding the 30 days prior to the procedure. Postoperative dependence was defined as the filling of opioid prescriptions beyond the initial postoperative prescription. Baseline characteristics, including preoperative opioid use, were tested for association with opioid dependence. Results: The rate of preoperative opioid use was 20.5%. The rate of postoperative opioid dependence was 31.3%. Patients who used opioids during the preoperative period had the highest risk for postoperative opioid dependence, at 59.6% (RR=2.5, 95% confidence interval = 1.9-3.2, p= 2 (RR=1.6, p=0.002), benzodiazepine use (RR=1.5, p=0.010), current smoker status (RR=1.5, p=60 years (RR=1.4, p=0.022), body mass index >= 30 kg/m2 (RR=1.4, p=0.027), antidepressant use (RR=1.4, p=0.050), and

Category: Other Introduction/Purpose: Patients are often made weight-bearing as tolerated (WBAT) in a controlled ankle motion (CAM) boot for the management of various foot and ankle conditions. The CAM boot causes a leg-length discrepancy (LLD) between the booted (longer) and contralateral (shorter) lower extremities. This discrepancy can potentially cause balance problems, undue strain on joints, and discomfort in patients. We hypothesized that a leg-length evening orthotic placed on the plantar aspect of the contralateral shoe improves balance among patients who are WBAT in a CAM boot. Methods: Patients made WBAT in a CAM boot were randomized to either the leg-length-evening orthotic intervention group or to a control group in which patients wore a normal shoe of their choice. Patients were followed for two weeks and asked a series of questions pertaining to balance and pain experienced at their knees, hips, and back. Balance was the primary outcome and was scored from 0 (no difficulty with balance) to 10 (great difficulty with balance). Results: Out of 107 subjects enrolled and randomized, 95 (88.8%) completed the study, satisfying the a priori sample size requirement of 94 patients. There were no differences in baseline characteristics between groups (p>0.05 for each). Intervention patients reported less difficulty with balance than control patients (intention-to-treat analysis: 2.0+-1.5 versus 3.2+-1.8, p=0.001; as-treated analysis: 2.1+-1.7 versus 3.0+-1.7, p=0.009). Intervention and control patients did not differ with respect to pain experienced at their knees, hips, or back, or in a composite total pain score (p>0.05 for each). Conclusion: This multicenter randomized controlled trial found that adding a limb-length-evening orthotic to the plantar aspect of the contralateral shoe in a patient that is WBAT in a CAM boot improves balance. The trial was powered to identify a difference in the primary outcome measure of balance and may have been insufficiently powered to identify differences in knee, hip, back, or total pain.

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: The Coleman block test has traditionally been used to distinguish between forefoot- and hindfoot-driven deformity as well as flexibility of cavovarus deformity. However, there has been no validation of the Coleman block test using x- rays or weightbearing CT scan. The purpose of this study was to compare hindfoot alignment in cavovarus feet with and without the Coleman block using clinical exam, x-ray, and weightbearing CT scan. Methods: We retrospectively evaluated 7 feet in 7 patients. The average age was 57, there were 5 males, and the average BMI was 34.7. Average calcaneal pitch was 30 degrees. Clinical measurements were made using standing talocalcaneal angle (STCA) and resting calcaneal stance position (RCSP) with and without a Coleman block using a camera positioned at 0 degrees to the heels. Hindfoot angle (HFA) was measured off of Saltzman-view x-rays and off of weightbearing CT coronal reconstructions with and without the Coleman block. Finally, foot ankle offset (FAO) was measured with and without the Coleman block from weightbearing CT using Cubeview TALAS software. Differences before and after Coleman block were measured using paired t- testing and correlations between different hindfoot alignment measurements were made using Pearson correlation coefficients. Results:: The average change in STCA before and after Coleman block placement was 2.9 degrees (7.14 varus without block, 4.28 degrees of varus with block; p

Background: Cavovarus foot constitutes a complex 3-dimensional deformity. The Coleman block test has traditionally been used to distinguish between forefoot- and hindfoot-driven deformity. However, there has been no objective evaluation of the Coleman block test using radiographs or weightbearing computed tomography (WBCT). The purpose of this study was to compare hindfoot alignment in adult cavovarus feet with and without the Coleman block using clinical examination, radiography, and WBCT. Methods: Six feet in 6 patients with a clinical diagnosis of cavovarus foot deformity were prospectively enrolled. All feet underwent clinical photography with the camera positioned at 0 degrees to the heel, hindfoot alignment view radiography with the beam positioned 20 degrees off the ground, and WBCT, both with and without the Coleman block in place. Clinical photos were characterized using the standing talocalcaneal angle (STCA), radiographs were characterized using the hindfoot alignment angle (HAA), and WBCTs were characterized using manual and automated hindfoot alignment angle (HAA) and foot and ankle offset (FAO). Using paired analyses, measurements taken with the Coleman block in place were compared to those taken without the Coleman block. Finally, the different methods of measuring hindfoot alignment were tested for correlation with each other. Mean age was 56 years (range 38-69). Results: On clinical photography, the STCA decreased by 3.8 degrees with addition of the block (from 10.0±6.6 degrees varus without block to 6.2±7.1 degrees varus with block; P = .001). On radiograph, HAA decreased by 9.0 degrees with addition of the block (from 16.8±8.4 degrees varus without block to 7.5±6.3 degrees varus with block; P = .07). On WBCT, hindfoot alignment angle changed an average of 3.2 degrees (33.4 degrees varus without block, 30.2 degrees varus with block; P = .008). On WBCT, FAO decreased by 1.4% (from 11.3% varus without block to 10.1% varus with block; P = .003). Clinical examination and automated WBCT measurements were strongly correlated with each other. Conclusion: Clinical examination, radiograph, and WBCT demonstrated improvements in hindfoot varus using the Coleman block test in adults, but no patient demonstrated complete resolution of deformity regardless of the measurement modality. Clinical examination correlated strongly with automated WBCT measurements. Level of Evidence: Level IV, retrospective case review.

Background: Patients are often made weightbearing as tolerated (WBAT) in a controlled ankle motion (CAM) boot for the management of various foot and ankle conditions. The CAM boot causes a leg length discrepancy (LLD) between the booted (longer) and contralateral (shorter) lower extremities. This discrepancy can potentially cause balance problems, undue strain on joints, and discomfort in patients. We hypothesized that a leg length–evening orthotic placed on the plantar aspect of the contralateral shoe improves balance among patients who are WBAT in a CAM boot. Methods: Patients made WBAT in a CAM boot were randomized to either the leg length–evening orthotic intervention group or to a control group in which patients wore a normal shoe of their choice. Patients were followed for 2 weeks and asked a series of questions pertaining to balance and pain experienced at their knees, hips, and back. Balance was the primary outcome and was scored from 0 (no difficulty with balance) to 10 (great difficulty with balance). Of 107 subjects enrolled and randomized, 95 (88.8%) completed the study, satisfying the a priori sample size requirement of 94 patients. There were no differences in baseline characteristics between groups ( P > .05 for each). Results: Intervention patients reported less difficulty with balance than control patients (intention-to-treat analysis: 2.0±1.5 vs 3.2±1.8, P = .001; as-treated analysis: 2.1±1.7 vs 3.0±1.7, P = .009). Intervention and control patients did not differ with respect to pain experienced at their knees, hips, or back, or in a composite total pain score ( P > .05 for each). Conclusion: This multicenter randomized controlled trial found that adding a limb length–evening orthotic to the plantar aspect of the contralateral shoe in a patient that is WBAT in a CAM boot improved patient-reported self-assessment of balance. The trial was powered to identify a difference in the primary outcome measure of balance and may have been insufficiently powered to identify differences in knee, hip, back, or total pain. Level of Evidence: Level II, prospective comparative study.

Arthrodesis of an osteoarthritic second metatarsophalangeal (MTP) joint is suboptimal because of altered gait mechanics; hence, joint-preserving procedures are of value. Autograft interpositional arthroplasty is one available option with excellent results, but there are potential concerns regarding donor site morbidity and insufficiency of the autograft material. We present here an alternative technique, an interpositional arthroplasty using allograft. Our technique includes a dorsal incision and joint exposure, removal of cartilage from the metatarsal head, and interposition of human decellularized dermal allograft sutured to the metatarsal head. Allograft interpositional arthroplasty is a feasible technique and can be further investigated as an alternative procedure for patients with second MTP osteoarthritis. Level of Evidence: Level V, expert opinion.

Talar osteonecrosis is a well-described phenomenon following talar neck fracture, but is a rarely described complication after procedures about the foot and ankle. Here we describe the clinical course of 5 cases of talar osteonecrosis following injection of calcium phosphate into the talus (subchondroplasty) with or without acute lateral ligament repair after acute lateral ankle ligament injuries performed at an outside institution. Practitioners should be aware of this potentially devastating complication. Future research is indicated to determine the safety and efficacy of subchondroplasty for the talus. Level of Evidence: Level V, case series.

Category: Prescription Practices Introduction/Purpose: Opioid abuse has recently reached the conscience of the US healthcare system and news cycle. This epidemic is in part propagated by surgeon over-prescription for common procedures. The purpose of this study is to examine postoperative opioid use following outpatient foot and ankle surgery in order to potentially guide prescription patterns of postoperative narcotics. Methods: Patients undergoing outpatient foot or ankle surgery, performed by one of four fellowship-trained orthopedic foot and ankle surgeons from a single institution, were prospectively enrolled from January to November 2018. Subjects were consented to participate in a phone interview within 7 days of their surgery, with subsequent interviews as needed for continued monitoring. Information collected included: age, gender, procedure, smoking status, payor type, analgesic regimen, number of tablets remaining, pain scale, pain control satisfaction, additional analgesic medications taken, reason for stopping opioid medications, and any adverse reactions encountered. Results: A total of 94 subjects were consented to participate. Of these, 11 were lost to follow up and 2 withdrew from the study, leaving 81 (86%) subjects for analysis. The mean (± standard deviation) number of opioid pills prescribed was 52.2 (±16.4; range: 6-80) pills. Subjects were satisfied or somewhat satisfied with their pain control in 91% of cases. On average, 18.4 (±14.9) pills were consumed by subjects, stopping consumption on post-operative day 4.8 (±3.6). There was no statistically significant difference in narcotic medications consumed whether undergoing ankle surgery (16.4, ±13.7) or foot surgery (20.7, ±15.9) (p=0.11). Overall, an average of 34.3 (±19.3) pills remained unconsumed at the completion of narcotic use, equaling a total of 2,706 excessively prescribed pills in the study cohort. Conclusion: There is a substantial excess of opioid pain medication prescribed to patients for outpatient foot and ankle surgeries, with a wide variation in prescription patterns. Based on our institutional data, a prescription of 35 opioid pills should be sufficient for approximately two-thirds of outpatient procedures and 50 pills should be sufficient for approximately 95% of patients regardless of whether the procedure is for the ankle or foot. This quality improvement assessment has influenced physician practice in our group and prospective follow-up analysis after intervention is warranted.

Category: Lesser Toes Introduction/Purpose: Success has been reported in treating first metatarsophalangeal joint osteoarthritis with allograft interpositional arthroplasty, but little has been published regarding the use of similar techniques for the second metatarsophalangeal joint. We hypothesized that second metatarsophalangeal joint allograft interpositional arthroplasty would result in improvement in patient-reported outcomes, a low rate of postoperative complications, and a low rate of reoperation at minimum follow-up of one year. Methods: A retrospective review of medical records was conducted for patients having undergone allograft interpositional arthroplasty of the second metatarsophalangeal joint with at least one year of postoperative follow-up. Our technique included a dorsal incision and joint exposure, removal of the cartilage from the metatarsal head using a conical reamer, suture of a human decellularized dermal allograft to the metatarsal head though drill holes, and capsular repair (Figure 1). Preoperative and postoperative findings were compared, including Foot Function Index (FFI) and radiographic joint space measured on the AP view. Postoperative range of motion and satisfaction with the procedure were quantified. Results: In total, 5 patients met inclusion criteria. Mean follow-up was 3.2+/-2.1 years. Three of 5 patients (60.0%) reported that they would have the procedure again, and mean satisfaction with the procedure was 6.0+/-5.1 out of 10. One patient had conversion to fusion at 2 postoperative years. Among the 4 unfused patients, Foot Function Index decreased from 75.7+/-29.8 preoperatively to 52.0+/-46.5 at final follow-up (p=0.526). Mean final arc of motion was 35.0+/-7.1 degrees. Radiographic joint space was 0.4+/-0.3 mm preoperatively, increased to 2.2+/-0.5 mm immediately postoperatively, and decreased to 1.5+/-0.8 mm at final follow-up. The final follow-up joint space trended towards a larger number among the patients who stated they would have the procedure again compared to the patients who stated they would not (2.6+/-1.0 mm versus 0.4+/-0.4 mm, p=0.178). Conclusion: Second metatarsophalangeal joint allograft interpositional arthroplasty is a reasonable alternative to arthrodesis for management of isolated late-stage second metatarsophalangeal joint osteoarthritis. Arthrodesis of the second metatarsophalangeal joint is suboptimal due to altered gait mechanics; hence, novel joint preserving procedures are of value. Despite the modest results of interpositional arthroplasty in this limited series, the procedure can result in pain relief while allowing for motion in a subset of patients. The major determinant of success among our cohort was the maintenance of radiographic joint space at final follow-up.

Category: Other Introduction/Purpose: Scribes are utilized as a means to reduce administrative burden on surgeons and enhance the physician- patient interaction. Virtual scribe services (VSS) are a contemporary take on the scribe that use a HIPAA-compliant smart device to record patient encounters for transmission, remote transcription, and insertion into the electronic medical record. The purpose of this study was to determine if the use of a VSS could decrease the total time an orthopaedic surgeon spends on documentation without diminishing the patient experience when compared to traditional post-encounter dictation (TD). Methods: Patients presenting for a first-time visit with an orthopaedic foot and ankle surgeon were consented and randomized to VSS or TD prior to the physician-patient encounter. Time spent with the patient in the exam room and time used to document away from the patient were recorded. A validated post-encounter survey assessed patient satisfaction, perception of physician empathy, understanding of the plan, and perception of the amount of time spent with the physician on scales of 0 to 10. An a priori sample size calculation with an alpha level set at 0.05 and power of 80% estimated that 50 patients were necessitated to demonstrate a 2-minute difference in time spent documenting away from the patient. Comparisons were made using a two-sample Student’s t-test. Results: Of the 50 patients enrolled, 25 were randomized to VSS. No differences in demographic characteristics were identified between cohorts (p>0.05 for each). Time spent documenting away from the patient differed between VSS and TD (1.19±0.65 minutes for VSS versus 5.80±1.70 minutes for TD, p0.05 for each; Table 1). Conclusion: VSS in an orthopaedic foot and ankle practice decreases documentation time by approximately 4 minutes per new patient compared to TD, resulting in 2 hours of reclaimed physician time for every 30 new patients. With VSS, documentation is completed during the visit versus TD which is dictated on average 2 hours later. A validated survey identified no differences in patient satisfaction, perception of physician empathy and sufficient time spent with the physician, or understanding of the plan with VSS versus TD. Orthopaedic surgeons should consider VSS a HIPAA-compliant documentation option with time savings and no measurable difference in patient satisfaction.

Category: Ankle, Ankle Arthritis, Hindfoot, Midfoot/Forefoot Introduction/Purpose: The interaction between hip pathology and spinopelvic alignment is a current subject of interest in orthopedics with a number of recently performed studies. However, little is known regarding the interaction between foot & ankle (F&A) pathology and spinopelvic alignment, despite common complaints from patients such as back pain potentially caused by an outturning foot. The purpose of this study is to test for associations between F&A pathology and spinopelvic alignment and degeneration. Methods: A retrospective cohort study was conducted involving consecutive patients who presented to both F&A and spine surgeons within the same practice. Inclusion criteria required that each patient have the following radiographic views while in a weight bearing, standing position: lateral of lumbar spine; anteroposterior (AP), lateral, and mortise of ankle; AP, lateral, and oblique of foot. Patients were excluded from analysis if there was radiographic evidence of previous surgical instrumentation in the spine, ankle, or foot. Bonferroni correction was performed to account multiple statistical analyses, which resulted in the level of significance set to p0.001 for each; Table 1). Conclusion: A common patient concern is that a foot condition may be contributing to low back pain through altered gait and postural dynamics. With the numbers available, we were unable to demonstrate statistical associations between F&A radiographic findings and spinopelvic alignment or degeneration. Orthopaedic surgeons can address patients’ concerns about the relationship

Category: Health Sciences Research Introduction/Purpose: In the era of decreasing reimbursement and increasing financial pressure on the orthopaedic foot and ankle surgeon, improving clinic efficiency has value. The purpose of this study was to identify which patients and which types of clinical visits consume the greatest amounts of an attending orthopaedic foot and ankle surgeon’s time. Methods: A prospective, observational study was conducted in an outpatient orthopaedic foot and ankle clinic at a tertiary medical center. 210 adult patients were enrolled from the clinics of two fellowship-trained, board certified orthopaedic surgeons. Time spent in the exam room with the attending surgeon was the primary outcome. Independent variables included patient and appointment characteristics (i.e. age, sex, new/follow-up appointment, etc.). Linear regression was used to test for association between the independent variables and the primary outcome. Results: Mean time spent by the attending surgeon in the exam room (± standard deviation) was 7.4±4.4 minutes (range, 1-20). Predictors of greater time spent in the exam room included patient age≥50 years (+2.0 minutes, 95% confidence interval [CI]=+0.8 to +3.1, p=0.001), female sex (+1.7 minutes, 95% CI=+0.5 to +2.9, p=0.005), outside medical records reviewed (+2.4 minutes, 95% CI=+0.6 to +4.2, p= 0.010), and new (versus follow-up) patient appointment (+1.7 minutes, 95% CI=+0.5 to +2.9; Table 1). In contrast, time spent in the exam room was not associated with the patient arriving late, completion of patient paperwork before the appointment, whether the patient obtained x-rays at the visit, or the type of provider that saw the patient prior to the attending (resident/physician assistant; p>0.05 for each). Conclusion: Patients who are age=≥50, identify as female, bring outside medical records for review, and are presenting to the surgeon for the first time consume the greatest amounts of a surgeon’s time in the examination room. Surgeons can anticipate spending more time in the room with these types of patients and should schedule their clinics accordingly.

Category: Hindfoot, Ankle, Midfoot/Forefoot, Injury and Rehabilitation Introduction/Purpose: The functional capacity evaluation (FCE) is used to determine a worker’s physical ability after treatment of a work-related injury. This evaluation is a critical determinant in the administration of benefits and the decision to return to work (RTW). The purpose of this study is to characterize FCE results and ability to RTW among patients treated for work- related orthopaedic injuries to the foot or ankle. Methods: A retrospective medical record review from the practices of four orthopaedic foot and ankle surgeons was conducted. Inclusion criteria were (1) treatment of a work-related injury to the foot or ankle, (2) at least 2 years of follow-up from the injury, and (3) documentation of an associated FCE. The FCE report and clinic notes were used to determine the patient’s pre-injury job requirement (Department of Labor Office category: light, medium, or heavy), post-injury FCE-determined work ability (light, medium, or heavy), specific FCE- or physician-imposed work restrictions, and clearance for RTW. Patients were considered cleared to RTW if their FCE-determined work ability met or exceeded their pre-injury job requirement and if there were no additional restrictions imposed by the FCE or physician that would prevent them from functioning in their pre-injury role. Results: A total of 188 patients met inclusion criteria. Missteps/rotational injuries (44.1%), falls from height (22.3%), and crush injuries (20.7%) were the most common mechanisms. 74.4% of patients had FCE-determined work abilities at or above their pre- injury job requirements, and 63.3% of patients were eventually cleared for RTW. The median time from injury to clearance for RTW was 2.0 ± 1.3 years. Reasons for not being cleared to RTW included failure to meet the pre-injury job requirement (67.2%), specific FCE-imposed limitations (28.3%), or specific physician-imposed limitations (4.5%). Less strenuous pre-injury job requirement was positively associated with both FCE-determined work ability meeting pre-injury job requirement and clearance for RTW (p

Category: Ankle, Hindfoot, Midfoot/Forefoot Introduction/Purpose: Sleep disturbance is a known risk factor for poor healing and is associated with medical co-morbidities. Poor sleep quality is also a common complaint of pre-operative patients; yet, there remains a paucity of investigations in this realm. The purpose of this study is to quantify the prevalence of sleep disturbance in patients undergoing surgical management of chronic foot and ankle conditions. Methods: Patients scheduled for first-time surgical management of a chronic foot and ankle condition were identified between May and November of 2018 at a tertiary care medical center. Patients with a known sleep disorder or refusal to participate were excluded. Of 139 patients initially identified, 84 (60.4%) were included and administered the Pittsburgh Sleep Quality Index (PSQI) pre-operatively. The PSQI ranges from 0-21, with a score ±5 indicative of poor sleep quality. Patients were also asked to rate their perception of how their foot or ankle pain influenced their sleep quality on a scale of 0-10 (foot ankle pain perception score, FAPPS). A multivariate linear regression model was used to determine predictors of sleep disturbance. Results: The mean (+/- standard deviation) age of the 84 included patients was 48.2+/-13.8 years; body mass index (BMI) was 28.9+/-5.0 kg/m2; 52.4% of patients identified as male; and conditions and treatments were varied (Table 1). The mean PSQI score was 7.6+/-4.3 (range, 2-21) and mean FAPPS was 3.2+/-2.7. A total of 64 (76.2%) patients had a PSQI score greater than/equal to 5, indicating presence of sleep disturbance. A total of 68 (81.0%) patients had a FAPPS greater than/equal to 1, indicating that a patient perceived that their foot or ankle pain contributed to sleep disturbance. Age, sex, BMI, and condition/treatment category were not correlated with PSQI score (p>0.05 for each); however, greater FAPPS was an independent predictor of a greater PSQI score (p

Category: Health Sciences Research Introduction/Purpose: Wait times represent a critical component of the patient experience, and prolonged waits are correlated with decreased patient satisfaction. We hypothesized that time spent waiting for radiology is the largest contributor to total patient wait time in our orthopedic foot and ankle clinic. Methods: A prospective, observational study was conducted in the outpatient orthopaedic foot and ankle clinic at a tertiary medical center. A total of 210 new and follow-up adult patients were enrolled. Patients were tracked from arrival until checkout with multiple time points being recorded by a trained observer. The time between patient arrival and first contact with the orthopaedic surgeon was broken down into five distinct categories. Total time between patient arrival and first contact with the orthopaedic surgeon was tested for association with patient and appointment characteristics using Student’s t-test. Results: The average total time spent waiting for first contact with the orthopaedic surgeon was 57.1±30.4 minutes. The largest contributor was time spent waiting for an exam room (33.1±25.5 minutes), followed by time spent waiting for radiologic imaging (21.7±19.9 minutes), time spent waiting for resident/PA (12.2±10.9 minutes), and time spent waiting for attending surgeon after seeing resident/PA (11.7±9.3 minutes). Factors contributing to a longer overall wait included obtaining x-rays at the visit (+15.4±4.2 minutes, 95% confidence interval [CI]=+7.0 to +23.8, p

Introduction: Hip fractures are common in the elderly patients with an incidence of 320 000 fractures/year in the United States, representing a health-care cost of US$9 to 20 billion. Hip fracture incidence is projected to increase dramatically. Hospitals must modify clinical models to accommodate this growing burden. Comanagement strategies are reported in the literature, but few have addressed orthopedic-hospitalist models. An orthopedic-hospitalist comanagement (OHC) service was established at our hospital to manage hip fracture patients. We sought to determine whether the OHC (1) improves the efficiency of hip fracture management as measured by inpatient length of stay (LOS) and time to surgery (TTS) and (2) whether our results are comparable to those reported in hip fracture comanagement literature. Methods: A comparative retrospective–prospective cohort study of patients older than 60 years with an admitting diagnosis of hip fracture was conducted to compare inpatient LOS and TTS for hip fracture patients admitted 10 months before (n = 45) and 10 months after implementation (n = 54) of the OHC at a single academic hospital. Secondary outcome measures included percentage of patients taken to surgery within 24 or 48 hours, 30-day readmission rates, and mortality. Outcomes were compared to comanagement study results published in MEDLINE-indexed journals. Results: Patient cohort demographics and comorbidities were similar. Inpatient LOS was reduced by 1.6 days after implementation of the OHC ( P = .01) without an increase in 30-day readmission rates or mortality. Time to surgery was insignificantly reduced from 27.4 to 21.9 hours ( P = .27) and surgery within 48 hours increased from 86% to 96% ( P = .15). Discussion: The OHC has improved efficiency of hip fracture management as judged by significant reductions in LOS with a trend toward reduced TTS at our institution. Conclusion: Orthopedic-hospitalist comanagement may represent an effective strategy to improve hip fracture management in the setting of a rapidly expanding patient population.

Category: Ankle Introduction/Purpose: Ankle fractures are an increasingly common musculoskeletal injury and represent a substantial source of societal economic loss due to missed days of work and utilization of healthcare resources. While common protocols exist for postoperative management of these fractures, predictors of time to union have not been analyzed. We aim to evaluate patient characteristics, injury features and perioperative factors that predict time to union and may allow for optimized postoperative protocols and improved patient counseling. Methods: A cohort of consecutive patients with isolated, closed operative ankle fractures treated by multiple surgeons at a tertiary care academic medical center from 2008-2012 was retrospectively reviewed for time to clinical union. Clinical union was defined as plain film radiographic evidence of bony healing and minimal to no pain clinically. Patients with pilon fractures, open injuries, additional fractures and incomplete outcomes data were excluded from analysis. Means and standard deviations were calculated and multivariate linear regression modeling was utilized to identify predictors of time to clinical union. Results: A total of 108 isolated, closed operative ankle fractures met inclusion criteria. Of these, 99.1% achieved clinical union in less than 6 months and the remaining one patient completed union in a delayed fashion with the use of non-operative adjuncts. Mean time to union was 14.1 weeks (SD 5.3 weeks). Statistically significant negative predictors of time to union were BMI, dislocation of the tibiotalar joint, external fixation for initial stabilization and delay of definitive management (all p < 0.05). Sex, age, diabetes mellitus, tobacco usage and high-energy mechanism were not significant after adjustment (Table 1). Fracture pattern and definitive operative fixation technique did not contribute to a parsimonious regression model and were excluded from final analysis. Conclusion: Time to clinical union after ankle fracture is significantly correlated with BMI, tibiotalar dislocation, external fixation for initial stabilization and delay of definitive management. In these instances, it is important to counsel patients about the potential for nonunion and consideration should be given to healing adjuncts such as prolonged non-weightbearing immobilization, bone stimulation and vitamin D.

Category: Ankle Arthritis Introduction/Purpose: Patients with ankle arthrodesis exhibit hypermobility of adjacent joints that is hypothesized to result in accelerated arthritis. One theoretical advantage of total ankle replacement (TAR) over arthrodesis is preserved ankle motion and reduced stress on adjacent joints. We hypothesized that sagittal plane radiographic assessment will demonstrate “true” ankle motion of the prosthesis is less than the total arc of hindfoot motion secondary to contributions from adjacent joints. We aimed to compare fixed versus mobile-bearing prostheses for: (1) true ankle motion after TAR, (2) contribution of adjacent joint and midfoot motion that can lead to artificially inflated observed ankle motion (3) progression of subtalar and talonavicular joint arthritis. Previously described radiographic parameters were measured to allow for comparison of TAR motion to published ankle arthrodesis values. Methods: Patients underwent standardized weightbearing maximum dorsiflexion and plantar flexion sagittal radiographs. Previously described ankle and foot measurements were performed on each dorsiflexion and plantar flexion radiograph to determine the maximum observed ankle motion, true ankle motion through the prosthesis, motion through the subtalar joint, motion through the talonavicular joint, and talo-first metatarsal (midfoot) motion. Pre- and post-operative modified Kellgren- Lawrence grades of subtalar and talonavicular osteoarthritis were assigned to each patient preoperatively and latest follow-up. A minimum of two years of follow-up was needed. Results: Three prostheses were evaluated and 197 patients met inclusion criteria (75 INBONE, 52 Salto-Talaris, 70 STAR). Mean time to final ROM radiographs was 42.9 months. Mean true ankle motion through the prosthesis (25.9°) was less than the mean hindfoot motion arc (37.4°) that would be observed during clinical assessment. Mean subtalar motion was 8.6° and mean change in Meary’s angle was 16.5°. No significant difference was identified between prosthesis or fixed versus mobile-bearing design for the above parameters. The mobile-bearing STAR demonstrated more talonavicular joint motion (7.2°) than both fixed-bearing prostheses (INBONE 5.0°, p=0.02; Salto-Talaris 4.8°, p=0.02). There was no identifiable progression of modified Kellgren- Lawrence grade of subtalar or talonavicular arthritis when stratified by prosthesis or bearing type and adjusted for time to final follow-up. Conclusion: This study demonstrated that true ankle motion after TAR is approximately 10 degrees less than the total arc of clinical hindfoot motion—a difference that can be attributed to adjacent joint and midfoot motion. Additionally, no difference in true ankle motion or total arc of hindfoot motion was identified between fixed versus mobile-bearing designs. Counterintuitively, the mobile-bearing STAR prosthesis demonstrated significantly more adjacent joint talonavicular motion than its fixed-bearing counterparts. Progression of subtalar or talonavicular arthritis was not correlated with prosthesis or bearing type in this study and subtalar motion (8.6°) appears similar between TAR and historical arthrodesis controls (9.3°).

Category: Ankle Arthritis Introduction/Purpose: Tibiotalocalcaneal arthrodesis (TTCA) by retrograde intramedullary nailing (RIMN) is commonly used to treat degenerative disease affecting both the tibiotalar and subtalar joints. In the event of TTCA failure, techniques for salvage arthrodesis are not well-described. The aim of this study is to demonstrate the feasibility of anterior plating with retention of nail as a salvage option for patients who experienced failed TTCA by RIMN. Methods: Six patients with failed TTCA following RIMN underwent revision ankle arthrodesis with anterior plating and retention of nail between July 2013 and July 2015. Patient demographics, presentation details, and clinical records were reviewed for clinical and patient-reported outcome measures. Postoperative outcomes consisted of visual analog scale (VAS) pain rating, Coughlin satisfaction scale, Foot & Ankle Activity Measure (FAAM) score, and complications. Results: Anterior plating was performed at a mean of 15.8 months (range, 6.3-25.7) after primary TTCA by RIMN. All patients achieved bony fusion at an average of 9.3 weeks (range, 5.4-16.1) postoperatively. Postoperative outcomes at 1 year follow-up demonstrated an average VAS score improvement from 7.8 to 5.3 (p = 0.019) and an average postoperative FAAM score of 50.9 (range, 37.5-75.0). One major complication occurred in a patient who had a posterior tibial nerve neuroma from the initial TTCA procedure. Despite achieving union following anterior plating, the patient had several subsequent procedures to manage the neuroma but eventually required amputation. There was one minor complication consisting of postoperative swelling requiring a compressive stocking. Conclusion: Anterior plating with retention of nail is a viable option for salvage arthrodesis in patients with failed TTCA after RIMN. Given the complex presentation of most patients with this problem, detailed preoperative counseling regarding the potential risks of surgery should be performed.

Category: Basic Sciences/Biologics Introduction/Purpose: In 1976, Ramsey and Hamilton published a landmark cadaveric study demonstrating a dramatic 42% decrease in tibiotalar contact area with only 1 mm of lateral talar shift. An increase in principal stress of at least 72% is predicted based on these findings though the delayed development of arthritis in minimally misaligned ankles does not appear to be commensurate with the results found in dry cadaveric models. We hypothesize that synovial fluid is a previously unrecognized factor that contributes significantly to stress distribution in the tibiotalar joint in anatomic and injured states. Methods: As it is not possible to directly measure contact stresses with and without fluid in a cadaveric model, finite element analysis (FEA) was employed for this study. FEA is a modeling technique used to calculate stresses in complex geometric structures by dividing them into small, simple components called elements. Four test groups were investigated utilizing a finite element model (FEM): baseline ankle alignment, 1 mm laterally translated talus and fibula, and the previous two bone orientations with fluid added. The FEM selected for this study was the Global Human Body Models Consortium (GHBMC) M50 version 4.2, a validated model of an average sized male. The ankle was loaded at the proximal tibia with a distributed load equal to the GHBMC body weight and first principal stress (which is also the maximum principal stress) was computed. Results: All simulations were stable and completed with no errors. In the baseline anatomic configuration, the addition of fluid between the tibia, fibula and talus reduced the maximum principal stress measured in the distal tibia at maximum load from 31.3 N/mm2 to 11.5 N/mm2. Following 1 mm lateral translation of the talus and fibula there was a modest 30% increase in the maximum stress in fluid cases. Qualitatively, translation created less high stress locations on the tibial plafond when fluid was incorporated in the model (Figure 1). Conclusion: The findings in this study demonstrate a potential role for synovial fluid in distributing stresses within the ankle that has not been considered in historical dry cadaveric studies. The increase in maximum stress predicted by simulation of an ankle with fluid is less than half that projected by cadaveric data, indicating a protective effect of fluid in the injured state. The trends demonstrated by these simulations suggest that bony alignment and fluid in the ankle joint change loading patterns on the distal tibia and should be accounted for in future experiments.

Category: Ankle Arthritis. Introduction/Purpose: Wound complications following total ankle replacement (TAR) potentially lead to devastating consequences. The aim of this study is to compare the surgical and demographic differences in those with and without wounds which require operative management. We hypothesize that increased tourniquet and surgical time negatively influences wound healing. Methods: We retrospectively identified a consecutive series of 760 primary TARs performed between January 1998 and December 2014 whose data was prospectively collected. We then identified patients who required a secondary surgery to treat wound complications (ie operative debridement, split-thickness skin grafting, soft tissue reconstruction). All patients had operative wound debridement. We then compared demographics, surgical characteristics, and functional scores to see if there were any differences between the two groups. Clinical outcomes including secondary procedures and implant failure rate were recorded. Results: Twenty-seven patients (3.6%) had a total of 50 procedures to treat wound issues. 18 patients had flaps and 13 had split- thickness skin grafts. The mean time to operatively treating the wound was 12.6 weeks after the index TAR. The follow-up time from wound procedure was 28 months. Compared to the control group, patients with major wounds had a significantly longer surgery (215.6 vs. 189.2 min, p=.028) and tourniquet time (150.9 vs. 140 min, p=.0037). The control patients were more likely to have post-traumatic arthritis, whereas those with wound complications were more likely to have osteoarthritis (p=.002). Post- operatively, only the FAOS pain score was worse in patients with wounds (p=.047). There were seven failures in the major wound complication cohort (25.9%), including 2 BKAs. Conclusion: Ankle wounds which require operative management have high failure rates and may result in devastating outcomes. Given our data, we recommend limiting tourniquet time.

Category: Other Introduction/Purpose: There is a growing demand for orthopaedic surgeons trained in management of foot and ankle conditions, yet there remains wide variation in the process of fellowship training and a dearth of outcomes assessment. The 2016- 2017 American Orthopaedic Foot & Ankle Society (AOFAS) Fellowship Match consisted of 75 available positions—a 44% increase over that a decade prior. Of the 48 programs offering positions, 6 offer standardization and oversight by the Accreditation Council for Graduate Medical Education (ACGME). We aimed to assess the educational curriculum, research production and career paths of 25 years of graduates from the longest running ACGME accredited foot and ankle fellowship program in the United States. Methods: A database of graduates from a single foot and ankle fellowship program was utilized to identify practice types and locations as well as tabulate PubMed indexed articles authored by fellows while in the program. The educational curriculum corresponding to their training is described. Additionally, historical data from the AOFAS Match Program was evaluated for trends. Results: Between 2005-2015, there were 515 graduates of AOFAS sponsored foot & ankle fellowship programs in the U.S. (Figure 1). Successful match rates for fellowship applicants ranged from 80-96% and program fill rates varied between 61-93%. Our fellowship program has graduated 50 fellows in the past 25 years of whom 37 (74%) practice in the U.S. and 13 (26%) practice abroad. When accounting for international, military and academic practitioners, 54% of our graduates entered practice types with a teaching component. Research articles for each fellow were examined and on average 1.9 PubMed indexed articles (range 0-12) were published by fellows during their tenure in the program. Graduates going into military, international and U.S. academic practices published 2.5, 2.8 and 3.7 articles during training, respectively. Conclusion: As technical and cognitive demands of foot and ankle surgeons increase, the need for optimized fellowship training has become paramount. Assessment of educational curriculum, research production and graduate practice type may help fellowships identify areas for improvement in order to meet program and trainee goals.