Introduction/Purpose: Syndesmotic injuries account for a substantial proportion of ankle trauma, yet fixation remains challenging, with malreduction rates exceeding 30% in some series. Although patient-specific factors such as foot alignment and osseous morphology are increasingly recognized as determinants of ankle mechanics, their contribution to syndesmotic instability has not been systematically investigated.
Weightbearing CT (WBCT) enables precise quantification of three-dimensional ankle kinematics under physiologic load, allowing both classification of morphological variation and direct linkage to injury response. We hypothesized that tibial incisura morphology, as the principal osseous constraint of the syndesmosis, may determine not only the severity but also the pattern of fibular displacement after ligamentous injury. Identifying anatomical morphologies prone to greater or distinct displacement patterns may explain persistently high malreduction rates and guide fixation strategies.
Methods: Thirty-six fresh-frozen cadaveric pairs (22 male, 14 female) underwent WBCT imaging with 356 N axial loading. Each specimen was scanned intact and again following sectioning of the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), interosseous ligament, and distal 3 cm of interosseous membrane, by a fellowship-trained foot and ankle surgeon. The deltoid and lateral ligament complexes were preserved to isolate pure syndesmotic pathology. An automated coordinate system pipeline with point-cloud registration quantified three-dimensional fibular and talar displacements relative to the tibia, including mediolateral, anteroposterior, and superoinferior translations, as well as rotations about the same axes, following standardized bone alignment. Unsupervised clustering (PaCMAP with k-means) was applied to objectively identify distinct patterns of injury response with machine learning. Statistical shape modeling was then used to evaluate morphometric variation across the tibia, fibula, and talus, with Hotelling’s T² tests localizing sites of significant anatomical differences between identified clusters.
Results: Clustering revealed two balanced, highly separable syndesmotic injury phenotypes (n=19 vs n=17, silhouette score 0.835). While both groups demonstrated similar displacement directions, their magnitudes differed. The high-instability phenotype (Cluster C1) exhibited significantly greater posterior fibular translation (1.62 vs 0.76 mm, p<0.001) and external rotation (3.29° vs 1.42°, p=0.034) compared to the stable phenotype (Cluster C0). Notably, talar displacements remained equivalent between groups, indicating that fibular instability was the primary differentiator. Statistical shape modeling identified significant morphological differences in the high-instability cluster, specifically, a shallower posterior incisura, with average depth reduced by over 2 mm compared to stable ankles (Figure 1). To eliminate confounding factors, Foot and Ankle Offset (FAO) analysis confirmed that global hindfoot alignment and loading patterns were equivalent between clusters (p=0.7).
Conclusion: Nearly half of all ankles studied possessed an anatomical variant that predisposed them to severe mechanical instability following ligamentous disruption. The shallow posterior incisura phenotype is a previously unrecognized but logical anatomical risk factor that directly governs injury severity. Patients with shallow incisura anatomy may require enhanced surgical stabilization, modified fixation strategies tailored to their anatomical vulnerability, intensified postoperative surveillance protocols, and earlier intervention to prevent chronic complications. This phenotype may confer elevated risk for postoperative complications, recurrent instability, and ultimately post-traumatic osteoarthritis. Future studies will work towards identifying if such morphology predisposes to an increased incidence of syndesmotic disruption.
A Novel Clinical Classification of Peroneal Tendon Disease Correlates with Tissue Pathology and Postoperative Outcomes
Julia Matthias, MD; Nicholas Austin, AS; Sara Buckley, DO; Samuel Stark, BS; Michael David, PhD; Michael Zuscik, PhD; Helena Jonsson, MD, PhD; Kenneth Hunt, MD
Introduction/Purpose: Peroneal tendon disease (PerTD) is a major cause of lateral ankle pain, including tendinosis, tenosynovitis, tears, and instability, all involving inflammation or degeneration of the tendon and tenosynovium (TS). The TS maintains tendon health by providing lubrication and nutrients, and its role in disorders like rheumatoid arthritis and trigger finger is well established. In PerTD, however, its contribution is poorly understood. Research has largely focused on tendon structure, leaving cellular and subcellular TS features understudied. Despite its clinical importance, no current classification of PerTD incorporates both tendon and TS pathology. Such classifications are essential for predicting outcomes, guiding treatment, and studying disease mechanisms. We aimed to develop a clinically meaningful TS and tendon classification and link TS phenotypes to molecular signatures and patient-reported outcomes.
Methods: We developed a 5-stage PerTD classification for surgically treated patients (IRB-approved): Type 0 (non-inflamed TS, normal tendons, n=9), Type 1 (inflamed TS, normal tendons, n=16), Type 2 (<50% tendon tear/tendinosis, n=6), Type 3 (>50% tear, n=6), and Type 4 (near-complete rupture, n=3; Fig1B).
Transcriptomic differences across types were analyzed, and Gene Ontology (GO) enrichment was performed. TS specimens were formalin-fixed and paraffin-embedded (FFPE), H&E-stained, and qualitatively assessed. Picrosirius Red (PSR)–stained FFPE sections were imaged under fluorescence microscopy, tiled into 10,000µm² regions, and collagen-positive fractions normalized per specimen. Multiplex IHC (CLIC5, CD68, CD31, DAPI) was imaged on the Akoya PhenoImager. PROMIS Pain Interference and Physical Function Scores were collected preoperatively and at 3, 6, 12, and 24 months postoperatively. Collagen fraction was modeled using mixed-effects beta regression with Tukey-adjusted estimated marginal means. PROMIS score trajectories were compared (Kruskal–Wallis test and Dunn’s correction). Analyses were two-sided (α=0.05) in R Studio.
Results: Transcriptomic analysis revealed stage-specific TS molecular signatures across PerTD (Fig1A) with distinct GO-term enrichments differentiating stages 1–4 (Fig1B). Early PerTD (types 1/2) showed enrichment of inflammatory and tissue-remodeling pathways, whereas advanced PerTD (types 3/4) demonstrated upregulation of mitochondrial genes, altered fatty acid metabolism, and neutrophil degranulation (Fig1B).
Histopathology showed progressive dense sublining connective tissue and thickened TS lining (Fig1C-D). IHC for CLIC5 (TS fibroblasts) and CD68 (TS macrophages) confirmed these findings (Fig1E). Quantitative PSR analysis showed significantly increased collagen-positive area in tendinopathic PerTD (types 2–4) vs type 1 (p=0.03; Fig1F). Patients with dense connective tissue exhibited greater postoperative improvement in PROMIS Physical Function and reduction in Pain (Fig1G), trends not observed in patients without a dense connective tissue reaction (data not shown).
Conclusion: Our classification defines PerTD categories with distinct histopathological and molecular profiles, including macrophage enrichment and fibroblast expansion within thickened TS lining, consistent with a macrophage–fibroblast activation axis driving fibrotic remodeling. While fibrosis and lining thickening were more common in advanced stages, they did not fully align with clinical categories, underscoring the need for refinement through integration of histopathology and non-invasive imaging. The observed association between dense connective-tissue reaction and greater postoperative functional improvement highlights the classification’s potential as a prognostic tool and a platform for biomarker discovery, ultimately informing preoperative decision-making and targeted therapeutic strategies.
Correction (April 2026): This abstract has been updated to correct the author byline.
Return To Sport After Excision of Os Trigonum In Athletes
Alexis Watson, BS; Gokul Kalyanasundaram; Alexander Wahl; Wen Chao, MD
Category: Hindfoot; Sports
Keywords: Os Trigonum Syndrome; Sports; Outcomes Measures
Introduction/Purpose: Os trigonum syndrome is a common cause of posterior ankle pain in athletes performing repetitive hyper-plantarflexion of the foot, in sports such as ballet, gymnastics, and soccer. The os trigonum, an accessory bone posterior to the talus, can remain unfused or join the posterior talar process, causing pain from overuse, trauma, or impingement. When conservative management fails, surgical excision is often necessary to restore function. Prior studies report favorable outcome but are limited by small samples and few athlete-focused analyses. This study evaluates pain reduction after os trigonum excision in a large cohort of athletes, using pre- and post-operative patient-reported pain scores and the ability to return to sports following surgical treatment for os trigonum syndrome.
Methods: A retrospective chart review identified patients who underwent os trigonum excision between March 2014 and March 2024 performed by a single surgeon using posterior medial surgical approach. Inclusion criteria were athletes diagnosed with os trigonum syndrome who underwent surgical excision after failing non-operative management. Exclusion criteria were patients that had concomitant ankle procedures or lost to follow up. Athletes were defined as individuals participating in organized sports. Demographic data collected included age, sex, sport type, the ability to return to sport, patient-reported pain scores, and complications. Patient-reported pain scores were recorded preoperatively, <1 month, 6 weeks, 3 months, and >1 year postoperatively. Paired t-tests compared postoperative pain scores at each interval with corresponding preoperative values. All athletes who met the inclusion criteria were interviewed by telephone at the most recent follow-up.
Results: Thirty-three athletes were identified through chart review. Two underwent concomitant procedures and five were lost to follow-up, leaving 26 athletes included. The mean follow-up was 6.7 ± 2.8 years (range, 1.6-11.6 years). Eight patients had staged bilateral procedures. Average age at surgery was 17.5 ± 4.6 years (range, 14-35 years), and 85% were female. Sports represented included ballet (n=23), football (n=1), lacrosse (n=1), and soccer (n=1). Twenty-five of 26 athletes returned to sport without difficulty, and no patients required re-operation. Mean preoperative pain score was 3.38 ± 3.28, improving at all postoperative intervals: <1 month (1.06 ± 1.59, p<0.001), 6 weeks (0.74 ± 1.26, p<0.001), 3 months (1.60 ± 2.04, p=0.055), and >1 year (0.00 ± 0.00, p<0.001).
Conclusion: Os trigonum excision is a safe and effective treatment for athletes with symptomatic os trigonum syndrome who failed conservative management. This procedure is successful with pain resolution on a long- term basis and has a high rate of return-to-sport in athletes.
Introduction/Purpose: The study’s purpose is to evaluate the efficacy of AFO bracing for Achilles tendinopathy after failed conservative management. Conservative management included physical therapy, eccentric stretching, night splinting, heel gel cushions, topical and/or oral anti-inflammatories for at least six months. Though operative management is noted to have success in treating chronic Achilles tendinosis, it is not without morbidity, risks, and an arduous period of recovery. Our hypothesis was that patients with chronic Achilles tendinosis can achieve satisfactory functional outcomes if the patient is compliant with a solid AFO brace for six months.
Methods: We collected data prospectively on a cohort of 113 patients at a single institution who were prescribed a custom AFO brace after failing conservative therapy. VISA-A scores were recorded at time of AFO prescription and then after at least six months of bracing. If patients did not complete a follow-up questionnaire in clinic, they were contacted via telephone for VISA-A scoring. The primary outcome was change in VISA-A score after treatment in the custom AFO brace. 33 patients were excluded due to noncompliance with bracing. 17 patients were excluded due to lack of follow up. Seven patients are still not six months from time 0.
Results: 56 patients aged 62±10 years and BMI 33±5 completed the second timepoint at a median 373 days. The mean VISA-A score at time 0 was 32±19, median 33, and the mean VISA-A score at follow-up was 59±25, median 61. The mean paired change in scores was 27±21 (median of 28 points better). Nine (16%) of patients progressed to surgery after failing to improve with six months of AFO bracing. An additional four patients (7%) were considering surgery at time of final follow up. Of the 43 patients who were improved and were no longer surgical candidates after six months of bracing, the mean VISA-A score at follow up was 68±20, an improvement of 35±17 points from time 0.
Conclusion: Of those patients who were compliant with six months of custom AFO bracing, 77% were able to avoid undergoing further consideration for surgery. Many of these patients reported being symptom free.
Long-term solid AFO bracing may be considered as an alternative to procedural treatment for chronic Achilles tendinosis. This may be especially useful for patients with comorbidity precluding surgical candidacy. Future research would consist of a larger patient cohort and a comparison group comprising those undergoing surgery.
Introduction/Purpose: Sodium–glucose cotransporter-2 inhibitors (SGLT2i) have gained widespread use in patients with type 2 diabetes mellitus (T2DM) due to their cardiometabolic benefits, and their popularity continues to grow. Recent evidence suggests that glucagon-like peptide-1 receptor agonists (GLP-1 RAs) may improve orthopaedic outcomes, including postoperative recovery, however, whether SGLT2i exert a similar effect on bone healing and surgical outcomes is unknown. Hindfoot arthrodesis procedures, including ankle, triple, and subtalar arthrodesis carry substantial risks of pseudarthrosis and infection. This study aimed to evaluate the association between SGLT2i use and clinical outcomes following hindfoot arthrodesis in patients with T2DM.
Methods: We performed a retrospective analysis using the TriNetX US Collaborative Network, which aggregates electronic health records from 71 health care organizations. Patients with T2DM undergoing ankle, triple, or subtalar arthrodesis between 2005–2025 were identified. Two cohorts were created: patients prescribed SGLT2i within one year prior to surgery (n=561) and those without SGLT2i exposure (n=9,012). Outcomes included pseudarthrosis (ICD-10 M96.0) and postsurgical infection (ICD-10 T81.4) within 12 months postoperatively. Propensity score matching was applied for age, sex, race, comorbidities, hemoglobin A1c, body mass index (BMI), and renal function, resulting in 556 patients per group. Risk ratios, odds ratios, and Kaplan–Meier survival analyses were performed, with significance set at p<0.05. This study design ensured balance across metabolic and demographic factors known to influence bone healing and infection risk.
Results: Following matching, baseline demographics, HbA1c levels, BMI, and renal function were comparable between groups. Failure to achieve fusion occurred in 10.0% of SGLT2i users versus 18.7% of non-users (risk ratio 0.53, 95% CI 0.39–0.73, p<0.001). Kaplan–Meier analysis demonstrated significantly improved probability of maintained fusion among SGLT2i users (HR 0.53, 95% CI 0.38–0.75, p<0.001). The mean number of pseudarthrosis instances was also significantly lower among SGLT2i patients (0.40 vs 0.73, p=0.013). Postsurgical infection rates did not differ significantly (10.8% vs 8.3%, p=0.15), and survival analysis confirmed no increased hazard of infection with SGLT2i exposure (HR 1.35, 95% CI 0.92–1.99, p=0.21).
Conclusion: In this multicenter analysis, SGLT2i use was associated with a significantly reduced risk of pseudarthrosis following hindfoot arthrodesis in patients with T2DM, without elevating infection risk. Beyond glycemic control, SGLT2i exert systemic effects—reducing insulin resistance, lowering advanced glycation end products, decreasing inflammation, and improving renal and cardiovascular function—that may create a more favorable biological environment for bone healing. The observed benefit is consistent with these mechanisms and highlights the importance of optimizing metabolic status in surgical patients. Future prospective studies should validate these findings and clarify the direct role of SGLT2i in promoting arthrodesis.
Ten Year Subsequent Hindfoot Fusion Rates do not Differ Following Total Ankle Arthroplasty or Ankle Arthrodesis in a Large-Scale Database with Verified Continued Patient Enrollment
Jean Louka, MD; Gregory Guyton, MD; Eslam Alkaramany, MD
Category: Hindfoot; Ankle Arthritis
Keywords: Wound Complications; Total Ankle Arthroplasty; Revision Ankle Arthroplasty
Introduction/Purpose: Total ankle arthroplasty (TAA) preserves motion, while ankle arthrodesis (AF) has historically been the gold standard for end-stage ankle arthritis. One potential advantage of ankle replacement over fusion is that it may reduce the risk of symptomatic hindfoot fusion requiring subsequent fusion, and this has been promoted as a relative benefit of the procedure. While limited small-scale data supports this contention, large-scale community-based data are missing. We sought to determine the relative rates of subsequent hindfoot fusion after both procedures using a large-scale commercial insurance database.
Methods: We performed a retrospective cohort study using the PearlDiver national claims database (2010– 2023). Patients undergoing primary TAA (CPT 27702) and AF (CPT 27870) were identified and included only if continuous enrollment for 10 or more years in the database was confirmed to ensure integrity of the data. Patients with Charcot/neuropathy, infection, tumor, or revision at the index were excluded. Subsequent hindfoot fusion (CPT 28725, 28715, 28705, 28730, 29907) was the primary endpoint. To exclude concomitant or staged procedures, we applied a 90-day exclusion period after the index procedure. Incidence rates were calculated, and Kaplan–Meier curves estimated fusion-free survival.
Results: Long-term claims data show that hindfoot fusion after TAA or AF is uncommon (<5% at 10 years), with similar incidence between procedures. The rate of subsequent hindfoot fusion of around 4% within 10 years after either TAA or AF highlights the durability of both procedures but failed to demonstrate an advantage for ankle replacement in this large-scale community database.
Conclusion: Long-term claims data show that hindfoot fusion after TAA or AF is uncommon (<5% at 10 years), with similar incidence between procedures. The rate of subsequent hindfoot fusion of around 4% within 10 years after either TAA or AF highlights the durability of both procedures but failed to demonstrate an advantage for ankle replacement in this large-scale community database.
Correction (April 2026): This abstract has been updated to correct the author byline.
A Retrospective Analysis of Radiographic Outcomes and Complication Rates Following First Tarsometatarsal Joint Arthrodesis with a Multiplanar Correction System
Introduction/Purpose: Hallux valgus (HV) is the most common forefoot deformity in adults, affecting up to one-third of the population. The Lapidus procedure is a well-documented technique that has become a cornerstone in HV correction. Despite its utility, it is technically demanding, with overall complication rates approaching 20% and risks including malunion, nonunion, and dorsiflexion deformity. A proprietary system incorporating a cutting guide and positioning instruments has been developed to simplify the procedure and improve outcomes. While early reports from designer centers have shown favorable outcomes, independent evaluation is limited. This study presents the first large, non-designer center series reporting radiographic outcomes with this system.
Methods: A retrospective analysis of 128 consecutive patients who underwent triplanar hallux valgus through tarsometatarsal arthrodesis was performed between March 2021 and September 2024 by multiple foot and ankle surgeons at a single institution with a minimum follow-up of 3 months. Institutional review board approval was obtained. Primary outcomes included pre- and postoperative intermetatarsal angle (IMA), hallux valgus angle (HVA), and tibial sesamoid position (TSP). Secondary outcomes included complication rates, nonunion incidence, and hardware removal requirements. Statistical analysis utilized paired t-tests for continuous variables with significance defined as p < 0.05.
Results: The cohort included 101 females (78.9%) and 27 males (21.1%) with a mean age of 54.4 years (range 20–78) and mean follow-up of 11.9 months. Significant radiographic correction was achieved, with mean IMA improving from 16.3° to 5.1° (p < 0.001), HVA from 34.5° to 11.2° (p < 0.001), and TSP from 6.2° to 3.1 (p < 0.001). Nine patients (7%) developed hallux varus, with mean IMA improving from 18.6° to 3.0° but HVA from 37.8° to -10.0°. Asymptomatic nonunion occurred in 10 cases (7.8%), symptomatic nonunion in 4 cases (3.1 %) and delayed union in 6 cases (4.6%). Hardware removal was required in 15 patients (11.7%).
Conclusion: Triplanar hallux valgus correction through tarsometatarsal arthrodesis using a proprietary cutting guide and realignment system demonstrates reliable radiographic correction of the deformity. This study represents the largest reported non-designer series for this system and shows consistent, reproducible correction of moderate to severe hallux valgus with a low risk of symptomatic nonunion. However, the Lapidus procedure remains technically complex, and the overall complication rate of approximately 30% in this study—including painful hardware, hallux varus, delayed union, and asymptomatic nonunion— underscores the need for meticulous surgical technique regardless of instrumentation.
Introduction/Purpose: Surgical management of Insertional Achilles Tendinopathy (IAT), often associated with a Haglund’s deformity, involves debridement of the diseased tendon and resection of the Haglund’s deformity. This has historically been performed via an open approach. Given risks including large incisions, wound healing complications and longer recovery times, minimally invasive (MIS) Achilles debridement and Haglund’s resection techniques have been developed to minimize recovery time and wound healing complications. However, literature is scarce regarding outcomes of these MIS techniques. This study compares patient-reported outcome scores (PROMIS Physical Function and Pain Interference scores) for patients undergoing open versus MIS Achilles debridement and Haglund’s resection to determine if there is a significant difference in patient outcomes between MIS and open approaches to surgical management of IAT.
Methods: Patients over 18 years of age undergoing open or MIS Achilles debridement and Haglund’s resections by four fellowship-trained Foot & Ankle surgeons at a single institution were identified between March 2018 and February 2025 after Institutional Review Board (IRB) approval was obtained. Demographic data as well as preoperative and postoperative patient-reported outcome (PROMIS Physical Function and Pain Interference) scores for function and pain were collected. Postoperatively, PROMIS scores were collected at two weeks, six weeks, three months, six months, one year and at final follow-up. Patients with less than six months of postoperative follow-up were excluded. Statistical analysis was performed using Microsoft Excel and MATLAB. Independent samples t-tests were performed with significance set at p<0.05.
Results: 20 patients in the MIS group and 26 patients in the open group were included. Mean age was 52.65 years for the MIS group and 50.92 years for the open group. Mean BMI was 36.64 for the MIS group and 32.46 for the open group (p=0.034). Preoperative PROMIS Physical function and Pain Interference scores were not significantly different between groups. Postoperatively, PROMIS Physical Function scores at six weeks were higher for patients in the MIS group (36.75 vs 26.73, p<0.001). At all other time points, PROMIS scores were not significantly different between groups. One patient in the open group sustained an Achilles avulsion postoperatively, and no Achilles avulsions or ruptures were sustained in the MIS group.
Conclusion: MIS Achilles debridement and Haglund’s resection results in similar postoperative patient- reported outcomes to standard open approaches. At six weeks postoperatively, patients who had undergone MIS surgery reported better functional outcomes as compared to the open group, with no differences in outcomes at all other time points. No Achilles ruptures were noted in the MIS group. MIS approaches to treatment for IAT are a viable alternative to classic open approaches, with promising patient-reported outcomes postoperatively.
Radiation Exposure and Safety in Minimally Invasive Foot and Ankle Surgery: A Comparative Analysis Between Minimally Invasive Distal First Metatarsal Transverse Osteotomy and Akin Osteotomy vs. Open Modified Lapidus Procedure
Preston Harrison, BS; Sarah Kiriluk, MD; Kevin Lee; Moawiah Mustafa, MD; Shawn Guirau, MA; John O’Keefe, MD; Ettore Vulcano, MD; A. Holly Johnson, MD; Jonathan Kaplan, MD; Oliver Schipper, MD; J. Benjamin Jackson III, MD, MBA; Tyler Gonzalez, MD, MBA
Category: Midfoot/Forefoot; Bunion Diabetes
Keywords: Ankle; Degenerative; Hindfoot Deformity
Introduction/Purpose: Intraoperative fluoroscopy has become essential in orthopedic surgery, particularly with the rise of minimally invasive surgery (MIS) techniques. Despite the advantages of minimally invasive foot and ankle surgery, it raises concerns about radiation exposure to both patients and surgical staff. The purpose of this study was to evaluate fluoroscopy time and radiation dose (cumulative air kerma) associated with open versus MIS bunion correction, comparing the open modified Lapidus procedure and the minimally invasive distal first metatarsal transverse osteotomy and akin osteotomy (META). It was hypothesized that the META procedure would be associated with increased radiation dose and fluoroscopy time compared to the open modified Lapidus procedure.
Methods: A retrospective review was conducted for patients who underwent bunion surgery between January 2021 and June 2025 by two fellowship-trained orthopedic foot and ankle surgeons at a single academic institution. A total of 294 patients met inclusion criteria. Of these, 258 patients underwent a META procedure and 36 underwent an open modified Lapidus procedure. Fluoroscopy time (minutes) and radiation dose (mGy) were compared between groups.
Results: A mean fluoroscopy time of 2.13±1.27 (range, 0.06-7.05) minutes and a radiation dose of 2.02±1.30 (range, 0.05-7.52) mGy were observed in the META cohort. An average fluoroscopy time of 1.63±1.83 (range, 0.08-7.70) minutes and a radiation dose of 1.31±1.43 (range, 0.07-5.98) mGy were observed in the open modified Lapidus cohort. There was no significant difference in fluoroscopy time between cohorts (p=0.123), however the META group demonstrated a higher radiation dose than the open modified Lapidus group (p=0.007).
Conclusion: The META procedure had a significantly higher radiation dose compared to the open modified Lapidus procedure, though both remain substantially below the International Commission on Radiological Protection (ICRP) recommended occupational exposure of less than 20.00 mSv per year. Despite the META procedure generating an average radiation dose of 2.02 mGy per case, surgeons receive only 0.50% of the dose; thus, nearly 1,980 procedures would be required to exceed the 20.00 mSv annual occupational limit. These findings suggest that concerns about radiation exposure should not necessarily deter providers from performing the META technique for bunion correction.
Correction (April 2026): This abstract has been updated to correct the author byline.
Comparing Patient Reported Outcomes and Complications Following Open Versus Minimally Invasive Double and Triple Arthrodesis for Rigid Flatfoot Deformity: A Retrospective Analysis
Paoloivan Fiore; Sarah Kiriluk, MD; Preston Harrison, BS; Lance Schacht; Alice Montagna; Tyler Gonzalez, MD, MBA; Ettore Vulcano, MD
Introduction/Purpose: Double or triple arthrodesis is a common surgical intervention for patients with rigid flatfoot deformity who have not responded to nonoperative treatment. While this procedure is traditionally performed as an open surgery, minimally invasive percutaneous (MIS) techniques have emerged as an alternative with benefits such as a lower wound complication rate, less pain, and improved cosmesis.5 However, currently there are limited studies available to compare the outcomes of open versus MIS techniques in double and triple arthrodesis procedures. The purpose of the current study was to analyze patient outcomes following open versus MIS double / triple arthrodesis, to offer valuable insights to guide clinical decision-making.
Methods: Ninety-seven open and 79 MIS arthrodesis procedures were retrospectively analyzed. Primary outcomes, including Visual Analog Scale (VAS) and Foot Function Index (FFI) scores, were assessed at each preoperative and postoperative clinic appointment. Secondary outcomes, such as time to union, nonunion, and postoperative complications were collected for each patient. Radiographic measurements such as Meary’s Angle, calcaneal pitch, and Kite’s Angle were collected at preoperative and final postoperative appointment. All continuous data were compared on t-test, while noncontinuous data were compared on a Chi-squared analysis.
Results: In the open arthrodesis cohort, mean age was 67.5 (range 32-88) years, while mean age was 70.7 (range 58-86) years in the MIS cohort. The mean follow-up duration was 31.3 (range 25-38) months amongst patients who underwent open arthrodesis, 33.7 (range 24-42) months amongst patients who underwent MIS. Both cohorts demonstrated significant improvements in VAS and FFI scores (p<0.001). The open cohort showed a slightly greater improvement in VAS scores (p<0.001), but no significant differences were found in the change in (∆) FFI scores between the groups. There were no significant differences in nonunion rates or time to union. However, the open cohort had a significantly higher incidence of wound dehiscence (8.2%) in comparison to the MIS group (0%) (p=0.009).
Conclusion: Both open and MIS techniques for double and triple arthrodesis for treatment of rigid flatfoot deformities resulted in similar improvement in patient reported outcome measures. MIS techniques offered a significant advantage in reducing postoperative wound dehiscence. Meanwhile, there was no difference in union rate between open arthrodesis and MIS arthrodesis. This retrospective study may aid in surgeons’ decision making when planning operative intervention for patients with rigid flatfoot deformity.
Introduction/Purpose: Complex foot deformities in skeletally mature patients, whether idiopathic or acquired, remain a challenge for foot and ankle and pediatric orthopedic surgeons. In low- and middle-income countries, approximately 78% of infants with clubfoot remain untreated due to barriers in healthcare access, resulting in rigid, multiplanar deformities that persist into adolescence or adulthood. These deformities often exhibit tense skin, hypertrophied tendon–ligament complexes, and muscle imbalance, making correction difficult. Standard reconstruction frequently requires extensive soft-tissue release, osteotomy, arthrodesis, or external fixation, all associated with morbidity and demanding rehabilitation. The Ponseti method is a cost- effective, minimally invasive standard for infants; however, its applicability in skeletally mature CFD remains unclear. This study evaluated a modified Ponseti-based serial casting protocol as a presurgical correction strategy for adolescent and adult CFD.
Methods: A retrospective cohort study encompassing fifty-eight skeletally mature patients (78 feet) with idiopathic or acquired CFD treated with a modified PM between 2020 and 2024 was conducted. Patients were analyzed by etiology group, and deformity severity in cavus, varus, adductus, and equinus were recorded at baseline, after casting, and postoperatively. Repeated-measures analysis of variance and Tukey honestly significant difference testing compared changes across time points. Postoperative and casting complications, relapsed deformity, and the Foot and Ankle Outcome Score (FAOS) were reported at final follow-up.
Results: Following casting, 55/58 (94.8%) of patients required adjunctive procedures. A plantigrade, shoable foot was achieved in 69/78 (88.5%) feet. Improvements in all deformity planes were primarily attributable to serial casting (p < 0.001), and, postoperatively, equinus improved significantly (p < 0.04 and p < 0.01) in both groups. Casting-related skin pressure injuries requiring wound care occurred in 9/78 feet (8.9%). After a median follow-up of 17 months, 10/78 feet (12.8%) relapsed. Postoperative complications included one wound dehiscence and one postoperative stiffness. Mean FAOS was 82.9 among respondents.
Conclusion: A modification of the PM, using serial leg casting as a preoperative correction strategy for idiopathic and acquired CFD, reduces the need for, or the complexity of, major reconstructive foot surgery, achieving high rates of plantigrade feet with low rates of arthrodesis. This could redefine treatment paradigms in resource-constrained settings and for multiplanar correction of foot deformity.
Single-Shot Liposomal Bupivacaine is a Safe and Effective Alternative to Continuous Catheter-Based Analgesia for Postoperative Pain Management of Foot and Ankle Surgery
Paoloivan Fiore; Sarah Kiriluk, MD; Sebastian Baquero; Tyler Gonzalez, MD, MBA; Ettore Vulcano, MD
Introduction/Purpose: Postoperative pain management is critical in foot and ankle surgery. Traditional opioid-based analgesia poses risks of dependency, and there is growing interest in opioid-sparing strategies, such as regional anesthesia. Liposomal bupivacaine (Exparel) has emerged as a promising alternative to continuous catheter-based analgesia. However, high-quality comparative studies for foot and ankle surgery remain limited. This study aims to compare the efficacy and safety of single-shot liposomal bupivacaine versus continuous catheter-based analgesia in managing postoperative pain in foot and ankle surgery.
Methods: This retrospective analysis evaluated patients who underwent foot and ankle surgery from January 2023 to December 2024. Two cohorts were compared: the Catheter group, receiving continuous peripheral nerve catheter-based analgesia, and the Exparel group, receiving a single-shot liposomal bupivacaine peripheral nerve block. Data collected included demographics, postoperative opioid consumption, and complication rates. Statistical analyses were performed using independent samples t-tests for continuous variables and chi-squared tests for categorical data.
Results: A total of 404 patients were analyzed (203 in the Catheter group, 201 in the Exparel group). The Exparel group had significantly lower opioid consumption across the first six postoperative days compared to the Catheter group (p < 0.001), with no significant difference in opioid consumption on day 7 (p = 0.834).
The complication rate in the Catheter group was significantly higher (22.17%) due to catheter-related issues (leakage, dislodgement, paresthesias), whereas no complications were observed in the Exparel group (p < 0.001).
Conclusion: Single-shot liposomal bupivacaine offers effective postoperative pain relief with fewer complications compared to continuous catheter-based analgesia in foot and ankle surgery. The findings support its use as an opioid-sparing, cost-effective, and practical alternative to continuous infusion catheters.
Introduction/Purpose: Online star ratings are increasingly visible and influential when patients select orthopaedic surgeons. However, the reliability of patient-initiated (unsolicited) reviews compared to institutionally administered (solicited) surveys remains unclear. In this multi-institutional analysis, we aimed to (1) quantify differences between solicited and unsolicited star ratings of surgeons, (2) compare review volumes across platforms, and (3) identify the minimum number of unsolicited reviews needed for an unsolicited rating to reach statistical equivalence with surgeons’ global ratings, comprised of both solicited and unsolicited ratings.
Methods: We analyzed the data of orthopaedic surgeons from three large health systems across each of the five regions in the continental United States. Each surgeon’s star ratings and review counts were gathered from each platform. Unsolicited data were collected from Google, Healthgrades, and Vitals. Solicited data were collected from institutional websites. All ratings utilized a 1 to 5-star scale. Surgeons were stratified into groups of 10-review increments based on their review count on a given unsolicited platform (1-9 reviews, 10-19 reviews, etc.). For each group, the weighted mean unsolicited rating and the paired global weighted mean were compared. The global mean was calculated using all reviews from both solicited and unsolicited sources of surgeons in that group. Normality was assessed using Shapiro-Wilk test. Paired t-tests, Wilcoxon signed- rank tests, and equivalence tests were conducted as appropriate. The Benjamini–Hochberg false discovery rate was used for multiple comparisons.
Results: 322,907 reviews across 629 orthopaedic surgeons (555 male, 74 female) were included in the analysis. There were 51,779 (16.0%) unsolicited reviews and 271,128 (84.0%) solicited reviews. The weighted mean unsolicited rating was significantly lower than the weighted mean solicited rating (4.5 ± 0.4 vs. 4.8 ± 0.1, p < 0.001). On average, per surgeon unsolicited review counts were significantly fewer than solicited counts (82 vs. 431; p < 0.001). The total unsolicited group (all unsolicited ratings combined) reached equivalence with the paired global group at 90 reviews, while Google ratings reached equivalence at 60 reviews, and Healthgrades at 80 reviews (p < 0.05). Vitals failed to reach equivalence with global ratings at all review volumes (p > 0.05).
Conclusion: Unsolicited ratings are lower and based on fewer reviews than solicited ratings. Equivalence with global ratings emerges at platform-specific review-volume thresholds: approximately 60 reviews for Google, 80 reviews for Healthgrades, and 90 reviews across all unsolicited reviews. These data support minimum review thresholds for public display of star ratings. They also underscore the value of solicited institutional survey platforms to increase response volume for more reliable and representative assessment of orthopaedic surgeons.
Subtalar Arthrodesis for Post-Traumatic Arthritis After Calcaneus Fracture is Associated with a Higher Nonunion Risk
James Padley, MD; Ryan LeDuc, MD; Kerri Bell; George Graham, MD; Kayla Hietpas, MPH; Robert Anderson, MD; Bruce Cohen, MD; J. Kent Ellington, MD; Todd Irwin, MD; Carroll Jones, MD; Scott Shawen, MD; Samuel Ford, MD
Category: Hindfoot; Trauma
Keywords: Calcaneus Fracture; Post Traumatic Osteoarthritis; Subtalar Arthrodesis
Introduction/Purpose: Post-traumatic subtalar arthritis following calcaneal fractures often leads to pain, deformity, and functional impairment. While subtalar arthrodesis aims to address these symptoms, there is a risk of nonunion, with rates ranging from 10% to 24%. Factors such as poor bone quality, altered anatomy, and compromised vascularity may negatively impact fusion in this population. Limited data exists specifically examining successful fusion rates in patients with a history of calcaneal or talar fracture. The purpose of this study is to evaluate fusion rates following subtalar arthrodesis in patients with post-traumatic arthritis secondary to prior calcaneal and talar fractures and identify factors associated with nonunion. We hypothesized that a prior calcaneal fracture would be associated with lower fusion rates compared to other surgical indications.
Methods: A retrospective case-control study was conducted on adult patients who underwent subtalar arthrodesis (CPT 28725) at a tertiary referral center between January 1, 2014, and December 31, 2024. Patients with at least three months of follow-up and available postoperative imaging (X-ray or CT) were included. Only cases with a primary diagnosis of post-traumatic arthritis following talar or calcaneal fracture were analyzed. Exclusion criteria included additional ankle or hindfoot fusions, neuropathic arthropathy, or calcaneal osteotomies beyond medial displacement. Fusion was defined by CT evidence of >25% bony bridging or radiographic signs plus minimal pain and no hardware loosening per clinic notes. Demographic and operative data (e.g., screw type, biologic use) were recorded. Statistical analysis included Chi-Square and Fisher’s exact tests for categorical variables, and t-tests or Wilcoxon Rank Sum tests for continuous variables, as appropriate.
Results: Of 374 patients who underwent subtalar arthrodesis for all diagnoses, 326 (87.2%) achieved fusion. There were no significant differences in age, BMI, sex distribution, bone graft usage, biologic adjuncts, or screw types between fusion and non-fusion groups (p> 0.05 for all). A history of post-traumatic arthritis secondary to talus fracture was not associated with fusion outcomes (p>0.999). However, post traumatic arthritis secondary to calcaneus fracture was significantly more common among patients who did not achieve fusion (31.3%) compared to those who did (15.3%, OR 2.5, p=0.0066) (Table 1).
Demographics and pain score summary.
Conclusion: Subtalar arthrodesis demonstrated a high overall fusion rate; however, patients with post- traumatic arthritis secondary to calcaneal fractures had significantly higher nonunion risk. These findings suggest that prior calcaneal fracture is a key risk factor for nonunion and should be carefully considered in surgical planning and patient counseling.
Younger Patients Undergoing Transfibular Total Ankle Arthroplasty Experienced Similar Outcomes as Older Patients at Midterm Follow Up
Kevin Schafer, MD; Jonathan Day, MD, MS; Morgan Motsay, BS; Zijun Zhang, MD, PhD; Lew Schon, MD
Category: Ankle Arthritis; Ankle
Keywords: Trabecular Metal Total Ankle; Transfibular Approach; Total Ankle Replacement
Introduction/Purpose: Multiple prior studies have documented inferior implant survivorship and increased complications in younger patient cohorts undergoing total ankle arthroplasty. However, no study has examined if lateral and anterior approach arthroplasties yield similar outcomes in this younger cohort. Lateral approach arthroplasty may be more durable in this population due to less bone resection that positions the implants in denser bone. This denser bone may better support the implants during a greater volume and higher level of patient activity that is expected in younger patients. The purpose of this study is to examine implant survivorship, radiographic outcomes, and patient-reported outcomes measures (PROM) at midterm follow up after transfibular total ankle arthroplasty (TAA) performed in patients younger than 55 years of age.
Methods: We retrospectively reviewed a group of prospectively followed patients who underwent primary transfibular TAA by a single surgeon from October 2012 to January 2020. Patients with minimum 5-year clinical and radiographic follow-up were analyzed. Patient demographics and perioperative data were collected. Pre- and postoperative patient-reported outcomes measures (PROMs) included: 12-item Short Form Health Survey (SF-12) physical (PCS) and mental (MCS) component scores, Ankle Osteoarthritis Scale (OAS), and Visual Analog Scale (VAS). Radiographic outcomes included alignment, ROM, and evaluation of periprosthetic cysts (lucency >2mm) utilizing a 12-zone system. Adverse events and reoperations were reported using the Canadian Orthopedic Foot and Ankle Society (COFAS) Reoperation Coding System (CROCS). Patients were divided into 2 groups for comparison based on age at time of surgery (Younger group, age <55; Older group, age ≥55).
Results: 251 ankles (237 patients) were included; younger cohort included 72 ankles (70 patients) with mean follow-up 6.9 years (range, 5-11), older cohort consisted of 179 ankles (166 patients) with mean follow-up of 7.0 (5-12) years. The younger group had a significantly higher primary diagnosis of post-traumatic arthritis (PTA, 83% vs. 61%) and history of previous ankle fracture fixation (84% vs. 68%; all p<0.05). There were no significant differences in concomitant procedures, rate of reoperation (40.3% vs. 33.0%), time to reoperation (21.7 vs. 27.4 months), implant revision (1.4% vs. 0%), or periprosthetic cysts (5.6% vs. 2.8%) between younger and older groups, respectively. Postoperative AOS Disability was significantly lower in the younger cohort (18.9 vs. 30.2, p=0.02), while AOS Pain, VAS, SF-12 PCS and MCS were similar.
Conclusion: Younger patients undergoing TAA had similar midterm implant survivorship, reoperation rate, and rate of periprosthetic radiolucency compared to patients 55 years of age or older. Lower postoperative disability scores suggest that the younger cohort was able to return to a lifestyle with higher functional demands. Overall, these results support transfibular TAA as a viable option in patients younger than 55 years- old, and highlight the need for longer term follow-up in this population.
Introduction/Purpose: The peripheral location of ankle fractures predisposes patients to postoperative wound complications, particularly in the setting of comorbidities that impair vascular function or immune response. Peripheral arterial calcifications (PACs) are radiographic markers associated with impaired blood flow, reduced tissue oxygenation, and increased ischemic risk. The purpose of this study was to report the incidence of radiographic PACs in operative ankle fractures and determine if they are a risk factor for wound complications and reoperations following surgical fixation.
Methods: A retrospective case-control study of all operatively treated ankle fractures at a single institution in a three-year period was conducted. Cases were identified via current procedural terminology (CPT) codes for ankle fracture open reduction internal fixation (ORIF). Preoperative radiographs of all injured ankles were reviewed for the presence of PACs. The clinical records of patients with PACs were reviewed for postoperative wound complications and reoperation rates. The same information was obtained for a propensity score-matched control group without PACs, accounting for patient demographics and comorbidities.
Results: A total of 430 operative ankle fractures were identified in patients aged 18-88 years between 2022 and 2025. 366 met the inclusion criteria. Of these, 33 (9.02%) had evidence of PAC on their injury radiographs. A propensity score-matched control cohort consisted of 59 patients. The average age was 62.2+/-14.5 years and 60.3+/-14.3 in the experimental and control groups, respectively (p=0.417). There were no statistically significant differences between the control group and experimental group with respect to their medical comorbidities, including BMI, tobacco use, CAD, PVD, DM2, and CKD. Of the 33 patients with radiographic PACs, 11 (33.3%, p=0.007) experienced postoperative wound complications, with 7 of 33 (21.2%, p=0.015) returning to the operating room for debridement and irrigation.
Conclusion: This study found that patients with PACs on injury radiographs are at an increased risk of wound complications and reoperation after ankle fracture surgical fixation. These findings suggest that radiographic evidence of PACs may serve as a useful preoperative risk stratification tool. Patients with PACs in the setting of a traumatic ankle fracture may benefit from a structured, multidisciplinary approach to perioperative care to minimize the risk of wound complications and optimize outcomes.
Association Between Male Sex Hormones and Bone Metabolism During U.S. Army Basic Combat Training
Olivia Swaim; Julie Hughes; Mary Bouxsein; Kristin Popp
Category: Ankle; Trauma
Keywords: Distal Tibia; Bone Stress Injuries; Bone Mineral Density
Introduction/Purpose: Repetitive loading during basic combat training (BCT) results in tibial bone adaptation. Men show increases in cortical thickness, trabecular thickness, trabecular volumetric bone density, and cortical bone density during 8-10 weeks of U.S. Army BCT, yet ~5-7% of men sustain bone stress injuries (BSIs) during training. BSIs are a leading cause of BCT attrition.
Sex steroid hormones regulate bone metabolism. While testosterone supports bone formation, work in older men suggests estradiol is a stronger determinant of skeletal health.8 Whether this is true in younger men remains to be studied. We tested whether cumulative estradiol, testosterone, and free testosterone exposure during BCT is associated with favorable changes in distal tibial microarchitecture.
Methods: We collected high resolution peripheral quantitative computed tomography (HR-pQCT) scans at the distal tibia (4% of tibial length) in 67 men at the beginning and end of BCT. We measured serial serum hormones by LCM/MS/MS at weeks 0, 2, 4, 6, 8 and 10. Exposures were log2-means of estradiol, total testosterone, and free testosterone across all timepoints. Outcomes included total bone mineral density (Tt.BMD), cortical BMD (Ct. BMD), Ct area (Ct.Ar), trabecular BMD (Tb.BMD), Tb Thickness (Tb.Th), and Tb spacing (Tb.Sp). We fit ANCOVA models with robust standard errors; coefficients for hormones represent change per exposure doubling. False-discovery rate control (Benjamini–Hochberg) was applied across outcomes.
Results: Participants were 17-28 (mean 20.9 ± 3.7) years old with normal BMI (mean 24.9 ± 3.9 kg/m²). Racial and ethnic diversity was represented: 38% identified as White, 23% as Black, and 39% as Other racial categories. Per-doubling estradiol was associated with higher distal tibial Tt.BMD (β=+2.6 mgHA/cm³; 95% CI 0.2–5.0; p=0.03), greater Ct.Ar (β=+1.13 mm2; 95% CI 0.17–2.10; p=0.02), and greater Tb.vBMD (β=+2.2 mgHA/cm³; 95% CI 0.1-4.3; p=0.04) at the end of BCT, adjusted for baseline bone parameter, age, and BMI. Other microarchitectural indices were null. Adding total or free testosterone did not attenuate estradiol effects, and testosterone measures were not independently associated with bone adaptation.
Conclusion: In male trainees, greater estradiol exposure was associated with greater gains in measures of distal tibial size, density and microarchitecture independent of testosterone. These findings suggest estradiol is a key regulator of bone adaptation in young adult men. Given the modest sample and multiple outcomes, larger studies should confirm these associations and test links to tibial bone stress injury risk.
Tendoscopy-Assisted Flexor Digitorum Longus Transfer and Spring Ligament Synthetic Suture Tape Reconstruction for Flexible Progressing Collapsing Foot Deformity
Donatas Chlebinskas, MD
Category: Arthroscopy; Hindfoot
Keywords: Spring ligament; FDL; Posterior Tibial Tendon Dysfunction
Introduction/Purpose: Progressive collapsing foot deformity (PCFD) is a complex deformity that is predisposed to by failure of the spring ligament, resulting in peritalar subluxation. A medializing calcaneal osteotomy and flexor digitorum longus (FDL) tendon transfer are standard surgical procedures for a symptomatic flexible deformity. Endoscopic-assisted FDL transfer and a minimally invasive medializing calcaneal osteotomy (MIMCO), allow a fully MIS approach to address flat foot reconstruction. Concerns remain regarding low correction potential, without surgically addressing the attenuated spring ligament.
Spring ligament augmentation with an internal brace provides benefits of high resistance to forefoot lateralization, reliably improved radiographic parameters, and patient-reported outcomes. We describe a tendoscopic-assisted FDL tendon transfer and a spring ligament synthetic suture tape reconstruction technique, used in conjunction with a MIMCO.
Methods: Commence with MIMCO. Once complete, position the patient into a supine position. Mark and place portals at the sustentaculum tali and 0.5cm under the navicular. View via proximal and work via distal portal. Identify FDL and divide its sheath distally until the knot of Henry is identified. Tack the FDL tendon with fiberwire using labral Scorpion suture passer. Secure the stitch, deliver the tendon outside the distal portal and cut it long. Whipstitch the FDL and pull it outside the proximal portal. Under fluoroscopy guidance introduce fibertape loaded 3.5 siwvelock into the sustentaculum tali. Establisch navicular tunnel 0.5mm larger than a measured tendon diameter. Pass FDL and the tape into the distal portal, feed to the Guide pin and pass through the navicular bone tunnel. Tighten the strands in inversion and secure with a SwiveLock, 0.25 - 0.5mm smaller than a drilled tunnel. Perform percutaneous triple hemisection of the Achilles tendon.
Results: This technique has proven itself to be safe in the cadaveric lab exercise and subsequent dissection demonstrating no damage to neurovascular structures in 5 specimens. It has been performed by a lead author in flexible PCFD with preserved clinical correction, radiographic parameters at 3 months follow up.
Conclusion: Tendoscopy-Assisted Flexor Digitorum Longus Transfer and Spring Ligament Synthetic Suture Tape Reconstruction for Flexible Progressing Collapsing Foot Deformity is a technically demanding procedure for advanced foot and ankle surgeons, which allows a completely minimally invasive approach to flexible progressive collapsing foot deformity reconstruction, with increased resistance to forefoot lateralization and the potential to more reliably improve and preserve radiographic parameters. The results of the larger sample size series are to be reported in the future.
Clinical Outcomes Following Revision Total Ankle Arthroplasty Using the INVISION Modular Implant System: A Systematic Review and Meta-Analysis
Shahab Yazdanpanah; Braeden Gooch, BS; Sashrik Sribhashyam, BA; Benjamin Cassidy, MD, ATC; Albert Anastasio, MD; Conor O’Neill, MD
Category: Ankle Arthritis; Ankle
Keywords: Total Ankle Arthroplasty Prostheses; Total Ankle Arthroplasty; Revision Total Ankle Arthroplasty
Introduction/Purpose: Ankle arthritis affects approximately 1% of the population and is expected to continue increasing in prevalence. Surgical options include arthrodesis and total ankle arthroplasty (TAA), the latter of which has seen increasing utilization over recent decades, accompanied by a parallel rise in revision TAAs (rTAAs). Consequently, there has also been an emergence of many innovative rTAA-targeted implant designs to better address the challenges of revision surgery. The INVISION system (Wright Medical/Stryker, Kalamazoo, MI) is one such design, notable for its modular, unique compatibility with other implants; however, there remains a paucity of patient outcome data. Given this, the present systematic review aims to collate the available literature on INVISION rTAA clinical outcomes to better guide implant-based decision- making and improve foot and ankle care.
Methods: Pre-registered on PROSPERO, this review queried PubMed/Medline, Embase, Cochrane, CINAHL, and Web of Science on August 18, 2025, for studies reporting rTAA outcomes that utilized the INVISION system. Article quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) scale. Extracted variables included demographics, operative details, patient-reported outcome measures (PROMs), reoperations, and re-revisions. Cohort statistics were calculated in Microsoft Excel using frequency weighted means (FWMs), pooled standard deviations, and pooled percentages, while meta-analyses (MA) with risk ratios (RRs) were calculated using the Statistical Package for the Social Sciences (SPSS).
Results: Five retrospective studies (mean MINORS= 10.2±0.84; n=100; 56.0% male; age=64.0±8.4 years; follow-up=2.8±1.1 years; BMI=30.5±5.5 kg/m2) were included. Revision tibial-talar implant permutations were Invision-Invision (25%), Invision-InboneII (19%), and InboneII-Invision (56%), most often for tibial/talar subsidence (27.8%), aseptic loosening (26.4%), or infection (20.8%). FWM time-to-revision was 4.5±2.4 years, with 1.0 additional procedures on average. The all-cause reoperation rate was 21%, primarily due to infection (38.1%) and aseptic loosening (23.8%). No significant difference in reoperation risk was observed between Invision-Invision and any Invision/InboneII groups (RR=1.09; p=0.83). The re-revision rate was 11%, again led by infection (45.5%) and aseptic loosening (36.4%), with no difference between Invision-Invision and any Invision/InboneII groups (RR=0.63; p=0.46).
Conclusion: INVISION appears to be an efficacious modular system for patients undergoing rTAA, with positive patient outcomes and relatively low reoperation and re-revision rates regardless of system-specific implant permutation. As the first and largest review to evaluate INVISION, future high-quality studies with more robust outcome reporting strategies are warranted to gain additional insights regarding risk factors and additional associations within the complex and expanding rTAA population.
Effect of Obesity on Complication Rates After Arthroscopy and Microfracture of Talar Osteochondral Lesions
Mir Saif Hossain, BSc; Victor Shen, BS; Ian Winthrop, MD; Rachel Ranson; Marc Chodos, MD
Category: Ankle; Ankle Arthritis
Keywords: Osteochondral Lesions; Osteochondral Lesions of the Talus; Ankle
Introduction/Purpose: Talar osteochondral lesions (OCLs) are a common cause of chronic ankle pain, mechanical symptoms, and disability. Symptomatic lesions often fail to improve with nonoperative treatment, and benefit from surgical intervention. Arthroscopy and microfracture is considered the first line surgical treatment for small and moderate sized symptomatic lesions, with approximately 87% good and excellent results. Yet, there is evidence that these results may degrade over time. There is very little in the literature assessing the impact of obesity on the outcomes following arthroscopy and microfracture of osteochondral lesions of the talus, especially in high body mass index patients. The goal of this study is to evaluate how varying degrees of obesity influence 90 day and 5 year outcomes after arthroscopy and microfracture treatment of talus OCLs.
Methods: This is a retrospective database cohort study using the TriNetX research database. Patients aged 18– 90 years with a body mass index (BMI, kg/m²) taken within three months prior to arthroscopic microfracturing were included. All patients had a minimum of two years of follow-up. The control group included nonobese patients (BMI <30). Obese patients were stratified into BMI groups: 30–34.9, 35–39.9, 40–44.9, and ≥45 kg/m2. Outcomes included 90-day postoperative medical complications and 5-year arthritis and reoperation rates. Categorical variables were analyzed using chi-squared tests and continuous variables were analyzed with student’s t-test. Cox regression was used to compare reoperation free survival rates. A total of 3,629 patients were included in this study: BMI <30 (n = 1504); BMI 30-34.9 (n = 963); BMI 35-39.9 (n = 589); BMI 40-44.9 (n = 355); BMI ≥45 (n = 218).
Results: Because TriNetX hides outcomes <10 to protect patient confidentiality, the higher BMI cohort was sequentially combined with the adjacent, lower BMI group until outcomes were >10 for 90-day complications. The 90-day incidence of deep vein thrombosis was higher in patients with BMI ≥ 35 compared to nonobese patients [OR 2.20 (95% CI, 1.22–3.96); p = 0.007]. The 5-year arthritis rate was higher in all obese cohorts compared to the control (p < 0.05 across all groups). The overall 5-year reoperation-free survival rate was decreased in obese patients with BMI 40–44.9 (81.73%, p = 0.0004) and BMI ≥ 45 (79.39%, p = 0.0003) compared to nonobese patients with BMI < 30 (88.79%).
Conclusion: This study characterized the effects varying degrees of obesity have on outcomes after arthroscopy and microfracture of talar OCLs. All obese cohorts demonstrated higher rates of arthritis at 5 years. Additionally, patients with BMI > 40 had significantly higher reoperation rates at 5 years. These findings can help counsel obese patients with their prognosis after arthroscopic microfracturing for talar OCLs. Given the disproportionate increase in reoperation rates in the morbidly obese cohort following arthroscopy and microfracture, future research addressing the best treatment approach of OCLs in this challenging population is indicated.
Introduction/Purpose: Approximately 30% of patients with hallux valgus (HV) have concomitant metatarsus adductus (MA), which is characterized by adduction of the lesser metatarsals. MA complicates the surgical management of HV because it obstructs the first-second intermetatarsal space. This leads to higher recurrence rates and decreased patient satisfaction following surgery. To optimize surgical intervention, it is crucial to understand the three-dimensional deformity of MA. The primary aim of this study was to determine if there are differences in lesser metatarsal rotation between HV patients with and without MA. Secondary aims were to investigate differences in hallux valgus angle (HVA), the triplanar angle of pronation (TAP), sesamoid station, and first-second intermetatarsal angle (IMA) between the two groups.
Methods: This retrospective study included patients with a primary diagnosis of HV who were treated at single academic institution between 2017-2023. Patients were included if they had preoperative weightbearing anterior posterior (AP) radiographs and weightbearing CT (WBCT) scans of the foot. Patients who previously underwent ipsilateral forefoot surgery were excluded. Metatarsus adductus angle (MAA), HVA, IMA, TAP, sesamoid station, and first metatarsal rotation were measured as previously described in the literature. To quantify second and third metatarsal rotation, novel measurements were designed and completed by two independent raters (Figure 1). Reliability was assessed using Intraclass Correlation Coefficients (ICC). Differences in radiographic and WBCT measurements between HV patients with and without MA were determined by dichotomizing patients into two groups based on an MAA cutoff of 20°.
Multivariable linear regressions were used to investigate the relationships between MAA and other radiologic variables after controlling for age, sex, and body mass index.
Results: 124 patients (mean age 53.1±12.3 years) were included. The average HVA and MAA were 31.8° ±8.9° and 20.57°±6.19°, respectively. Intra-rater and inter-rater reliability was greater than 0.70 for all measurements. Patients with MA had a larger HVA than patients without MA (Difference: 3.36°; 95% CI, 2.13°-8.25°). Patients with MA had greater supination of the first and second metatarsals compared to patients without MA (First: 2.33°; 95% CI, 0.29°-3.57° and Second: 2.14°; 95% CI, 0.16°-4.12°, respectively). This relationship was not observed for the third metatarsal. MAA was positively correlated with HVA (Correlation Coefficient (CC): 0.28, p<0.001) but negatively correlated with IMA (CC: -0.53, p<0.001). There was no association between MAA and TAP or sesamoid station.
Conclusion: Patients with HV frequently present with concomitant MA, which complicates surgical management. In this patient population, correcting the IMA may require addressing the second and third metatarsals due to the correlation between increased MA severity and worsening HVA in the setting of a smaller IMA. Despite this, our study suggests that there are minimal differences in the rotational deformities of the first through third metatarsals between HV patients with and without MA. Consequently, surgical correction of the metatarsals in HV patients with MA may primarily focus on correcting the deformity in the axial plane.
Introduction/Purpose: Patient-Reported Outcome Measures (PROMs) are invaluable tools to measure and record individual and population responses to treatment, but their collection burdens patients, clinicians, and health care systems with often lengthy and time-consuming questionnaires. We developed the Universal Pain and Function score (UPAF) with only two questions to address this burden: the Visual Analog Scale for pain (VAS) and the Single Assessment Numerical Evaluation for function (SANE). We tested the hypothesis that UPAF is valid, reliable, and responsive for surgeries below the knee.
Methods: Between August 2023 and June 2025, VAS, SANE, PROMIS Global mental health (PROMIS- GMH), PROMIS Physical Function 10b (PROMIS-PF), and Satisfaction with the Outcome of Surgery (SOS) were prospectively collected from 355 patients before and at least 60 days after below knee orthopedic surgeries. UPAF was calculated as [10 * (10 - VAS) + SANE] / 2. Validity was measured using the concepts of convergent, discriminant, and concurrent-criteria validity by calculating Spearman rank order correlation (ρ) between UPAF and PROMIS-PF, PROMIS-GMH, and SOS. Reliability was assessed using the concepts of internal consistency and measurement error by calculating the Spearman rank order correlation (ρ) between VAS and SANE and by calculating the Standard Error of Measurement (SEM), Smallest Detectable Change at 95% confidence (SDC-95), and floor & ceiling effects. Responsiveness was measured using Cohen’s d, standardized response mean (SRM), and the correlation between change in UPAF and change in PROMIS-PF.
Results: UPAF strongly correlates with PROMIS-PF (ρ=0.71) confirming convergent validity (Fig-1), but not with PROMIS-GMH confirming discriminant validity (ρ=0.18). UPAF moderately correlates with SOS indicating concurrent-criteria validity (ρ=0.46), which is superior to PROMIS-PF (ρ=0.33). VAS and SANE moderately correlate, confirming internal consistency without redundancy (ρ=-0.44). SEM ranges from 6.57-10.23, and SDC-95 (18.21 to 28.35) is less than change in UPAF for all time points, demonstrating measurement reliability. Floor-ceiling effects are seen in 1.05%-1.58% of preoperative and 0%-4.42% of postoperative patients, respectively. The effect size of surgery is very large for UPAF (Cohen’s d 1.22, SRM 1.10), which exceeds PROMIS-PF (Cohen’s d 1.02, SRM 0.85). Furthermore, the change in UPAF very strongly correlates with the change in PROMIS-PF (ρ=0.89), which confirms UPAF’s responsiveness.
Conclusion: UPAF only requires two questions to deliver a valid, reliable, and responsive measure of outcomes after orthopedic surgeries below the knee. It correlates well with PROMIS-PF and SOS and appropriately does not correlate with PROMIS-GMH. Its component questions measure similar concepts without redundancy, and it reliably delivers measurable changes greater than SDC-95 after surgery with small floor and ceiling effects. Its effect size is comparable to PROMIS-PF, making it suitable for studies requiring limited sample sizes. Surgeons and health care systems wishing to measure surgical outcomes should consider this two-question score given its decreased survey burden, validity, reliability, and responsiveness.
Introduction/Purpose: Naviculocuneiform joint (NC) arthrodesis is commonly indicated for midfoot arthritis and other pathologies, however it is associated with a high rate of nonunion. Recent studies have identified a higher nonunion rate when fusing just the medial NC joint (NC1) compared to fusion of the medial and middle (NC2) NC joint. This study aims to evaluate if there is any increase in the contact forces and contact area at NC1 after NC2 undergoes compression in a cadaveric model. We hypothesized that joint preparation and compression of both NC1 and NC2 will achieve greater compression across NC1 than when NC1 is fused alone.
Methods: A static foot model using 13 fresh-frozen cadaveric feet measured intra-articular peak forces at NC1with Tekscan electronic pressure sensors after preparation and compression with a 20mm nitinol staple. Using the same foot models, NC2 was then prepped and fused with another nitinol staple. The difference between contact forces, contact area, and peak pressures at the NC1 joint after single vs double NC compression was measured and analyzed.
Results: There was a statistically significant increase in mean force recorded at NC1 between the single (8.94 ± 3.05 N) and double joint compression (11.33 ± 2.93 N) groups (p < 0.01). The total contact force across both joints was significantly higher in the double compression group versus the single compression group (35.39 ± 13.29 N vs. 19.36 ± 9.17 N, p < 0.01). Peak pressure (measured in pounds per square inch, PSI) was markedly increased in the double compression group (348.15 ± 38.48 vs. 268.00 ± 91.95, p < 0.001). Contact area at NC1 increased with the addition of compression of NC2 (50.69 ± 16.23 mm² vs. 44.62 ± 18.44 mm², p = 0.041).
Conclusion: When compared to single joint compression, compression of both NC1 and NC2 resulted in a statistically significant increase in the mean force, contact force and peak contact forces observed at NC1. Greater compression across NC1 may correlate with an increased likelihood of successful arthrodesis in vivo.
Durable Pain Relief After Deep Peroneal Neurectomy: A Longitudinal PROMIS Study
Seif El Masry, BS; Cesar Ramirez, DO; Edward Haupt, MD; Glenn Shi, MD
Category: Midfoot/Forefoot; Other
Keywords: PROMIS; Midfoot; Joint Preserving Surgery
Introduction/Purpose: Midfoot arthritis can cause severe pain and functional limitation. Deep peroneal nerve (DPN) neurectomy has emerged as a minimally invasive, motion-sparing procedure that addresses dorsal midfoot pain through selective denervation. A recent study demonstrated high satisfaction and meaningful pain relief at two years, but durability beyond this timeframe remains unknown. To our knowledge, no other study has reported long-term outcomes of DPN neurectomy. The purpose of this study was to evaluate changes in patient-reported physical function (PF) and pain interference (PI) between midterm and long-term follow-up using validated PROMIS instruments. We hypothesized that improvements in PI would be maintained at long-term follow-up and that PF would remain stable without significant decline.
Methods: We conducted a retrospective review of patients who underwent isolated DPN neurectomy for midfoot arthritis between 2017 and 2021. Inclusion criteria required available PROMIS PF and PI scores at both midterm (≥2 and <4.5 years) and long-term (≥4.5 years) postoperative intervals. Patients who had undergone conversion to arthrodesis were excluded from the final analysis. Patient demographics, including age at surgery, sex, BMI, and laterality, were recorded. PROMIS PF and PI T-scores were collected at both follow-up intervals. Within-patient differences were analyzed using paired t-tests. Clinically meaningful improvement was defined using published minimal clinically important difference (MCID) thresholds: +5.5 for PF and –5.8 for PI. The proportion of patients achieving MCID improvement or demonstrating worsening scores was recorded.
Results: The final cohort included 32 patients (81.2% female, mean age 68.4 ± 7.3 years, mean BMI 29.6 ± 6.6). Of note, 4 patients were excluded due to conversion to arthrodesis. Surgery was right-sided in 53.1%, left-sided in 34.4%, and bilateral in 12.5%. PROMIS PF improved from 37.7 ± 6.2 to 39.0 ± 7.5 (Δ = +1.3, p = 0.188), while PROMIS PI decreased from 62.6 ± 8.8 to 59.2 ± 9.0 (Δ = −3.3, p = 0.020). Clinically meaningful improvement was achieved by 7/32 patients (21.9%) for PF and 15/32 (46.9%) for PI. Five patients experienced worsening scores, associated with notable events including one stroke, one ankle fracture ORIF, one new diagnosis of chronic pain syndrome, and two cases of severe contralateral arthritis.
Conclusion: Patients undergoing DPN neurectomy for midfoot arthritis demonstrated sustained improvements in PROMIS PI through an average of six years of follow-up, with PF remaining stable. Nearly half of patients achieved clinically meaningful reductions in pain, while only a small minority deteriorated, often due to unrelated comorbidities or contralateral disease. These findings support the long-term durability of DPN neurectomy and its role as a motion-sparing option for dorsal midfoot pain refractory to conservative management. Longitudinal PROMIS assessment highlights that pain relief can be maintained beyond midterm, underscoring the procedure’s durability in selected patients.
Introduction/Purpose: Hammertoes, claw toes, and mallet toes are common deformities of the lesser toes. Most result from excessive extension across the metatarsophalangeal (MTP) joint, which can beget contracture of the proximal interphalangeal (PIP) and/or distal interphalangeal (DIP) joints. Common surgical options include release arthroplasty or arthrodesis. Arthrodesis can be performed through internal fixation (implants) or percutaneous fixation (K-wires), either with PIP preparation alone or with both the PIP and DIP joints concurrently (Figure 1a). Concurrent PIP-and DIP fixation has been proposed to yield a straighter construct and reduce recurrent deformity but may increase complication risks due to additional surgical sites. The purpose of this study was to compare surgical outcomes, complication rates, and patient-reported measures among release arthroplasty, PIP-only arthrodesis, and concurrent PIP-and-DIP arthrodesis techniques.
Methods: A retrospective chart review was conducted of all lesser toe surgeries performed at a single academic orthopedic department over four years. Preoperative demographics and comorbidities relevant to surgical healing were collected. Surgical technique comparison groups (Figure 1a) included release arthroplasty versus arthrodesis. Further, within arthrodesis, comparisons were made between concurrent PIP- and-DIP fusion versus PIP-only fusion; within PIP-only fixation– between internal versus percutaneous fixation. Outcomes were assessed per surgical case for complications and, when available, per toe for radiographic and patient-reported outcomes (PROs). PRO measures included Pain Interference (PI) and Foot and Ankle Outcome Scores (FAOS). Radiographic measures (Figure 1b) included medial-lateral (ML) and dorsal-plantar (DP) angulation. Statistical comparisons were made between surgical comparison groups for complication rates, PROs, and radiographic correction.
Results: A total of 173 cases were reviewed: 45 release arthroplasty, 128 arthrodesis (49 concurrent PIP-and- DIP fusion fixation, 47 PIP-only fusion, 32 PIP-only percutaneous fixation). Minor complications occurred in 30% and major complications in 16% of cases. Non-union or recurrence was higher in PIP-only versus PIP- and-DIP arthrodesis (18% vs 2%). Hardware failure was more common in arthroplasty (10% vs 0%).
Revision surgery and hardware removal occurred in 9% overall, significantly higher in release arthroplasty than arthrodesis (16% vs 6%). In the PRO subset (41 cases, 87 toes), all groups showed significant FAOS improvement, while PI scores remained unchanged. Radiographs demonstrated improved alignment in all groups, with arthrodesis achieving better ML and DP angulation than arthroplasty, and concurrent PIP-and- DIP arthrodesis achieving the best DP angulation.
Conclusion: Arthrodesis, compared with release arthroplasty, is associated with fewer complications, lower revision rates, and straighter toes. Within PIP-only arthrodesis, internal and percutaneous fixation demonstrated similar favorable outcomes. Importantly, concurrent PIP-and-DIP arthrodesis resulted in the lowest recurrence rates and the most favorable dorsal-plantar alignment, despite theoretically higher complication risk. Patient-reported outcomes improved equally across all techniques, indicating comparable symptom relief regardless of approach. These findings suggest that while all methods are effective for improving function, arthrodesis—particularly concurrent PIP-and-DIP arthrodesis—offers superior structural correction and durability in the surgical management of lesser toe deformities.
Introduction/Purpose: Minimally invasive metaphyseal transverse and Akin osteotomies (META) have gained global popularity, with satisfactory mid- and long-term outcomes. Various instrumentation systems have been developed to guide bone correction and screw placement. These systems aim to reduce the learning curve, improve deformity correction, and optimize screw placement. To date, no comparative studies have evaluated the outcomes of the conventional unguided technique and the guided technique using instrumentation.
Methods: This retrospective cohort study included patients with symptomatic hallux valgus who underwent surgery using the META technique performed by two fellowship-trained foot and ankle surgeons with over 10 years of experience. The first 20 feet operated on by each surgeon were included, with a total of 40 patients included in the study. One surgeon began their learning curve using the standard technique without a guide jig (NG), whereas the other surgeon began with the guided jig technique (GT). Functional outcomes were assessed using the Manchester-Oxford Foot Questionnaire (MOXFQ) preoperatively and at one-year follow-up. Weight-bearing radiographs were used to measure pre- and post-operative parameters, including the hallux valgus angle (HVA), intermetatarsal angle (IMA), proximal IMA, sagittal angulation, and anterior and lateral head translation percentages. Complications were recorded from medical charts during a minimum of one year of follow-up and were compared between the groups.
Results: All MOXFQ domains showed significant improvement (p < 0.05) in both groups, with no significant differences in the magnitude of improvement between the two techniques (p < 0.01). Significant correction was achieved in both groups for HVA, IMA, and proximal IMA. No significant differences were found between the groups in terms of the magnitude of correction for HVA (p = 0.39) or IMA (p = 0.41). However, the GT group showed significantly greater correction of the proximal IMA angle (p < 0.01) and head translation percentage (p = 0.02). First-TMT Slippage was significantly higher (p < 0.01) in the GT group (55%) than in the NG group (10%). The complication rate was 20% in the NG group and 25% in the GT group, with no statistically significant difference.
Conclusion: Percutaneous META osteotomy, with or without a guide jig, yielded comparable clinical and radiological outcomes. However, the guided technique results in greater proximal segment medialization and head translation, leading to more distal screw positioning and a wider midshaft foot width postoperatively.
The use of a jig in this study was significantly related to postoperative 1st TMT joint slippage. The long-term implications of this compensatory locking effect warrant further investigation. The complication rates were similar between the groups during the follow-up period.
Introduction/Purpose: All primary total ankle replacements (TARs) over a seven year period were retrospectively reviewed. This was a single surgeon consecutive case series involving primary TARs using a low profile tibial component. The senior author noticed a trend of increased early revision of metal components starting in 2024 and undertook a study to identify potential root causes. This study evaluates patient factors, radiographic factors, degree of deformity, and prosthetic type on incidence of early revision.
Methods: A single surgeon, community practice retrospective review was undertaken from 2018-2024. Only primary total ankle replacements with the Infinity or Infinity Adaptis prosthesis were considered. As most modern ankle replacements are press fit, and rely on bony ingrowth and on growth, we hypothesized a number of factors that might impact rates of loosening and subsidence. In this study, early revision (within the first two years) was evaluated, but infections and gutter debridement surgeries were excluded.
Asymptomatic loosening and presence of radiographic lucency was also excluded. Early revision was defined as need for revision surgery during the first two years after the index surgery.
Rates of complication were compared over two implant designs. We also looked at the effect of patient factors such as weight, and presence of osteoporosis / osteopenia, and preoperative hounsfield unit measurements. Further, we investigated the role of pre-operative deformity and decreased ankle dorsiflexion.
Results: From 2018-20220, a total of 88 Infinity total ankle prostheses were implanted. There were no revisions for loosening or implant subsidence (0.0%). From 2020 -2024, a total of 165 Adaptis Infinity total ankles were implanted. There were five incidences of implant subsidence, and four incidences of aseptic loosening, requiring revision within the first two years of implantation (5.45%). This difference was found to be statistically significant (p = 0.0293)
Overall, the sample size was too small to identify patient factors, such as age, limited dorsiflexion or presence of osteopenia /osteoporosis to account for the higher complication rate. Presence of preoperative deformity in the ankle or foot may have been a contributing factor, but did not reach statistical significance.
Conclusion: TAR remains a challenging operation. Prosthesis choice may have an impact on complications. Low profile implants may have a higher rate of loosening / subsidence due to the smaller surface area for bonding and higher contact pressure at the bone / implant interface.
This study examined various factors associated with early revision for two different low profile TAR prostheses. There was a significant increase in early revision after adoption of the Infinity Adaptis Prosthesis, compared to the Infinity prosthesis. As this was a single surgeon series, our findings may not be generalizable, but warrant further investigation.
A Better Block: A Prospective Randomized Control Trial of Single-Shot Liposomal Bupivacaine Combined with Dexamethasone vs. Liposomal Bupivacaine Alone Prior to Foot and Ankle Procedures
Grant Thomas, BS; Nana Amponsah, BA; Corinne Sommi, MD; Amy Nghe, BS; Armen Voskeridjian, MD; Selene Parekh, MD, MBA; Joe Daniel, DO; David Pedowitz, MD, MS
Category: Ankle; Other
Keywords: Pain; PRO; ORIF
Introduction/Purpose: Preoperative nerve blocks are commonly used in foot and ankle surgery to reduce postoperative pain. However, there is a lack of consensus regarding the formulation to provide optimal pain relief. Liposomal bupivacaine is a long-lasting nonopioid analgesic approved for use in interscalene brachial plexus nerve blockade. It is theorized that the addition of dexamethasone to liposomal bupivacaine may prolong analgesic duration. Patients have reported an opioid-free recovery and complete pain relief for almost a week with preoperative blocks of steroid and liposomal bupivacaine at our institution. We examine postoperative narcotic use and analgesic effect time with the use of liposomal bupivacaine combined with dexamethasone vs. liposomal bupivacaine alone when administered in a popliteal and saphenous block prior to foot and ankle orthopedic procedures.
Methods: A prospective, randomized controlled trial was performed at a single surgery center. Foot and ankle procedure patients willing to consent were randomized in a 1:1 ratio to undergo preoperative block into one of the following two arms, noted as Dex and Control respectively: 20 mL liposomal bupivacaine (266 mg) + 10 mL of 0.75% bupivacaine (75 mg) administered in popliteal and saphenous block (30 mL total) vs. 20 mL liposomal bupivacaine (266 mg) + 1 mL of 10 mg dexamethasone + 10 mL of 0.75% bupivacaine administered in popliteal and saphenous block (31 mL total). Postoperatively, patients were asked their pain scores, opioid consumption, and other pain medication every twelve hours from day of surgery to postoperative day seven in a standardized pain diary and/or via telephone. On postoperative days seven and fourteen, patients were also asked to gauge subjective block duration and overall satisfaction with the block.
Results: The cohort included 120 patients with a mean age of 44.9 years and no differences in comorbidities between the Dex and No Dex groups (all p > 0.31). Daily pain scores were lower each day in the Dex group vs. the control group with a significant difference on postoperative days two and six (p<.001; p=.031). Dex group patients also noted a mean block length of 7.8 days vs. 5.6 days in No Dex (p<0.001). The percent of patients taking narcotic medication was never more than 8% in the Dex group, vs. about 19% in the control group. The most significant difference in narcotic use occurred on day three, with a higher mean narcotic use in the control group (p=.049).
Conclusion: This study demonstrates the added benefit of dexamethasone to liposomal bupivacaine popliteal and saphenous nerve block as a postoperative pain strategy for foot and ankle procedures. Patients reported lower pain and a longer perceived block length with a dexamethasone liposomal bupivacaine nerve block as compared to liposomal bupivacaine alone. We would be remiss to exclude the high efficacy of nerve blockade in general; about one third of all postoperative patients who had elected for a block used absolutely no narcotics.
Mobile-Bearing Implant Design Increases Failure Risk after Concomitant Subtalar Arthrodesis and Total Ankle Arthroplasty
Rachit Saggar, MD; Abdulganeey Olawin, BS; Warren Austin; Joseph Mullen, BS; Eva Heidinger, MsC; Soichi Hattori, MD, PhD; Andrew Cramer, DO; Jarrett Cain, DPM; Peter Mangone, MD; MaCalus Hogan, MD, MBA, FAAOS, FAOA
Category: Ankle Arthritis; Hindfoot
Keywords: Total Ankle Arthroplasty; Subtalar Arthrodesis; Clinical Outcomes
Introduction/Purpose: Previous literature reports variable outcomes for concomitant total ankle arthroplasty (TAA) with subtalar arthrodesis (STA). Several studies suggest higher failure and nonunion rates than isolated procedures. Approximately one in seven TAA patients undergo concomitant STA for subtalar pathology refractory to conservative management. However, the specific contributors to failure remain poorly defined, and results across cohorts are inconsistent. Biomechanical investigations also conflict regarding the clinical impact of altered hindfoot mechanics after STA. Moreover, staging procedures in patients with comorbidity can increase anesthetic exposure, prolong rehabilitation, and escalate healthcare costs. This study evaluated outcomes of concomitant TAA with STA and sought to identify factors associated with failure and nonunion, emphasizing implant design features and surgical technique variables that might influence union and survivorship in this challenging population.
Methods: We conducted an IRB-approved, single-center retrospective cohort study of consecutive primary TAA with simultaneous STA performed between 2010-2023. Exclusion criteria included revision total ankle replacements, staged procedures, total talus replacements, triple arthrodesis, midfoot fusion, or <1-year follow-up. Three implant systems were utilized: STAR (mobile-bearing), INFINITY, and INBONE II (both fixed-bearing). Primary endpoints were aseptic TAA revision (removal/replacement of metal components, conversion to arthrodesis) and radiographic subtalar union rates assessed by plain radiography and computed tomography when indicated. Cases of periprosthetic joint infection were excluded from survivorship analysis. Revision-free survival was analyzed using Kaplan-Meier methodology comparing fixed versus mobile bearing implants. Secondary outcomes included complications requiring re-operation. Statistical analysis utilized chi-square tests and Fisher exact tests. Significance was set at P<0.05.
Results: 87 ankles in 85 patients (55 males, 30 females; mean age 65.2±9.5), follow-up 4.4 years (range 1–13.5). TAA revision 17% (15/87); time to revision 43.7 months. Three revisions for deep infection excluded, yielding aseptic revision 14.3% (12/84). Mobile-bearing implants had higher aseptic failure than fixed- bearing (34.6% vs 5.2%, p<0.001). Subtalar fusion 81.6% (71/87). STA failure: seven nonunions and nine partial unions (six asymptomatic). Failed STA predicted TAA failure: 6.66-fold higher revision risk (56.3% vs 8.5%, p<0.001) with partial/nonunion. Fusion differed by bearing: fixed 86.9% vs mobile 69.2% (p=0.043). Complications in 25%: hardware removal 18%, arthroscopic debridement 17%. No associations between revision risk or nonunion and age, BMI, diabetes, smoking, etiology, corticosteroid injection, BMAC, or graft type.
Conclusion: Concomitant TAA with STA, when necessarily indicated, achieves excellent function without compromising implant longevity when implants and technique are selected appropriately. Bearing design is pivotal: mobile-bearing implants showed higher failure and inferior fusion than fixed-bearing designs, noting their longer mean follow-up (8.3 vs 2.6 years). Even mobile-bearing “failures” retained good long-term function; one bilateral patient experienced a decade of activity before revision. Fixed-bearing outcomes approximated isolated procedures reported in the literature. Surgeons can offer this combined procedure, counseling that despite reduced hindfoot adaptability on uneven terrain, patients could expect pain relief, improved walking ability, and high satisfaction and functional gains.
Introduction/Purpose: Controlled ankle motion (CAM) boots are commonly used after orthopaedic injuries, both during nonoperative treatment and in the post-operative setting. CAM boot use is not without complications, including pressure injuries. Prior studies have identified that dermal arteriolar capillaries collapse with a pressure of 32mmHg and that “floating” the heel (no direct contact with surface beneath) effectively reduces heel contact pressures in both plaster splints as well as CAM boots. No biomechanical studies have measured contact pressures on the dorsum of the foot in a rigid CAM boot. The purpose of this study was to quantify contact pressures on the dorsum of the foot with the CAM boot applied as per typical instructions as compared to without the anterior plastic component of the CAM boot.
Methods: Preliminary data of six legs from three healthy subjects was analyzed after Institutional Review Board (IRB) approval was obtained. A pressure transducer (Tekscan I-scan system) was placed over the dorsum of the foot at the apex of the medial longitudinal arch, between the talonavicular and first TMT joints. Peak contact pressures were measured with the CAM boot applied per typical instructions and with the anterior plastic component of the CAM boot removed. Subjects were instructed to tighten the straps of the CAM boot to a comfortably snug fit.
Results: For the six legs tested, the average contact pressure with the anterior plastic portion of the CAM boot in place was 62.95mmHg. With the plastic removed, the average contact pressure for the six legs was 28.82mmHg, indicating a 54.4% decrease in pressure. With the anterior plastic portion of the CAM boot in place as per manufacturer instructions, no leg reached below the critical 32mmHg threshold for vascular compromise. When the plastic piece was removed, 5/6 legs (83.3%) achieved contact pressures below 32mmHg.
Conclusion: Patients should be cautioned as to the risk of pressure-related injuries while wearing CAM boots for prolonged periods. While prior evidence demonstrates “floating” the heel is important to reduce heel pressure, the dorsum of the foot is also a source of possible pressure injury. Patients should be counseled that removal of the anterior plastic portion of the CAM boot, especially while at rest or when more rigid immobilization is not required, is beneficial in lowering the contact pressures to the dorsum of the foot, which can reduce the risk of pressure injuries, particularly in patients at risk for skin compromise.
Introduction/Purpose: Bunionectomy is one of the most common procedures performed in foot and ankle surgery, and the modified Lapidus has become a prominent technique for surgical correction of hallux valgus in the United States. The emerging minimally invasive (MIS) approach has sparked discussion regarding the comparative advantages and limitations over the established open technique for modified Lapidus. The clinical distinctions, including patient-reported outcomes, radiographic measurements, and complication rates between the two operative methods have not yet been well-described. To our knowledge, this is the first study to compare patient-reported outcomes measured by Patient-Reported Outcome Measurement Information System (PROMIS) scores between the two techniques. We hypothesize that at one year after surgery, the changes in clinical outcomes will be comparable between the MIS and open cohorts.
Methods: 140 severe hallux valgus patients (66 MIS, 74 open) between June 2017 – April 2024 with both pre- and post-operative weight-bearing CT (WBCT) scans, PROMIS scores, a minimum of one-year follow- up were identified via retrospective review. The MIS Lapidus was performed through three percutaneous 6mm incisions using two screws spanning the first TMT joint and one screw spanning the medial cuneiform and second metatarsal base following joint preparation with a burr through a small incision. In open Lapidus cases, joint preparation was performed using saw cuts and removal of a small lateral wedge from the medial cuneiform before dorsal plate and screw fixation across the first TMT joint. Hallux valgus angle (HVA) and 1-2 intermetatarsal angle (IMA) were measured on X-rays. Meary’s angle, first ray length, first ray elevation, first ray pronation, and sesamoid position were analyzed on WBCT. Surgical complications were identified through chart review and postoperative radiographic assessments.
Results: MIS Lapidus and open Lapidus patients reported clinically meaningful improvements in PROMIS physical function, pain interference, pain intensity, and global physical health scores at one year after surgery, along with modest changes in global mental health and depression scores. There were no statistically significant differences in PROMIS scores between either approach (adj. p > 0.05, 95% CI). Open Lapidus patients experienced statistically significant greater correction of HVA, IMA, and Meary’s angle of 3.82º, 2.02º, and -3.16º respectively (adj. p < 0.05). There were no statistically significant differences (MIS - Open) in correction of first ray length (-1.4 mm), elevation (0.445°), pronation (2.92°) or sesamoid position. Rates of postoperative events were not statistically significant between surgical cohorts (Table 2).
Conclusion: Our data show that there are no statistically significant differences between MIS and open Lapidus groups across all collected PROMIS measures, implying surgeons can expect to see similar patient- reported outcomes at one year postoperatively. Additionally, the statistically significant differences in HVA, IMA and Meary’s angle were small and thus not clinically significant. Though there were no statistically significant differences in complication rates, studies with larger patient samples are needed to better assess these rates clinically. Future studies comparing these surgical techniques should assess short-term patient recovery to capture and compare weight-bearing and return to work timelines among other functional outcomes.
Introduction/Purpose: Accurate diagnosis of syndesmotic disruption remains a challenge, as conventional radiographs and CT demonstrate limited sensitivity, detecting subtle instability in only up to 67% of cases. Missed injuries can lead to chronic pain, loss of function, and post-traumatic arthritis, highlighting the need for more reliable diagnostic methods. Weightbearing CT (WBCT) enables three-dimensional assessment of the ankle under physiologic load, with the potential to quantify fibular and talar displacement relative to the tibia. However, objective criteria for classifying syndesmotic injury on WBCT have not been established.
This study aimed to evaluate whether referencing the contralateral ankle as an internal control during standard-of-care WBCT evaluation can improve diagnostic accuracy by quantifying translational and rotational differences of the fibula and talus relative to the tibia.
Methods: This IRB-approved study evaluated 36 fresh-frozen through-the-knee cadaveric specimens (22 male, 14 female), each scanned bilaterally with WBCT under a 356N axial load. Scans were obtained in the intact state and again following sectioning of all syndesmotic ligaments (AITFL, interosseous ligament, distal 3 cm of interosseous membrane, PITFL) while preserving the deltoid complex, lateral ligaments, and superior peroneal retinaculum. Three-dimensional bone models were analyzed using an automated tibial coordinate system pipeline with point-cloud registration to generate fibular and talar translations and rotations relative to the tibia. Six kinematic parameters were quantified, comprising mediolateral, anteroposterior, and superoinferior translations, together with rotations about the same axes. As these parameters are correlated and do not occur in isolation, dimensionality reduction was performed with principal component analysis prior to predictive modeling. Matched-pair conditional logistic regression then compared each specimen’s intact and destabilized ankles, and model discrimination was assessed using receiver operating characteristic analysis.
Results: Syndesmotic disruption produced distinct displacement patterns compared with controls (Figure 1). The fibula showed the most consistent differences, with greater lateral translation (0.51 vs 0.16 mm, p=0.007), posterior translation (–0.86 vs 0.01 mm, p<0.001), inferior displacement (–0.44 vs –0.12 mm, p=0.015), and external rotation (2.42° vs 0.03°, p<0.001). These changes defined a injury pattern of fibular posterolateral translation with external rotation, consistent with rotational instability. Principal component analysis explained 83.2% of total variance across five components. A matched-pair logistic regression model classified injured versus intact ankles with high accuracy (AUC 0.889, p<0.0001). The primary displacement component was strongly associated with injury (OR 0.05, 95% CI 0.003–0.75, p=0.030), indicating that displacement in the injury direction increased odds nearly 20-fold.
Conclusion: This study demonstrates that computational analysis of contralateral ankle differences can accurately predict syndesmotic injury with high discrimination in a cadaveric model. Characteristic displacement patterns were identified, with fibular lateral–posterior translation and external rotation emerging as key discriminators of disruption. Automated analysis within clinical WBCT platforms could provide orthopedic surgeons with immediate, objective assessment of syndesmotic integrity during routine imaging.
Quantitative thresholds derived from these measurements may also guide surgeons with specific anatomical targets for reduction during fixation. Future studies should validate these findings in patient populations and establish optimal diagnostic thresholds for clinical use.
Introduction/Purpose: Total ankle replacement (TAR) is increasingly used to treat end-stage ankle osteoarthritis, but failure and complication rates remain significant. These are often attributed to implant and patient factors, including obesity, which affects 42.4% of U.S. adults (BMI ≥30 kg/m²). While obesity is well established as a risk factor for higher complication, infection, and revision rates in total knee and hip replacement, there is a limited literature investigating the impact of obesity on TAR outcomes. This study evaluates complication, infection, and revision rates of primary TAR in patients across BMI cohorts. We hypothesized that TAR patients with BMI 35-39.9 kg/m2 and BMI >40.0kg/m2 would have higher short-term complications and long-term infection and revision rates compared to those without obesity.
Methods: This is a retrospective database cohort study using the TriNetX research database. Patients ≥18 years who underwent primary TAR from database inception to 2025 with minimum 2-years of follow-up were included. Patients were stratified by BMI: non-obese (BMI<30) (control), BMI 30.0-34.9, BMI 35.0-39.9, and BMI≥40. Outcomes of interest included 90-day surgical site infections and major complications, as well as 1- and 5-year implant failure and PJI rates. Major complications included death, stroke, myocardial infarction, pulmonary embolism, acute kidney injury, and sepsis. Implant failure included mechanical loosening, displacement, osteolysis, periprosthetic fractures (PPF), revisions, and any ORIF. Categorical variables were analyzed using chi-squared tests and Fisher’s exact tests. Continuous variables were analyzed with student’s t-test. Kaplan-Meier survival analysis with log-rank tests compared implant survival. A total of 3,533 patients (44.9% female; mean age of BMI cohorts ranged 59.2-64.3 years) were included.
Results: At 90-days postoperatively, patients with BMI≥40 had higher risk of major complications (4.7% vs 2.0%, p=0.005) (Table). A higher risk of PPF was observed in patients with BMI 35.0-39.9 (4.7% vs 2.4%, p=0.025) and BMI≥40 (4.3% vs 2.4%, p=0.030) (Table). No significant differences in implant failures or PJI were observed across all BMI groups at 1- and 5-years postoperatively (p>0.05 for all). Kaplan-Meier analysis showed no significant differences in survival rates between cohorts (5-year survival: BMI<30: 90.0%; BMI 30.0-34.9: 90.3% (p=0.949); BMI 35.0-39.9: 91.6% (p=0.364); and BMI≥40: 86.4% (p=0.106)).
Conclusion: TAR demonstrates good 5-year survivorship across BMI groups. However, at 90-days, patients with BMI ≥35 face increased risk of periprosthetic fractures and those with BMI ≥40 have increased medical complications. These findings suggest that while obesity does not appear to compromise overall 5-year implant survivorship, careful preoperative patient optimization and patient selection is needed to reduce early postoperative risks in patients with elevated BMI. In addition, patients with BMI ≥35 are at a higher risk for periprosthetic fracture and may benefit from prophylactic malleolar fixation.
Introduction/Purpose: Prior literature suggests that concurrent medial and syndesmotic instability are risk factors for higher rates of postoperative dissatisfaction and failure to return to pre-injury activity. However, few studies have evaluated patient-reported outcomes following concurrent deltoid and/or syndesmotic repair in patients suffering from chronic ankle instability (CAI). While Rigby, et al. suggested that patients with associated deltoid repair had improved Patient Reported Outcomes Measurement Information System (PROMIS) and American Orthopaedic Foot and Ankle Society (AOFAS) scores, average follow-up was less than one year. This investigation aims to understand the extent to which deltoid and/or syndesmotic repair bolster ankle stability in patients suffering from CAI as measured by the validated Cumberland Ankle Instability Tool (CAIT) and PROMIS in patients with minimum one year follow-up.
Methods: All patients who underwent lateral ankle ligament reconstruction at a single institution (2013-2024) were retrospectively reviewed by two independent investigators. Revisions, allografts, nonanatomic reconstructions, flexor digitorum longus transfers, progressive collapsing foot deformities, concomitant hindfoot arthrodesis, associated ankle arthroplasties, concomitant fractures, those without minimum one year follow-up, and those who did not have preoperative CAIT (routinely collected at our institution) were excluded. 113 patients with deltoid and/or syndesmotic injury were identified. Deltoid injury was identified via MRI as edema at the medial malleolus and signal changes at the deltoid origin. Syndesmotic injury was determined via intraoperative fluoroscopic and direct visual examination. These 113 patients were contacted to complete postoperative surveys containing CAIT and PROMIS. 71/113 completed surveys and were included for final analysis. Primary outcome was change in CAIT compared to preoperative CAIT. Paired T-tests were used to compare CAIT preoperatively and postoperatively.
Results: For concomitant deltoid repair (n=27), mean postoperative CAIT improved by 16.9 points (95%CI=13.8-20.0, P<.001). Mean scoring for PROMIS physical function (PF) was 52.8±6.5, PROMIS pain interference (PI) was 47.5±7.5, and postoperative CAIT was 22.1±7.2. Mean PF, PI and postoperative CAIT among those who underwent concomitant syndesmotic reconstruction (n=30) were 50.5±7.4, 49.9±7.9, and 18.9±8.7, respectively; mean postoperative CAIT improved by 12.5 (95%CI=8.3-16.8, P<.001) in this cohort. For patients who underwent both syndesmotic and deltoid repair (n=14), average CAIT improved by 17.7 (95%CI=13.7-21.8, P<.001). Mean PF, PI, and postoperative CAIT in this group were 51.9±6.3, 48.2±6.7, and 22.3±7.0, respectively.
Conclusion: Concomitant deltoid and/or syndesmotic repair in patients undergoing Broström due to CAI results in significant improvements in ankle stability as measured by CAIT compared to patients’ preoperative baseline. These improvements exceed the minimal clinically important difference reported for CAIT. Addressing global stability should be prioritized in patients suffering from CAI, as patients who had deltoid and/or syndesmotic repair were able to achieve population mean functional outcomes as measured by PROMIS. This study is the first to evaluate CAIT in patients who underwent Broström associated with deltoid and/or syndesmotic repair.
Tibiotalocalcaneal Arthrodesis in Severe Deformities and Uncontrolled Diabetics
Christina Klouda, MD; Austin Alecxih, MD, MS; Joseph Duff, MD; Austin Hughes; Andrew Wilson, ATC; Jesse Doty, MD
Category: Ankle; Hindfoot
Keywords: TTC; Ankle Arthrodesis; Ankle Fusion
Introduction/Purpose: Advanced pathology involving the tibiotalar and the subtalar joint poses a significant treatment challenge to orthopedic surgeons. Tibiotalocalcaneal (TTC) arthrodesis is an orthopedic surgical procedure used to manage end-stage pathologies of the ankle and hindfoot. A variety of surgical techniques exist to accomplish TTC arthrodesis. We retrospectively reviewed and compared postoperative outcomes of two different TTC arthrodesis constructs, including intramedullary nail (IMN) and open reduction and internal fixation (ORIF) with a plate/screw construct, in a population of patients with a wide range of deformity and comorbidities.
Methods: A retrospective review was conducted on 76 ankles of 72 consecutive patients who underwent TTC fusion by one fellowship-trained foot and ankle orthopaedic surgeon at a tertiary referral academic center between 2015 and 2025. Diagnoses at presentation, patient characteristics and comorbidities, postoperative outcomes, and operative data were recorded. IMN TTC fusion was performed on 57 ankles (75%) and ORIF TTC fusion on 19 ankles (25%). Mean (SD) age was 59 (15) years, 45 were female (59%), BMI was 35.9 (10.0) kg/m2, 21 were cigarette smokers (28%), 40 were diabetic (53%), 38 were neuropathic (50%), and 18 had cardiovascular disease (24%). At initial presentation, 69 had osteoarthritis (91%), 53 had a subluxation (70%), 34 had Charcot arthropathy (45%), 23 had previous ankle fracture surgeries (30%), 19 had a nonunion (25%), 7 had an osteomyelitis infection (9%), and 4 had avascular necrosis (5%).
Results: Revision TTC fusion was required after 2 of 57 IMN procedures (4%) and 5 of 19 ORIF procedures (26%) (OR, 0.10 [95% CI, 0.02-0.58]). IMN revisions included 2 periprosthetic fractures. ORIF revisions included 1 persistent nonunion, 1 periprosthetic fracture, 3 nonunions. Amputation was performed after 4 IMN procedures (7%) and 1 ORIF procedure (5%) (OR, 1.36 [95% CI, 0.14-12.96]). Complications in 19 patients that presented with nonunion included 2 revision TTC fusions (11%), 1 persistent nonunion (5%), 1 amputation (5%), and 1 broken implant (5%). Complications in 34 patients that presented with Charcot arthropathy included 5 broken implants (15%), 4 amputations (12%), 2 nonunions (6%), 2 periprosthetic fractures (6%), and 2 revision TTC fusions (6%). Hardware was removed after 13 surgeries (17%).
Conclusion: A variety of techniques exist for performing TTC arthrodesis without any current clear indications for a specific fixation method. This study demonstrated an increased rate of revision surgery in the ORIF group versus the IMN group, as well as lower rates of nonunion. Overall, IMN may be a favorable construct compared to ORIF. Further research considerations would focus on increasing sample size to isolate complex comorbidities, including severe deformity, Charcot arthropathy, cigarette smokers, etc., in order to optimize outcomes and decrease complication and revision rates.
Identifying Risk Factors for Postoperative Stiffness After Total Ankle Arthroplasty
Grant Thomas, BS; Yoni Dulitzki; Zhongxuan Chen; Joseph McCahon, DO; Selene Parekh, MD, MBA; Joseph Daniel, MD; David Pedowitz, MD
Category: Ankle; Ankle Arthritis
Keywords: Total Ankle Arthroplasty; Ankle Arthroplasty; Outcomes Measures
Introduction/Purpose: Total ankle arthroplasty (TAA) preserves motion compared to arthrodesis and has been associated with improved patient-reported outcomes. However, postoperative stiffness remains a common complication and is linked to poorer function and satisfaction. Limited adequately powered data exist on patient- or surgery-specific predictors of final ankle motion after TAA. The purpose of this study was to identify risk factors associated with postoperative stiffness following TAA.
Methods: We retrospectively reviewed 379 consecutive primary TAAs performed by a single surgeon between 2010 and 2023 with minimum 2-year follow-up. Patients were identified through CPT code search, and 165 met inclusion criteria of ≥1-year postoperative follow-up radiographs and documented preoperative ROM.
Data collected included demographics (age, sex, BMI), comorbidities (diabetes, smoking, alcohol use, Charlson comorbidity index), surgical history, and adjuvant procedures such as gastrocnemius recession (GR) or tendo Achilles lengthening (TAL). Weight-bearing lateral radiographs in maximal dorsiflexion and plantarflexion were used to calculate total ROM. Preoperative ROM was classified as full (≥20° dorsiflexion) or limited.
Comparisons were made between pre-op full vs. limited ROM groups and final follow-up full vs. limited ROM groups. T-tests or Mann-Whitney U tests were used for continuous variables and chi-square or Fisher’s exact tests for categorical data. Multivariable logistic regression was performed to identify independent predictors of final stiffness.
Results: The cohort included 168 patients with a mean age of 64 and BMI 30.7. Preoperatively, 64 patients (38.8%) demonstrated full ROM, and 101 (61.2%) had limited ROM. Patients with prior ankle surgery were more likely to have limited pre-op ROM (57% vs. 34.4%, p=0.009). At final follow-up of a mean 3 years (range 365-3410 days), 63 patients (38.2%) achieved full ROM, while 102 (61.8%) were limited. Patients with full preop ROM were more likely to achieve greater dorsiflexion (19.5 vs 16.5, p = 0.001) and full ROM at final follow up (52.4% vs. 30.4%, p=0.008). Adjuvant procedures were less common in patients who achieved full ROM (24.5% vs. 9.5%, p=0.029). In the regression model, preoperative ROM was the only significant predictor of achieving full final ROM.
Conclusion: Preoperative ROM was the strongest predictor of final postoperative stiffness following TAA. Patients with limited pre-op motion were significantly less likely to regain full ROM, while traditional comorbidities such as diabetes, BMI, and smoking were not associated with stiffness. These findings emphasize the importance of preoperative motion assessment and patient counseling. Future work should evaluate targeted surgical and rehabilitation strategies to improve motion recovery in high-risk patients.
Introduction/Purpose: One of the main surgical treatments for ankle arthritis is arthrodesis. Mixed results are reported in the literature regarding which technique is superior: open arthrodesis or arthroscopic arthrodesis. This systematic review aims to report and summarize all available literature on this topic.
Methods: Two independent authors performed a systematic literature search using the following databases: PubMed, Embase, and the Cochrane Library. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) protocol and the Cochrane Handbook guidelines were followed. The search criteria were for open and arthroscopic ankle arthrodesis. The MINORS score criteria were used to evaluate the strength and quality of the selected studies.
Results: A total of 19 studies including 719 open and 835 arthroscopic arthrodesis were included. Average age and BMI for the open and arthroscopic groups were 56.6 and 56.8 years and 29.3 and 28.8 kg/m2, respectively. A statistically significant lower infection rate 8.5% vs. 1.1% and length of stay 5.4 vs. 3.3 days was found in the arthroscopic group (P = 0.05, 0.05). The union rate was 656 (91.2%) and 793 (94.9%) for the open and arthroscopic groups. Revision procedures were required in 40 open procedures (5.9%) and 28 arthroscopic procedures (3.5%); additional revision surgery (excluding revisions) was required after 89 open (13.2%) and 55 arthroscopic (6.9%) arthrodesis surgeries. A total complication rate of 41% and 20.4% was reported among the open and arthroscopic groups, respectively.
Conclusion: Both open and arthroscopic ankle arthrodesis surgeries are safe and effective treatments for ankle arthritis. This systematic review found with significance a lower infection rate and length of stay for the arthroscopic group. We hope the current review will help surgeons’ when planning surgical management for patients with severe ankle arthritis.
Revision of Failed Total Ankle Arthroplasty to a Low-Profile Transfibular Trabecular Metal Prosthesis
Jonathan Day, MD, MS; Kevin Schafer, MD; Daniel Choi, MD; Katherine Convery, BS; Zijun Zhang, MD, PhD; Lew Schon, MD
Category: Ankle Arthritis; Ankle
Keywords: Trabecular Metal Total Ankle; Revision Ankle Arthroplasty; Transfibular Approach
Introduction/Purpose: Revision total ankle arthroplasty (TAA) is a technically challenging procedure with increasing demand. Modes of primary TAA failure requiring revision most commonly include aseptic loosening, instability, component migration and less commonly, periprosthetic infection. The management of inadequate bone stock after explantation of primary components as well soft tissue compromise from repeat surgical exposure pose great difficulties during revision procedures. Conversion to arthrodesis and/or amputation, traditionally have been and still are options within the treatment algorithm of TAA failure. We believe the management of this problem with transfibular TAA has great potential and has been understudied. This study presents minimum 2 year clinical and radiographic outcomes following revision of failed TAA with transfibular, trabecular metal (TM) TAA.
Methods: A total of 11 ankles (11 patients; average 72.1 years-old; 45% females) were retrospectively identified from October 2012 to June 2023. All patients had presented to the treating surgeon with failed primary or revision TAA (STAR, n=6; Agility, n=2; Salto Talaris, n=2; Infinity, n=1) performed at outside institutions, and were indicated for revision arthroplasty using a transfibular TM prosthesis. Failure included aseptic loosening/subsidence (n=7) and periprosthetic joint infection (PJI, n=4). Patient demographics, comorbidities, and surgical history were recorded. Any complications or reoperations following revision TAA were noted. Pre- and postoperative patient-reported outcomes were assessed using Short Form Health Survey (SF-12) physical (PCS) and mental (MCS) component scores, Ankle Osteoarthritis Scale (AOS), and Visual Analog Scale (VAS). Tibiotalar range of motion (ROM) was assessed on postoperative flexion-extension films, and alignment and incidence of implant subsidence were assessed on standing films.
Results: Average time to revision TM TAA was 9.9 years (range, 2-20); average follow-up from revision TM TAA was 2.9 years (range, 2.1-3.5). All 4 cases with PJI were successfully treated with two-stage revision (explantation with antibiotic spacer followed by TM TAA). There was significant improvement in VAS and AOS Pain (p<0.05). Mean coronal (90.7°) and sagittal (86.1°) alignment was within normal limits. Tibiotalar ROM was 11.4° (range, 4.6-18.9°) dorsiflexion, 12.6° (range, 4.6-24.3°) plantarflexion. There was 1 (9%) revision and 4 (36%) reoperations: 1 revision at 1.5 months for tibial component migration; 1 I&D with polyethylene exchange and implant retention at 4.5 months for deep infection; 1 exostectomy at 6.5 months for tibial exostosis; 2 gutter debridements for impingement.
Conclusion: In patients with failed TAA who wish to avoid fusion or amputation, revision arthroplasty using a transfibular approach can provide a viable treatment option and should be considered. However, it remains a challenging procedure and patients should be counseled regarding the increased risk for reoperations. Longer- term follow-up is needed to determine the durability of revision arthroplasty to TM TAA.
