AOFAS Winter Meeting Abstracts 2025

A Prospective Evaluation of a 3-D Printed 4th Generation Total Ankle Prosthesis with Patient Specific Instrumentation with 1-year Follow-Up

Christopher Gross, MD; Scott Ellis, MD; David Friscia, MD, MBA; Daniel Scott, MD, MBA; Jesse Doty, MD; Richard Owens, MD

Submission Type: Total Ankle Arthroplasty

Research Type: Level 2 - Prospective comparative study, Meta-analysis of Level 2 studies or Level 1 studies with inconsistent results

Introduction/Purpose: Fourth-generation ankle replacements is evolving to account for the continued high rate of complications and revision following implantation. Previous studies have highlighted the importance of adequate positioning of total ankle implants for achieving favorable outcomes. Additionally, poor alignment has been associated with premature component wear. Moreover, literature in total joint arthroplasty has indicated that increased operative time is associated with increased postoperative complications. Patient specific instrumentation (PSI) has been proposed as a tool with implications to increase the accuracy of implant placement and reduce operative time. The purpose of this study is report on and compare prospectively collected patient reported outcome measures (PROMs) in a multi-institutional study of a 3D printed fourth-generation total ankle implanted with PSI.

Methods: Patients presenting for a total ankle replacement at 12 institutions were prospectively enrolled and implanted in both academic and private settings. A total of 129 of 199 subjects enrolled have reached one year in follow-up currently, 124 (96.1%) of which were implanted using PSI. Patients had demographics and PROMs recorded pre-operatively and at 6 month and 12-month intervals. The following PROMs were collected: Ankle Osteoarthritis Score (AOS), PROMIS Global Physical Health, Foot and Ankle Outcome Score (FAOS), and satisfaction scores. The preoperative and latest follow-up scores for patients with minimum 1-year of follow-up were analyzed.

Results: From the 199 enrolled (51.0% male) with an average age of 63.2 ± 9.91 years old with an average BMI of 31.0 ± 6.3. The most common preoperative diagnosis was post-traumatic arthritis (69.8%), followed by degenerative arthritis (28.6%) and rheumatoid arthritis (1.6%). One patient experienced an intra-operative complication and at 1-year, there were 5 (4.0%) device related adverse events. The patients improved in all PROMs domains at one year, including: Mean Total AOS (PSI = −35.8 ± 22.6) PROMIS Global Physical Health (PSI = 1.7 ± 12.7); Total FAOS Symptom Scores (PSI = 33.2 ± 23.3). At 1 year 89.4% of PSI patients rated excellent or good in satisfaction with their surgery.

Conclusion: At the one-year post-implantation follow-up, the fourth-generation 3D printed total ankle replacement utilizing Patient-Specific Instrumentation (PSI) demonstrated a low revision rate and exhibited safety and effectiveness. Patients who received implants with PSI reported experienced statistically significant clinical improvements across all domains of their PROMs as well as overwhelming patient satisfaction.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00001

©The Author(s) 2025

Application of Fresh Frozen Structural Allografts in Flatfoot Reconstruction

Sean Peden, MD; Irvin Oh, MD; Wonyong Lee, MD; Young Yi, MD

Submission Type: Other

Research Type: Level 4 – Case series

Introduction/Purpose: Various bone grafts (freeze-dried, fresh frozen) or substitute inserts (metal wedges) have been proposed to fill the osteotomy sites and provide structural support for the reconstruction of progressive collapsing foot deformity (PCFD). Among them, the fresh frozen structural allograft (FFSA) undergoes a preservation process involving freezing, which helps maintain its biological and structural integrity. FFSA avoids donor site morbidity while providing structural support. The clinical and radiographic outcomes of FFSA application for PCFD reconstruction-such as lateral column lengthening (LCL), Cotton osteotomy, and mid- and hindfoot fusions-have not been thoroughly investigated. We sought to investigate (1) the clinical and radiographic outcomes of FFSA use in LCL, Cotton osteotomy, and mid- and hindfoot joint fusions, and (2) whether additional fixation improved the rate of union in these patients.

Methods: This study investigated PCFD patients who underwent surgical reconstruction performed by two fellowship-trained orthopedic foot and ankle specialists at two different academic institutions between April 2021 to October 2023. Patients with minimum follow up of 6 months were included in the study. A total of 40 patients were identified to have received FFSA as part of their reconstructive procedures, including LCL in 26 cases, Cotton osteotomy in 20 cases or subtalar joint fusion in 13 cases, among others, such as medializing calcaneal osteotomy (Table 1). Clinical outcome, including pain improvement (VAS), intra- and post-operative complications, time to union, union rate, and changes in radiographic parameters before and after surgery, were assessed for each patient. The union time, union rate, and complications were comparatively analyzed between LCL fixation vs. non-fixation groups.

Results: Forty patients who underwent PCFD reconstructive procedure using FFSA, with a mean follow-up of 24 months, were included. Radiographic union was achieved in 39/40 (97.5%) patients with 57/59 (96.6%) osteotomy or fusion sites impacted with FFSA. The average radiographic union time was 8.5 ± 1.67 weeks. The AP T-1MT angle, Meary’s angle and calcaneal pitch angle significantly improved after surgery (Table 2, P < 0.001). There were 12 subjects in the non-fixation group (LCL and/or Cotton), and 28 in the fixation group. All LCL site impacted with FFSA achieved radiographic union, regardless of fixation. Complications occurred in 4 out of 12 cases in the non-fixation group and in 11 out of 24 cases in the additional fixation group (Table 3).

Conclusion: FFSA provided satisfactory correction and union rate in patients undertaking reconstruction for AAFD. Our results demonstrated satisfactory union rates at the LCL, Cotton osteotomy and subtalar joint fusion sites. FFSA exhibits excellent natural healing potential, promotes bone regeneration, and possesses biomechanical properties capable of withstanding compressive force at open wedge osteotomy sites, often eliminating the need for additional fixation.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00002

©The Author(s) 2025

Assessing Articular Cartilage and CFL Damage Following Fibular Nailing: A Cadaveric Study

Hirbod Abootalebi, BSc; Jacob Matz, MD; Erin Bigney, MA; William Mayer, PhD; Siyum Mohiuddin, BScKin; Madeline Power, MSc; Xiuming Shi, BPhil

Submission Type: Ankle Fractures

Research Type: Level 5 - Case report, Expert opinion, Personal observation

Introduction/Purpose: Traditional surgical fixation of ankle fractures involves the application of plates and screws, which carries a risk of wound complications, hardware prominence, and soft tissue irritation. Intramedullary (IM) fibular nailing offers a minimally invasive alternative with potentially lower complication rates. Evidence is lacking regarding the impact of fibular nailing on structures around the insertion site of the nail, particularly the articular cartilage of the distal fibula and the calcaneofibular ligament (CFL), where damage could lead to degenerative changes, instability, or pain.

Methods: In order to address this gap, this study assessed the risk and extent of damage to surrounding anatomical structures during IM nail fixation on 10 clinical-grade cadaver lower extremities. Risk was classified based on distances from the nail to the CFL, anterior talofibular ligament (ATFL), sural nerve (SN), superficial peroneal nerve (SPN), peroneus longus (PL), peroneus brevis (PB), and articular cartilage: high-risk (0–5 mm), moderate-risk (5.1–10 mm), or low-risk (over 10 mm). Distance measurements and damage quantification was completed by two observers.

Results: The CFL was damaged in 3 out of 10 specimens, ranging from 14% to 64% of the ligament’s width. The average distances to the CFL (1.20 mm), ATFL (3.43 mm), PB (3.19 mm), and articular cartilage (3.45 mm) were within the high-risk range, though no significant damage was observed to the articular cartilage, ATFL, SN, or SPN.

Conclusion: This study further confirms that IM fibular nailing is a generally safe and a reliable option for treating ankle fractures, though careful attention should be given to the potential for iatrogenic damage to high-risk soft-tissue structures, particularly the CFL and peroneal tendons.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00003

©The Author(s) 2025

Assessing the Predictive Accuracy of Popular Comorbidity Indices in Total Ankle Arthroplasty Outcomes

Weston McDonald, BS; Alexander Guareschi, MD; Joshua Morningstar, BS; Christopher Gross, MD; Daniel Scott, MD, MBA

Submission Type: Ankle Arthritis

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: As the incidence of TAA increases, identifying ways to stratify a patient’s risk for adverse outcomes becomes imperative. Two potential tools, the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI), have been widely supported and utilized across various fields of medicine and orthopaedic surgery. Despite encouraging results in TAA literature, the validity of the CCI and ECI as predictive tools for postoperative complications and functional outcomes following TAA remains ultimately unexplored. This study aims to describe and compare the predictive capacity of the CCI and ECM on the outcomes of TAA to further understand the reliability of such comorbidity indices in orthopaedic research.

Methods: The Nationwide Readmissions Database (NRD) was queried from 2015 to 2020 to identify 29,705 patients undergoing primary TAA. Patients’ comorbidity was measured via CCI and ECI score, with patients who experienced adverse postoperative outcomes (any complication, readmission, mortality, extended length of stay (LOS), and adverse discharge) identified. Each index’s predictive ability was measured using the c statistic, a measure of area under the receiver operating characteristic curve (AUC). The value for AUC ranges from 0.50 to 1.0, indicating the discriminative ability of each index in assigning probability of the examined outcome, with 0.50 indicating no ability to discriminate and 1.0 indicating perfect ability to discriminate. AUC was categorized into poor (AUC < .70), acceptable (0.70 < AUC < 0.80), excellent (0.80 < AUC < 0.90), and outstanding (0.90 < AUC < 1.0) regarding the predictive capability of each model. The indices were also compared to a base model, which considered age, sex, and primary payer.

Results: The overall cohort was majority male (54.2%) with a mean age of 64.15 (range 17-90) years, and the majority of patients had Medicare as their primary expected payer (58.9%). Elixhauser comorbidity index provided a superior predictive ability for any complication (ECI AUC = 0.61, CCI AUC = 0.59; p < .001), extended LOS (ECI AUC = 0.69, CCI AUC = 0.65; p < .001), and adverse discharge (ECI AUC = 0.70, CCI AUC = 0.68; p < .001) as compared to the Charlson comorbidity index. Examination of each model’s predictive ability found mortality was the only variable that both ECI (AUC = 0.88, 95%Confidence Interval [CI] = 0.77–1.00) and CCI (AUC = 0.88; 95% CI = 0.79–0.96) were able to predict with excellent capability. Additionally, the ECI predicted adverse discharge with acceptable capability (AUC = 0.70; 95%CI = 0.69-0.71).

Conclusion: In this study, the ECI outperformed the CCI in predicting any complication, extended length of stay ≥4 days, and adverse discharge to a facility in patients undergoing total ankle arthroplasty. However, the only variable that was excellently predicted was 180-day mortality, in which there was no difference in the predictive capability of each index. These findings indicate that while ECI and CCI are capable of predicting postoperative mortality following TAA, there is a need for alternative models that offer better predictive capability when examining other postoperative adverse outcomes.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00004

©The Author(s) 2025

Augmented Anterior Inferior Tibiofibular Ligament Repair in Ankle Fractures and the Postoperative Effect on 3D Syndesmotic Volumes

Blake Moore, MD; Ashley Suttmiller

Submission Type: Ankle Fractures

Research Type: Level 2 - Prospective comparative study, Meta-analysis of Level 2 studies or Level 1 studies with inconsistent results

Introduction/Purpose: Dynamic fixation using the TightRope® (TR) system has led to improvements in outcomes after complex ankle syndesmotic injuries. Augmenting TR fixation with a repair of the anterior inferior tibiofibular ligament (TR+AITFL) has been proposed to reconstruct the syndesmosis more accurately. Clinical studies using this technique, however, are limited. The purpose of our study was to determine if surgical technique influenced short-term postoperative reduction of the syndesmosis and short- and mid-term patient-reported outcomes (PROs). We also explored relationships between postoperative volumes and PROs.

Methods: Twenty patients with syndesmotic injuries participated in our randomized clinical pilot study. Participants were blinded and randomly assigned into TR (n = 11; 50.5 ± 13.3 yrs) or TR+AITFL (n = 9; 55.9 ± 19.3 yrs) groups. Postoperative reduction was assessed by 3D volumetric ratios and measured by weight-bearing CT at 6-weeks and 3-months post-operation. PROs were collected preoperatively, and at 6-weeks, 3-months, 6-months, and 1-year post-operation and included the Foot and Ankle Outcome Score and the RAND-36. Differences in volumetric ratios and PROs were evaluated between groups and time periods.

Results: No statistically significant differences were found in syndesmotic volumetric ratios between groups at either time point. Very limited sample suggests an increase in postoperative volumes in those with Weber C fractures between 6-weeks and 3-months, and though not significant, these participants also had greater postoperative volumes than those with Weber B fractures. Both TR and TR+AITFL groups reported improved PRO scores after fixation, but surgical technique did not significantly influence them. Additionally, we did not find any relationship between volumetric ratios and PROs.

Conclusion: TR stabilization with and without a repair of the AITFL produced similar short-term syndesmotic reduction outcomes and were equally effective at improving short- and mid-term PROs. Future studies with larger samples and those looking at the potential influence of these techniques in various fracture classifications are warranted.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00005

©The Author(s) 2025

Camera-Based System to Track Arch Height Index and Angle of Foot Pronation during Pregnancy

Michelle Meyers, BS; Devyn Russo, BS; Celeste Durnwald, MD; Josh Baxter, PhD; Casey Humbyrd, MD

Submission Type: Other

Research Type: Level 5 - Case report, Expert opinion, Personal observation

Introduction/Purpose: Foot structural changes and pain are some of the most common musculoskeletal conditions experienced during pregnancy [1]. Symptomatic flatfoot and pronation during pregnancy is hypothesized to result from increased body mass and circulating hormones that promote ligament laxity [2,3]. Accurately and reliably tracking foot structure is critical to understand the effects of pregnancy on the foot and to identify patients at increased risk of long-term pain and disability. This study developed a camera-based method to quantify arch height index (AHI) and angle of foot pronation (AOP) with the goal of reducing experimental time. This method offers an inexpensive, reliable, and quick technique to track and study changes in foot structure throughout pregnancy.

Methods: Our camera-based foot structure measurement system captures top, side, and hind-view images of the foot simultaneously (Figure 1.). We recruited a cohort of non-pregnant control participants (n = 7, age = 27.9 ± 3.2 years) to acquire foot images in the standing position at two timepoints to test repeatability and reliability of the camera-based system. We then recruited a cohort of pregnant individuals (n = 33, age = 34.8 ± 4.2 years, gestational week = 12.2 ± 2.1 weeks) during their first trimester to acquire foot images in the standing position at 12, 24, and 36-weeks of pregnancy. We used a MATLAB script to calculate AHI and AOP (Figure 1.). We performed paired t-tests in the control group to confirm no significant differences over time. Additionally, we used paired t-tests to compare right and left foot measures as well as first and second trimester measures in the pregnant cohort.

Results: Our repeated measurements of AHI and AOP in our control cohort did not change over time and was comparable to previous studies in similar patient cohorts [4,5]. We did not detect differences between first and second trimester patients (AHI: p = 0.56, AOP: p = 0.85), but our preliminary findings suggests that AHI decreased by 7% and AOP increased by 74% between the second and third trimester (Table 1.). These anticipated third trimester effects are greater than natural variations observed in the control cohort. We detected significant differences in foot structure between the right and left foot in our patients (AHI: p < 0.01, AOP: p < 0.01).

Conclusion: Our novel camera-based system reliably quantifies foot structure without ionizing radiation and advanced equipment that are intrinsic to standing x-ray imaging. Our early data found that foot structure does not change between the first and second trimester but is likely to change between the second and third trimester due to increased body mass and ligament laxity that are exacerbated during this time. We expect to have a larger cohort of patients through 3 trimesters by November 2024 and will be properly powered to detect changes in foot structure similar to Segal et al. (d = 0.8) [2].

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00006

©The Author(s) 2025

Can ChatGPT-4 Think Like an Orthopaedic Surgeon? Testing Clinical Judgement and Diagnostic Ability in Bony and Soft Tissue Pathologies of the Foot and Ankle

Hayden Hartman, BS; Maritza Essis, MD, MS; Wei Shao Tung, BS; Sean Peden, MD; Irvin Oh, MD; Arianna Gianakos, DO

Submission Type: Achilles Tendon Rupture

Research Type: Level 4 – Case series

Introduction/Purpose: ChatGPT-4, a chatbot with an ability to carry human-like conversation, has attracted attention after demonstrating aptitude to pass professional licensure examinations and perform at the level of a postgraduate level three orthopaedic surgery resident on the Orthopaedic In-Service Training Examination question bank sets. The purpose of this study was to explore the diagnostic and decision-making capacities of ChatGPT-4 in clinical management specifically assessing for accuracy in identification and treatment of soft tissue foot and ankle pathologies.

Methods: This study presented 16 soft tissue related foot and ankle cases to ChatGPT-4, with each case assessed by 3 fellowship-trained foot and ankle orthopaedic surgeons. The evaluation system included 5 criteria within a Likert scale, scoring from 5 (lowest) to 25 (highest possible). The criteria included stating the correct diagnosis (1), stating the most appropriate procedure (2), identification of alternative treatments (3), providing comprehensive information beyond treatment (4), and not mentioning nonexistent therapies (5). ChatGPT-4 was referred to as “Dr. GPT”, using role prompting to encourage step-by-step processing and establish a peer dynamic so that the role of an orthopaedic surgeon was emulated by the chatbot.

Results: The average score across all criteria for all 16 cases was 4.47, with an average sum score of 22.4. The plantar fasciitis case received the highest score, with an average sum score of 24.7. The lowest score was observed in the peroneal tendon tear case, with an average sum score of 16.3. Subgroup analyses of each of the 5-criterion using Friedman Rank Sum tests showed no statistically significant differences in surgeon grading. Criterion 5, lack of mention of nonexistent treatment options, and criterion 1, ChatGPT’s ability to correctly diagnose, received the highest subgroup scores of 4.88 and 4.77, respectively. The lowest criteria score was observed in criteria 4 (4.05), evaluating ChatGPT-4 providing comprehensive information beyond treatment options.

Conclusion: This study demonstrates that ChatGPT-4 effectively diagnosed and provided reliable treatment options for most soft tissue foot and ankle cases presented, noting consistency amongst surgeon evaluators. Individual criterion assessment revealed that ChatGPT-4 was most effective in diagnosing and suggesting appropriate treatment, but limitations were seen in the chatbot’s ability to provide comprehensive information and alternative treatment options. Additionally, the chatbot successfully did not suggest fabricated treatment options, a common concern in prior literature. This resource could be useful for clinicians seeking reliable patient education materials without fear of inconsistencies, though comprehensive information beyond treatment may be limited.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00007

©The Author(s) 2025

Celecoxib Decreases Risk of Developing Heterotopic Ossification after Total Ankle Arthroplasty

Caroline Cristofaro, BSc(Hons), MBChB; Mohammad Athar; Ellie Pinsker, PhD; Bradley Meulenkamp, MD, MSc, FRCSC; Timothy R. Daniels, MD, FRCSC; Mansur Halai, BSc (Hons), MBChB, MRCA, MRCS, FRCS

Submission Type: Ankle Arthritis

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Total ankle arthroplasty (TAA) is an effective procedure for end-stage ankle arthritis. Heterotopic ossification (HO) is a common postoperative complication and can potentially have a significant impact on patient reported outcome measures (PROMs). Currently, no guidelines exist for HO prophylaxis following TAA. The aim of this study was to determine whether HO prophylaxis is associated with decreased presence and severity of radiographic HO as well as its impact on PROMs.

Methods: This retrospective cohort study included all patients who underwent a primary TAA between April 2019 to May 2023 at a single academic institution. The intervention group comprised of patients prescribed 4 weeks of Celecoxib postoperatively and was compared to controls who received no HO prophylaxis. Radiographs at ≥8 months were reviewed and graded using the modified Brooker classification for severity of HO. American Orthopaedic Society Pain, Disability, Short Form Survey – 36 Physical Function, and Mental Health were assessed at follow-up.

Results: One-hundred and eighty-two patients, 98 (53.8%) males and 84 (46.2%) females, were included. The mean age was 66.0 ± 9.5 years. Ninety (49.5%) patients received HO prophylaxis and 92 (50.5%) did not. The prevalence of HO at time of follow-up was 53 (29.1%) with grade 0, 78 (42.9%) with grade 1, 22 (12.1%) with grade 2, 23 (12.6%) with grade 3, and 6 (3.3%) with grade 4. The odds of developing HO and of having increasing severity of HO were 2.30 (95% CI 1.16, 4.57) and 2.42 (95% CI, 1.38, 4.25) times greater for patients without HO prophylaxis compared to those prescribed prophylaxis (p < 0.05), respectively. There was no significant association between Celecoxib use and PROMs.

Conclusion: Celecoxib for 4 weeks following primary TAA is an effective method to decrease the risk of developing HO and reducing its severity. HO has no statistically significant impact on PROMs. Celecoxib for HO prophylaxis should be considered following primary TAAs in patients who can tolerate non-steroidal anti-inflammatories.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00008

©The Author(s) 2025

Clinical Deformity Correction Following Minimally Invasive Akin Osteotomy Fixated with Single 2.5 mm Screw, A Prospective Study

Austin Alecxih, MD; Tyler Goodwin, MD; Joseph Duff, MD; Dillon Morrow, MD; Andrew Wilson, BS; Jesse Doty, MD

Submission Type: Hallux Valgus

Research Type: Level 2 - Prospective comparative study, Meta-analysis of Level 2 studies or Level 1 studies with inconsistent results

Introduction/Purpose: The medial closing wedge osteotomy of the proximal phalanx, known as the Akin osteotomy, is a common procedure in combination with metatarsal osteotomies and soft tissue realignment procedures to achieve hallux valgus deformity correction. With developments in surgical instrumentation, the option to perform osteotomies percutaneously has grown in popularity. There is limited data analyzing individualized performance and maintenance of correction with the addition of a percutaneous Akin osteotomy. Prior studies have referenced radiographic alignment and outcomes following minimally invasive Akin osteotomy. This is the first prospective study analyzing both radiographic and clinical alignment, as well as outcomes scores using 2.5 mm screw fixation for MIS (Minimally Invasive Surgery) correction.

Methods: Consecutive subjects were prospectively enrolled prior to percutaneous Akin osteotomy fixated with a single 2.5 mm cannulated fully threaded compression screw over a two-year period. Interphalangeal angle (IPA), proximal distal phalanx articular angle (PDPAA), and distance between first and second toes (mm) were recorded. The clinical shift of the Akin osteotomy was measured intra-operatively, and the maintenance of correction documented during follow-up. Patient demographics, visual analog scales, and patient-reported outcome measures were compiled.

Results: 86 Akin osteotomies were performed on 83 patients over a two-year period. Median follow-up was 56 (range, 43 to 151) weeks. IPA changed by median −5.0 (interquartile range, −7.5 to 0.5) degrees (P < .001). PDPAA changed by median −4.0 (interquartile range, −7.5 to 0.0) degrees (P < .001). Distance between first and second toes changed by median −6.0 (interquartile range, −7.0 to −3.0) mm (P < .001). VAS Pain Score, MOXFQ, AOFAS, and Coughlin functional scores improved postoperatively. 8 of 86 osteotomies (9%) required removal of painful hardware, and there was 1 (1%) deep infection requiring removal of hardware. 76 (88%) of cases had no complications. There were no proximal phalangeal non-unions.

Conclusion: Patients undergoing minimally invasive Akin osteotomy with use of 2.5 mm cannulated fully threaded screws demonstrated improvement in radiographic and clinical alignment as well as improvement in patient-reported outcome measures at the time of initial and final follow-up. Complication rates were low, and incremental improvement in hallux valgus deformity correction was maintained.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00009

©The Author(s) 2025

Comparing Outcomes of Procedures Using Allograft, Autograft, or No Adjuvants in Foot and Ankle Fusions

Chase Gauthier, MD; Elizabeth Nadeau, MD; Joshua Morningstar, BS; Tyler Gonzalez, MD, MBA; J. Benjamin Jackson, MD, MBA; Daniel Scott, MD, MBA; Christopher Gross, MD

Submission Type: Other

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: There is great interest in orthobiologics as surgical adjuvants to decrease rates of complications, including non-union, and time to fusion. While there are a limited number of studies investigating the role of orthobiologics in healing following foot and ankle fusion procedures, there is an even greater lack of large studies investigating the use of allographic or autographic adjuvants as compared to those procedures without. As such, the purpose of this study is to compare the outcomes of patients receiving crushed cancellous allograft, autograft, or no biological adjuvant to determine if there is a difference in complications and time to fusion following foot and ankle arthrodeses.

Methods: A multi-institutional retrospective review was conducted of 296 patients with minimum 6-month follow-up, undergoing arthrodesis by one of four fellowship-trained foot and ankle orthopaedic surgeons from 2016-2022. Patients underwent ankle (n = 74), subtalar (ST) (n = 124), midfoot (n = 154), or forefoot (n = 27) fusions. Data collected included demographics, medical history, orthobiologics used, postoperative complications, readmission and reoperation rates. 58 (19.6%) cases used no biological adjuvant, 224 (75.7%) used allograft, and 14 (4.7%) used autograft. Union was defined as bridging bone on three joint quadrants on AP and lateral radiographs, or greater than 50% bridging bone of the joint space on computed tomography (CT). The overall cohort was majority female (58.4%) with a mean age 56.49 (range 18-81) years, BMI 31.96 (range 16.16-56.17) kg/m² and follow-up duration 1.43 (range 0.50-5.96) years.

Results: The allograft cohort was significantly older (p = .019) with significantly higher rates of cardiac disease (p < .001) and hypertension (p = .006), the no graft group had significantly lower BMI (p < .001). Allograft was used at a statistically significantly higher rate in ST (p < .001) and ankle fusions (p = .044) while forefoot fusions had a higher rate of no graft use (p < .001). The overall union rate was 88.9% and mean time to fusion 153.41 ± 102.36 days, with no significant difference between cohorts. Similarly, there was no statistically significant difference in rate of postoperative infection, reoperation, or revision following fusion procedures regardless of graft usage.

Conclusion: Joints treated with no biological adjuvant, allograft, or autograft demonstrated equivalent fusion rates in this large study. Additionally, there was no difference in the rate of postoperative adverse outcome regardless of graft usage. These findings should be considered by providers and patients alike when considering the use of biological adjuvants in foot and ankle fusion procedures.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00010

©The Author(s) 2025

Comparing the Cost Effectiveness of Locking vs Nonlocking Plates for Traumatic Ankle Fractures Using PROMIS Scores

Abhinav Balu, BS; Mehul Mittal, BS; Rachel Bergman, MD; Muhammad Mutawakkil, MD; Milap Patel, DO; Anish Kadakia, MD

Submission Type: Ankle Fractures

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: The choice between locking and nonlocking plates for the fixation of traumatic ankle fractures often involves a trade-off between cost and potential clinical outcomes. Locking plates are perceived to offer increased fixation stability, especially in osteopenic bone, due to the compression achieved through the screw-plate interface compared to the bone-plate interface. However, this benefit comes at the cost of a more expensive implant. Our study aims to evaluate the cost-effectiveness of these two fixation methods by comparing surgical costs, PROMIS (Patient-Reported Outcomes Measurement Information System) scores, and complication rates.

Methods: A retrospective review was conducted on all patients who underwent fixation of ankle fractures at our institution from 2016 to 2021. Data on surgical costs and outcomes/complications were meticulously gathered through comprehensive chart reviews. PROMIS scores were systematically collected through structured telephonic interviews. Differences in PROMIS scores were analyzed using two-sided t-tests with Python version 3.11.4 and the SciPy library. Variations in complication rates were evaluated using Chi-square analysis with Python version 3.11.4 and the statsmodels library.

Results: 283 patients underwent ankle fracture fixation with a locking plate. 210 patients underwent fixation with a nonlocking plate. The average cost of fixation with a locking plate was $3,094.90. Reoperations cost $1,807.63, with average OR time of 120 minutes valued at $7,440. The average cost of fixation with a nonlocking plate was $858. Reoperations cost $435.50, with an average OR time of 72 minutes valued at $4,464. PROMIS pain interference and physical function scores did not differ significantly. Complications occurred in 17% of patients with a locking plate and 23% of patients with a nonlocking plate (p = 0.10). Hardware removal (excluding plate removal) occurred more frequently in the nonlocking group (p < 0.001). Infection occurred more frequently in the locking group (p < 0.05).

Conclusion: Our study demonstrates that while locking plates are significantly more expensive than nonlocking plates, there is no statistically significant evidence of their clinical superiority. Locking plates did, however, show a trend towards fewer overall complications. Locking plates were also removed significantly less frequently than the nonlocking plates, indicating that there may be greater irritation of local soft tissue and bone with the compression achieved through nonlocking plates, potentially justifying the higher cost associated with these plates.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00011

©The Author(s) 2025

Correcting Tibiotalar Alignment Correlates with FAO Changes after Total Ankle Replacement

Ricardo Villar, MD; Emily Teehan, MS; Kira Lu; Ranqing Lan, MS; Patricia Friedmann, MS; Jensen Henry, MD; Constantine Demetracopoulos, MD

Submission Type: Ankle Arthritis

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Re-establishing anatomic ankle and foot alignment is critical to optimize clinical outcomes and longevity of total ankle replacement (TAR). The foot and ankle offset (FAO) is a semiautomatic 3D biometric weight-bearing computed tomography (WBCT) measurement that represents the relationship between the tripod of the foot and the center of the ankle joint. Notably, FAO correlates with increased need of additional procedures in TAR. Yet to our knowledge, no study has utilized FAO to quantify the extent to which TAR can improve alignment in the absence of foot realignment procedures. Our study aims to evaluate associations between preoperative and postoperative FAO and coronal radiograph Tibiotalar Alignment (TTA) for TAR. We hypothesize that TAR alone may significantly improve FAO in patients with ankle deformity.

Methods: This study is a single-institution retrospective review of prospectively collected data from primary TARs from March 2022 – November 2023 that obtained preoperative and postoperative (between 4 months and 1 year postoperatively) WBCT scans. Patients who underwent concomitant foot realignment procedures (foot osteotomy or fusion) at the time of primary TAR were excluded. There were 85 ankles that underwent primary TAR during the study period who obtained preoperative and postoperative WBCT scans and radiographs. Excluding 23 ankles with concomitant foot realignment procedures and 7 ankles with inadequate scans, there were 55 ankles included for analysis. Patients were classified as varus, neutral or valgus using the cutoff of 5 degrees for TTA and based on the classification described by Lintz for FAO. Correlation between changes in TTA and FAO was addressed by Pearson’s correlation test. Linear regression was used to investigate the association between changes in TTA with changes in FAO.

Results: Changes in TTA had a strong positive correlation (PCC 0.832, p < .0001) with changes in FAO. Every 1 degree of increase in TTA pre to post is associated with 0.367 unit increase in FAO pre to post (R^2 0.693, p < 0.0001). In terms of TAR ability to improve FAO, there was a median pre to post FAO change of 2.66 [−0.11, 5.86] for the varus pre-op FAO group and of – 4.69 [−7.52, −2.985] for the valgus pre-op FAO group. Postoperatively, 80% of patients that had pre-op varus FAO remained varus, while 59% that had pre-op neutral FAO persisted neutral and 22% that had pre-op valgus FAO stayed valgus. 98% of patients had neutral post TTA, confirming coronal alignment improvement with TAR.

Conclusion: In this study, with each 1-degree change in TTA, there was a 0.367 change in FAO with a strong positive correlation between the 2D and the 3D measurements. TAR was able to improve FAO in patients with tibiotalar deformity and a more powerful change was noticed in valgus alignment. After TAR, patients with pre-op varus FAO are most likely to remain varus, while patients with valgus pre-op FAO are most likely to improve to neutral FAO. Understanding how FAO changes after TAR can help surgeons predict when an additional procedure could be necessary.

Figure 1.

(a) Preoperative and Postoperative Foot and Ankle Offset (FAO). (b) Change in FAO as a Function of Change in Tibiotalar Alignment.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00012

©The Author(s) 2025

Critical Bone Defect and Deformity Correction with a Custom 3D Printed Cage

Jacob Priester, MD; Justin Haghverdian, MD; Christopher Kreulen, MD

Submission Type: Ankle Arthritis

Research Type: Level 4 – Case series

Introduction/Purpose: Failed total ankle arthroplasty, hindfoot fusion, Charcot arthropathy, and infection can pose a significant reconstructive challenge. Previously, large bone defects were difficult to reconstruct, often requiring bone-transport lengthening procedures or large allograft placement with unfavorable results. The advent of custom, 3D-printed cages has allowed for addressing large, complex bone defects and deformities in potentially a single procedure. The purpose of this study is to evaluate the fusion and complication rates following treatment of critical bone defects of the ankle and hindfoot with a patient-specific, 3D-printed titanium cage.

Methods: Retrospective review was performed at a single institution from 2019-2024. Demographic data including age, sex, comorbidities was obtained. The surgical indication for reconstruction of the ankle and hindfoot was recorded. Standard weightbearing radiographs of the ankle were obtained to evaluate for fusion. Complete fusion was defined as circumferential fusion mass on plain radiographs without evidence of hardware failure. CT scans were reviewed to confirm complete fusion with interdigitation of bone within and surrounding the implant. Fixation type used to secure the implant was recorded. Major and minor complications including surgical site infection, deep infection, subsequent surgery, hardware failure, and neuropathy were recorded.

Results: A total of 20 patients were included in the study. The average age of the patient at the time of surgery was 60 years old. 64% of patients were male and 36% patients were female. The most common surgical indication was for a failed total ankle arthroplasty in the setting of previous infection. The average defect size was measured to be approximately 40 mm. 88% of patients went onto complete fusion with integration of the custom 3D printed cage. 90% of patients underwent fixation with a Nitinol dynamic compression nail. There were 2 major wound related complications requiring below knee amputation. There were 3 minor wound related complications which were successfully treated with irrigation and debridement or local wound care.

Conclusion: The use of a dynamic compression hindfoot nail with a custom 3D printed cage is a promising treatment option for addressing critically sized defects, particularly in the setting of failed total ankle arthroplasty.

Figure 1.

Pre- and postoperative lateral radiographs demonstrating reconstruction of a failed total ankle arthroplasty.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00013

©The Author(s) 2025

Do Interval PROMIS Scores Correlate with Interval MCID Achievement following Surgery for Lateral Ankle Instability?

Tyler Kelly, MD; Julian Acosta-Garcia; Garrett Jebeles; Marc Bernstein, MS; Jacob Burke; Fabio Pencle, MD; Gerald McGwin, PhD, MS; Ashish Shah, MD

Submission Type: Ankle Instability

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Of the various surgical techniques available for Chronic Ankle Instability (CAI), the Brostrom-Gould (BG) procedure is the gold standard. This study aims to assess interval changes in patient reported outcomes following BG surgery and to identify at which time points, patients achieve a minimal clinically important difference (MCID). Secondary objectives include determining if there are any sociodemographic factors that impact a patient’s likelihood of achieving MCID following BG repair. To our knowledge, this study is the first to assess interval changes with the inclusion of preoperative PROMIS score data to allow for a more comprehensive understanding of postoperative changes in overall well-being, pain, and physical function after surgery for lateral ankle instability.

Methods: A retrospective review of 78 patients undergoing a BG procedure at a single institution by two fellowship-trained foot and ankle surgeons between July 2022 and February 2024. Patients were identified via CPT codes and an extensive review of the surgical scheduling record. Inclusion criteria were restricted to patients age >16, a diagnosis of CAI undergoing a BG procedure (primary or revision) with completed preoperative PROMIS assessments. Prospectively collected PROMIS scores, including PROMIS Global 10 Mental Health (MH), Physical Function (PF), and Pain Interference (PI) were collected preoperatively and at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year postoperatively. Patient sociodemographic data and past medical history was collected via chart review. MCIDs were calculated according to a distribution-based method. Descriptive and inferential statistics were performed. Univariate linear regression analysis was performed to determine associations between patient demographics and the achievement of MCID.

Results: Among the 43 patients included, 76.7% were female. Mean age at time of surgery was 39.6 [range 16-72 years]. Mean preoperative BMI was 32.8 [8.96]. Mean preoperative MH was 51.3 [8.9], PF was 40.2 [6.9], and PI was 61.6 [6.8]. Changes in mean PROMIS scores relative to baseline were seen in PROMIS PF (p < 0.0001), PI (p = 0.0003), and MH (p = 0.8832). The greatest improvement in PF and PI occurred between 6 weeks and 3 months. Throughout 1 year follow up, 25.0% of patients achieved MCID in Global PROMIS MH, 51.28% achieved MCID in PROMIS PF, and 13.16% achieved MCID in PROMIS PI. With our confidence level, there were no statistically significant associations between the odds of achieving MCID and patient sociodemographic or past medical history.

Conclusion: Although average PROMIS PF and PI significantly improved following BG surgery, preoperative PROMIS scores may not be the best determinant of post-operative achievement of MCID based on the results seen among our patient cohort. However, as one of the first studies to assess changes in interval PROMIS scores with the inclusion of achievement of MCID at each interval, this study contributes valuable insight to provide patients and providers with an appropriate frame of reference for expectations at several intervals following BG surgery.

Figure 1.

Interval changes in mean PROMIS scores over time.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00014

©The Author(s) 2025

Do Patients with Prior Distraction Arthroplasty Fare Worse after Total Ankle Replacement?

Allison Boden, MD; Kira Lu; Emily Teehan, MS; Jensen Henry, MD; Constantine Demetracopoulos, MD

Submission Type: Total Ankle Arthroplasty

Research Type: Level 4 – Case series

Introduction/Purpose: Distraction arthroplasty aims to treat ankle osteoarthritis while preserving the native ankle joint, with the goal to prevent or delay ankle arthrodesis or total ankle replacement (TAR) for younger patients. Yet when these distraction patients do go on to TAR, there are anecdotal reports of increased stiffness and higher levels of dissatisfaction. However, no study to date has explored TAR outcomes in patients who have had prior distraction arthroplasty. Thus, this study described the clinical, radiographic, and patient-reported outcomes (PROs) for TAR in patients who had undergone prior ankle distraction arthroplasty. We hypothesized that TAR patients with prior distraction arthroplasty would have high rates of radiographic complications, reoperations and revisions, and a low achievement of patient-acceptable symptom state (PASS) thresholds at 2-years follow-up.

Methods: A retrospective review of prospectively collected data within an institutional TAR patient registry was performed. All patients with a history of ipsilateral ankle distraction arthroplasty who underwent primary TAR between January 2011 and March 2022 were identified. Nineteen ankles in 17 patients met inclusion criteria and were included in the study analysis. Clinical, radiographic, and patient-reported outcomes were collected. The primary aims were to evaluate complication rate and patient satisfaction following TAR. Revisions, reoperations, and radiographic complications within our cohort were compared to literature values to determine potential effects of prior distraction arthroplasty on TAR. Patient-reported outcomes were evaluated using PROMIS before and after undergoing TAR. Statistically significant differences in PROMIS scores at 2-year follow-up were detected using non-parametric Mann-Whitney U tests. Finally, the proportion of patients achieving PASS thresholds at final follow-up was used to assess patient satisfaction following TAR.

Results: At mean 4.4-year follow-up, 18/19 (94.7%) ankles remained implanted. One TAR was revised due to talus failure. There were four reoperations (1 FHL contracture release, 1 posteromedial ankle arthrotomy for arthrofibrosis, 1 irrigation and debridement for infection, and 1 revision talonavicular fusion); notably, 4 of these 5 ankles had a history of talus ORIF. Radiographic complications, including lucencies, subsidence, and periprosthetic cysts, were observed in 37% at 2 years postoperatively. Patients experienced clinical and statistical improvement in PROMIS domains for Physical Function (P = 0.002), Pain Interference (P = 0.007), and Pain Intensity (P = 0.010). At final follow-up, PASS was achieved by 65% and 71% of patients in the Physical Function and Pain Interference PROMIS domains respectively, but only 35% of patients achieved PASS in the Pain Intensity domain (Table).

Conclusion: TAR is a viable option to treat ankle osteoarthritis symptoms that persist after distraction arthroplasty, with patient-reported outcomes demonstrating statistically significant improvement following TAR. However, PROs demonstrate relatively lower rates of satisfaction following surgery, which may necessitate increased patient education and expectation management. Furthermore, many of these patients present with posttraumatic etiology and a complex surgical history prior to distraction and therefore may already be at greater risk for reoperation for stiffness-related complications. Ultimately, while TAR and distraction are both useful procedures, using distraction arthroplasty to delay TAR may only further complicate an already-challenging patient cohort and exacerbate subpar outcomes.

Table.

Average PROMIS Scores Preoperatively and at 2-years Postoperatively.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00015

©The Author(s) 2025

Does Syndesmotic Fixation Technique Impact Complication Rates and Functional Outcomes Measured by PROMIS Scores Following Operative Repair of Ankle Fractures?

Steven Hadley, BA; Rachel Bergman, MD; John Peabody, MD; Sarah Westvold, MPH; Ryan Filler, MD; Milap Patel, DO; Anish Kadakia, MD

Submission Type: Ankle Fractures

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Various techniques are used to repair the distal tibiofibular syndesmosis. While traditionally performed with syndesmotic screws, recent techniques including the Syndesmosis TightRope® XP (TightRope, Arthrex) and InternalBrace™ (IB, Arthrex) have been developed to optimize natural flexibility and movement of the syndesmosis. It remains unclear whether syndesmotic fixation technique impacts complication rates and outcomes. This study aims to determine which repair technique results in the fewest complications and best functional outcomes as measured by Patient Reported Outcome Measurement Information System (PROMIS) computerized adaptive tests (CATs) of physical function (PF) and pain interference (PI). To our knowledge, this is the largest retrospective study comparing PROMIS scores between these syndesmotic fixation techniques. We hypothesized that Tightrope and IB would reduce complications and improve PROMIS scores compared to screws.

Methods: 782 patients who underwent ankle fracture surgery at a single institution between January 2016-December 2021 were reviewed retrospectively. Two foot and ankle fellowship-trained orthopaedic surgeons independently reviewed all radiographs, determined fixation technique, and assessed complications at final follow-up. Multiple extremity injuries, open fractures, and pilon variants were excluded. 328 patients with syndesmotic ruptures were sent post-operative questionnaires. 159 patients with minimum one-year follow-up were analyzed for complications. 70 patients who completed PROMIS CATs were analyzed for functional outcomes. Due to rarity of complications and perfect separation in the data, we were unable to use statistical tests to compare complication incidence across techniques. The Kruskal-Wallis test compared PROMIS scores across repair types. Analysis of PROMIS scores had 80% power to detect large effect sizes (Cohen’s f = 0.40) with a 0.05 significance level but was underpowered for small and medium effects. PROMIS scores were modeled by repair technique using linear regression.

Results: 62/159 patients underwent syndesmotic fixation with screw placement, 59/159 with Tightrope, and 38/159 with IB. Overall complication rates with syndesmotic screw fixation were 12.9% (8/62): 8.1% (5/62) degenerative joint disease (DJD), 0% end-stage arthritis, 1.6% (1/62) syndesmotic malreduction, 4.8% (3/62) syndesmotic malunion. Overall complication rate in Tightrope was 1.7% (1/59): 1.7% (1/59) DJD. IB had no radiographic complications. Mean PF was 50.38 ± 9.39 screw, 53.87 ± 9.70 Tightrope, and 52.18 ± 13.08 IB (p = 0.71). Mean PI was 49.28 ± 8.22 screw, 47.91 ± 8.80 Tightrope, and 49.15 ± 10.46 IB (p = 0.79). Compared to screws, adjusted models demonstrated mean PF 4.00 points greater for Tightrope (p = 0.17) and 2.94 points greater for IB (p = 0.34). Adjusted models for PI revealed mean scores of 2.05 points less for Tightrope (p = 0.42) and 1.23 points less for IB (p = 0.65) compared to screws.

Conclusion: Our findings indicate that syndesmotic fixation with the Tightrope and IB reduce radiographic complications compared to screws. While this study was underpowered to detect small or medium effect sizes and thus was unable to demonstrate statistically significant differences in PROMIS scores, the higher PF and lower PI for Tightrope and IB compared to screws may reach statistical significance in larger sample sizes. Nevertheless, differences in PF scores in the adjusted model suggest that Tightrope and IB improve PF compared to screw, reaching the lower end range of the minimal clinically important difference for this outcome measure reported in the literature.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00016

©The Author(s) 2025

Effect of Kidney Function on Outcomes Following Ankle Fracture ORIF

Carson McKoon, BA MS; Paul Pottanat, MD; Joshua Morningstar, BS; Daniel Scott, MD, MBA; Christopher Gross, MD

Submission Type: Ankle Fractures

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Estimated glomerular filtration rate (eGFR) is commonly used as a preoperative evaluation of kidney function in patients undergoing surgery. To date, there is a paucity of literature investigating the effect of eGFr on outcomes following ankle fracture open reduction and internal fixation (ORIF). As such, this study aims to analyze the effect of kidney function, as measured by eGFR, on short-term adverse outcomes following ankle fracture ORIF procedures.

Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 – 2019 to identify patients undergoing ankle ORIF. After exclusion of patients missing data for age, race, gender, preoperative creatinine, or with eGFR greater than 3 standard deviations from the mean (91.1 mL/min/1.73 m²), 21,815 patients met criteria for the study. Patients were grouped by eGFR into cohorts: ESRD (<15 [1.49%]), moderate to severe kidney function loss (15-60 [17.73%]), mild kidney function loss (60-90 [33.76%]), and normal kidney function (>90 [47.01%]).

Results: Nearly half of patients were found to have “normal” eGFR criteria of greater than 90 mL/min/1.73 m². As eGFR decreased, indicating poorer kidney function, patient age (p < .001), BMI, rate of female sex, and rate of numerous comorbidities statistically significantly increased. Multivariate regression to control for differences in demographics and comorbidities found that as compared to a normal eGFR, patients with ESRD or moderate to severe loss of kidney function had statistically significantly predicted increased risk of any complication (ESRD: Odds Ratio [OR] = 1.505)(15-60:1.261), reoperation (ESRD: OR = 1.706)(15-60: 1.314), and readmission (ESRD: OR = 1.890)(15-60: 1.649).

Conclusion: Low eGFR values, indicative of kidney injury or disease, are significantly predictive of increased risk of postoperative complications, reoperation, and readmission for patients undergoing ankle fracture ORIF. This finding should be considered by surgeons and patients when considering ankle ORIF for patients with decreased kidney function.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00017

©The Author(s) 2025

Evaluating Implant Survivorship and Revision Rates in Salto Talaris Total Ankle Arthroplasty

Adam Kohring, DO; Nana Amponsah, BA; Joydeep Baidya, BS; Kush Mody, MD, MBA; Amy Nghe, BA; Alexander Zavitsanos, BS; Maximilliano Buckner, BS; Matthew Culkin, BS; Quinn Kirkpatrick, BS; David Pedowitz, MD; Joseph Daniel, DO; Selene Parekh, MD, MBA

Submission Type: Total Ankle Arthroplasty

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Total ankle arthroplasty (TAA) is known for its significant complication and failure rates. This study assesses the Salto Talaris, a fixed-bearing prosthesis inspired by the successful mobile-bearing Salto model. We analyze revision rates, survival, early complications, postoperative care, and functional outcomes.

Methods: We conducted a retrospective analysis of patients who received the Salto Talaris Total Ankle Arthroplasty between 2010 and 2024. Complications and reoperations were recorded using the American Orthopaedic Foot & Ankle Society (AOFAS) TAA reoperation coding system. Patient-reported outcomes were evaluated with the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sport subscales, SF-12 Mental (MCS) and Physical (PCS) Component Summaries, and visual analog scale (VAS) pain ratings (0-100). Statistical analyses included T-tests or Mann-Whitney U tests for continuous variables and Chi-Square or Fisher’s Exact tests for categorical variables.

Results: The study included 530 patients with a mean age of 69.3 years and BMI of 29.8 kg/m². Of these, 17 cases (3.2%) were revised, and Kaplan-Meier survival analysis demonstrated a cumulative survival rate of 96.8% (95% CI, 95.3% to 98.3%) at 2442 days post-surgery. Out of the 17 patients who had a 1st revision, 6 (35.3%) patients required a 2nd revision, with a cumulative survival rate of 69.7% (95% CI, 50.6% to 95.9%) at 686 days post 1st revision. No significant differences in physical therapy, bracing, or postoperative care were observed. Preoperative FAAM and PCS scores were similar between groups, with no significant changes in one-year postoperative scores (p > 0.18). However, lower BMI and debridement were associated with higher revision rates.

Conclusion: The Salto Talaris implant demonstrated excellent long-term survival with a low incidence of revision. Although some revised cases required a second revision, the overall success rate remains strong. Lower BMI and debridement were identified as factors influencing revision risk. Functional outcomes were consistently maintained, with no significant changes in scores pre- or postoperatively.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00018

©The Author(s) 2025

Examination of Preoperative Conditions and Treatment Techniques on Outcomes Following Tibiotalocalcaneal Arthrodesis

Joshua Morningstar, BS; Jen Xu, BS; Chase Gauthier, MD; Daniel Scott, MD, MBA; Christopher Gross, MD; J. Benjamin Jackson, MD, MBA; Tyler Gonzalez, MD, MBA

Submission Type: Other

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

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.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00019

©The Author(s) 2025

Fibromyalgia Patients Have Markedly Greater Postoperative Opioid Use and Emergency Department Visits Following Bunionectomy

Andrew Sauer, BA; Jung Yoo, MD; Lara Atwater, MD

Submission Type: Hallux Valgus

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Fibromyalgia is a chronic disorder characterized by widespread pain, localized areas of hyperesthesia, and pervasive fatigue. Worldwide, it affects 2.7% of the population. Diagnostic criteria include point pain that notably excludes the feet and ankles without specific laboratory findings. Limited research has investigated how a fibromyalgia diagnosis affects outcomes following foot surgery, despite the prevalence of fibromyalgia in foot surgery patients which is estimated to be 13.9%. One of the most common foot conditions is hallux valgus. This deformity typically has favorable surgical outcomes, but it can cause significant pain, functional limitations, and decreased quality of life if untreated. This study aims to determine whether fibromyalgia patients experience worse postoperative outcomes, as measured by opioid usage and emergency department (ED) visits following bunionectomy.

Methods: We conducted a retrospective cohort analysis using a national insurance database, Pearldiver. This database contains deidentified, longitudinal data on 161 million patients through most private and government insurance products. We identified patients who underwent bunionectomy between 2017 and 2019 using the CPT code 28296, which encompasses correction of hallux valgus with bunionectomy, with or without sesamoidectomy and distal metatarsal osteotomy utilizing any method. We stratified patients by preoperative fibromyalgia diagnosis using the ICD-10 code M797. Preoperative and postoperative opioid use within 90 days of surgery was measured using mean morphine equivalents (MME). The number of patients visiting the ED within a 6-month postoperative period and the number of admissions by each patient were collected. Fibromyalgia patients were compared to those without a diagnosis using Chi-squared tests for categorical variables and independent t-tests for continuous variables. Odds ratios (OR) were calculated for frequency data, and p < 0.01 was used for statistical significance.

Results: Between 2017 and 2019, we identified 45,648 patients underwent bunionectomy, including 1,854 with fibromyalgia. Fibromyalgia patients were 3.2 times more likely to use opioids preoperatively and took 7.6 times more opioids per day. Postoperatively, they were 5.6 times more likely to take opioids and used 5.6 times more opioids per day. Fewer patients in both groups used opioids a year after surgery. Fibromyalgia patients were 5.1 times more likely to visit the ED during the six-month postoperative period. Among fibromyalgia patients, 12.7% had one visit, 10.5% had two, 5.6% had three, 3.4% had four, 2.4% had five, and 8.9% had more than five visits. No non-fibromyalgia patient visited the ED more than once in this period. This data is summarized in Table 1.

Conclusion: This study shows that patients with fibromyalgia have significantly more preoperative and postoperative opioid use and significantly more emergency department admissions postoperatively. The scale of these findings is surprising, as similar research for total hip arthroplasty outcomes in fibromyalgia patients found much lower odds ratios. Given the reported coincidence of fibromyalgia in bunion patients, counseling should consider if challenges surrounding exacerbations of postoperative pain or incomplete resolution of preoperative pain outweigh a patient’s preoperative condition. Future research could investigate how postoperative bunionectomy pain compares to baseline fibromyalgia pain and if emergency admissions stem from bunionectomy pain versus other healthcare needs.

Table 1.

Healthcare utilization for patients undergoing bunionectomy between 2017 and 2019, stratified by fibromyalgia diagnosis.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00020

©The Author(s) 2025

Improvement in Patient Reported Outcome is Maintained 8 Years after Ankle Replacement and Arthrodesis

Bruce Sangeorzan, MD; William Ledoux, PhD; Daniel Norvell, PhD; Jane Shofer, MS; Chris Coetzee, MD; John Anderson, MD; Don Bohay, MD; James Davitt, MD; John Maskill, MD; Michael Brage, MD

Submission Type: Ankle Arthritis

Research Type: Level 2 - Prospective comparative study, Meta-analysis of Level 2 studies or Level 1 studies with inconsistent results

Introduction/Purpose: Patients seeking surgical treatment for end stage ankle arthritis (ESAA) have two primary options: ankle arthrodesis (AA) and total ankle arthroplasty (TAA). It is imperative to understand the long-term comparative effectiveness of these two surgical options. The objectives of this study were to compare these two treatments and determine if the trajectory of improvement in patient reported outcomes in the first four years after surgery is sustained up to 8-years.

Methods: A multisite prospective cohort study including 517 participants (414 TAA and 103 AA) presenting for surgical treatment after failed conservative management. Participants were compared during the interval 4 to 8 years post-surgery using the Foot and Ankle Ability Measure (FAAM) activities of daily living (ADL) and sports scores, the Short Form-36 physical component summary (PCS) scores), pain scores (Chronic Pain Grade), and satisfaction with surgery. Overall satisfaction question was validated against the Nottingham Health Profile, SF-36, SF-12, Oxford-12, and the WOMAC. This IRB-approved prospective cohort study included six sites with recruitment beginning in May 2012 and ending in May 2015. Inclusion criteria ensured patients were suitable for both treatments while exclusion criteria were disabilities and diseases that effected ambulatory function. PRO were measured before surgery and at 12 month increments. All surgeons performed both procedures. Baseline differences were adjusted statistically.

Results: All outcomes in both groups maintained strong improvement compared to pre-op (p < .0.0001). Mean eight-year improvement for the FAAM ADL and Sports scores was 27 (95% CI, 25-29) and 28 (95% CI, 25-31) points. Mean eight-year improvement in the SF-36 PCS was 8.6 (95% CI, 7.5-9.7) points and worst and average pain scales was 5.3 (95% CI, 5.0-5.6) and 4.0 (95% CI, 3.8-4.3) points, respectively. Those undergoing TAA maintained an 11 point (95% CI, 6-15) greater mean improvement in the FAAM ADL score than those undergoing AA (p < .0001).

Conclusion: In conclusion, both established treatments for ESAA are effective maintaining pain relief and improving patient-reported functional outcomes. These gains are sustained over an eight-year period after surgery. While there is some attenuation in functional outcomes between four and eight years in both groups, this same attenuation is not observed in pain reduction. Despite both surgical approaches being effective, it appears TAA leads to greater improvement in most patient-reported outcome measures up to eight years after surgery.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00021

©The Author(s) 2025

Is the Hip Keeping the Ankle Out of Work after Total Ankle Arthroplasty?

Frank DiLiberto, PT, PhD; Maxine Olson, MS; Finola Summerville, Stacey Meardon, PhD, PT; Anand Vora, MD

Submission Type: Total Ankle Arthroplasty

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Total ankle arthroplasty (TAA) outcomes include substantially improved gait speed and physical function scores. However, these outcomes remain deficient compared to age-associated norms in a large proportion of individuals after TAA. Of note, postoperative ankle energy production (i.e. power, work) during gait is also deficient and related to lower gait speed and physical function scores. These findings raise questions regarding if people after TAA have the capacity to generate greater ankle energy or rely on proximal joint (e.g. hip) energy during walking and more challenging daily functional tasks. Therefore, our purpose was to determine the energetic response of the ankle, knee, and hip during multiple functional tasks in people after TAA in comparison to healthy controls.

Methods: Ten people after TAA (69.6 ± 8.6 years, 5 female, 45.4 ± 9.2 months post TAA) and five healthy control participants (66.8 ± 8.3 years, 2 female) have completed this ongoing case-control study. Speeds were standardized and matched between groups during four functional tasks of increasing energy demand: normal walking, fast walking, standard step ascent (17 cm), and high step ascent (35 cm). A reliable biomechanical model was applied to collected motion capture and force plate data. Ankle, knee, and hip positive joint work (i.e. power across time) were derived to reflect the magnitude of propulsive energy at each joint during the gait cycle. Outcomes included ankle work and the ipsilateral proximal positive work ratio as ((hip+knee work) – ankle work) / total work, where larger values indicate a relatively greater contribution of hip and knee energy. Differences across tasks within the TAA group were analyzed with Friedman’s ANOVAs. Preliminary between-group differences were assessed descriptively.

Results: TAA group ankle work increased as task demand increased from walking to stair ascent conditions (p < .01), but was lower than control values for each task (Figure 1). TAA group proximal positive work ratio increased across tasks (p = .03), and was higher than controls during each task. Specifically, proximal positive work ratio group differences of 5-9% during the walking conditions and 13-23% during stair ascent conditions indicated a greater reliance on hip and knee work in the TAA group.

Conclusion: While ankle work increased as task demand increased, lower than normal ankle work appears to necessitate greater proximal joint work (e.g. hip) for task completion in people at least 3 years after TAA. The consequences, and potential adaptability, of this compensatory strategy deserve further attention to best guide postoperative interventions towards a realistic profile of joint performance to optimize mechanical efficiency, implant/joint integrity, and patient function long-term.

Positive Ankle Joint Work During Functional Tasks.

Ankle work values during normal walking (NW), fast walking (FW), standard step ascent (SS), and high step ascent (HS) are provided in bar graph form. Values above each task indicate the percent difference between groups (J/kg). Error bars correspond to one standard deviation. TAA = total ankle arthroplasty group.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00022

©The Author(s) 2025

Metatarsus Adductus Influence on Fifth Metatarsal Fractures: Radiographic Analysis

Delaney Lagrew, MD; Chris Lamprecht; Alex Barnett, MS; Miqi Wang, MD

Submission Type: Base of the Fifth Metatarsal Fractures

Research Type: Level 4 – Case series

Introduction/Purpose: Metatarsus adductus is the most prevalent congenital foot disorder and results in soft tissue contractures and foot remodeling. Metatarsus adducutus can regress into numerous pathologies including hallux valgus, skew foot, and recurrent fifth metatarsal fractures. Fifth metatarsal fractures can also result from cavovarus foot deformity. There is no known literature directly comparing the percentage of fifth metatarsal fracture patients with either cavovarus foot deformity or metatarsus adductus. We hypothesize that having an elevated metatarsal adductus angle (MAA) of over 15 degrees predisposes patients to proximal fifth metatarsal fractures more than neutral or cavovarus deformity.

Methods: Patients with fifth metatarsal fractures were assessed for the age, sex, fracture side, and fracture type. Fractures were radiographically classified as zone 1 (pseudo-Jones), zone 2 (Jones), or zone 3 (stress fracture). MAA and lateral Meary’s angle (LMA) of the affect foot measured radiographically. These measurements were used to quantitively compare the degree of metatarsus adductus and cavus deformity with the fracture type.

Results: A total of 17 patients (4 men, 13 women) were identified with a mean age of 41. The patients who sustained a stress fracture had a mean MAA of 29.2 degrees (20.9 to 36.9) and LMA of 10.5 degrees of planus (−28.8 to +3). The Jones fracture group had a mean MAA of 19.7 degrees (19.1 to 20.7) and LMA of 1.1 degrees of cavus (−3.9 to 3.7). The pseudo-Jones group had a mean MAA 16.8 degrees (9.9 to 19.8) and LMA of 0.1 degrees of planus (−8.4 to 7.5).

Conclusion: In conclusion, there is a high MAA in patients with fifth metatarsal Jones, pseudo-Jones, and stress fractures. The patient group with the highest MAA was the stress fracture group. Of note, patients with fractures do not necessarily have cavus deformity, but rather our results show that many patients have neutral to planus arches. There may be a role of custom shoe inserts to prevent future problems in patients with metatarsus adducts in the setting of bilateral pathology or recurrent fractures.

Example of Radiographic Measurements.

Figure on left demonstrates metatarsal adductus angle. Figure on the right demonstrates lateral Meary’s angle.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00023

©The Author(s) 2025

Mid-Term Outcomes of Total Ankle Arthroplasty in High-Risk Populations

Brody Fitzpatrick, MD; Caitlyn Patton, MD; Dominic Lombardo, BS, MS; Tyler Agard, MD; Armen Aprahamian, BA; Robert Santrock, MD; Matthew Dietz, MD; Naji Madi, MD

Submission Type: Total Ankle Arthroplasty

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Total ankle arthroplasty (TAA) preserves ankle motion and avoids complications associated with ankle arthrodesis. However, initial designs demonstrated poor outcomes and implant survivorship. Modern TAA designs mimic the ankle anatomy, minimize bone cuts and rely on cementless fixation. Current literature suggests that 4th generation implants have favorable clinical outcomes compared to older generations. However, heterogeneity of outcome reporting and lack of long-term outcomes in the reported studies is common. Evaluation of the mid-to-long term outcomes is warranted to guide appropriate patient selection and manage patient expectations. The purpose of this study is to evaluate the mid-term clinical and radiographic outcomes of modern TAA implants with particular focus on high-risk populations including obese patients, diabetics, smokers, and those with severe pre-operative tibiotalar coronal deformity.

Methods: This is a retrospective review of patients who underwent primary TAA at a tertiary referral center from January 1, 2018 to September 20, 2022. Inclusion criteria included age ≥18 years and pre-operative diagnosis of primary osteoarthritis or post-traumatic tibiotalar arthritis. Exclusion criteria included fusion takedown TAA, pre-operative diagnosis of inflammatory tibiotalar arthritis, less than 2 years follow up, and patients lost to follow-up. A total of 170 primary TAAs were identified, and 78 were ultimately included. Mean follow-up was 3.9 years (range 2.0-8.3). There were 6(7.7%) smokers, 17(21.8%) diabetics, 2(37%) with BMI 30-34.9, and 26(33%) with BMI≥35. Implants included 65(83%) Inbone II, 9(12%) Vantage, and 4(5%) Infinity. Revision surgery was defined as removal or exchange of the metal components. Radiographic tibiotalar coronal deformity was evaluated at four time periods: pre-operative as well as 3 months, 1 year, and most recent post-operative. Severe pre-operative coronal deformity was defined as ≥10 degrees.

Results: TAA survivorship was 96% at mean follow-up. There were 47 complications in 23(30%) ankles. Revision surgery was required in 15(19%) ankles due to deep infection (10, 67%), component subsidence (4, 27%), and talar AVN (1, 7%). Primary revision included revision TAA (10, 67%), tibiotalocalcaneal arthrodesis (2, 13%), ankle arthrodesis (1, 7%), total talus (1, 7%), and BKA (1, 7%). Six ankles required a second revision: 5 (83%) conversion to TTC, 1(7%) revision TAA. Diabetes mellitus, tobacco, BMI ≥ 30 had no increased complication or revision rates. BMI ≥ 35 had significantly higher likelihood of any individual or total complication and infection. Pre-operative coronal deformity ≥10 degrees had no increased revision rates. Post-hoc analysis showed significantly increased revision surgery rate with pre-operative coronal deformity ≥19 degrees.

Conclusion: At mid-term follow-up, 4th generation TAA demonstrated excellent implant survivorship (96%). Revision surgery was required in 15(19%) ankles, primarily due to deep infection (10, 65%). Post-hoc analysis showed significantly increased revision surgery rate with pre-operative coronal deformity ≥19 degrees. Morbid obesity (BMI ≥ 35) was associated with higher rates of any individual complication, total complications, and infection, but was not associated with increased rates of revision surgery. Future studies with larger sample size and longer follow-up periods are needed to further delineate the long-term effects of medical comorbidities and severe deformity on implant survivorship and outcomes after total ankle arthroplasty.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00024

©The Author(s) 2025

Normative Data for Lateral Talar Subluxation in the Weight-Bearing Ankle

Amanda Vandewint, BSc; Madeline Power, MSc; Jacob Matz, MD

Submission Type: Ankle Instability

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Measurement of lateral talar subluxation (LTS) is proposed in the literature as an adjunct and perhaps superior metric to medial clear space (MCS) for distinguishing intact versus disrupted medial restraints in SER-variant ankle fractures. Arbitrary cutoff values have been explored for dichotomizing increased compared to normal LTS. The present study sought to elucidate normative data for LTS which can assist with treatment decision-making for SER fractures. The objectives of this investigation were as follows: (1) define the mean LTS value in a population with normal ankle anatomy; (2) define the mean LTS value with subanalyses according to biological sex and ankle side; (3) compare mean LTS to mean values for existing radiographic measurement tools of MCS and superior clear space (SCS).

Methods: Adult patients (aged 19 and over) seen in consultation at a foot and ankle orthopaedic outpatient office over a 2.5 year period without a primary pathology of the ankle joint were considered eligible. Patients were included provided x-rays had been obtained of separate bilateral weight-bearing films with a mortise view. Exclusion criteria consisted of evidence of prior trauma, prior operative intervention or concurrent degenerative changes to the ankle joint, as well as inadequate imaging technique. Radiographic measurements of LTS, MCS and SCS were retrospectively performed by two independent observers with overall mean values calculated. Subanalyses offering comparisons based on biological sex and ankle side were performed using a two-sample unpaired t-test and descriptive statistics, respectively. Assessment of intrarater and interrater reliability was facilitated by producing intraclass correlation coefficients (ICC).

Results: Data from 120 patients were included (88 with adequate bilateral ankle views; 106 with left and 102 with right ankle radiographs). The population mean age was 55.23 [±13.28 SD] years, with 78.3% being female. Mean measurements were: LTS 1.09 [±0.76 SD; range 0-3.70] mm, MCS 2.36 [±0.50 SD; range 1.42-4.23] mm, and SCS 3.23 [±0.47 SD; range 2.08-4.48] mm. Ankle side subanalysis showed mean LTS of 0.97 [±0.91 SD] mm for the right and 1.21 [±0.93 SD] mm for the left, with no significant difference evident. There was no significant difference in mean LTS for female (1.07 [±0.78 SD]) versus male (1.16 [±0.74 SD]) patients. Mean ICC for LTS was 0.64 for intrarater and 0.56 for interrater reliability representing moderate agreement.

Conclusion: Our investigation generated a mean normative LTS value of 1.09 mm, expanding upon limited literature on this measurement tool in uninjured ankles by using a sample of sufficient size. Only 1.2% of initial LTS measurements by the two observers were >4.0 mm, suggesting this previously proposed cutoff should provide an effective threshold for detecting increased LTS. The current study newly demonstrated that a single LTS cutoff may be generalizable regardless of biological sex or ankle side. However, our work found achieving reliable LTS values presented a greater challenge compared to other commonly applied measurement tools, namely MCS.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00025

©The Author(s) 2025

Patient-Specific Instrumentation Benefits for INBONE II Total Ankle Arthroplasty

Charlotte Jones, BS; Allison Boden, MD; Patricia Friedmann, MS; Suzy Wang, MS; Ricardo Villar, MD; Constantine Demetracopoulos, MD; Jonathan Deland, MD; Elizabeth Cody, MD; Matthew Conti, MD; Jensen Henry, MD; Scott Ellis, MD

Submission Type: Total Ankle Arthroplasty

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Total ankle arthroplasty (TAA) is a surgical procedure that has been shown to effectively reduce pain and improve mobility in patients with ankle arthritis. Achieving optimal alignment is crucial for implant longevity and patient outcomes. The PROPHECY patient-specific instrumentation (PSI) (Stryker, Mahwah, NJ, USA) has been developed to aid in accurate and efficient implant placement, including the INBONE II implant, which has been shown to offer enhanced stability and alignment correction. This study aimed to determine the accuracy of PSI regarding implant alignment and implant size, and compare outcomes between PSI implantation and the traditional jig method. We hypothesized that compared to the standard jig method (non-PSI group), PSI will improve alignment accuracy, deformity correction, and reduce radiation exposure, tourniquet and operative time.

Methods: This retrospective study of 92 patients (46 PSI and 46 non-PSI cases) was performed at a single institution between 2006-2024 and included patients who had a TAA with INBONE II implants. The PSI group (n = 46) was matched with the non-PSI group (n = 46) by age (±3 years) and sex. Chart review was performed to collect demographic data including primary surgeon, concomitant procedures, body mass index (BMI), age, tibial and talus implant sizes, total procedure time and total inflated tourniquet time. Intraoperative radiographs were used for fluoroscopy time. Radiographic evaluation using the Picture Archiving and Communication System (PACS, Sectra Inc. Shelton CT) of pre- and post-operative radiographs were analyzed to assess the accuracy of PROPHECY by comparing alignment of the implant in the PSI group to the intended preoperative plan, as well as compare the post operative deviation of the tibiotalar angle (TTA) and talar tilt (TT) in both groups.

Results: The PROPHECY PSI demonstrated high accuracy in predicting correct implant size, 68% (n = 32) of talus implants and 89% (n = 42) of tibial implants. Most changes stemmed from downsizing the talus by one size. Median implant absolute deviation in the mortise and sagittal planes was less than 2 degrees, indicating accurate surgical alignment with the preoperative plan. 71% of PSI cases were performed by one surgeon, while a different surgeon with extensive experience with the jig performed 96% of the non-PSI cases. For both groups, median TTA deviation was less than 2 degrees and median post-operative TT was less than or equal to 1 degree. While no difference between groups for fluoroscopic time was found, the PSI group had a longer total inflated tourniquet and procedure time.

Conclusion: For INBONE II implantation, PSI achieves similar alignment and implant sizing compared to standard instrumentation. Surgeons reliably and accurately aligned the tibial component per the preoperative plan. This study, the first to compare the two techniques with INBONE II, has strengths of matched pair analysis and validated outcomes. The longer tourniquet and operative time in the PSI group likely reflects the primary surgeon’s initial experience with the guides, while a surgeon experienced with the jig opted for the extramedullary approach. The patient-specific approach may help less experienced surgeons achieve desired alignment with less operative time.

Accuracy and Alignment of Patient-Specific Instrumentation in Comparison with Prophecy Predicted Values and Non-PSI Cases using Radiographic and Intraoperative Measurements.

Figure 1.

A) Accuracy of alignment in INBONE II TAAs performed using PSI cases. In the mortise and sagittal views, mean implant deviation from the anatomic axis was below 2 degrees. B) Comparison of Deviation of TTA from Anatomic Axis, Post-Operative Talar Tilt, Fluoroscopy, Tourniquet and Procedure Time for INBONE II TAA Performed with or without PSI. Post-operative Mortise View TTA was measured using the medial angle created from the anatomic axis with the base of the tibial implant (Mortise View Tibial Base) and with the superior margins of the articular surface of the talar dome (Mortise View Talus Surface). In the sagittal view, post-operatively, the TTA was measured using the anterior angle created from the anatomic axis with the base of the tibial implant. Post-operative TT was calculated using the angle created from the superior margins of the articular surface of the talar dome and the base of the tibial implant.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00026

©The Author(s) 2025

Peak Contact Pressures of the Posterior Heel in a Commonly Used Controlled Ankle Motion (CAM) Orthosis

Erik Nakken, MD; Barrie Sugarman, MD; Kempland Walley, MD; Davin Gong, MD; Vandan Patel; David Walton, MD; Paul Talusan, MD; James Holmes, MD

Submission Type: Other

Research Type: Level 4 – Case series

Introduction/Purpose: Controlled ankle motion (CAM) boots are commonly and increasingly used after orthopaedic injury or in the post-operative setting. However, the use of a CAM boot is not benign, and pressure injury is a concern. The incidence of complications related to prefabricated pneumatic braces is on the rise. “Floating” the heel (no direct contact) has been studied and is important for pressure injury prevention in lower extremity plaster splints. Dermal arteriolar capillaries collapse with a pressure of 32 mmHg, but no biomechanical studies have measured posterior heel contact pressures nor described the significance of floating the heel in a rigid CAM boot. This study aims to quantify baseline contact pressures of the posterior heel and assess the efficacy of floating the heel in a CAM boot.

Methods: Twenty legs from ten healthy subjects were analyzed. A pressure transducer was positioned over the posterior heel to measure peak contact pressure in a CAM boot with the heel both resting flat and when elevated with a pillow under the calf and ankle. Both absolute pressures and relative pressure improvements were recorded.

Results: With the posterior heel in the CAM boot resting flat, no leg reached a pressure below the critical 32 mmHg threshold. However, when the heel was floating freely, 55% (11/20) of legs achieved contact pressures below 32 mmHg. The average contact pressure with the heel floating was 40 mmHg, indicating a 53% improvement in pressure reduction compared to the heel resting down.

Conclusion: Prolonged used of a CAM boot should be undertaken with some degree of caution due to the risk of pressure-related complication. Patients must be counseled to float the heel when at rest. Frequent skin assessment and position changes are recommended to detect signs of impending pressure injury in the posterior heel. In cases where rigid immobilization is not essential, alternative orthoses that offload the heel should be considered, especially in those with neurogenic compromise, specifically the neuropathic patient and those with prolonged regional peripheral nerve blocks.

Figure 1.

Contact Pressure of the Posterior Heel in a Controlled Ankle Motion (CAM) Orthosis.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00027

©The Author(s) 2025

Risk Factors for Post-Operative Complications and Reoperation in Patients undergoing Ankle Arthrodesis and Total Ankle Arthroplasty

Edward Haupt, MD; Ramiro Lopez, BS; Cole Herbel, BS

Submission Type: Ankle Arthritis

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Total ankle arthroplasty (TAA) and ankle arthrodesis (AA) are two commonly used procedures in the treatment of end-stage ankle arthritis. Procedural complexity required to achieve the soft-tissue balance and plantigrade foot necessary for a successful patient outcome may require additional simultaneous adjunctive procedures versus temporally staged surgical management. There is little evidence evaluating the effect of additional procedures on patient outcomes and complication risks that could possibly advise surgeon management for simultaneous or temporally staged procedures. This study aims to evaluate adjunctive procedure number in AA/TAA and correlate to post-operative outcome. The primary outcome measures are increased complications, reoperations, and intraoperative data (blood loss, fluoroscopy time, tourniquet time). The secondary outcome was to detect differences in AA versus TAA via a matched cohort analysis.

Methods: A retrospective chart review of AAs and TAAs performed at a single institution from the years 2008-2024 was performed utilizing CPT codes encapsulating both procedures. Patients were included if they received either AA or TAA within the assigned period and placed into two demographically matched patient groups. Chart review was undertaken to evaluate comorbidities, operative data, and post-operative outcome. Statistical analyses, including odds ratios, analysis of variance, and regression analysis were then performed. A priori power analysis revealed a minimum of 200 patients in each group would be required to detect an increase in complication or reoperation for the primary and secondary outcome.

Results: 491 patients were initially identified. 455 remained after exclusion, of which 210 underwent AA and 245 underwent TAA. One patient underwent staged TAA conversion from AA. Mean patient age (67.7 years, TAA vs. 62.5 years, AA) and preoperative comorbidities (5.8, TAA vs. 4.8, AA) were significantly different between groups. TAA patients experienced a lower overall rate of complications (20%), and reoperation (8%) compared to AA (32% and 16%, respectively). As the number of adjunctive procedures increased, complication and reoperation rates in TAA patients also increased, but in AA patients the rates remained relatively constant. Procedure duration and tourniquet time were significantly longer in TAA. Additionally, regression analysis revealed specific comorbidities correlated to post-operative outcomes regardless of adjunctive procedural risk.

Conclusion: Patients who undergo TAA, but not AA, have an increased risk of complication and reoperation as adjunctive procedures are added in a simultaneous surgical event. Adjunctive procedures seem to increase complication risk as each is added, thus complication risk mirrors case complexity. This is the first study to evaluate complication risk and adjunctive procedure number in TAA and AA with adequate statistical power. Surgeons should carefully consider planned surgical treatment to minimize perioperative surgical risk. Study limitations are problems common to retrospective reviews, including both selection and recall bias.

Figure 1.

(Top Left): Number of Adjunct Procedures vs Complication Rate in Both Groups. Figure 2 (Top Right): Number of Adjunct Procedures vs. Reoperation Rate in Both Groups. Figure 3 (Bottom): Mean Number of Adjunct Procedures vs. Complication Rate in TAA.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00028

©The Author(s) 2025

Sagittal Alignment May Not Correlate with Range of Motion in Ankle Arthritis and TAR

Ricardo Villar, MD; Kira Lu; Jaeyoung Kim, MD; Joseph Nguyen, MPH; Jensen Henry, MD; Constantine Demetracopoulos, MD

Submission Type: Ankle Arthritis

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Improving range of motion (ROM) is one of the most challenging objectives in total ankle replacement (TAR). While preserving motion is one of the advantages of TAR in comparison to ankle fusion, factors that interfere with ROM are not well established in the literature. Movement in the ankle joint predominantly occurs in the sagittal plane, yet no study has analyzed how sagittal alignment interferes with ROM. Our study aims to evaluate associations between preoperative and postoperative ROM and Sagittal Tibiotalar Alignment for TAR. We hypothesized that sagittal alignment parameters would correlate with ankle ROM.

Methods: This study is a single-institution retrospective review of prospectively collected data from primary TARs from March 2019 – April 2022 with preoperative and postoperative weight-bearing radiographs. Ankle and global range of motion measurements were performed using previously validated methods. Sagittal alignment was evaluated by 2 observers using 3 methods: the sagittal tibiotalar ratio (TT ratio) pre and postoperatively, the anteroposterior offset ratio, and the tibial implant sagittal slope on the postoperative radiograph. 61 ankles were included for analysis (31 Wright Infinity, 21 Exactech Vantage and 9 Wright Inbone II). Correlation between changes in sagittal alignment and ROM measurements was addressed by Pearson’s correlation test (PCC). A PCC of 0.4 to 0.7 was considered moderate, while a PCC greater than 0.7 was strong and lesser than 0.4 was considered a weak correlation. Interclass correlation coefficients (ICC) and 95% confidence intervals were used to address interobserver reliability for the sagittal radiograph measurements.

Results: Pre-operatively, the median TT ratio was 36.5 ± 7.5, while post-operatively it was 35.9 ± 6.3. The average tibial implant sagittal slope angle was 88.5° ± 2°. We found no moderate or strong correlation between any of the sagittal measurements and ROM. A statistically significant (p < 0.05) negative weak correlation was found between the sagittal pre op TT ratio and the pre op plantarflexion offset and global plantarflexion offset, indicating that an anterior translated talus may be associated with more plantarflexion preoperatively. Similarly, a weak negative correlation was found between the offset ratio and the post op dorsiflexion offset and post op total ROM, suggesting that an anterior translated talar implant may interfere with post op ROM, especially in dorsiflexion.

Conclusion: Although restoring alignment is crucial in TAR, our study suggest a weak or no correlation between sagittal alignment and ROM in fixed bearing implants. Several facts could have influenced our findings. Variables that were not controlled, such as etiology. The literature is scarce in terms of ankle sagittal alignment, so we need a better understanding of what is abnormal. Our cohort was limited in terms of variations in sagittal alignment: TT ratio pre and post were very similar, tibial sagittal implant slope varied little and 33 patients had neutral AP offset. Further studies should take this into consideration.

Figure 1.

Alignment Measurements on Lateral Radiographs Including. (a) Tibial Implant Sagittal Slope Angle, (b) Sagittal Tibiotalar Ratio, and (c) AP Offset Ratio.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00029

©The Author(s) 2025

Socioeconomic Distress Does Not Influence Postoperative and Patient-Reported Outcomes Following Surgical Management of Insertional Achilles Tendinopathy with Haglund Deformity

Joydeep Baidya, BS; Nana Amponsah, BA; Kush Mody, MD, MBA; Amy Nghe, BA; Omar Sarhan, BS; Nate Rose, BS; Tyler West, BS; David Pedowitz, MD; Joseph Daniel, DO; Selene Parekh, MD, MBA

Submission Type: Achilles Tendinosis

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Insertional Achilles Tendinopathy (IAT) with calcaneal exostosis, or Haglund deformity (HD), can result in debilitating heel pain. The first course of treatment is nonsurgical modalities including physical therapy, shoe wear modification, and injections. While outcomes following surgery for IAT with HD have previously been explored, there is a paucity of literature investigating the impact of socioeconomic factors. Distressed Communities Index (DCI) is a metric that captures neighborhood-level socioeconomic distress utilizing zip codes, where higher scores indicate greater distress in the community. Previous studies have demonstrated higher DCI to be associated with adverse outcomes following a number of orthopedic surgical procedures. Therefore, this study aimed to identify the impact of DCI as a proxy for socioeconomic distress on outcomes after surgical management of IAT with HD.

Methods: Patients > 18 years of age who underwent surgical management for IAT with HD at a tertiary care center from 2017-2022 were reviewed. Patients’ zip code of residence was queried and matched to DCI score and quintile provided by the Economic Innovation Group. Demographic and surgical characteristics including age, race, sex, BMI, Charlson Comorbidity Index (CCI), length of stay, insurance, marital status, diabetes, smoking status, history of injury, time to surgery, history of ankle surgery, preoperative physical therapy, steroid injection, and bracing, and usage and type of graft for repair. Outcomes of interest were readmission, revision, debridement, Achilles tendon retear, manipulation under anesthesia, time to weightbearing, postoperative physical therapy, steroid injection, and bracing. Patient-reported outcome of Foot and Ankle Ability Measure (FAAM) was collected preoperatively and at 1- and 2-year postoperatively. ANOVA or Kruskall-Wallis tests were used for continuous variables. Chi-Square or Fisher’s Exact tests were used for categorical variables.

Results: A total of 165 patients who met inclusion criteria were identified. Of these, 61, 49, 30, 12, and 13 patients were in the prosperous, comfortable, mid-tier, at-risk, and distressed quintiles, respectively. The proportion of females in the distressed quintile (92.3%) was significantly different but all other demographic and surgical variables were comparable between groups. Patients in the distressed group experienced the highest rate of 30-day readmission (23.1%), revision (15.4%), and debridement (7.69%), and those in the at-risk group experienced the greatest improvement in FAAM scores at 1-year postoperatively, but these were not significantly different from the remaining groups. All other surgical and patient-reported outcomes were similar across quintiles.

Conclusion: Patients residing in distressed communities as delineated by the DCI were not found to experience any additional burden of adverse postoperative events or patient-reported outcomes up to 2 years following surgery for IAT with HD compared to their counterparts in other DCI quintiles. Further research should be aimed at examining the impact of socioeconomic factors on a more granular scale in order to identify potential risk factors for complications and methods of reducing them.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00030

©The Author(s) 2025

The Effect of Osteoporosis on Postoperative Outcomes Following Total Ankle Arthroplasty

Ronit Kulkarni, BS; Richard Friedman, MD, FRCSC; Joshua Morningstar, BS; Christopher Gross, MD; Daniel Scott, MD, MBA

Submission Type: Total Ankle Arthroplasty

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Recent literature, particularly in the fields of total joint arthroplasty, has raised concern for increased perioperative complications following joint arthroplasty in patients with osteoporosis. The purpose of this study is to evaluate the influence of preoperative osteoporosis on 6-month postoperative outcomes following total ankle arthroplasty (TAA).

Methods: The Nationwide Readmissions Database (NRD) was queried from 2015-2020 to identify 29,705 patients undergoing primary elective TAA. Patients were divided into two cohorts based on the presence of preoperative osteoporosis (as defined by ICD-10 CM codes M81, M80, M80.07XX), with 943 (3.3%) having this diagnosis. Preoperative demographics, comorbidities, postoperative outcomes, cost of admission, and total length of stay (LOS) were analyzed between cohorts. Multivariate regression analyses were conducted to control for predictors of adverse postoperative outcomes other than preoperative osteoporosis.

Results: The overall cohort was majority male (54.2%) with mean age of 64.15 (range 17-90) years, and Charlson-Deyo Comorbidity Index (CCI) score of 0.65 (range 0-12). Patients diagnosed with preoperative osteoporosis patients were statistically significantly older (Osteoporosis = 68.72 years; non-osteoporosis = 65.03 years; p < .001), more likely to have Medicare insurance (p < .001), and had a higher CCI score (Osteoporosis = 0.98; Non-Osteoporosis = 0.64; p < .001). Multivariate regression analysis of 180-day postoperative outcomes found that preoperative osteoporosis was significantly predictive of increased risk of any complication (OR = 1.428; p < .001), transfusion (OR = 3.370; p < .001), pulmonary embolism (OR = 5.625; p = .016), Pneumonia (OR = 3.872; p < .001), adverse discharge (OR = 1.445; p < .001), and extended stay greater than 4 days (OR = 1.310; p < .001). Further, the presence of osteoporosis is predictive of nearly a $3,000 increase in total cost of procedure (β = 2980.22; p < .001).

Conclusion: The presence of osteoporosis was significantly predictive of higher rates of postoperative complications, LOS, and a substantially higher cost of procedure following TAA. Physicians and patients alike should consider this comorbidity when stratifying risk for outcomes following total ankle arthroplasty.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00031

©The Author(s) 2025

The Effect of Preoperative Smoking Status on Outcomes Following TAA

Weston McDonald, BS; Sarah Jenkins, MD; Joshua Morningstar, BS; Christopher Gross, MD; Daniel Scott, MD, MBA

Submission Type: Total Ankle Arthroplasty

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: With total ankle arthroplasty (TAA) emerging as an increasingly prevalent treatment for advanced ankle arthritis, continual reevaluation of patient factors that may influence postoperative outcomes is critical. In other disciplines of orthopaedic surgery, the current evidence associating smoking with increased rates of poor wound healing, infection, and functional outcomes is robust. However, in TAA, the literature remains relatively sparse and inconclusive. This study aims to address this gap by comprehensively analyzing the impact of preoperative smoking on the outcomes of TAA.

Methods: The Nationwide Readmissions Database (NRD) was queried from 2016 to 2020 to identify 29,705 patients undergoing primary elective TAA. Patients were divided into two cohorts based on their preoperative smoking status, with 7,526 (25.3%) being active smokers at the time of surgery. Preoperative demographics, comorbidities, postoperative outcomes, cost of admission, and total length of stay (LOS) were analyzed between cohorts. Multivariate regression analyses were conducted to identify independent predictors of postoperative outcomes other than preoperative smoking status.

Results: The cohort was mostly male (54.2%) with mean age of 65.14 (range 17-90) years, and Charlson-Deyo Comorbidity Index (CCI) score of 0.65 (range 0-12). Active smokers were significantly older (Smoker = 66.75, Nonsmoker = 64.6; p < .001), more likely to be male (Smoker = 58.81%, nonsmoker = 52.66%; p < .001), and had higher rates of comorbidity as measured by CCI score (Smoker = 0.79, Nonsmoker = 0.60; p < .001). Multivariable regression showed that preoperative active smoking was predictive of increased risk of intraoperative or postoperative bleeding (Odds Ratio [OR] = 5.309, p = .001), readmission (OR = 1.149; p = .002), and adverse discharge (OR = 1.067; p = .039). This analysis found active smokers to be at a decreased risk of sepsis (OR = 0.163; p = .006) and ARF (OR = 0.451; p < .001). Additionally, it was found that preoperative active smoking status was significantly predictive of over a $400 increase in total cost of admission (b = 412.51; p = .029).

Conclusion: Active smokers undergoing total ankle arthroplasty face a higher risk of intraoperative or postoperative bleeding, readmission, and adverse discharge compared to non-smoking patients. They also incur greater healthcare costs. Interestingly, active smokers have a lower risk of sepsis and acute renal failure, signaling potential areas for future research.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00032

©The Author(s) 2025

The Use of Autologous Bone Graft vs Allograft Viable Cell Matrix in Forefoot, Midfoot, and Hindfoot Fusion

John O’Keefe, MD; Sarah Hall, BA; Chase Gauthier, MD; Christopher Toussaint, MD; Edward Haupt, MD; J. Benjamin Jackson, MD, MBA; Tyler Gonzalez, MD, MBA

Submission Type: Other

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: The use of autograft is considered the gold standard for improving the fusion rate in foot and ankle surgeries. Allograft may be useful as an alternative to autograft given its high accessibility and lack of harvesting complications. Newer generation allograft mixtures containing osteoconductive, osteoinductive and osteogenic factors which may have similar or even higher rates of success compared to older generations of allograft. The current study pursued comparisons of the rate of fusions, complications, and improvement in patient reported outcomes for patients treated with newer generation allograft mixtures, autograft, or a combination of allograft and autograft for forefoot, midfoot, and hindfoot fusions.

Methods: A retrospective review was performed on patients who underwent forefoot, midfoot, or hindfoot arthrodesis procedures between March 2021 and May 2023 at a single academic institution. Allografts utilized included: Augment® (Wright Medical Group) with Bio4TM (Stryker) and Vivigen® (DePuy Synthes). A total of 208 joints in 140 patients were included in the study. 105 joints in 71 patients were treated with allograft, 29 joints in 19 patients were treated with autograft, 74 joints in 50 patients were treated with both autograft and allograft. Demographic information, graft specifications, and postoperative outcomes were collected. Categorical and continuous data were compared using Chi-squared test and analysis of variance (ANOVA), respectively. Paired t-tests were utilized to compare preoperative and postoperative Patient Reported Outcome Measurement Information System (PROMIS) scores. All p < 0.05 were considered statistically significant.

Results: There were no significant differences between those treated with allograft, autograft, or both grafts in terms of fusion (97.14% vs 89.66% vs 90.54%, respectively), or readmissions (2.86% vs 0.00% vs 1.35%). Chi-squared revealed the incidence of revision surgery was statistically lower in cases where allograft was used alone (0% allograft vs 10.34% autograft vs 9.46% both, p < 0.001). PROMIS pain scores were improved in the allograft (∆−5.41 ± 9.62, p < 0.001), autograft (∆−10.41 ± 18.46, p = 0.010), and allograft + autograft groups (∆−6.63 ± 11.45, p < 0.001). However, only patients treated with allograft or allograft + autograft demonstrated statistical improvement in PROMIS function (∆2.97 ± 9.63, ∆4.57 ± 7.88, p < 0.010) or mobility scores (∆4.57 ± 7.88, ∆3.05 ± 8.36, p < 0.001) at postoperative follow-up (Table 1).

Conclusion: In patients undergoing forefoot, midfoot, and hindfoot arthrodesis procedures, superior outcomes and fewer revision surgeries were observed in those who received newer generation allograft in comparison to autograft alone. These results suggest newer-generation allografts may be used as an alternative to autograft in carefully selected patients. Data from the current study suggests these allografting strategies are as effective, if not more effective than autograft in promoting fusion during foot and ankle arthrodesis procedures. Longer duration, randomized studies, and cost analysis may be warranted to effectively expand on these findings.

Table 1.

A summary of outcomes in cases where forefoot, midfoot, hindfoot fusion was performed with use of allograft, autograft, or a combination of both matrixes.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00033

©The Author(s) 2025

Three-Dimensional Distance Maps Demonstrate Intercuneiform and Naviculocuneiform Joint Involvement in Hallux Valgus Patients Compared with Matched Control Patients

Brian Closkey, BS; Brett Steineman, PhD; Scott Ellis, MD; Matthew Conti, MD

Submission Type: Hallux Valgus

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Hallux valgus (HV) is a complex three-dimensional (3D) deformity of the first ray. Recurrence rates following surgical intervention for HV remain high, which may be due to unrecognized midfoot instability. Previous studies have suggested that instability at the first tarsometatarsal (TMT1) is source of the deformity, but separate work suggests that midfoot joints such as the intercuneiform (IC) and naviculocuneiform joints may also be involved. No studies have investigated whether joint space widening may occur in other joints along the medial column. The primary purpose of this study was to determine if there were differences in medial column joint space distances in HV patients compared with patients with no foot deformity using 3D distance maps (DMs) on weightbearing CT (WBCT) scans.

Methods: Twenty-one patients (12 female) with HV who had a preoperative WBCT scan were retrospectively identified and matched with 20 control patients (12 female) with no foot deformity or arthritis who underwent a WBCT scan. Matching was performed based on age, sex, and body mass index. Semi-automatic bone segmentation was performed for each WBCT scan using Disior Bonelogic. The segmented WBCT scans were uploaded to Geomagic Design X, and automated coordinate systems for each bone were calculated using a previously published open-source code in Matlab. The TMT1 joint was divided into dorsal and plantar regions, the IC joint was divided into distal and proximal regions, and the NC joint was divided into medial and lateral regions. Minimum normal distances extracted from the joint DMs were then calculated for each region. Unpaired t-tests were then used to determine if there were differences in joint spaces between HV and control patients.

Results: There were no significant differences in minimum joint distances at the dorsal and plantar regions of TMT1 (P-values > 0.31), distal region of the IC joint (P = 0.66), or lateral region of the NC joint (P = 0.08) between HV and control patients (Figure 1). However, at the proximal region of the IC joint, the mean minimum distance between joint surfaces was 0.95 ± 0.14 mm for the HV patients and 0.74 ± 0.26 mm for the control patients (P = 0.002). At the NC joint, HV patients had significantly increased minimum distance in the medial region of 1.27 ± 0.19 mm for the HV patients compared with 1.10 ± 0.20 mm for the control patients (P = 0.009).

Conclusion: Our study found widening of the proximal aspect of the IC and medial aspect of the NC joint spaces in HV patients. This suggests a more valgus alignment of the medial cuneiform in relation to the navicular and middle cuneiform, which may be compensatory to the varus deformity of the first metatarsal in HV (Figure 1). This widening may reflect involvement of the more proximal joints of the medial column of the foot in HV and may be a source of recurrence. Further work examining surgical stabilization of these midfoot joints may help to decrease recurrent rates after HV surgery.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00034

©The Author(s) 2025

Total Ankle Replacement Outcomes in Obese Patients with > 10 Year Follow Up

Zakir Haider, BSc MBBS FRCS (Tr&Orth) MSc; Ellie Pinsker, PhD; Ryan Khan, BA, MSc; Timothy R. Daniels, MD, FRCSC; Mansur Halai, BSc (Hons), MBChB, MRCA, MRCS, FRCS

Submission Type: Total Ankle Arthroplasty

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Obesity prevalence continues to increase. Clinical studies investigating the effects of obesity on outcomes following total ankle replacement (TAR) have demonstrated variable and contradictory results. The follow-up in these studies is less than 5 years and they have shown opposite values on the percentage of poor outcomes and revision rates, when compared to non-obese cohorts. Longitudinal long-term studies with an average follow-up past 10 years are lacking.

Methods: This was a single-institution, retrospective study of primary TARs performed between 2001 and 2014 in patients with a Body Mass Index (BMI) ≥30 kg/m². Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were collected pre-operatively(pre-op) and post operatively (post-op). Any secondary operations were recorded. Univariate statistical analysis was undertaken for descriptive statistics including standard deviation (SD) and paired t-test and Wilcoxon signed-ranks test were completed to compare pre-operative and postoperative outcome scores. Statistical analyses were performed using SPSS, Version 29 (IBM Corp., 2023), and significance was determined at a p-value threshold of <0.05.

Results: 168 patients were included with a mean age of 62.3 years (SD ± 8.5 years) and a mean BMI of 34.9 kg/m² (SD ± 5.9 kg/m²). At mean follow up of 14.4 years (SD ± 3.0 years) AOS pain (51.7 ± 18 to 24.3 ± 22.2), AOS disability (64.0 ± 17.9 to 35.8 ± 27.0) and SF-36 PCS scores (31.2 ± 8.6 to 36.8 ± 10.5) remained significantly improved from pre-operative baseline status (p < 0.001). SF-36 MCS deteriorated from 52.8 ± 11.3 pre-operatively to 50.4 ± 10.9 post operatively (p = 0.02). 109 patients (64.9%) required no further procedures following TAR. 20 patients (11.9%) required ankle gutter/heterotopic ossification or osteolytic cyst debridement, 14 patients (8.3%) underwent further ligament repair or osteotomy, 11 patients (6.5%) experienced polyethylene liner failure with subsequent exchange and 3 patients (1.8%) experienced implant failure with revision. 4 patients (2.4%) had a deep infection requiring further intervention.

Conclusion: At long term follow up, obese patients continue to experience a significant improvement in ankle pain, ankle disability, and overall physical health scores with TAR. 35% of patients required further procedures. Implant/ P.E failure and infection rate is comparable to non-obese patient rates published in the literature. There is a significant decrease in overall mental health (p = 0.02) after 10 years, the SF- 36 MCS is a measure of general health status and may reflect the detrimental long-term mental impact of obesity. To our knowledge, this study is first to present outcomes of TAR in obesity with follow up >10 years.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00035

©The Author(s) 2025

Trends in Abstracts Presented at the American Orthopaedic Foot & Ankle Society Annual Meeting: 2017–2023

Thelma Jimenez Mosquea, MD; Yasmeen Saeed, BS; Hugo Ubillus, MD; Raymond Walls, MD, FRCS (Tr&Orth)

Submission Type: Other

Research Type: Level 5 - Case report, Expert opinion, Personal observation

Introduction/Purpose: As one of the leading global conferences in foot and ankle surgery, the American Orthopaedic Foot & Ankle Society (AOFAS) Annual Meeting attracts cutting-edge research from around the world. This annual event serves as a pivotal platform for presenting novel advancements and emerging trends in the field. The objective of this study is to analyze trends in abstracts presented at the AOFAS Annual Meeting from 2017 to 2023. We aim to identify shifts in research focus and topic prevalence, providing insights into the evolving landscape of foot and ankle surgery research.

Methods: We conducted a comprehensive search of the Foot & Ankle Orthopaedics (FAO) and Foot & Ankle International (FAI) journals to identify issues containing the AOFAS Annual Meeting Abstracts from 2017 to 2023. We extracted data on article titles, authors, categories, and keywords. This data was analyzed to determine the distribution of articles across different categories and to identify the frequency of specific terms in titles based on a pre-developed term list. Trends were assessed to evaluate variations in category representation and keyword usage over the years.

Results: The analysis identified key trends in research categories and terms from AOFAS Annual Meeting abstracts between 2017 and 2023. Ankle-related topics consistently ranked first annually. Trauma was the second most common category in 2017 and 2019, while ankle arthritis was second in 2018. From 2020, midfoot/forefoot research rose in prominence, securing the second spot through 2023. Outcomes-related terms were most frequent, with arthroplasty and imaging appearing in five of the seven years analyzed. Arthritis, second in 2017, was no longer in the top five by 2023. Terms like calcaneus, arthrodesis, syndesmosis, and hallux valgus/bunion consistently appeared in the top five. The proportion of systematic reviews or meta-analyses increased from 8.72% (2017-2020) to 15.22% (2021-2023), indicating a greater focus on high-level evidence.

Conclusion: The trends in AOFAS Annual Meeting abstracts from 2017 to 2023 reflect the evolving focus of foot and ankle surgery research. Ankle-related topics consistently dominate, underscoring their importance in clinical practice and innovation. Trauma remains prominent, while the rise in midfoot/forefoot research suggests advancing treatments in these areas. Key terms such as arthroplasty and imaging also gained prominence, reflecting growing interest in advanced procedures and diagnostic techniques. Notably, the increased presence of systematic reviews and meta-analyses highlights a shift toward higher-level evidence. These trends suggest a broadening scope of research beyond ankle conditions toward a wider range of foot pathologies.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00036

©The Author(s) 2025

Volumetric 3D Reconstruction of Large Osteochondral Lesions of the Talus Being Reconstructed with Viable Osteochondral Allograft Combined with Autograft

Nathaniel Zona, BA; Daniel Moon, MD, MS, MBA

Submission Type: Other

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Symptomatic osteochondral lesions of the talus (OLT) are challenging to treat. Articular Regional Reconstruction (ARR) is a novel technique combining viable osteochondral allograft with morselized autograft bone to address large, volumetric OLT lesions. OLT’s involve a wide spectrum of presentations varying in surface and bony defect involvement, so improving OLT characterization will be important to selecting appropriate surgical reconstruction techniques. OLTs are often described based on maximal linear dimension and localized based on talar surface zones. Methods approximating lesion size based on simple geometric shapes such as prisms, ellipsoids, or cylinders may oversimplify OLTs. We describe a consecutive series of patients undergoing ARR with accurate lesion volumes calculated via slice-by-slice tracing and 3D reconstruction.

Methods: Patients indicated for the ARR procedure from a single surgeon were identified. OLT volume was determined for all patients with a preoperative weight bearing CT. Lesions were traced in consecutive CT slices in both sagittal and coronal views. Volume is reported as an average of the two views. Surgically, the OLTs were initially inspected arthroscopically then converted to open debridement. Medial malleolar osteotomies were utilized for access as necessary. A stable bony base and viable cartilage rim was established, removing all damaged cartilage and nonstructural bone debris from the OLT. Talar body structure and morphology was restored using autograft iliac crest or tibial placed into the bony defect. Viable osteochondral allograft (Cartiform®) was shaped and then secured over the autograft using suture anchors placed at the lesion periphery. Patient Reported Outcome (PRO) measures included PROMIS-physical function (PROMIS-PF), PROMIS-pain interference (PROMIS-PI), and single assessment numeric evaluation (SANE).

Results: Sixteen patients with an average age of 34.2 (±13.9 years) received ARR. Ten patients underwent medial malleolar osteotomy at time of surgery. To date, only one (6.3%) patient required revision OLT treatment, and the lesion had shrunk - amenable to all-arthroscopic intervention. Five others have undergone hardware removals allowing for ‘second looks’ of the revision, all demonstrating incorporation of the graft without delamination. Eight patients with preoperative and postoperative PROMIS-PF improved from 41.5 to 46.0 (p = 0.088), PROMIS- PI improved from 59.5 to 55.6 (p = 0.112), and SANE improved from 51 to 71.5 (p = 0.023). The average lesion was 0.464 cm². Average coronal volume was smaller than average sagittal volume by 0.043 cm², but these differences were not significant (p = 0.124).

Conclusion: Articular Regional Reconstruction (ARR) is a reproducible procedure with demonstrated potential for improvement in pain and physical function among patients with symptomatic, large volumetric osteochondral lesions of the talus, whether ‘contained’ or ‘uncontained’. Slice-by-slice tracing of OLTs can accurately determine lesion volume, particularly when lesions are non-uniform and cannot be approximated using uniform geometric shapes. Current work is being done to compare volume approximations with accurately traced volumes, and to assess associations between volume, preoperative and postoperative measures. Further studies on ARR of the talus are necessary to elucidate proper indications and strengthen long-term outcome data.

Figure 1.

Preoperative 3D reconstruction of ankle showing a large osteochondral lesion the lateral talar dome (A,B). Intraoperative image of debrided lesion, accessed through medial malleolar osteotomy (C). OLT lesion after autograft bone reconstruction of talar body bulk and placement of osteochondral allograft (D). Intraoperative images of reduced talus in plantarflexion and dorsiflexion (E).

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00037

©The Author(s) 2025

Weight-Bearing Protocols following Tibiotalar Arthrodesis and the Relationship to Union and Complications: A Systematic Review and Meta-Analysis

Laura Clarke, PhD; Diane Riddiford-Harland, PhD; Casey Johnson; Joshua Mattock, PhD; Evangelos Pappas; Meghan Dares

Submission Type: Ankle Arthritis

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: Weight-bearing protocols post tibiotalar arthrodesis via internal fixation methods vary considerably. Extended non-weightbearing postoperatively may protect the bone fixation but may result in greater complications and suboptimal patient outcomes. This systematic review and meta-analysis aimed to compare union rates and complications as well as functional outcomes of early weight-bearing (EWB < 6 weeks non-weight-bearing) versus late weight-bearing (LWB ≥ 6 weeks) following ankle fusion using internal fixation.

Methods: We performed a systematic review and meta-analysis of cohort and comparative studies using five databases. We included all studies that documented the post operative weight-bearing protocol following internal fixation of the tibiotalar joint (excluding Charcot arthropathy, failed ankle arthrodesis or revised total ankle replacement). Greater than 50% tibiotalar trabecular surface area radiographically suggested union and the American Orthopaedic Foot and Ankle Score (AOFAS) determined functional outcomes. Risk of bias was assessed using MINORS. Data extraction was performed with Covidence online software and the meta-analysis by using RStudio.

Results: This systematic review included 97 cohort or comparative studies. Values for relative risk indicated no significant effect of EWB compared to LWB for joint union following tibiotalar arthrodesis. There was also no significant risk outcome for either major or minor complications between these protocols. Patients reported positive outcomes (as early as three weeks after surgery) following both procedures with no significant between-group differences.

Conclusion: Based on the studies reviewed, early weight-bearing following tibiotalar fusion via internal fixation does not appear to affect union or complication rates for patient rehabilitation. An early weight-bearing protocol may be associated with improved functional outcomes as limited consequences were reported.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00038

©The Author(s) 2025

Younger Age Correlates with Increased Gutter Impingement Rates after Total Ankle Arthroplasty

Kevin Wu, BS; Albert Anastasio, MD; Kishen Mitra, BS; James Nunley, MD, MS; Mark Easley, MD; James DeOrio, MD; Samuel Adams, MD

Submission Type: Total Ankle Arthroplasty

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies

Introduction/Purpose: While total ankle arthroplasty (TAA) has evolved over the years with improved designs and fixation methods, it remains a technically demanding procedure with substantial early postoperative complication rates. One of the most common complications associated with TAA is medial and lateral gutter ankle impingement, which can lead to issues such as increased pain and more outcomes. However, there is a paucity of information in the literature discussing the impact of certain risk factors on gutter impingement complications.

Methods: A retrospective analysis was conducted on a cohort of patients who underwent a revision TAA at a single institution from 2003 to 2019 with a minimum of 2-year follow-up. Patient were identified as having gutter impingement based on diagnostic imaging and/or clinical examination. Data collection included demographics, implant type, follow-up time, and co-morbidities. Multivariate odds ratios (OR) of experiencing gutter impingement were calculated for perioperative variables.

Results: The study included a total of 908 patients who underwent TAA with 121 patients (13.3%) who subsequently experienced gutter impingement. The average follow-up time was. 5.84 ± 3.07 years. There were 178 patients under 55 years old, 495 patients aged 55 to 70, and 235 patients over 70 years old. A higher rate of gutter impingement was observed in patients under 55 compared to those aged 55 to 70 and over 70 (20.8% vs. 13.5% vs. 7.2%; p < 0.01). Multivariable logistic regression revealed that patient age was a significant predictor of gutter impingement following TAA with an OR 0.96 (p < 0.01).

Conclusion: This study demonstrated increased prevalence of gutter impingement in younger patients who underwent TAA. Propensity for scar tissue formation may be higher in this population. Scar tissue following surgery can cause the narrowing of the medial and lateral gutter potentially leading to gutter impingement. Scar tissues may compress the prosthetic components of the ankle leading to pain, swelling, and limited range of motion in the ankle joint. Increased impingement after TAA may require the need for additional debridement surgeries. Grasping the intricate relationship between age, scar tissue formation, and gutter impingement is vital for managing complications following TAA.

Table 1.

ORs of gutter impingement for perioperative variables calculated using a multivariate logistic regression model that also controls for implant type.

Foot & Ankle Orthopaedics, 10(1S)

DOI: 10.1177/2473011425S00039

©The Author(s) 2025