Posterior Ankle Impingement: It's Not Only About the Os Trigonum.

Background: Os trigonum and Stieda process are common etiologies for posterior ankle impingement syndrome (PAIS), and diagnosis is typically made by radiographs, computed tomographic, or magnetic resonance imaging. However, these static tests may not detect associated soft tissue and bony pathologies. Posterior ankle and hindfoot arthroscopy (PAHA) is dynamic, providing at least ×8 magnification with full anatomical visualization. The primary aim of this study was to report the prevalence of associated conditions seen with trigonal impingement treated with PAHA. Methods: In this retrospective comparative study, patients who underwent PAHA for PAIS due to trigonal impingement, from January 2011 to September 2016, were reviewed. Concomitant open posterior procedures and other indications for PAHA were excluded. Demographic data were collected with pre- and postoperative diagnosis, arthroscopic findings, type of impingement, location, associated procedures, and anatomical etiologies. Trigonal impingements were divided in os trigonal or Stieda and subgrouped as isolated, with flexor hallucis longus (FHL) disorders, with FHL plus other impingement, and with other impingement lesions. Results: A total of 111 ankles were studied-74 os trigonum and 37 Stieda. Isolated trigonal disorders accounted for 15.3% of PAIS (n = 17). Cases having associated conditions had a mode of 3 additional pathologies. FHL disorders were found in 69.4%, subtalar impingement in 32.4%, posteromedial ankle synovitis in 25.2%, posterolateral ankle synovitis in 22.5%, and posterior inferior tibiofibular ligament impingement in 19.8% of cases. Associated pathologies were observed in 58.6% of cases when FHL was not considered. Significant differences were noted comparing os and Stieda (isolated: 20.3% to 5.4%, P = .040; FHL plus others: 35.1% to 59.5%, P = .015). Conclusion: Trigonal bone (os trigonum or Stieda) was found to cause impingement in isolation in a small proportion of cases even when the FHL was considered part of the same disease spectrum. This should alert surgeons when considering removing trigonal impingement. Open approaches may limit the visualization and assessment of associated posterior ankle and subtalar pathoanatomy, thus possibly overlooking concomitant causes of PAIS. Level of Evidence: Level III, retrospective comparative study.

Republication of "Perspectives in Treatments of End-Stage Ankle Arthritis Among Orthopaedic Surgeons: Analysis of an American Orthopaedic Foot & Ankle Society (AOFAS) Member Survey".

Background: This study aimed to assess the preferred operative treatment for patients over the age of 60 with end-stage ankle arthritis and perspectives on total ankle replacement (TAR) among American Orthopaedic Foot & Ankle Society (AOFAS) members. Associated factors were analyzed for potential contraindications among members with different levels of experience. Method: A questionnaire containing 6 questions was designed and sent to 2056 members of the AOFAS. Responses were received from 467 orthopaedic surgeons practicing in the United States (76%), Canada (5%), and 26 other countries (20%). Participants were grouped for response comparisons according to country as well as experience level. Differences in contraindications were compared using χ2 tests or exact tests. Results: Respondents practicing in the United States and surgeons who perform 11 or more TARs per year tended to recommend operative treatments favoring TAR and displayed recognition of its increasing role (P < .05). Overall, respondents felt that 41% of typical patients over 60 years old with end-stage arthritis would be best treated with TAR. Talus avascular necrosis, morbid obesity (body mass index >40 kg/m2), and poorly controlled diabetes with neuropathy were most recognized as the absolute contraindications to TAR. Surgeon's experience affected the consideration of these clinical factors as contraindications. Conclusions: Total ankle replacement has a substantial and increasing role in the treatment of end-stage ankle arthritis in patients over the age of 60. Absolute and potential contraindications of the procedures were indicated from a cross-sectional survey of AOFAS members. Surgeons more experienced with total ankle replacement felt more comfortable employing it in a wider range of clinical settings. Level of Evidence: Level III, therapeutic.

Outcomes of Surgical Treatment for Sural Neuritis: A Retrospective Case Series.

BACKGROUND: Somatic nerve pain is one of the most common complications following surgery of the foot and ankle but may also arise following traumatic injury or chronic nerve compression. The sural nerve is a commonly affected nerve in the foot and ankle; it is at risk given the proximity to frequently used surgical approaches, exposure to crush injuries, and traction from severe ankle inversion injuries. The purpose of this study is to investigate the outcomes of sural nerve neurectomy with proximal implantation for sural neuromas (SN) and chronic sural neuritis (CSN). METHODS: Patients that underwent neurectomy with proximal implantation (20 muscle, 1 adipose tissue) by 2 foot and ankle specialists for isolated SN- and CSN-related pain at a single tertiary institution were included. Demographic data, baseline outcomes including 36-Item Short Form Health Survey (SF-36), Foot and Ankle Ability Measure (FAAM), and visual analog scale (VAS) were recorded. Final follow-up questionnaires using Patient Reported Outcomes Measurement Information System (PROMIS) lower extremity function, pain interference (PI), and neuropathic pain quality, FAAM, and VAS were administered using REDCap. Perioperative factors including neuropathic medications, diagnostic injections, the use of collagen wraps, and perioperative ketamine were collected from the medical record. Descriptive statistics were performed and potential changes in patient-reported outcome measure scores were evaluated using Wilcoxon signed-rank tests. RESULTS: The 21 patients meeting inclusion criteria for this study had a median age of 47 years (interquartile range [IQR], 43-49) and had median follow-up duration of 33.7 months (IQR, 4.5-47.6). Median FAAM activities of daily living score improved from 40.6 (38.7-50.7) preoperatively to 66.1 (53.6-83.3) postoperatively, P = .032. FAAM sports scores improved from 14.1 (7.8-21.9) to 41.1 (25.0-60.9) postoperatively, P = .002. VAS scores improved from a median of 9.0 (8.0-9.0) to 3.0 (3.0-6.0), P < .001. At final follow-up, patients reported PROMIS lower extremity function score median of 43.8 (35.6-54.9), PROMIS neuropathic pain quality score of 54.1 (43.6-61.6), and PROMIS PI of 57.7 (41.1-63.8). Patients with both anxiety and depression reported less improvement in pain and physical. Other perioperative factors lacked sufficient numbers for statistical analysis. CONCLUSION: Sural nerve neurectomy and proximal implantation (20 muscle, 1 adipose) provided significant improvement in pain and function for patients with sural neuromas and chronic sural neuritis at median follow-up of 33.7 months. Anxiety and depression were associated with significantly poorer outcomes following surgery. Patients with CRPS as well as recent nicotine use tended to report less improvement in pain and worse function after surgery, although this sample size was too limited for statistical analysis of these variables. Further research is needed to identify the ideal surgical candidates and perioperative factors to optimize patient outcomes. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Risks Associated With Posterior Ankle Hindfoot Arthroscopy Complications.

BACKGROUND: The use of posterior ankle and hindfoot arthroscopy (PAHA) has been expanding over time. Many new indications have been reported in the literature. The primary objective of this study was to report the rate of PAHA complication in a large cohort of patients and describe their potential associations with demographical and surgical variables. METHODS: In this IRB-approved retrospective comparative study, patients who underwent posterior ankle and/or hindfoot arthroscopy in a single institution from December 2009 to July 2016 were studied. Three fellowship-trained orthopaedic foot and ankle surgeon performed all surgeries. Demographic data, diagnosis, tourniquet use, associated procedures, and complications were recorded. To investigate a priori factors predictive of neurologic complication after PAHA, univariate and multivariable logistic regression was utilized. Where appropriate, sparse events sensitivity analysis was tested by fitting models with Firth log-likelihood approach. RESULTS: A total of 232 subjects with 251 surgeries were selected. Indications were posterior ankle impingement (37%), flexor hallux longus disorders (14%), subtalar arthritis (8%), and osteochondral lesions (6%). Complications were observed in 6.8% (17/251) of procedures. Neural sensory lesions were noted in 10 patients (3.98%), and wound complications in 4 ankles (1.59%). Seven neurologic lesions resolved spontaneously and 3 required further intervention. In a multivariable regression model controlled for confounders, the use of accessory posterolateral portal was the significant driver for neurologic complications (odds ratio [OR] 32.19, 95% CI 3.53-293.50). CONCLUSION: The complication rate in this cohort that was treated with posterior ankle and/or hindfoot arthroscopy was 6.8%. Most complications were due to neural sensorial injuries (sural 5, medial plantar nerve 4, medial calcaneal nerve 1 ) and 3 required additional operative treatment. The use of an accessory posterolateral portal was significantly associated with neurologic complications. The provided information may assist surgeons in establishing diagnoses, making therapeutic decisions, and instituting surgical strategies for patients that might benefit from a posterior arthroscopic approach. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Failed Surgery for Achilles Tendinopathy.

Treatments of Achilles tendinopathy continue to evolve. The body of literature is inadequate to provide a comprehensive guide to evaluation and treat failed surgeries. Issues related to failed surgical treatment may be divided into infection/wound issue, mechanical failure, and persistent pain. Awareness of the potential problems described in this article will allow surgeons to have a foundation in clinical assessment and making accurate diagnoses. Various surgical treatment options are available and should be executed carefully to treat individualized patient conditions.

Outcomes and Complications of Open vs Posterior Arthroscopic Subtalar Arthrodesis: A Prospective Randomized Controlled Multicenter Study.

BACKGROUND: Open subtalar arthrodesis is the standard treatment for subtalar arthritis. Posterior arthroscopic subtalar arthrodesis (PASTA) has recently gained increasing popularity due to a shorter recovery time and better cosmesis. However, studies comparing outcomes and complications between these 2 techniques are limited. METHODS: In total, 56 patients with subtalar joint arthritis were prospectively randomized to 2 parallel groups to receive either PASTA (n = 28 patients) or open subtalar arthrodesis (n = 28 patients). The minimum follow-up period was 12 months. Primary outcome was union rate confirmed on postoperative computed tomography (CT) scan. Secondary outcomes were union time; visual analog scale (VAS), Short Form-36 (SF-36), and Foot and Ankle Ability Measure (FAAM) scores; tourniquet time; and complications. RESULTS: Union time (9.4 vs 12.8 weeks) and recovery time (time to return to activities of daily living [8.4 vs 10.8 weeks], work [10.6 vs 12.9 weeks], and sports [24.9 vs 32.7 weeks]) were significantly shorter with PASTA than with the open technique (P < .05 all). Both techniques led to significant improvements in all functional outcomes (FAAM, SF-36, and VAS scores; P < .01 all); however, there was no significant difference between the techniques in these outcomes (P > .05 all). Other outcomes, including tourniquet time (55.8 vs 67.2 min), union rate (96.3% vs 100%), and complication rate, were not significantly different between the techniques. CONCLUSION: Both open and PASTA techniques led to significant improvements in pain and function in patients with isolated subtalar joint arthritis. Although short-term functional outcomes and complication rates were not significantly different between the techniques, the PASTA technique was better at shortening the union and recovery times. LEVEL OF EVIDENCE: Level I, prospective multicenter randomized controlled trial.

Weightbearing Computed Tomography for Assessment of Foot and Ankle Deformities: The Iowa Experience.

BACKGROUND: Weightbearing computed tomography (WBCT) is a reliable and precise modality for the measurement and analysis of bone position in the foot and ankle, as well as associated deformities. WBCT to assess three dimensional relationships among bones allowed the development of new measurements, as the Foot and Ankle Offset (FAO), which has high inter and intra-rater reliability. This study reports the University of Iowa's experience utilizing WBCT for the care of foot and ankle patients by describing its utility across different orthopedic diseases in improving diagnostic assessment, aiding surgical planning, and expanding the use for objective clinical follow-up. METHODS: The medical records of consecutive patients with various foot and ankle disorders that underwent WBCT examination as part of the standard of care at a single institution between November 2014 and August 2020 were retrospectively reviewed. Patient factors, including body mass index (BMI), sex, and patient comorbidities were collected. 3D coordinates for calculation of FAO were harvested using the Multiplanar Reconstruction (MPR) views were calculated from the obtained exams. Descriptive statistics were performed with Shapiro-Wilk test and the Anderson-Darling tests. RESULTS: 1175 feet and ankles (820 patients) had a WBCT performed over the studied 68 months. 53% of the subjects were male and 47% female. 588 of the acquisitions were from the right side (50.04%) and 587 from the left side (49.96%). Diabetes was present in 15.47% of, Rheumatic diagnoses in 4.52% and smoking habits in 44.10% of patients. Mean BMI of the sample was found to be 32.47 (32.03-32.90, 95% CI). The mean Foot and Ankle Offset (FAO) encountered in the study's population was 2.43 (2.05-2.82, 95% CI; min -30.8, max 37.65; median 2.39). CONCLUSION: This study contains the largest cohort of WBCTs with accompanied FAO measurements to date, which can aid with establishing a new baseline FAO measurement for multiple pathological conditions. Acquiring WBCTs resulted in a variety of more specific diagnoses for patient with foot and ankle complaints. The ability to utilize WBCT for presurgical planning, the capability to provide a 3D reconstruction of patient anatomy, and its use for assessment of advanced relational foot and ankle measurements, such as FAO, demonstrate how WBCT may serve as a remarkable utility in clinical practice and has become a standard of care in our practice at the University of Iowa.Level of Evidence: IV.

Preliminary Experience with Conservative Sharp Wound Debridement by Nurses in the Outpatient Management of Diabetic Foot Ulcers: Safety, Efficacy, and Economic Analysis.

Background: Treatment of diabetes costs the United States an estimated $245 billion annually; one-third of which is related to the treatment of diabetic foot ulcers (DFUs). We present a safe, efficacious, and economically prudent model for the outpatient treatment of uncomplicated DFUs. Methods: 77 patients (mean age = 54 years, range 31 to 83) with uncomplicated DFUs prospectively enrolled from September 2008 through February 2012. All patients received an initial sharp debridement by one of two orthopaedic foot and ankle fellowship trained surgeons. Ulcer dressings, offloading devices, and debridement procedures were standardized. Patients were evaluated every two weeks by research nurses who utilized a clinical management algorithm and performed conservative sharp wound debridement (CSWD). Results: Average time to clinical healing was 6.0 weeks. There were no complications of CSWD performed by nurses. The sensitivity for the timely identification of wound deterioration was 100%, specificity = 86.49%, PPV = 68.75% and NPV = 100% with an overall accuracy of 89.58%. The estimated cost savings in this model by having nurses perform CSWD was $223.26 per encounter, which, when extrapolated to national estimates, amounts to $1.56 billion to $2.49 billion in potential annual savings across six to ten-week treatment periods, respectively. Conclusion: CSWD of DFUs by nurses in a vertically integrated multidisciplinary team is a safe, effective, and fiscally responsible clinical practice. This clinical model on a national scale could result in significant healthcare savings. Surgeons and other licensed independent practitioners would have more time for evaluating and treating more complex and operative patients; nurses would be practicing closer to the full extent of their education and training as allowed in most states.Level of Evidence: III.

Subsequent Pain or Injury After Foot and Ankle Surgery in Patients Receiving Workers' Compensation.

BACKGROUND: Workers' compensation (WC) has been associated with poor outcomes following a variety of injuries and surgeries, but rates of subsequent pain or injury (SPI) following surgery have not been studied. The purpose of this study was to investigate the rates, locations, and risk factors of SPI in WC patients and non-WC patients who underwent the same surgeries. METHODS: With institutional review board approval, records from foot or ankle surgery performed by author P.P. from 2009 to 2015 were obtained. A retrospective chart review was performed on all WC and non-WC patients with at least 1 Current Procedural Terminology code of interest. SPI was defined as a new injury at a different anatomical location occurring 2 months to 2 years after the index surgery. Chi-square and 2-tailed t tests were used to compare risk factors and rates of SPI in both groups. RESULTS: The WC population had higher rates of SPI than the non-WC population. Specifically, 13 of 56 WC patients (23.2%) vs 12 of 165 non-WC patients (7.3%) reported SPI (P = .001). The hip, knee, and contralateral foot and ankle were common areas of SPI in both groups. Legal representation and increased age were risk factors for SPI in the WC population. Specifically, 10 of 13 WC patients with SPI had legal representation vs 16 of 43 WC patients without SPI (P = .02). Female sex was a risk factor for SPI in the non-WC population. CONCLUSIONS: WC patients had higher rates of subsequent pain or injury than non-WC patients. Legal representation was a risk factor for SPI in the WC population. LEVEL OF EVIDENCE: Level III, comparative series.

Factors Impacting Initial Arthroscopy Performance and Skill Progression in Novice Trainees.

Background: Arthroscopy is one of the cornerstone skills learned during orthopaedic residency training. Previous studies have attempted to identify characteristics of arthroscopy naive individuals leading to superior initial arthroscopic performance with conflicting findings. Furthermore, other virtual reality simulator studies consisting of beginner trainees, have noted that certain individuals fail to progress at the rate of their peers despite rigorous training. Therefore the purpose of this study was to 1) identify trainee characteristics that may have an impact on initial arthroscopy skill and performance and 2) identify trainee characteristics affecting their ability to improve through training on an arthroscopy simulator. Methods: Forty-three medical students with no prior arthroscopy experience performed a diagnostic knee arthroscopy using an anatomic virtual reality simulator. Prior to the procedure, information was collected about each participant regarding various demographics, sports involvement, hand dominance, specialty interest, 3-D video game use and experience assisting in the operating room. Their baseline performance was measured using the following outcomes: time (seconds), camera path length (CPL) (centimeters), and an overall composite score. A subgroup consisting of 22 students underwent training with a non-anatomic virtual arthroscopy simulator consisting of a series of 5 self-guided modules after their initial knee scope. This group was retested using the same diagnostic knee scope one to two weeks later. Participant background characteristics were correlated with initial performance on the knee scope and the change from the first to second knee scope in the sub-group that completed the training. Results: At the time of the initial diagnostic knee arthroscopy, performance was most strongly correlated with how often an applicant currently plays video games and how often they have played video games in the past. However, this was only a weak correlation (r= 0.29 and 0.24, respectively). Interestingly, students pursuing a non-surgical residency outperformed those interested in a surgical specialty in all outcome measurements at baseline, although this did not reach a level of significance. Year of training in medical school, age, hand dominance, current or past participation in sports requiring hand-eye coordination, and number of surgical cases they have assisted in for did not influence initial performance. Participants that have operated another type of scope (e.g. bronchoscopy, laparoscopy) in the past showed a trend towards higher performance in composite score (21.6 vs 14.9, p = 0.07), although this did not reach a level of significance. Regarding the change in performance of those that completed the non-anatomic training prior to the second knee scope, change in time to complete the procedure was significantly different between participants in different years of medical school. Fourth year medical students improved by an average of 421 seconds compared to 98 seconds, 127, and 140 seconds for the other classes, p = 0.02. Those who have regularly participated in sports requiring hand eye coordination in the past improved their time (182 vs 78 seconds, p = 0.0245) and camera path length (96 vs 31 cm, p = 0.0372) significantly more than those were not involved in sports. Discussion and Conclusions: Our study demonstrates that baseline arthroscopy performance correlates most highly with 3D video game experience. The ability of trainees to learn arthroscopy using a virtual reality simulator appears to be influenced more by those who have regularly participated in sports requiring hand eye coordination rather than video game use.Level of Evidence: III.

Minimally Invasive and Endoscopic Approach for the Treatment of Noninsertional Achilles Tendinopathy.

Minimally invasive treatment can offer an earlier recovery with less pain and scarring compared with traditional open surgeries. The goals of minimally invasive surgery are to debride degenerative tendon, stimulate healing, and, when appropriate, repair damaged tendon. Sclerotherapy and prolotherapy have been shown to reduce neovascularization and pain. Percutaneous stripping and endoscopic debridement are better options for diffuse tendinopathy. Plantaris release can be useful in diffuse disease in patients with primarily medial-sided Achilles pain. Overall, minimally invasive surgery provides similar benefits as open procedures with reduced complications and morbidity.

Anatomic Ligament Repairs of Syndesmotic Injuries.

Poor clinical results are seen with syndesmotic injuries in the setting of ankle sprains and ankle fractures. The goal of syndesmosis repair is to restore the normal anatomic relationship of the distal tibiofibular joint and prevent ankle arthritis. Indications for surgical intervention for isolated syndesmotic injuries include frank syndesmosis diastasis, medial clear space widening on plain radiographs, significant radiographic syndesmosis diastasis during stress examination, or subtle syndesmotic diastasis detected by arthroscopic evaluation. Complications after syndesmosis repair include symptomatic hardware, malreduction, and arthritis. Anatomic reduction of the syndesmosis leads to better outcomes following surgery.

Clinical Examination and Radiographic Assessment of the Cavus Foot.

The purpose of the clinical examination is to detect subtle cavus or cavovarus deformity, assess the severity and type of deformity, differentiate between idiopathic versus secondary etiologies of cavus foot deformity, and evaluate for other associated abnormalities. The clinical examination should begin with a gait analysis. The neurologic examination reveals peripheral neuropathy or central nervous system etiology for the foot deformity. On plain radiographs, forefoot-driven deformity can be assessed using the Meary angle, and hindfoot-driven deformity can be measured by the calcaneal pitch. Computed tomography and MRI scans can assess for tarsal coalitions and soft tissue pathologies, respectively.

Achilles Tension Mitigates Fibular Malalignment Measured in Cadaveric Studies of Syndesmotic Clamping.

BACKGROUND:: Fibular malreduction is becoming a commonly recognized complication of surgical repair of the syndesmosis when a reduction clamp is used. The goal of this work was to determine the interdependent effects of transsyndesmotic reduction clamp position and applied compression force on fibular alignment in a realistic cadaveric preparation of complete syndesmotic injury. METHODS:: Six through-the-knee cadaveric specimens were CT scanned intact, with the distal syndesmosis fully destabilized, and with 53, 102, and 160 N clamping forces each applied along an anteriorly, centrally, and posteriorly directed transsyndesmotic axis. Testing was repeated incorporating 178 N of Achilles tendon tension using all 3 clamping forces applied along the centrally directed axis. Fibular reduction was automatically quantified from CT scan-generated bony surfaces as rotation of the fibula around the tibia, rotation of the fibula within the incisura, medial/lateral fibular displacement, and anterior/posterior fibular displacement. RESULTS:: Transsyndesmotic clamping along the anteriorly directed axis resulted in the best reduction quality by all 4 quantified measures. Along the centrally and posteriorly directed axes, progressively greater forces caused significantly greater sagittal plane fibular malreduction. Addition of Achilles tension reduced the magnitude of fibular malreduction and overcompression. CONCLUSION:: Placing the medial tine of a transsyndesmotic reduction clamp on the anterior medial tibia resulted in the most accurate syndesmotic reduction and provided some protection against overcompression with large reduction clamp forces. Achilles tension appeared to contribute to reduction, decreasing the magnitude of measured malreduction from clamping. CLINICAL RELEVANCE:: Previous studies estimating fibular malpositioning in cadaveric models that lacked passive muscle tension may have overestimated expected magnitudes of malalignment in patients treated with syndesmotic clamping. However, syndesmotic malreduction, particularly in the sagittal plane, was a real complication of syndesmotic clamping that was reduced by using an anterior position of the medial tine on the tibia.

Screw fixation of the syndesmosis alters joint contact characteristics in an axially loaded cadaveric model.

BACKGROUND: The purpose of this study was to quantify the effects of rigid syndesmotic fixation on functional talar position and cartilage contact mechanics. METHODS: Twelve below-knee cadaveric specimens with an intact distal syndesmosis were mechanically loaded in four flexion positions (20° plantar flexion, 10° plantar flexion, neutral, 10° dorsiflexion) with zero, one, or two 3.5-mm syndesmotic screws. Rigid clusters of reflective markers were used to track bony movement and ankle-specific pressure sensors were used to measure talar dome and medial/lateral gutter contact mechanics. RESULTS: Screw fixation caused negligible anterior and inferior shifts of the talus within the mortise. Relative to no fixation, mean peak contact pressure decreased by 6%-32% on the talar dome and increased 2.4- to 6.6-fold in the medial and lateral gutters, respectively, depending on ankle position and number of screws. CONCLUSIONS: Two-way ANOVA indicated syndesmotic screw fixation significantly increased contact pressure in the medial/lateral gutters and decreased talar dome contact pressure while minimally altering talar position.

Neurovascular and Clinical Outcomes of the Percutaneous Endoscopically Assisted Calcaneal Osteotomy (PECO) Technique to Correct Hindfoot Malalignment.

BACKGROUND:: Standard open calcaneal osteotomies to correct hindfoot malalignment have been associated with high complication rates, including nerve damage and wound infection. This has resulted in the development of minimally invasive techniques such as the percutaneous endoscopically assisted calcaneal osteotomy (PECO), which in cadaver studies has been shown to be potentially safer than open surgeries. The aim of this study was to demonstrate the safety and effectiveness of PECO in a clinical setting, with regard to neurovascular injury rates, infection, and short-term radiographic and functional outcomes. METHODS:: Forty-one (41) patients with planovalgus or cavovarus foot deformities underwent treatment using PECO. Outcomes were analyzed at 6 months and primarily included neurovascular outcomes and wound infection rates. Secondarily, radiographic and functional (visual analog scale for pain [VAS], 36-Item Short Form Medical Outcomes Survey [SF-36], and Foot Function Index [FFI] scores) outcomes were also assessed. RESULTS:: There were no reported cases of superficial wound infections, lateral calcaneal or sural nerve dysesthesia. Minor complications occurred in 6/41 feet. The mean postoperative hindfoot correction was 8.3 ± 2.2 mm (range: 6-15mm) compared to preoperative status. Compared to preoperative status, significant improvements ( P = .001 for all) were seen in the VAS, SF-36, and FFI at 6 months postoperatively. CONCLUSIONS:: PECO resulted in minimal complications with no lateral calcaneal or sural nerve dysesthesias and no wound complications. It also resulted in significant improvements in postoperative radiographic and functional outcomes from baseline to 6-months postoperatively, demonstrating its use as a safe and effective means of treating hindfoot malalignment. LEVEL OF EVIDENCE:: Level IV, retrospective case series.