Incidence and predictors of valgus tibiotalar tilt after progressive collapsing foot deformity reconstruction using subtalar fusion with concomitant procedures.

PURPOSE: Development of valgus tibiotalar tilt is a significant complication after subtalar fusion for progressive collapsing foot deformity (PCFD) correction. However, its incidence and etiologic factors have not been extensively studied. The purpose of this study was to define the incidence of valgus tibiotalar tilt after subtalar fusion for PCFD reconstruction, and to determine predictors of this complication. METHODS: This study included 59 patients who underwent PCFD reconstruction with subtalar fusion. Patients with tibiotalar tilt prior to surgery were excluded. On standard weightbearing radiographs, the talonavicular coverage angle, talo-1st metatarsal angle, calcaneal pitch, hindfoot moment arm (HMA), and medial distal tibial angle were measured. Weightbearing computed tomography (WBCT) was used to determine the presence of lateral bony impingement. A radiologist evaluated the superficial and deep deltoid ligaments using magnetic resonance imaging (MRI). Univariate regression analysis was used to identify the factors associated with development of postoperative valgus tibiotalar tilt, defined as tilt > 2 degrees. RESULTS: Seventeen patients (28.8%) developed postoperative valgus tibiotalar tilt at a mean of 7.7 (range 2-31) months. Eight (47.1%) of these patients developed valgus tibiotalar tilt within 3 months. Univariate logistic regression demonstrated association between preoperative HMA and postoperative valgus tibiotalar tilt (odds ratio 1.06, P = 0.026), with a 6% increase in risk per millimeter of increased HMA. Deltoid ligament status and concomitant procedures on other joints did not correlate with postoperative valgus tilt. CONCLUSION: Our findings indicate that surgeons should be cognizant of patients with a greater degree of preoperative hindfoot valgus and their propensity to develop a valgus ankle deformity. Additionally, our relatively high incidence of valgus tibiotalar tilt suggests that weightbearing ankle radiographs should be included in the initial and subsequent follow-up of PCFD patients with hindfoot valgus treated with subtalar fusion.

Lower limb alignment in patients with primary valgus ankle arthritis: A comparative analysis with patients with varus ankle arthritis and healthy controls.

BACKGROUND: While it is commonly acknowledged that the combined effect of lower limb orientation and ankle and hindfoot alignment play a fundamental role in ankle arthritis, supramalleolar/lower limb alignment has received less attention in valgus ankle arthritis. The purpose of this study was to analyze the lower limb alignment of patients with valgus ankle arthritis with primary origin, compared to that of varus ankle arthritis and normal controls. We hypothesized that patients with valgus ankle arthritis would have the opposite pattern of lower limb alignment as those with varus ankle arthritis. METHODS: A retrospective radiographic analysis was performed on 61 patients (62 ankles, mean age, 59.3 ± 12 years) with primary valgus ankle arthritis. On preoperative radiographs, seven parameters, including talar tilt angle, medial distal tibial angle (MDTA), talar center migration, anterior distal tibial angle, talo-first metatarsal (Meary's) angle, hindfoot moment arm (HMA), and mechanical axis deviation (MAD), were measured and compared to those of primary varus ankle arthritis (n = 55; mean age, 59.7 ± 8.1 years) and control patients (n = 59; mean age, 29.3 ± 7.3 years). RESULTS: The valgus group had a significantly lower mean MDTA than the control group (p < 0.0001), indicating a varus distal tibial plafond in comparison to the control group. Meary's angle and HMA were significantly lower in the valgus group compared to the varus group (p < 0.05 and p < 0.0001, respectively), indicating a lower medial longitudinal arch and valgus hindfoot alignment. On whole limb radiographs, the valgus group showed a greater MAD than the control group, indicating varus lower limb alignment (p < 0.05). However, the MAD did not differ significantly between the valgus and varus groups (p = 0.7031). CONCLUSION: Our findings indicate that a significant proportion of ankles with primary valgus arthritis have a varus tibial plafond and a varus lower limb mechanical axis. This study contributes to our understanding of primary valgus ankle arthritis and suggests that lower limb alignment should be analyzed and considered throughout valgus ankle arthritis realignment procedures.

The influence of concomitant hammertoe correction on postoperative outcomes in patients undergoing hallux valgus correction.

BACKGROUND: Patients with hallux valgus often develop secondary hammertoe deformities of the lesser toes. Operative management of bunions with hammertoe can be more extensive; however, it is unclear whether this affects patient-reported outcomes. The aim of this study was to compare postoperative patient-reported outcome measures and radiographic outcomes between patients who underwent isolated bunion correction and patients who underwent simultaneous bunion and hammertoe correction. METHODS: Preoperative, postoperative, and change in Patient-Reported Outcomes Measurement Information System (PROMIS) scores were compared between patients who underwent isolated hallux valgus correction and those who underwent concomitant hammertoe correction. Radiographic measures including hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal-articular angle (DMAA), and Meary's angle were also compared. Targeted minimum-loss estimation (TMLE) was used for statistical analysis to control for confounders. RESULTS: A total of 221 feet (134 isolated bunion correction, 87 concomitant hammertoe correction) with a minimum of 12 months follow-up were included in this study. Both cohorts demonstrated significant improvements in the physical function, pain interference, pain intensity, and global physical health PROMIS domains (all p < 0.001). However, patients in the concomitant hammertoe cohort had significantly less improvements in pain interference and pain intensity (p < 0.01, p < 0.05 respectively). The concomitant hammertoe cohort also had significantly higher postoperative pain interference scores than the isolated bunion cohort (p < 0.01). Radiographic outcomes did not differ between the two groups. CONCLUSION: While both isolated bunion correction and concomitant hammertoe correction yielded clinically significant improvements in patient reported outcomes and normalized radiographic parameters, patients undergoing simultaneous bunion and hammertoe correction experienced substantially less improvement in postoperative pain-related outcomes than those who underwent isolated bunion correction.

Mid-term functional outcomes following reoperation after total ankle arthroplasty: A retrospective cohort study.

BACKGROUND: Despite a significant reported rate of non-revision reoperation after total ankle arthroplasty (TAA), it is uncertain if these subsequent procedures have an impact on the longer term outcomes. This study aimed to compare minimum five-year functional outcomes of patients who had undergone reoperation after TAA to those who did not require reoperation. METHODS: Seventy-six ankles (74 patients) who underwent TAA with the Salto Talaris fixed bearing system between 2007 and 2014 were allocated into two groups based on presence (n = 16) or absence of reoperation (n = 60). Reoperations included all secondary procedures after index TAA, excluding revision surgeries requiring removal or exchange of the original prosthesis. The foot and ankle outcome score (FAOS) at preoperative and minimum five-year follow-up was compared between the groups. Additionally, improvements in FAOS subscales were compared. Preoperative deformity, postoperative implant alignment, number of periprosthetic cysts, and subsidence between groups were compared using standard weightbearing radiographs. RESULTS: The most common cause of reoperation was gutter impingement (n = 11), followed by stress fracture of the medial malleolus (n = 2), tarsal tunnel syndrome (n = 1), periprosthetic cyst (n = 1), and infection (n = 1). In comparison to the non-reoperation group, all FAOS subscales except for the Sports and Recreational Activities subscale were significantly lower in the reoperation group at final follow-up. The reoperation group exhibited significantly less improvement in the Pain, Symptoms, and Quality of Life subscales at final follow-up (p < 0.05). There were no statistical differences in the radiographic parameters between both groups. CONCLUSIONS: Patients who underwent reoperation after TAA demonstrated inferior functional outcomes at mid-term follow-up. An emphasis should be placed on preventing possible causes of reoperations to achieve favorable patient outcomes. Additionally, if a reoperation is deemed necessary, a thorough evaluation and surgical correction of underlying causes should be achieved.

Leveraging splice-affecting variant predictors and a minigene validation system to identify Mendelian disease-causing variants among exon-captured variants of uncertain significance.

The genetic heterogeneity of Mendelian disorders results in a significant proportion of patients that are unable to be assigned a confident molecular diagnosis after conventional exon sequencing and variant interpretation. Here, we evaluated how many patients with an inherited retinal disease (IRD) have variants of uncertain significance (VUS) that are disrupting splicing in a known IRD gene by means other than affecting the canonical dinucleotide splice site. Three in silico splice-affecting variant predictors were leveraged to annotate and prioritize variants for splicing functional validation. An in vitro minigene system was used to assay each variant's effect on splicing. Starting with 745 IRD patients lacking a confident molecular diagnosis, we validated 23 VUS as splicing variants that likely explain disease in 26 patients. Using our results, we optimized in silico score cutoffs to guide future variant interpretation. Variants that alter base pairs other than the canonical GT-AG dinucleotide are often not considered for their potential effect on RNA splicing but in silico tools and a minigene system can be utilized for the prioritization and validation of such splice-disrupting variants. These variants can be overlooked causes of human disease but can be identified using conventional exon sequencing with proper interpretation guidelines.

Does the Presence of Asymptomatic Flatfoot Deformity Impact the Clinical and Radiographic Outcomes of the Minimally Invasive Chevron and Akin Bunionectomy?

BACKGROUND: Flatfoot deformity is believed to play a role in hallux valgus development and recurrence. While symptomatic flatfoot deformity can be treated with separate procedures at the time of hallux valgus correction, the question remains whether the patient undergoing correction of a symptomatic hallux valgus deformity should have their asymptomatic flatfoot concurrently addressed. We aimed to investigate whether the presence of asymptomatic flatfoot influences patient-reported and radiographic outcomes of the minimally invasive chevron and Akin bunionectomy. METHODS: A total of 104 patients were included in this study. Forty-two asymptomatic patients met the radiographic criteria for flatfoot while 62 had a normal arch. Patient-reported outcomes were evaluated and compared between the two groups using validated PROMIS measures preoperatively and at a minimum one-year postoperatively. Radiographic outcomes including hallux valgus angle (HVA), intermetatarsal angle (IMA), Meary's angle, calcaneal pitch (CP), and talonavicular coverage angle (TNCA) were measured and compared preoperatively and minimum six-months postoperatively. RESULTS: Both groups demonstrated similar preoperative and postoperative PROMIS scores with significant improvements in physical function, pain interference, pain intensity, and global physical health. Preoperatively, HVA was similar between both groups, however the flatfoot group showed a greater IMA, Meary's angle, TNCA, and lower CP. Postoperatively, HVA and IMA were similar between groups, although patients in the flatfoot group retained a significantly greater Meary's angle, TNCA, and lower CP. Both groups showed significant improvements in HVA, IMA, and TNCA. CONCLUSION: Our study indicates that the minimally invasive chevron and Akin bunionectomy leads to improved clinical and radiographic hallux valgus outcomes without adversely impacting radiographic flatfoot parameters. Therefore, the MIS bunionectomy may be an effective option for hallux valgus correction in patients with mild, asymptomatic flatfoot. LEVEL OF EVIDENCE: Level III, retrospective cohort.

A Patient-Reported Outcome-Based Comparison of Cheilectomy With and Without Proximal Phalangeal Dorsiflexion Osteotomy for Hallux Rigidus.

INTRODUCTION: This study provides the first comparison of patient-reported outcomes between isolated cheilectomy (C) and cheilectomy with Moberg (CM) osteotomy for hallux rigidus. METHODS: A single-center, retrospective registry search identified all patients with preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores who underwent cheilectomy, with and without concomitant proximal phalangeal dorsiflexion osteotomy, for hallux rigidus between January 2016 and December 2020. Because there were far fewer isolated cheilectomies (62), all C patients were compared with a commensurate number of consecutive CM cases (67) using preoperative, 1-year, and 2-year PROMIS scores for physical function, pain interference, pain intensity, global physical health, global mental health, and depression, as well as complication and revision data from a chart review. A multivariable linear regression analysis was performed to compare adjusted postoperative PROMIS scores between the 2 cohorts. RESULTS: There were no differences between groups among the demographic and preoperative variables compared. The CM cohort reported worse pain interference scores preoperatively (P < .001) and at 1 year postoperatively (P = .01). However, the C cohort reported worse pain intensity scores preoperatively (P < .001) and at 1 year postoperatively (P < .001). Adjusted postoperative PROMIS score comparison demonstrated that the CM cohort had better 1-year postoperative pain intensity scores (P < .05). However, there were no differences between cohorts for additional PROMIS scores or complications data. CONCLUSION: The addition of a Moberg osteotomy does not appear to significantly change short- to medium-term outcomes of cheilectomy for hallux rigidus treatment. LEVELS OF EVIDENCE: Level III: Retrospective comparative study.

Realignment Surgery for Failed Osteochondral Autologous Transplantation in Osteochondral Lesions of the Talus Associated With Malalignment.

BACKGROUND: While osteochondral autologous transplantation (OAT) offers favorable results in most patients with osteochondral lesions of the talus (OLT), some patients continue to experience persistent pain following the procedure. Information regarding the etiology of this pain and outcomes of revision surgery are limited. This study aimed to report results of revision surgery with realignment procedures in patients with failed OAT who demonstrated concomitant malalignment at the distal tibia or hindfoot. METHODS: Eight patients (8 ankles), who had been experiencing persistent pain for more than 1 year following OAT, underwent realignment procedures during revision surgery. All patients underwent primary OAT for the treatment of medial OLTs. Patients were divided into 2 groups based on the main location of deformity: the supramalleolar realignment group (SRG, 5 ankles) and the hindfoot realignment group (HRG, 3 ankles). No direct procedure was performed on the osteochondral lesion at the time of revision surgery. Ankle and hindfoot alignment were evaluated using 6 parameters in weightbearing radiographs. Computed tomography (CT) was used to assess for medial gutter narrowing, spur formation, and cyst volume around transplanted osteochondral plug preoperatively and postoperatively. Clinical outcomes were assessed using Foot Function Index and Visual Analogue Scale. RESULTS: All patients had medial gutter narrowing or spur formation, which are early signs of ankle arthritis. The SRG had varus distal tibial alignment with a median medial distal tibial angle of 85.7 degrees (interquartile range [IQR], 3.2). The HRG had valgus hindfoot alignment and a lower medial longitudinal arch with a median hindfoot moment arm of 8.4 mm (IQR, 6.1) and a median Meary's angle of 11.8 degrees (IQR, 1.4). Spontaneous restoration of the osteochondral lesion was observed after realignment surgery, with cyst volume decreasing from 0.2592 to 0.0873 cm3 (P < .05). Clinical scores improved in all patients. CONCLUSION: The current study demonstrates the effectiveness of realignment surgery in a selected patient group who experienced persistent pain and showed radiographic evidence of malalignment after primary OAT. Our study provides evidence supporting the use of realignment procedures in these cases, with results indicating improved patient-reported outcomes and spontaneous restoration of osteochondral lesions. LEVELS OF EVIDENCE: Level IV: Case series.

Axial Plane Rotation of the Talus in Progressive Collapsing Foot Deformity: A Weightbearing Computed Tomography Analysis.

BACKGROUND: Progressive collapsing foot deformity (PCFD) is recognized as a 3-dimensional deformity centered around the talus. Previous studies have described some features of talar motion in the ankle mortise in PCFD, such as sagging in the sagittal plane or valgus tilt in the coronal plane. However, axial plane alignment of the talus in the ankle mortise in PCFD has not been investigated extensively. The purpose of this study was to examine this axial plane alignment of PCFD vs controls using weightbearing computed tomography (WBCT) images and to determine if talar rotation in the axial plane is associated with increased abduction deformity, as well as to assess the medial ankle joint space narrowing in PCFD that may be associated with axial plane talar rotation. METHODS: Multiplanar reconstructed WBCT images of 79 patients with PCFD and 35 control patients (39 scans) were retrospectively analyzed. The PCFD group was divided into 2 subgroups depending on preoperative talonavicular coverage angle (TNC): moderate abduction (TNC 20-40 degrees, n=57) and severe abduction (TNC >40 degrees, n=22). Using the transmalleolar (TM) axis as a reference, the axial alignment of the talus (TM-Tal), calcaneus (TM-Calc), and second metatarsal (TM-2MT) were calculated. Difference between TM-Tal and TM-Calc was calculated to examine talocalcaneal subluxation. A second method to assess talar rotation within the mortise utilized an angle between the lateral malleolus and the talus (LM-Tal) in the axial slices of WBCT. In addition, the prevalence of medial tibiotalar joint space narrowing was assessed. These parameters were compared between the control and PCFD groups, and between moderate and severe abduction groups. RESULTS: The talus was significantly more internally rotated with respect to the ankle TM axis and the lateral malleolus in PCFD patients compared to controls, and in the severe abduction group compared with the moderate abduction group, using both measurement methods. Axial calcaneal orientation did not differ between groups. There was significantly greater axial talocalcaneal subluxation in the PCFD group, and this was also greater in the severe abduction group. The prevalence of medial joint space narrowing was higher in PCFD patients. CONCLUSION: Our findings suggest that talar malrotation in the axial plane should be considered an underlying feature of abduction deformity in PCFD. The malrotation occurs in both the talonavicular and ankle joints. This rotational deformity should be corrected at the time of reconstructive surgery, especially in cases of severe abduction deformity. In addition, medial ankle joint narrowing was observed in PCFD patients, with a higher prevalence of medial ankle joint narrowing in those with severe abduction. LEVEL OF EVIDENCE: Level III, case-control study.

Clinical Outcomes of the Lateral Trabecular Metal Total Ankle Replacement at a 5-Year Minimum Follow-up.

BACKGROUND: The Trabecular Metal (Zimmer Biomet, Warsaw, IN) total ankle arthroplasty (TAA) system uses a lateral approach with a fibular osteotomy to gain access to the tibiotalar joint and a sagittally curved tibial component. This is the first TAA system to laterally approach the ankle, and few studies have explored outcomes associated with this implant. This study aimed to report the 5-year clinical and radiographic outcomes as well as the survivorship of the implant. METHODS: Over a 3-year period, 2 fellowship-trained foot and ankle surgeons used this implant system to treat 38 end-stage arthritic ankles. Reoperation and revision data were collected from all patients (100%) as part of the local prospective database. Patients completed the Foot and Ankle Outcome Score (FAOS) questionnaire preoperatively and at each annual follow-up visit; scores for a minimum of 5 years were available for 28 (73.7%) patients. A radiographic analysis compared postoperative coronal and sagittal alignment in weightbearing radiographs at a minimum of 5 years with that at 3 months postoperatively, as well as cyst or lucency formation, which was available for 21 patients (55.3%). RESULTS: At 5 years, there were 3 revisions (7.9%) and 9 reoperations (23.7%). Reoperations included 4 fibular hardware removal and 5 medial gutter debridement procedures. The FAOS significantly improved for all domains (P < .05). Implant positioning did not significantly change between 3 months and 5 years postoperatively. CONCLUSION: Our 5-year results in this small series using this unique prosthesis showed good overall survivorship (92.1%) and a reoperation rate of 23.7%, along with clinically significant improvement in patient-reported outcomes. LEVELS OF EVIDENCE: Level IV: Retrospective case series.

Midterm Clinical Outcomes, Radiographic Outcomes, and Survivorship of the Infinity Total Ankle Arthroplasty.

BACKGROUND: The Infinity Total Ankle Arthroplasty (Stryker, Mahwah, NJ) is a low-profile fixed-bearing implant first introduced in 2014. Although the short-term survivorship (2-4 years follow-up) and complication rates of the Infinity TAA have been reported, there are limited midterm outcome reports. The aim of this study was to describe the survivorship and clinical outcomes of a single-center experience with the Infinity implant at minimum 5-year follow-up. METHODS: Retrospective review of 65 ankles that underwent primary total ankle arthroplasty (TAA) with the Infinity implant was conducted. Mean clinical follow-up was 6.5 years (range, 5.0-8.0). Preoperative and postoperative radiographs were measured to assess tibiotalar alignment, periprosthetic lucencies, and cysts. Preoperative, 2-year, and 5-year postoperative Foot and Ankle Outcome Score (FAOS) subscores were compared to assess midterm clinical outcomes. Survivorship assessment was determined by removal of 1 or both metallic implant components. RESULTS: Survivorship of the implant was 93.8% at final follow-up. There were 4 revisions: 2 for tibial implant loosening, 1 for talar loosening, and 1 for loosening of both components. Three of the 4 revisions occurred within the first 2 years following implantation, and the last failure occurred at 7 years postoperatively. There were 11 reoperations in 10 (15%) ankles and 3 wound complications. There were 17 ankles (26.2%) with radiographic abnormalities around the implants, including 14 cases with tibial component lucencies and 4 cases of periimplant cysts. FAOS outcome measurement showed general stability between 2 and 5 years and substantial improvement from preoperative status. CONCLUSION: To date this study is the largest midterm report on the Infinity total ankle prosthesis, with 65 implants at a mean follow-up of 6.5 years. We found good midterm implant survivorship, and patients experienced significant improvements in FAOS outcome scores and radiographic alignment at final follow-up. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Risk Factors Associated With Worse Clinical Outcomes of Ankle Fractures Involving the Posterior Malleolus.

Background: Ankle fractures involving the posterior malleolus (PM) tend to result in inferior clinical outcomes compared to other ankle fractures. However, it is unclear which specific risk factors and fracture characteristics are associated with negative outcomes in these fractures. The aim of this study was to identify risk factors for poor postoperative patient-reported outcomes in patients with fractures involving the PM. Methods: This retrospective cohort study included patients who sustained ankle fractures involving the PM between March 2016 and July 2020 and had preoperative computed tomography (CT) scans. In total, 122 patients were included for analysis. One patient (0.8%) had an isolated PM fracture, 19 (15.6%) had bimalleolar ankle fractures involving the PM, and 102 (83.6%) had trimalleolar fractures. Fracture characteristics including the Lauge-Hansen (LH) and Haraguchi classifications and posterior malleolar fragment size were collected from preoperative CT scans. Patient Reported Outcome Measurement Information System (PROMIS) scores were collected preoperatively and at a minimum of 1 year postoperatively. The association between various demographic and fracture characteristics with postoperative PROMIS scores was assessed. Results: Involvement of more malleoli was associated with worse PROMIS Physical Function (P = .04), Global Physical Health (P = .04), and Global Mental Health (P < .001), and Depression scores (P = .001). Elevated BMI was also associated with worse PROMIS Physical Function (P = .0025), Pain Interference (P = .0013), and Global Physical Health (P = .012) scores. Time to surgery, fragment size, Haraguchi classification, and LH classification were not associated with PROMIS scores. Conclusion: In this cohort, we found that trimalleolar ankle fractures were associated with inferior PROMIS outcomes compared with bimalleolar ankle fractures involving the PM in multiple domains. Level of Evidence: Level III, retrospective cohort study.

Clinical Outcomes of Revision Surgery Using a Dorsal Approach After Failed Primary Interdigital Neuroma Excision.

BACKGROUND: Revision neurectomy may be approached with either a dorsal or a plantar incision. Although a plantar approach is more commonly described, few studies have investigated outcomes following a dorsal revision neuroma excision. In this study, we performed a case series on a group of patients who underwent revision neuroma excision through a dorsal approach and reported complications and outcomes using validated patient-reported outcome measures (PROMs). METHODS: This retrospective case series included 10 patients who underwent a dorsal-approach revision neuroma excision and had preoperative and minimum 1-year postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores. Complications including neuroma recurrence and continued unresolved pain were obtained from the electronic medical record. Preoperative and postoperative PROMIS scores were compared to assess improvement in PROMs. RESULTS: There were significant improvements in the PROMIS pain interference (P = .026), pain intensity (P = .008), and global physical health (P = .017) domains. One patient experienced recurrence of their neuroma 4 years after surgery. CONCLUSION: This case series provides preliminary data indicating that revision neurectomy using a dorsal approach leads to satisfactory outcomes in pain-related PROMs. Further research with comparative study designs is necessary to determine if one approach is superior to the other. LEVELS OF EVIDENCE: Level IV: Retrospective.

Impact of Asymptomatic Flatfoot on Clinical and Radiographic Outcomes of the Modified Lapidus Procedure in Patients With Hallux Valgus.

Background: Patients with hallux valgus commonly present with concomitant flatfoot deformity. First-ray hypermobility, among other biomechanical factors, has been suggested as a potential link between these deformities. However, not all hallux valgus patients exhibit symptoms associated with flatfoot deformity, and the necessity of correcting the asymptomatic flatfoot at the time of hallux valgus correction is unclear. We aimed to investigate the relationship between asymptomatic flatfoot and patient-reported and radiographic outcomes after the Lapidus procedure. Methods: This study included 142 patients who underwent the Lapidus procedure for hallux valgus at a single institution. Sixty-one patients met radiographic criteria for flatfoot. No patients exhibited symptoms related to flatfoot deformity on review of clinical notes. Preoperative, minimum 1-year postoperative, and change in Patient-Reported Outcomes Measurement Information System (PROMIS) scores between asymptomatic flatfoot and control groups were compared. Radiographic outcomes including hallux valgus angle (HVA), intermetatarsal angle (IMA), Meary angle, talonavicular coverage angle (TNCA), and calcaneal pitch (CP) were compared. Results: Preoperatively, the flatfoot group had higher BMI 22.6 vs 24.6 (P < .01) and IMA 15.32 vs 14.0 degrees (P < .05). Both groups demonstrated preoperative to postoperative improvement in PROMIS physical function (P < .01), pain interference (P < .001), pain intensity (P < .001), and global physical health (P < .001). There were no preoperative or postoperative differences in PROMIS scores between groups. Postoperatively, there were no differences in HVA or IMA between groups; however, the flatfoot group exhibited greater deformity in Meary angle, TNCA, and CP (all P < .001). Conclusion: There were no significant postoperative differences in patient-reported outcomes of the Lapidus procedure between patients with and without asymptomatic flatfoot, and both groups achieved similar radiographic correction of their hallux valgus deformity. The Lapidus procedure appears to be a reasonable surgical option for hallux valgus correction in patients with asymptomatic flatfoot deformity.Level of Evidence: Level III, retrospective cohort study.

Relationship Between Preoperative PROMIS Scores and Postoperative Outcomes in Hallux Rigidus Patients Undergoing Cheilectomy.

BACKGROUND: Previous studies have demonstrated that preoperative patient-reported outcome measures are associated with postoperative outcomes in foot and ankle surgery, and also in specific procedures such as bunionectomy, flatfoot reconstruction, and total ankle replacement. The primary purpose of this study was to determine if preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function, pain interference, pain intensity, and depression scores were associated with the ability of patients undergoing cheilectomy for hallux rigidus to achieve a minimal clinically important difference (MCID) of improvement. METHODS: This retrospective study included preoperative and ≥2-year postoperative PROMIS physical function, pain interference, pain intensity, and depression scores for 125 feet in 118 patients undergoing cheilectomy collected from an institutional review board (IRB)-approved foot and ankle registry database. MCIDs were established using distribution-based methods to determine clinical significance of improvements in PROMIS scores. Receiver operating characteristic (ROC) curves and area under the curve analyses were used to determine which preoperative PROMIS scores were associated with patients meeting the MCID. RESULTS: ROC analysis found statistically significant areas under the curve (AUCs) for the physical function domain (AUC 0.71), pain intensity (AUC 0.70), and depression (AUC 0.79) PROMIS domains. Subsequent analyses were unable to identify clinically useful 95% sensitivity and specificity preoperative thresholds, with the exception of the 95% sensitivity PROMIS physical function threshold. A preoperative physical function score of greater than 53.2 resulted in a 63% probability of achieving the MCID. The pain interference PROMIS domain did not demonstrate a statistically significant AUC. CONCLUSION: Preoperative PROMIS physical function, pain interference, pain intensity, and depression scores are minimally associated with preoperative to 2-year postoperative improvement in patients undergoing cheilectomy. It may be difficult to determine which patients improve from a cheilectomy based on the severity of symptoms they exhibit preoperatively. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Incidence of Lateral Prominence Pain Following Open Medial Displacement Calcaneal Osteotomy and the Efficacy of Crushplasty as a Preventive Technique.

BACKGROUND: There has been concern about lateral prominence pain at the osteotomy site following medial displacement calcaneal osteotomy (MDCO). However, no study has investigated this complication. This study aimed to investigate the incidence of lateral prominence pain following MDCO and examine the efficacy of crushplasty as a surgical technique to minimize this complication. METHODS: This was a retrospective cohort study in which 137 patients (148 feet) who underwent MDCO were divided into 2 groups by whether they had concurrent crushplasty at the time of MDCO (crushplasty [n = 81] vs noncrushplasty group [n = 67]). Crushplasty was performed by flattening the bony step-off using a rongeur and bone impactor. Lateral prominence pain was defined as pain or irritating symptoms over the osteotomy site that persisted over 12 months after MDCO. The overall incidence of lateral prominence pain after MDCO and within each group was investigated. Multiple logistic regression analysis was used to determine the influence of possible risk factors on the development of postoperative lateral prominence pain. RESULTS: The overall incidence of lateral prominence pain was 9.5% (14 of 148): 3.4% (3 of 87) in the crushplasty group, and 18% (11 of 61) in the noncrushplasty group, and χ2 analysis showed a statistically significant relationship between crushplasty and lateral prominence pain (P < .05). A relationship between the amount of medial displacement and the development of lateral prominence pain was observed in the noncrushplasty group (OR = 5.31, 95% CI 2.35-16.4, P < .05), but this was not observed in the crushplasty group (P = .641). The amount of medial displacement was an independent risk factor for the development of lateral prominence pain (OR = 2.72, 95% CI 1.54-4.79, P < .05), and concurrent crushplasty had a negative relationship with lateral prominence pain development (OR = 0.12, 95% CI 0.03-0.57, P < .05). CONCLUSION: This study revealed that lateral prominence pain is a significant complication of MDCO, especially in the setting of a larger displacement. The crushplasty following MDCO may minimize this complication, particularly when a greater degree of hindfoot correction is attempted.

Radiographic Cutoff Values for Predicting Lateral Bony Impingement in Progressive Collapsing Foot Deformity.

BACKGROUND: Lateral bony impingement is a major cause of lateral foot pain in progressive collapsing foot deformity (PCFD). Weightbearing computed tomography (WBCT) provides better sensitivity than standard radiographs for detecting impingement. However, many orthopaedic centers have not yet acquired WBCT imaging. This study aimed to (1) investigate the correlation of common radiographic parameters measured on standard weightbearing radiographs with talocalcaneal and calcaneofibular distance assessed with WBCT and (2) establish radiographic cutoff values to detect bony impingement as identified on WBCT. METHODS: Ninety-one patients treated for PCFD with standard preoperative radiographs and WBCT were identified. Patients with asymmetric ankle arthritis (talar tilt >2 degrees) were excluded. The talocalcaneal distance at the sinus tarsi and calcaneofibular distance were measured in multiplanar reconstructed WBCT images. Impingement was defined as direct abutment between bones. The relationships between WBCT measurements and 4 common parameters (talonavicular coverage angle [TNC], talo-first metatarsal angle, calcaneal pitch, and hindfoot moment arm [HMA]) in standard radiographs were assessed with Pearson correlations. Receiver operating characteristic curve analysis evaluated the ability of radiographic cutoffs to detect sinus tarsi or calcaneofibular bony impingement, and the area under curve (AUC), sensitivity, specificity, negative and positive predictive value (PPV) were calculated. RESULTS: Talocalcaneal distance narrowing at the sinus tarsi strongly correlated with TNC (r = 0.64, P < .001), and the calcaneofibular distance narrowing correlated with the HMA moderately yet best among the parameters (r = 0.55, P < .001). TNC (AUC = 0.837, 95% CI 0.745-0.906) and HMA (AUC=0.959, 95% CI 0.895-0.989) provided the best predictive ability for sinus tarsi and calcaneofibular bony impingement, respectively. A TNC threshold of 41.2 degrees had a 100% PPV for predicting sinus tarsi impingement, whereas an HMA threshold of 38.1 mm had a 100% PPV for calcaneofibular impingement. CONCLUSION: This study provides evidence that TNC and HMA measurements made on standing radiographs could be used to indicate potential lateral bony impingement in PCFD. Narrowing of talocalcaneal distance best correlated with abduction deformity of the foot, and the narrowing of calcaneofibular distance was best correlated with valgus hindfoot deformity. LEVEL OF EVIDENCE: Level III, case control study.

Assessment of Flatfoot Deformity Using Digitally Reconstructed Radiographs: Reliability and Comparison to Conventional Radiographs.

BACKGROUND: Digitally reconstructed radiographs (DRRs) generated from weightbearing computed tomography (WBCT) may potentially substitute for weightbearing plain radiographs (XRs) but have not been clinically validated. This study aims to test the reliability of 6 radiographic parameters of progressive collapsing foot deformity (PCFD) as measured on DRR, to investigate whether DRR represents comparably to XR through the same measurements, and to compare agreement of DRR and XR measurements of a standardized arch height parameter with reference measurements made on WBCT. METHODS: DRR generated from preoperative WBCT of 71 patients (72 feet) treated surgically for PCFD were retrospectively compared with preoperative weight-bearing XR after exclusion criteria were applied. Six radiographic measurements were performed, including Meary angle, calcaneal pitch (CPA), medial cuneiform height (MCH), AP talar-first metatarsal angle (T-1MT), talonavicular coverage (TNCA), and talar incongruency (TIA). Arch height was measured on XR, DRR, and WBCT using a validated, standardized, navicular-based index. Intraclass correlation coefficients assessed DRR intraobserver and interobserver reliability. Paired samples t tests tested differences between XR and DRR. Bland-Altman limits of agreement analysis compared DRR and XR agreement with WBCT measurements. RESULTS: Measurements were within standard PCFD ranges on XR and DRR. All measurements demonstrated excellent intrarater reliability and good to excellent interrater agreement, consistent with previous literature on XR. No differences were found for Meary, CPA, or TNCA. Minor differences were observed for MCH, T-1MT, and TIA. DRR measurements demonstrated greater agreement with WBCT than XR measurements. CONCLUSION: DRR from WBCT may be a promising substitute for XR in the clinical evaluation of PCFD. Radiographic measurements made on DRR demonstrated good to excellent reliability. Although small differences were found between XR and DRR for certain measurements, DRR more accurately represented medial arch anatomy compared to gold standard WBCT data than XR. If validated as a clinical substitute, DRR could eventually obviate XR where WBCT is available. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Return to Physical Activity Following Flatfoot Reconstruction.

BACKGROUND: Progressive collapsing foot deformity (PCFD) is a debilitating condition encompassing several interrelated, progressive deformities requiring a combination of reconstructive procedures. Few studies investigate returns to activity following flatfoot reconstruction, and existing studies only examine 1 or 2 of the numerous procedures employed. This study aims to provide the first generalizable assessment of returns to sports and physical activity following reconstruction surgery in patients with flexible flatfoot deformity. METHODS: Patients aged 18-60 years who underwent reconstructive surgery between February 16 and May 19 for symptomatic flexible-stage flatfoot deformity were identified by registry review. Eighty-two of 113 eligible patients (73%) were reached at a mean 2.9 years (range, 2.0-5.4) of follow-up with mean age at surgery of 48.9 years (range, 18-59). Returns to physical activity were evaluated with a sports-specific survey. Clinical outcomes were evaluated with Patient-Reported Outcomes Measurement Information System (PROMIS) scores. RESULTS: Patients reported participation in 21 specific sports and activities. One-fourth (25.6%) of patients (21/82) reported increased difficulty with physical activities postoperatively, 15.9% reported equal difficulty, and 58.5% (48/82) reported decreased difficulty. Median return times were 9-12 months for participation and 12-18 months to reach maximum preoperative participation levels. Improvements in Physical Function (P= .001), Pain Interference (P < .001), Pain Intensity (P <.001), and Global Physical Health (P = .004) were associated with increased satisfaction with respect to sports and physical activities. DISCUSSION: This study investigated participation in specific sports and physical activities following flatfoot reconstruction. Our findings suggest mixed outcomes, where many patients reported life-changing improvements but many also experienced prolonged pain and difficulty after surgery. Some patients reported increased difficulty or inability to return to their preoperative maximum level of participation, indicating that flatfoot reconstructions can lead to athletic limitations. CONCLUSION: Although flatfoot reconstruction can be a powerful tool to increase patients' capacity to engage in physical activity, in our cohort many patients had reduced physical activity outcomes. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Clinical Outcomes and Rotational Correction of First Metatarso-Cuneiform Fusion With First Metatarsal to Second Cuneiform Fixation.

Background: The modified Lapidus procedure (first metatarso-cuneiform fusion) is a powerful technique for correcting triplanar deformity in hallux valgus. Although traditionally fixed with cross-screws (CS), growing awareness of intercuneiform stability and pronation deformity has led to fixation using a plate and first metatarsal-second cuneiform (1MT-2C) screw fixation (PS). We investigated Lapidus patient cohorts using CS vs PS fixation to understand patient-reported outcomes, angular and rotational correction, and complication rates. Methods: We retrospectively reviewed cases of modified Lapidus for hallux valgus by a single surgeon. Patients were divided into CS or PS groups according to fixation. All patients had preoperative Patient Reported Outcome Measurement Information System (PROMIS) scores and minimum 12 months of follow-up. PROMIS scores in 6 key domains were compared within and between groups. Radiographic assessment of hallux valgus angle and intermetatarsal angle were performed on pre- and postoperative XR. Pronation of the first ray was measured on pre- and postoperative weightbearing computed tomography. Results: We compared 42 patients with PS fixation to 43 with CS fixation. Both groups had significant improvement in hallux valgus angle and intermetatarsal angle (P < .001), with no difference between groups. PS patients experienced a greater correction of first metatarsal pronation, an average reduction of 11 degrees, compared to 8 degrees in the CS group (P < .039). Both cohorts experienced improvement in PROMIS physical function, pain interference, pain intensity, and global physical function. There were no differences in PROMIS score improvements between the cohorts. The CS group started weightbearing at 6 weeks vs 3.6 weeks for the PS group. Complication and revision rates were similar. Conclusion: A plate and 1MT-2C screw fixation provides safe, robust fixation of Lapidus procedure and prevents instability through the intercuneiform joint. We observed similar improvement in PROMIS compared with patients treated with cross-screws. Complications did not increase despite the PS group weightbearing much earlier. PS patients achieved greater first ray rotational correction. Level of Evidence: Level III, retrospective cohort study.