Talipes Equinovarus in Loeys-Dietz Syndrome.

BACKGROUND: Loeys-Dietz syndrome (LDS) commonly presents with foot deformities, such as talipes equinovarus (TEV), also known as "clubfoot." Although much is known about the treatment of idiopathic TEV, very little is known about the treatment of TEV in LDS. Here, we summarize the clinical characteristics of patients with LDS and TEV and compare clinical and patient-reported outcomes of operative versus nonoperative treatment. METHODS: We identified 47 patients with TEV from a cohort of 252 patients with LDS who presented to our academic tertiary care hospital from 2010 to 2016. A questionnaire, electronic health records, clinical photos and radiographs, and telephone calls were used to collect baseline, treatment, and outcome data. The validated disease-specific instrument was used to determine patient-reported foot/ankle functional limitations after treatment. Patients were categorized into nonoperative and operative groups, with the operative group subcategorized according to whether the posteromedial release was performed. RESULTS: Within our TEV cohort, bilateral TEV was present in 40 patients (85%). Thirty-seven patients underwent surgery (14 involving posteromedial release), and 10 were treated nonoperatively. The operative group had a higher incidence of posttreatment foot/ankle functional limitation (71%) than the nonoperative group (25%) ( P =0.04). The pain was the most common functional limitation (54%). The posteromedial release was associated with a higher incidence of developing hindfoot valgus compared with surgery not involving posteromedial release (43% vs. 8.7%, P =0.04) and compared with nonoperative treatment (43% vs. 0.0%, P =0.02). CONCLUSIONS: We found that patients with LDS have a high incidence of bilateral TEV. Operative treatment was associated with posttreatment foot/ankle functional limitations, and posteromedial release was associated with hindfoot valgus overcorrection deformity. These findings could have implications for the planning of surgery for TEV in LDS patients. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Is Dual Semitendinosus Allograft Stronger Than Turndown for Achilles Tendon Reconstruction? An In Vitro Analysis.

BACKGROUND: Large Achilles tendon defects pose a treatment challenge. The standard treatment with a turndown flap requires a large extensile incision, puts the sural nerve at risk, and demands slow, careful rehabilitation. Dual allograft semitendinosus reconstruction is a new clinical alternative that has the theoretical advantages of a smaller incision, less dissection, and a stronger construct that may allow for faster rehabilitation. QUESTIONS/PURPOSES: In a cadaver biomechanical model, we compared the dual allograft semitendinosus reconstruction with the myofascial turndown in terms of (1) mechanical strength and resistance to deformation and (2) failure mechanisms in reconstruction of large segmental Achilles defects. METHODS: An 8-cm segmental Achilles defect was created in 18 cadaveric lower extremities, nine matched pairs without defect or previous surgery (mean age, 78.4 years; range, 60-97 years; three female and six male pairs). Femoral neck densitometry to determine bone mineral density found that all specimens except two were osteopenic or osteoporotic. Specimens in each pair were assigned to allograft or turndown reconstruction. The constructs were mounted on a load frame and differential variable reluctance transducers were applied to measure deformation. Specimens were preconditioned and then loaded axially. Tensile force and proximal and distal construct deformation were measured at clinical failure, defined as 10 mm of displacement, and at ultimate failure, defined as failure of the reconstruction. Failure mechanism was recorded. RESULTS: Tensile strength at time zero was higher in the allograft versus the turndown construct at clinical failure (156.9 ± 29.7 N versus 107.2 ± 20.0 N, respectively; mean difference, -49.7 N; 95% CI, -66.3 to -33.0 N; p < 0.001) and at ultimate failure (290.9 ± 83.2 N versus 140.7 ± 43.5 N, respectively; mean difference, -150.2 N; 95% CI, -202.9 to -97.6 N; p < 0.001). Distal construct deformation was lower in the turndown versus the allograft construct at clinical failure (1.6 ± 1.0 mm versus 4.7 ± 0.7 mm medially and 2.2 ± 1.0 mm versus 4.8 ± 1.1 mm laterally; p < 0.001). Semitendinosus allograft failure occurred via calcaneal bone bridge fracture in eight of nine specimens. All myofascial turndowns failed via suture pullout through the fascial tissue at its insertion. CONCLUSION: In this comparative biomechanical study, dual semitendinosus allograft reconstruction showed greater tensile strength and construct deformation compared with myofascial turndown in a cadaveric model of large Achilles tendon defects. CLINICAL RELEVANCE: Further study of dual semitendinosus allograft for treatment of severe Achilles tendon defects with cyclic loading and investigation of clinical results will better elucidate the clinical utility and indications for this technique.

The First Tarsometatarsal Joint in Lisfranc Injuries.

BACKGROUND: Lisfranc injuries are among the most debilitating injuries to the foot. Characterization of first tarsometatarsal (TMT) joint involvement in Lisfranc injuries is limited. Multiple studies have indicated that this joint is damaged in a variety of Lisfranc injury patterns, but there is sparse information regarding how often and in what form. METHODS: A retrospective review was performed of operative Lisfranc fractures from 2010 to 2020 with patients identified by Combined Procedural Terminology codes. Hardcastle and Myerson Lisfranc injury classifications and computed tomography and radiograph characterizations of the first TMT joint were evaluated by 3 foot and ankle fellowship-trained orthopaedic surgeons. Radiographic characteristics were collected. Light's kappa coefficient evaluated interrater reliability for injury classification. Injury mechanism and Lisfranc classification effects on the first TMT joint were further assessed using inferential statistics. RESULTS: Of 71 patients with a Lisfranc injury of which 37 (52%) were high energy, 61 (86%) showed radiographic evidence of first TMT joint injury. A fragment was present in the TMT articular surface in 33 (47%) with median size = 8.7 mm and medial capsular avulsion in n = 25 (35%). Forty-eight patients (68%) had medial/lateral TMT joint incongruence ≥2 mm (median overhang = 4 mm), 21 (30%) had dorsal/plantar incongruence (median overhang = 6 mm). Angulation of TMT articular surfaces ≥5 degrees on the transverse/anteroposterior plane occurred in n = 32 (45%) and in n = 12 (17%) on the sagittal/lateral plane, which significantly differed between classifications (P = .020). CONCLUSION: The overwhelming majority of Lisfranc midfoot injuries seen at our tertiary referral center had imaging evidence of damage to the first TMT joint (86%), and the incidence may be higher. The most common patterns of first TMT joint involvement we found were joint incongruity, articular surface fractures, angulation of the articular surfaces, and medial capsular ligament avulsion fractures. A better understanding of injuries to the first TMT joint can help orthopaedic surgeons with diagnosis.

Factors Associated With Nonunion and Infection Following Ankle Arthrodesis Using a Large Claims Database: Who Has Elevated Risk?

Background: Complications such as nonunion and infection following ankle arthrodesis can lead to increased patient morbidity and financial burden from repeat operations. Improved knowledge of risk factors can improve patient selection and inform post-ankle arthrodesis surveillance protocols. Methods: This is a large retrospective, database study with structured query of a national insurance claims database (PearlDiver Technologies) for patients treated with ankle arthrodesis from 2015 to 2019 as identified by International Classification of Diseases, Tenth Revision (ICD-10), codes. Patients with any operation 1 year prior to or following ankle arthrodesis were excluded from analysis to prevent attributing complications to another operation. Likelihoods of nonunion and infection within 1 year and 3 years following ankle arthrodesis were analyzed using Kaplan-Meier estimations. Patient characteristics associated with the identified complications following ankle arthrodesis were analyzed using multivariable logistic regression analyses. Results: Our query yielded 2463 patients in the 5-year period who underwent ankle arthrodesis. Nonunion occurred in 11% (95% CI 10-12) of patients within 1 year of ankle arthrodesis and 16% (95% CI 14-17) of patients within 3 years. Infection occurred in 3.9% (95% CI 3.1-4.7) of patients within 1 year of ankle arthrodesis and in 6.2% (95% CI 5.1-7.2) of patients within 3 years. Obese patients increased odds of nonunion on multivariable analysis (OR 1.6, 95% CI 1.3-2.0; P < .001). On multivariable analysis, diabetes (OR 1.7, 95% CI 1.2-2.6; P = .010) and each 1-unit increase in Elixhauser Comorbidity Index scores (OR 1.1, 95% CI 1.1-1.2; P < .001) contributed to increased odds of infection after ankle arthrodesis. Conclusion: Nonunion and infection following ankle arthrodesis have a 3-year probability of 16% and 6%, respectively. More than one-quarter of patients with nonunion following ankle arthrodesis experience a delay in diagnosis beyond 1 year. The risk of post-ankle arthrodesis nonunion is highest in patients with obesity; the risk of post-ankle arthrodesis infection is highest in patients with diabetes or an elevated Elixhauser Comorbidity Index score. Level of Evidence: Level III, prognostic study.

A 10-Year Review of Designated Leadership Positions of the American Orthopaedic Foot & Ankle Society (AOFAS).

Background: In 2019 the majority of US medical students were women (50.5%). However, despite this representation, female representation within orthopaedic surgery remains low when compared to male counterparts. Previously, the American Society for Surgery of the Hand (ASSH) and Pediatric Orthopaedic Society of North America (POSNA) published their gender diversity data. No such study has been conducted in the American Orthopaedic Foot & Ankle Society (AOFAS), which is the largest membership organization for foot and ankle-trained orthopaedic surgeons. This study sought to investigate whether increased female representation in the AOFAS membership roster is reflected in different levels within the organization. Methods: The 2012-2022 membership rosters were obtained from the AOFAS and compared by gender. Volunteer, elected, and appointed leadership positions as well as rates of engagement were compared for each of the activities. Leadership positions were defined as committee chair, vice chair, or board of directors (BOD). When available, time for advancement through leadership positions to the presidential role was analyzed by gender. Comparative data were available for 2 other respective subspecialty groups, ASSH and POSNA, from previously published studies. Results: Between 2012 and 2022, the percentage of female membership in the AOFAS has continued to increase from 7.5% (n=76) to 13% (n=163). Engagement in committee membership positions during this time has more than doubled from 11 of 26 (14.4%) to 57 of 163 (34.9%). When participation trends were evaluated by gender, women showed higher rates of committee involvement than their male counterparts. In 2021 compared to 2012, the percentage of female committee members more than doubled compared with their male counterparts (female 34.9% to male 23.2% vs female 14.4% to male 16.8%). This increase in female gender committee composition trend has been seen in the ASSH and POSNA, but it is more pronounced in the AOFAS. Representation of women in committee chair positions and elected positions has not seen this same parallel increase. Conclusion: The female membership of the AOFAS has a similar gender composition to other orthopaedic subspecialities. Female membership within the society has increased over the past 10 years. The rates of female involvement within committee membership positions have seen a parallel increase. It will take time to mature into leadership roles as we continue to increase diversity within our respective subspecialty organizations. Inception of the AOFAS Diversity Equity and Inclusion and Women's Subcommittee demonstrate a continued emphasis on this core value within the society. Level of Evidence: Level IV, cohort study.