The Influence of Resilience on Outcomes After Total Ankle Arthroplasty.

BACKGROUND: Resiliency is the ability to recover from stressful events and has been shown to correlate with patient outcomes following certain orthopaedic procedures. The purpose of this study was to determine the relationship between resiliency and outcomes following TAA. METHODS: A retrospective analysis of patients undergoing primary TAA between April 2015 and September 2022 was performed (N = 83). Data included demographics, comorbidities, complications, preoperative and postoperative visual analog scale (VAS) pain and Foot and Ankle Ability Measure (FAAM) functional scores, Brief Resilience Scale (BRS) scores, and surgical satisfaction. Patients were defined as having low resilience (LR), normal resilience (NR), or high resilience (HR) based on a BRS score of <3, 3-4.30, and >4.3, respectively. RESULTS: High resilience patients had significantly higher postoperative FAAM ADL, Sports, and Overall scores as well as a significantly greater increase from preoperative scores compared with LR and NR patients. Low resilience patients had significantly lower FAAM Sports and Overall scores compared with normal and high resilience patients. BRS scores positively correlated with postoperative FAAM scores. We found no difference in satisfaction or VAS between the 3 cohorts. Multivariate regression analysis identified BRS scores to be an independent predictor for greater changes in FAAM scores following TAA. CONCLUSION: Although functional improvements following TAA are expected, patients with higher resilience at baseline are more likely to experience greater improvements in functional outcomes following surgery. LEVEL OF EVIDENCE: Level III.

Outcomes of cobalt-chrome 3D-printed total talus replacement with and without combined total ankle replacement.

BACKGROUND: Collapse of the talus and peri-talar arthritis pose treatment challenges due to the anatomy and location of the talus as a keystone of the foot and ankle. Custom 3D-printed total talus replacement (TTR) and combined total ankle total talus replacement (TATTR) have emerged as treatment options for these pathologies. However, the safety and efficacy of these implants is unknown due to the limited number of cases and short follow-up durations. METHODS: This was a retrospective study to assess surgical outcomes of patients who underwent a TTR and TATTR with or without subtalar fusion. Patient demographics, intraoperative parameters, device related surgical and non-surgical events, imaging and clinical evaluations, and patient reported outcome (PRO) measures were compiled. RESULTS: A total of 38 patients received a custom 3D-printed implant with mean follow-up time of 22.1 (range: 12-45) months. In this cohort, 7 (18.4 %) required secondary surgery and 3 (7.9 %) required implant removal. Multivariate logistic regression revealed that patient diagnosis of depression was a significant predictor of secondary surgery with an OR 17.50 (p = 0.037). Significant postoperative improvements were observed in the talocalcaneal height (p = 0.005) and talar declination angle (p = 0.013) for the TATTR group. VAS and PROMIS pain interference (PI) scores demonstrated an initial significant improvement in pain, but this improvement did not maintain significance at most recent follow-up. However, there was a significant increase in the PROMIS physical function (PF) scores (p = 0.037) at most recent follow-up. CONCLUSION: These results demonstrate that TTR and TATTR provide significant improvement in post-operative radiographic foot and ankle alignment and physical function at the two-year timepoint. PRO findings suggest that patients are more active after surgery. Surgeons considering proceeding with either of these procedures should counsel patients about pain and functional outcomes as well as realistic expectations in patients with depression. LEVEL OF EVIDENCE: Level 3.

Effect of Cigarette Smoking on Postoperative Outcomes After Arthroscopic Bone Marrow Stimulation for Osteochondral Lesions of the Talus.

BACKGROUND: Bone marrow stimulation (BMS) is presently considered first-line surgical treatment for osteochondral lesions of the talus (OLTs); however, some patients still experience pain or dysfunction after surgery, and the reasons for success or failure remain somewhat unclear. This study aimed to investigate the effect of smoking on postoperative outcomes after arthroscopic BMS for OLTs. METHODS: Consecutive patients with OLTs who underwent BMS between January 2017 and January 2020 were included. Smokers were defined as patients who actively consumed cigarettes before surgery and postoperatively, whereas nonsmokers were patients who never smoked. Visual analog scale (VAS), American Orthopaedic Foot & Ankle Society ankle hindfoot score (AOFAS), Karlsson-Peterson, and Tegner scores were assessed preoperatively and at follow-up. Additionally, a general linear model (GLM) was performed, followed by the interaction analysis to explore the potential influence of smoking. RESULTS: The study enrolled 104 patients with a mean follow-up of 30.91 ± 7.03 months, including 28 smokers and 76 nonsmokers. There were no significant differences in patient age (35.2 ± 10.0 years vs 37.6 ± 9.7 years, P = .282) or OLT area (63.7 ± 38.7 mm2 vs 52.8 ± 37.0 mm2, P = .782). Both univariate analysis and GLM revealed that smoking was associated with worse postoperative pain levels, Karlsson-Peterson, and AOFAS scores (P < .05). The interaction analysis showed a significant interaction between smoking and OLT area for postoperative Karlsson-Peterson scores (general ankle function) (P = .031). Simple main effects analysis revealed that the negative effect of smoking on Tegner score significantly increased among patients >32 years old or with OLT area>50 mm2 (P < .05). CONCLUSION: Smoking was associated with worse clinical outcomes following BMS of OLTs. As the size of OLTs increased, the difference in general ankle function between smokers and nonsmokers also increased. Furthermore, smokers who were older than 32 years or had larger OLTs were less likely to resume participation in high-level activities.

Early Outcomes of Third-Generation Minimally Invasive Chevron-Akin (MICA) Osteotomy for Symptomatic Hallux Valgus Deformity.

Hallux valgus is a common progressive forefoot deformity. Although open techniques have shown good outcomes, no technique has been shown to be superior to other techniques. The current third generation of minimally invasive Chevron-Akin (MICA) technique features a percutaneous procedure with a stable internal fixation. The technique used in this study resulted in stable internal fixation; however, 1 screw was used in intramedullary fashion in the majority of cases. The purpose of this study is to review the early outcomes of MICA. Electronic Health Records (EHR) were queried for patients who underwent MICA to treat hallux valgus (HV) deformity, by a single surgeon. The primary clinical outcomes assessed were visual analog pain score (VAS), rate of revision surgery, and recurrence. Radiographic outcomes were assessed including pre and postoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), and bony foot width. The secondary outcomes included postoperative complications. A total of 91 feet underwent MICA to correct symptomatic HV deformity. The mean age of this cohort was 53.63 ± 15.42 years, mean body mass index (BMI) of 26.81 ± 6.21 kg/m2, mean follow-up of 6.33 ± 6.39 months and 87 feet belonged to female patients. Patients showed significant improvement in VAS and radiographic outcomes at final follow-up, with a mean improvement of 10.70° ± 6.42°, 2.39° ± 3.55°, and 5.30 mm ± 4.23 mm for the HVA, IMA, and bony foot width, respectively. Two patients (2.2%) required revision surgery for nonunion and removal of symptomatic hardware. One patient had a second metatarsal fracture treated nonoperatively. No feet had recurrence, hardware loosening, infection, or scar hypersensitivity. The current study reported on early outcomes for MICA. This technique appears to be effective and safe with no failure of fixation in our patients. We showed in our short-term follow-up, MICA led to significant improvement in pain and radiographic scores.Levels of Evidence: III, retrospective study.

Short-Term Outcomes of Jones-Specific Implant Versus Intramedullary Screw and Plate Fixation for Proximal Fifth Metatarsal Fractures.

Although intramedullary screw fixation is commonly performed for proximal fifth metatarsal fractures, high rates of nonunion, refracture, and hardware prominence have been reported. The Jones Specific Implant (JSI) is a novel surgical implant which contours to the native curvature of the fifth metatarsal allowing for a more anatomic fixation. The purpose of this study was to compare short-term complication rates and outcomes of patients treated with the JSI to other fixation types such as plates and intramedullary screws. Electronic records were queried for adult patients with proximal fifth metatarsal fractures who underwent primary fixation from 2010 to 2021. All patients were treated by a foot and ankle fellowship-trained surgeon with intramedullary screws, plates, or JSI (Arthrex Inc., Naples, FL). Visual analog scale (VAS) and the American Orthopedic Foot and Ankle Score (AOFAS) were recorded and compared using univariate statistics. Eighty-five patients underwent fixation using intramedullary screw (n = 51, 60%), plate (n = 22, 25.9%), or JSI (n = 12, 14.1%) with a mean follow-up of 11.1 ± 14.6 months. The total cohort demonstrated a significant improvement in VAS pain (p < .0001) as well as AOFAS (p < .0001) scores. When comparing the cohort treated with JSI and the cohort treated with all other types of fixation, there were no significant differences in postoperative VAS or AOFAS scores. Only 3 complications, one with JSI (3.5%) required removal of the symptomatic hardware. The JSI is a novel treatment for proximal fifth metatarsal fractures, with similar early outcomes and complication rates when compared with intramedullary screw and plate fixation.

Effect of Arthroscopically Confirmed Syndesmotic Widening on Outcome Following Isolated Broström Operation for Chronic Lateral Ankle Instability.

BACKGROUND: Tibiofibular syndesmosis (TFS) widening sometimes is not evident on radiography but can be found under arthroscopy in chronic lateral ankle instability (CLAI). This study aimed to evaluate the effect of TFS widening severity on clinical outcomes and return to activities after isolated Broström operation in CLAI patients and to propose an indication for its surgical intervention. METHODS: A total of 118 CLAI patients undergoing diagnostic ankle arthroscopy and open Broström-Gould operation were included. Based on the middle width of TFS measured under arthroscopy, patients were divided into the TFS-2 group (≤2 mm, n = 44), the TFS-3 group (2-4 mm, n = 42), and the TFS-4 group (≥4 mm, n = 32). The time to return to recreational sport and work, Tegner activity score, and proportion of returning to preinjury sports at the final follow-up were evaluated and compared. Other subjective evaluations included the American Orthopaedic Foot & Ankle Society score, visual analog scale, and Karlsson-Peterson score. RESULTS: Among the 3 groups, the TFS-4 group demonstrated the longest mean time to return to work and recreational sports, with the lowest proportion returning to preinjury sports. The TFS-4 group showed a significantly higher rate of sprain recurrence (12.5%) than the other 2 groups (P =.021). All the other subjective scores significantly improved after the operation without differences among the 3 groups. CONCLUSION: Concomitant severe syndesmotic widening adversely affects the return to activities after Broström operation in CLAI cases. The CLAI patients with a middle TFS width ≥4 mm were associated with delayed return to work and sports, a lower proportion of returning to preinjury sports, and more sprain recurrence, which might require further surgical intervention for syndesmosis in addition to Broström surgery. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Revision Surgery After Failed Index Synthetic Cartilage Implant Resurfacing for Hallux Rigidus: Single-Surgeon 5-Year Experience.

BACKGROUND: While metatarsophalangeal joint (MTPJ) arthrodesis is regarded as the gold standard treatment option for end-stage hallux rigidus (HR), synthetic cartilage implant (SCI) resurfacing has gained popularity. This study aimed to identify the SCI resurfacing failure rate for a single surgeon, while also comparing clinical outcomes of patients who underwent SCI replacement or MTPJ arthrodesis after failed index SCI resurfacing. METHODS: Health records were queried from 2016 to 2021 for patients with HR who were treated with SCI resurfacing by a single surgeon. Preoperative and postoperative range of motion, visual analog scale (VAS) pain scores, and hallux valgus angles were compared. A subgroup analysis was performed on patients who underwent revision with SCI replacement or MTPJ arthrodesis. SCI replacement included the use of bone graft, bone putty, or a custom 3D printed baseplate to prevent implant subsidence. RESULTS: A total of 219 SCI resurfacing procedures were performed by a single surgeon, including 23 revisions. When analyzing index procedures, an 8.2% revision rate was determined. The revision cohort (n = 23) consisted of 19 female patients and presented with a mean body mass index of 29.5 ± 5 kg/m2, mean age of 52.8 ± 11 years, mean follow-up duration of 22.3 (range, 3-54) months, and mean time to a revision surgery of 12.1 ± 12 (range, 1-50) months. Specifically, 12 procedures resulted in an SCI replacement, while 11 procedures resulted in arthrodesis. While all patients experienced significant improvement in their VAS pain scores (P < .001), the arthrodesis cohort experienced a greater improvement than the SCI revision cohort (P = .04). CONCLUSION: When analyzing SCI revision procedures, MTPJ arthrodesis reduced pain more significantly than SCI replacement. LEVELS OF EVIDENCE: Level IV: Retrospective case series.

Outcome of Turf Toe Injuries in NFL Players.

The increase in artificial turf in the 1970s was thought to have contributed to increased incidence of turf toe injury in National Football League (NFL) players. To our knowledge, there are no publications that have analyzed the impact of this injury on performance. This is a retrospective case series. Online resources were used to identify NFL players who sustained a turf toe injury between the 2011 and 2014 seasons. The performance of each offensive skill player was analyzed separately by calculating their power rating (PR) over 6 seasons. Injured offensive skill players were then compared to a control group consisting of all RBs and WRs without a turf toe injury who competed in the 2012 season. Seventy-one turf toe injuries were identified. Twenty-nine occurred on grass, 29 on turf and the playing surface of 13 injuries could not be identified. The average PR prior to injury was 105.7/season (7.3/game), 87.3 (6.9/game) for the season of injury and 115.5 (8.1/ game) for postinjury seasons. The PR was not significantly different after a turf toe injury compared to before injury or to uninjured control player. There was no significant difference in NFL players' performances after turf toe injury based on power ratings.

Pain Reduction With AbobotulinumtoxinA for the Treatment of Hallux Valgus in Adult Participants: Results of a Randomized and Placebo-Controlled Phase 2 Trial.

AbobotulinumtoxinA (aboBoNT-A, Dysport® [Ipsen, Paris, France]) inhibits acetylcholine release at the neuromuscular junction and may modulate pain signaling in hallux valgus (HV). This randomized study (NCT03569098) included a double-blind phase (aboBoNT-A 300U, 500U or placebo injections into forefoot muscles) and an open-label aboBoNT-A treatment period in participants with an HV diagnosis and no HV surgery. The primary endpoint was change from baseline in numeric pain rating scale (NPRS) score at week 8. Secondary endpoints included change in NPRS (other time points) and proportion of participants with ≥20% reduction from baseline NPRS (responders). Post-hoc analyses assessed number of days in a 7-day evaluation period that participants spent in a lower pain state than at baseline. Participants received aboBoNT-A 300U (n = 63), 500U (n = 60) or placebo (n = 63). Superiority to placebo was not observed with either aboBoNT-A dose at week 8, thus the primary endpoint was unmet. At week 12, a trend toward efficacy was observed with aboBoNT-A 500U versus placebo and the proportion of participants with ≥20% reduction from baseline NPRS was greater with aboBoNT-A 500U versus placebo (p = .006). Participants in the aboBoNT-A 500U group spent more days with lower NPRS than their lowest baseline score, and with NPRS ≥2 points lower than their mean baseline NPRS at weeks 8 and 12 versus placebo (all p < .05; post-hoc). AboBoNT-A was well tolerated. Although the primary endpoint was unmet, other endpoints showed a nominal advantage for aboBoNT versus placebo for treatment of HV-related pain, particularly at week 12. Further clinical evaluation is needed to establish whether botulinum toxins represent a viable non-operative treatment option for HV-associated pain. PLAIN LANGUAGE SUMMARY: Hallux valgus is the medical name for a bunion, a foot deformity that can worsen over time. Patients with bunions experience pain and walking can become difficult, which can affect their quality of life. Foot support aids (e.g., braces, splints and inserts) are available, but surgery is the standard treatment. This study looked at how injections of a specific type of botulinum toxin, called abobotulinumtoxinA or "aboBoNT-A", into the foot may help to reduce pain in patients with bunions. The study included 186 patients aged 18 to 75 years who had not had surgery on their bunion. The researchers looked at how well the injections worked using scales that measure the pain levels the patient experienced. The main outcome was whether patients who had aboBoNT-A injections had less pain after 8 weeks than they did before treatment. The study included patients who were injected with saltwater (no treatment) to check that any treatment effect was real. Researchers also looked at the results after 12 weeks, as well as how many patients had less pain after treatment than before and how many days in a given week patients experienced less pain after treatment than they did before. There was no reduction in pain levels with aboBoNT-A injections after 8 weeks compared with no treatment. However, the other study outcomes suggested that aboBoNT-A resulted in a small benefit compared with no treatment, especially after 12 weeks. Further medical research is needed to establish whether botulinum toxins represent an alternative treatment to surgery for the pain associated with bunions.

Burnout Rates Among General Orthopedic Surgeons and Subspecialists: A Pilot Study.

Burnout among physicians is a syndrome of emotional exhaustion, de-personalization, and reduced sense of personal accomplishment that can negatively affect personal relationships, physician well-being, and patient outcomes. Although burnout rates of up to 50% to 60% among orthopedic surgeons have been reported, no studies have evaluated burnout among orthopedic generalists and subspecialists. The primary goal of this study was to examine the prevalence of burnout among orthopedic disciplines. We conducted a multicenter study from March 2019 through December 2019 involving 149 orthopedists. An abbreviated Maslach Burnout Inventory-Human Services Survey was used to measure burnout. Demographic information, personal characteristics, professional characteristics, family life and spousal support, and depression were also assessed. The mean rate of burnout among all respondents was 62%, whereas 16.77% screened positive for depression. Subspecialties with the highest rates of burnout were oncology (100%), sports medicine (68%), and trauma (63%). Similarly, trauma (50.00%), oncology (40.00%), and general orthopedics (20.00%) had the highest positive depression screening rates. In contrast, shoulder and elbow (50%), pediatric (52%), and foot and ankle (54%) specialists had the lowest rates of burnout, whereas shoulder and elbow (0.00%), spine (0.00%), and sports medicine (6.50%) specialists had the lowest rates of positive depression screening. Older age, higher debt load, and oncology subspecialty were associated with increased burnout risk. This study sought to determine burnout rates within each orthopedic discipline, with a secondary aim of disclosing contributing factors. Trauma and oncology had the highest rates of burnout and positive depression screening. Because this study represents a small orthopedic cohort, larger studies are needed to appropriately manage burnout in the future. [Orthopedics. 2022;45(6):333-339.].

Orthopaedic Foot and Ankle Surgery Leadership Trends: A Cross-Sectional Study of Fellowship Directors and Division Chiefs.

Background: In orthopaedic surgery departments, foot and ankle fellowship directors are tasked to create a robust clinical curriculum for trainees, while division chiefs manage the division's delivery of patient care. The primary aim of this study was to describe characteristics of foot and ankle surgery fellowship directors and division chiefs in an effort to recognize trends or disparities in leadership traits. Methods: The American Orthopaedic Foot and Ankle Society (AOFAS) fellowship directory for 2021 to 2022 was reviewed for AOFAS-recognized fellowship programs in the United States. Between March 2021 and June 2021, 48 fellowship directors and 23 publicly recognized division chiefs were administered an electronic survey to collect demographic, educational, and professional data. Univariate and bivariate statistical analyses were performed. Results: A total of 42 of the 48 (87.5%) fellowship directors and 18 of the 23 (78.3%) division chiefs responded to the questionnaire. Of the 48 fellowship directors, 45 (93.8%) were male, 43 (89.6%) identified as Caucasian, their average age at leadership appointment was 42.6 ± 7.5 (range, 32-70) years, and the average time between fellowship graduation and leadership appointment was 9.9 ± 7.8 (range, 0-36) years. Of the 23 chiefs, 22 (95.7%) were male, 20 (87.0%) identified as Caucasians, their average age at leadership appointment was 41.7 ± 7.8 (range, 32-53) years, and the average time between fellowship graduation and leadership appointment was 9.8 ± 6.8 (range, 2-21) years. The average H-index for the chiefs was greater than that of the fellowship directors (18.4 vs 13.4, P = .0373) when controlling for years of training>. Conclusion: The majority of current leaders identify as middle-age Caucasian males, demonstrate high research productivity, and have attended a select number of the same residency and fellowship training programs. By demonstrating the lack of diversity within foot and ankle surgery leadership, this study serves as a call to action for making inclusivity a priority.Levels of Evidence: Level IV: Cross-sectional study.

Histologic grading correlates with inflammatory biomarkers in tibialis posterior tendon dysfunction.

BACKGROUND: It has been theorized that tibialis posterior tendon dysfunction (TPTD) is a degenerative process unrelated to inflammation. The purpose of this study was to determine if inflammatory cytokines, matrix metalloproteases (MMPs), and glutamate were elevated in diseased tibialis posterior tendons (TPTs). METHODS: Matched diseased TPT, TPT insertion, and flexor digitorum longus (FDL) samples were collected from 21 patients. The samples were individually incubated in media, which was analyzed for inflammatory cytokines, MMPs, and glutamate. Histology and statistical analyses were performed. RESULTS: Diseased TPT and TPT insertion were significantly elevated compared to transferred FDL in eight inflammatory markers (p < 0.005). Only the diseased TPT was significantly elevated compared to the transferred FDL tendons for glutamate (p < 0.01). Histologic grading correlated with inflammatory cytokine levels. CONCLUSION: Diseased TPT and TPT insertion demonstrated significantly elevated levels of inflammatory markers compared to the transferred tendons used as controls, suggesting a role for inflammation in the disease process. The amount of inflammation correlated with increased tendon degradation. LEVEL OF EVIDENCE: Level III.

Achilles: Failed Acute Repair.

Acute Achilles tendon ruptures are commonly managed with surgical repair. This particular surgery is prone to rerupture, wound complications, deep vein thrombosis, and sural nerve injuries. In this chapter the authors discuss complications, how to avoid them, and ultimately how to manage complications with your patients.

Medical Malpractice Trends in Foot and Ankle Surgery.

Medical malpractice lawsuits can place significant economic and psychologic burden on a provider. Orthopedic surgery is one of the most common subspecialties involved in malpractice claims. There is currently no study examining malpractice lawsuits within foot and ankle surgery. Accordingly, the purpose of this work is to examine trends in malpractice claims in foot and ankle surgery. The Westlaw legal database was queried for lawsuits pertaining to foot and ankle surgery from 2008 to 2018. Only cases involving medical malpractice were included for analysis. All available details pertaining to the cases were collected. This included plaintiff demographic and geographic data. Details regarding the cases were also collected such as anatomical location, pathology, complications, and case outcomes. Forty-nine malpractice lawsuits pertaining to foot and ankle were identified. Most plaintiffs in these cases were adult females, and the majority of cases occurred in the northeast (53.1%). The most common anatomical region involved in claims involved the forefoot (29%). The majority of these claims involved surgery (65%). Infection was the most common complication seen in claims (22%). The jury ruled in favor of the defendant surgeon in most cases (73%). This is the first study to examine trends in medical malpractice within foot and ankle surgery. Infection was the most frequent complication seen in claims and forefoot surgery was the most common anatomic location. A large portion of claims resulted after nonoperative treatment. A better understanding of the trends within malpractice claims is crucial to developing strategies for prevention.

Avascular Necrosis of the Talus After Subchondroplasty.

BACKGROUND: Subchondroplasty (SCP) is a relatively new procedure, developed in 2007 for the treatment of bone marrow lesions (BMLs), that has shown promising results in the knee through several different case series. The foot and ankle literature, however, is sparse, with only a few documented case reports or case series. At our institution, we have identified several patients with complications after this specific procedure. As a result, we report our case series of patients who developed talar avascular necrosis (AVN) after undergoing SCP. METHODS: A retrospective review was performed of patients who underwent SCP for a talar BML at our facility or who were referred to our facility after undergoing SCP at an outside institution. Patients were included if they developed radiographic evidence of talar AVN after the procedure. Patient demographics, comorbidities, concomitant intraoperative procedures, complications, and subsequent interventions were reviewed. RESULTS: Seven patients were identified as having radiographic evidence of talar AVN after SCP. Average time interval was 23 months postoperative from index procedure to radiographic confirmation of AVN. Two of the index procedures were performed at our institution, whereas 5 of the index procedures were performed at outside institutions and referred for further management. Three patients had documented risk factors for AVN before the SCP procedure. All 7 patients were symptomatic from the AVN. CONCLUSION: We identified 7 patients who went on to develop talar AVN after having undergone SCP. LEVEL OF EVIDENCE: Level IV, case series.

Pathologies of the Peroneals: A Review.

Peroneal tendon disorders remain an often overlooked source of lateral hindfoot pain and tenderness. Medical professionals who specialize in foot and ankle care are still far more likely to diagnose a peroneal tendon disorder as an ankle injury. In fact, acute peroneal dislocations are misdiagnosed in up to 40% of cases. The major subsets of peroneal disorders include peroneal tendonitis and tenosynovitis, painful os peroneum syndrome, subluxation, and tearing of the peroneal tendons. Proper history and physical exam maneuvers must be performed to help identify the source of the injury and differentiate these categories. Detailed imaging through X-ray and magnetic resonance imaging must also be used to diagnose the etiology of the patient's condition in order to direct management. Currently, there is very limited knowledge on peroneal pathologies, and treatment protocol is highly variable and limited to expert opinion. Despite the individual preferences and nuances held by each surgeon when it comes to operating, the overarching principles that guide appropriate management of tendonitis, subluxation, and tendon tear should maintain a higher level of consistency. Therefore, the authors of this review aim to elucidate the most current methods to diagnose these disorders as well as evidence-based practices for optimal management.Levels of Evidence: Level V.

Incorporating 3D Printing Into Your Practice: Lessons Learned.

Three-dimensional (3D) printing has greatly benefited medicine, manufacturing vital organs like skin, hearts, kidneys, and livers. Early studies on 3D printing in surgery have consistently reported decreased operative time and improved precision. This technology has gained popularity with orthopaedic surgeons in knee, hip, and shoulder surgeries because 3D printing is associated with enhancing osseointegration. However, this innovation is still not commonly used among foot and ankle surgeons; one reason is that whereas the literature on 3D printing-assisted surgery is populated with studies on operative techniques and clinical outcomes, there exists an ambiguity on how to incorporate this feature into the clinic. Thus, the aim of this technology column is to consolidate and standardize a workflow to guide foot and ankle surgeons on integrating 3D printing into one's practice. We describe a model developed by a single surgeon at one institution who directs a large caseload of 3D-printed foot and ankle surgeries. From the initial patient visit to the interaction between the surgeon and the implant engineering team, to documentation of data adding to the preliminary literature, this work has great implications on streamlining the assimilation of a highly successful technology to improve foot and ankle surgery for both surgeons and patients.Level of Evidence: Level V.

Clinical Outcomes and Complications Following Limited Open Achilles Repair Without an Instrumented Guide.

BACKGROUND: We report the clinical outcomes and complications following our limited open incision Achilles tendon repair technique without instrument guides. METHODS: A total of 33 patients were included in this study. We recorded pre- and postoperative scores on the Foot and Ankle Disability Index (FADI), visual analog scale (VAS), and the Foot and Ankle Outcome Score (FAOS). Subgroup analyses were performed for acute (<2 weeks) and subacute (2-6 weeks) Achilles tendon repairs. A P value <.05 was considered significant for all statistical analyses. RESULTS: The median time from injury to surgery was 10.0 days (range, 1-45 days). At a median follow-up of 3.7 years (range, 1.0-9.8 years), the average pre- and postoperative outcome scores improved significantly for the following: FADI index (49.1-98.4, P < .001), VAS (4.8-0.2, P < .001), FAOS Pain (54.8-99.2, P < .001), FAOS Symptoms (84.6-97.0, P < .001), FAOS activities of daily living (61.4-97.2, P < .001), FAOS Sports and Recreational Activity (39.5-98.5, P < .001), and FAOS quality of life (39.7-88.7, P < .001). There were no significant differences between pre- and postoperative outcome scores between the acute and subacute Achilles repair groups. There were no wound complication, reruptures, or reoperations in the entire cohort. CONCLUSION: Patients showed improvements in postoperative patient-reported outcome scores with minimal complications. There was no significant difference in outcomes for acute vs subacute repairs. Our limited open incision Achilles tendon repair, which required no additional targeting instrumentation, had favorable midterm results. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Early Outcomes of 3D Printed Total Talus Arthroplasty.

BACKGROUND: Patients with talar avascular necrosis (AVN) have limited treatment options to manage their symptoms. Historically, surgical options have been limited and can leave patients with little ankle motion and have high failure rates. The use of custom 3D printed total talar replacements (TTRs) has arisen as a treatment option for these patients, possibly allowing better preservation of hindfoot motion. We hypothesized that patients undergoing TTR will demonstrate a statistically significant improvement in Foot and Ankle Outcome Score (FAOS) at 1 year after surgery. METHODS: We retrospectively reviewed 15 patients who underwent a TTR over a 2-year period. Patient outcomes were reviewed, including age, sex, comorbidities, etiology of talar pathology, number and type of prior surgeries, radiographic alignment, FAOS and Visual Analog Scale (VAS) score, and range of motion. Data analysis was performed with Student t-tests and multivariate regression. RESULTS: FAOSs and VAS scores showed statistically significant improvements postoperatively as compared with preoperative scores. There was a statistically significant decrease in VAS pain scores from 7.0 preoperatively to 3.6 (P < .001). Average follow-up was 12.8 months. With the number of patients available, there was no statistically significant change in radiographic alignment parameters postoperatively as compared with preoperatively (P values ranged from .225 to .617). CONCLUSION: Our hypothesis that these patients show statistically significant improvements in FAOSs at 1 year was confirmed. TTR represents an exciting treatment option for patients with talar AVN, though longer-term follow-up is needed.Level of Evidence: Level IV: Case series.

Clinical Safety and Efficacy of a Novel Ultrasound-Assisted Bioabsorbable Suture Anchor in Foot and Ankle Surgeries.

BACKGROUND: Suture anchors have been used for soft tissue repair in orthopedic surgery for decades. Recently, bioabsorbable suture anchors have increased in popularity and have spurred the introduction of ultrasound-assisted systems. The purpose of our study was to determine the clinical safety and efficacy of a new ultrasound-assisted suture anchor system for foot and ankle procedures. METHODS: We retrospectively reviewed 50 cases using the ultrasound-assisted suture anchor with at least 24 months of follow-up. We reviewed demographic data including comorbidities, type of procedure, adverse events, and clinical outcomes using the Foot and Ankle Outcome Score (FAOS) and visual analog scale (VAS) score. We divided complications into minor and major, with major complications requiring revision surgery or leading to long-term morbidity. Our primary outcome was complication rates and our secondary outcome was improvement in clinical scores. RESULTS: The most frequent cases using the anchor included lateral ankle ligament reconstruction (n = 19), insertional Achilles repair (n = 15), lateral ligament reconstruction in conjunction with a total ankle arthroplasty (n = 6), and plantar plate repair (n = 3). There were 5 superficial wound infections that resolved with wound care and/or oral antibiotics. There were 3 major complications (6%): a deep wound infection that required an irrigation and debridement, a deep venous thrombosis, and a recurrence of varus deformity in a patient who underwent a total ankle arthroplasty with lateral ligament reconstruction. Only the varus deformity recurrence case could possibly be directly linked to the suture anchor (2% of all cases). VAS scores improved from 6.0 to 1.2 (P < .001) and FAOS improved from 54.7 to 94.2 (P < .001). CONCLUSION: This bioabsorbable anchor was a safe device with low failure rates, and it was used for soft tissue repair cases in the foot and ankle with successful clinical outcomes. LEVEL OF EVIDENCE: Level IV, retrospective case series.