Considering the cellular landscape in marrow stimulation techniques for cartilage repair.

BACKGROUND: Marrow stimulation is a common reparative approach to treat injuries to cartilage and other soft tissues (e.g., rotator cuff). It involves the recruitment of bone marrow elements and mesenchymal stem cells (MSCs) into the defect, theoretically initiating a regenerative process. However, the resulting repair tissue is often weak and susceptible to deterioration with time. The populations of cells at the marrow stimulation site (beyond MSCs), and their contribution to inflammation, vascularity, and fibrosis, may play a role in quality of the repair tissue. SUMMARY: In this review, we accomplish three goals: 1) systematically review clinical trials on the augmentation of marrow stimulation and evaluate their assumptions on the biological elements recruited; 2) detail the cellular populations in bone marrow and their impact on healing; and 3) highlight emerging technologies and approaches that could better guide these specific cell populations towards enhanced cartilage or soft tissue formation. KEY MESSAGES: We found that most clinical trials do not account for cell heterogeneity, nor do they specify the regenerative element recruited, and those that do typically utilize descriptions such as "clots", "elements", and "blood". Furthermore, our review of bone marrow cell populations demonstrates a dramatically heterogenous cell population, including hematopoietic cells, immune cells, fibroblasts, macrophages, and only a small population of MSCs. Finally, the field has developed numerous innovative techniques to enhance the chondrogenic potential (and reduce the anti-regenerative impacts) of these various cell types. We hope this review will guide approaches that account for cellular heterogeneity and improve marrow stimulation techniques to treat chondral defects.

Lower Extremity Fractures in Hospitalized Pediatric Patients Following Road Traffic Accidents.

Lower extremity fractures (LEFs) caused by road traffic accidents (RTAs) can result in significant morbidity and account for a substantial part of nonfatal injuries requiring hospitalization. This study investigated the epidemiology of RTA-associated LEFs in the pediatric population. Based on the National Trauma Registry, data of 28,924 RTA hospitalized pediatric patients were reviewed. Data were analyzed according to LEF mechanism of injury, age distribution, fracture types, associated injuries, surgical treatment, and their interrelations.A total of 4970 (17.18%) sustained LEFs, with the highest risk for motorcycle-associated RTA, followed by pedestrians. Approximately 1 of 4 patients had multiple fractures. Forty percent (2184 cases) sustained additional injuries, for which car-associated RTAs were at the greatest risk (61%, P < 0.0001), followed by pedestrians and motorcycles (46%-45%, P < 0.0001). Overall, head/neck/face injuries were the most commonly associated injuries. The tibia was the most fractured bone (42%), followed by the femur, fibula, foot, and ankle. This distribution varied according to RTA mechanism. Forty-one percent of cases required fracture treatment in an operating room. As patients were older, the greater the chance they required further treatment in the operating room (P < 0.0001).This large-scale study on the epidemiology of LEFs in the pediatric population following RTA provides unique information on epidemiological characteristics of LEF, pertinent both to medical care providers and to health policy makers allocating resources and formulating prevention strategies in the attempt to deal with the burden of road traffic accidents.Level of Evidence: Prognostic and epidemiologic study, level II.

Lateral malleolus closed reduction and internal fixation with intramedullary fibular rod using minimal invasive approach for the treatment of ankle fractures.

BACKGROUND: Ankle fractures are extremely common and represent nearly one quarter of all lower-limb fractures. Techniques for fixation of displaced fractures of the lateral malleolus have remained essentially unchanged in recent decades. The current gold standard of treating unstable fractures is with open reduction and internal fixation (ORIF), using plates and screws construct. This study evaluates the use of fibula intramedullary nailing based on minimal invasive surgical approach. METHODS: Thirty-nine cases treated with fibula intramedullary nailing between the years 2014-2016 were retrospectively studied. A fibular nail was utilized for the treatment of various ankle fractures either as the sole method of fixation or combined with another method. Patient charts were reviewed for fracture patterns, comorbidities, quality of reduction, complications and additional surgeries. RESULTS: Out of 39 cases in the study cohort, 37 were closed fractures while 2 had an associated medial malleolus open injury. According to Weber classification of lateral malleolus fractures, 20 cases were type B, 18 cases type C, and one case of a pathologic fracture type B like fracture. Quality of reduction was based on previously published criteria. It was determined to be good in 32 cases, fair in 5 cases and poor in 2 cases that were revised intraoperatively to plate fixation. Overall no systemic complications occurred. Eight patients have undergone additional surgeries, namely hardware removals. In two cases, the nail was later revised to a different fixation method: one case to a plate, due to secondary displacement at 2 weeks, and one to an intramedullary tibiotalocalcaneal arthrodesis secondary to hardware failure and Charcot neuroarthropathy. CONCLUSION: Intramedullary fibular nail offers a satisfactory and safe procedure to establish good reduction and fixation of lateral malleoli fractures. It may be considered as treatment of choice for patients with soft tissue problems due to its minimal invasive approach. The current study shows that while good fracture reduction can be achieved, without major complications, more than fifth of patients, required secondary procedures, mainly hardware removals. LEVEL OF EVIDENCE: Level IV.

Early radiographic and clinical results of Salto total ankle arthroplasty as a fixed-bearing device.

BACKGROUND: Total ankle replacement has increased in popularity in the management of severe tibiotalar arthritis. Most previous clinical reports focused on mobile-bearing designs. This study evaluates early radiographic and clinical results of the Salto fixed bearing design. METHODS: Twenty-three Salto fixed-bearing implants were prospectively studied. Records were reviewed for clinical outcome scores (VAS, AOFAS, SF36), subsequent surgeries, complications, radiographic data and implant survivorship. Average follow-up was 36 months. RESULTS: Statistically significant improvements in VAS, AOFAS ankle/hindfoot scores, and SF36 scores were shown at an average of 3 years postoperatively. At 3 years followup, survivorship of the implant was 82.6% with any reoperation as the endpoint and 95.6% for revision or removal of components. Seven patients had radiolucencies around the implant, one of which required revision to arthrodesis. CONCLUSION: The fixed-bearing Salto ankle replacement has comparable early radiographic and clinical results to reports of the mobile-bearing Salto of comparable followup. LEVEL OF EVIDENCE: Level IV.

Fungal osteomyelitis and septic arthritis.

Management of fungal osteomyelitis and fungal septic arthritis is challenging, especially in the setting of immunodeficiency and conditions that require immunosuppression. Because fungal osteomyelitis and fungal septic arthritis are rare conditions, study of their pathophysiology and treatment has been limited. In the literature, evidence-based treatment is lacking and, historically, outcomes have been poor. The most common offending organisms are Candida and Aspergillus, which are widely distributed in humans and soil. However, some fungal pathogens, such as Histoplasma, Blastomyces, Coccidioides, Cryptococcus, and Sporothrix, have more focal areas of endemicity. Fungal bone and joint infections result from direct inoculation, contiguous infection spread, or hematogenous seeding of organisms. These infections may be difficult to diagnose and eradicate, especially in the setting of total joint arthroplasty. Although there is no clear consensus on treatment, guidelines are available for management of many of these pathogens.

Early catastrophic failure of trochanteric fixation with the Dall-Miles Cable Grip System.

Multi-filament orthopaedic cerclage cables have been used in clinical practice for several decades, and are commonly utilized to provide greater trochanteric fixation following an osteotomy or fracture. We present the first known report of patients who experienced early catastrophic failure following use of the Dall-Miles Cable Grip System (DMCGS). A root cause analysis determined that the jaws of one crimper had an increased distance at closure, resulting in inadequate ultimate fixation strength. It was discovered that operating room staff had not been trained to perform regular calibration checks and the required calibration tool was not included in any of the institution's DMCGS sets. Surgeons should be aware that these surgical instruments require regular maintenance and should be gauge tested prior to every use.

Trichophyton rubrum osteomyelitis after calcaneus external fixation pin stabilization of a pilon fracture.

Fungal organisms are an uncommon cause of osteomyelitis, and no dermatophyte osteomyelitis infections have been reported in published studies. We present the case of Trichophyton rubrum osteomyelitis of the calcaneus. Our patient initially presented with a pilon fracture requiring temporary external fixation while awaiting definitive fixation. From our review of the published data, the present case is the first of this type of fungal osteomyelitis to be reported. The patient was evaluated for a left neck mass during his hospitalization that was later found to be consistent with salivary duct carcinoma of the tail of the parotid gland. A left neck dissection and superficial excision of the parotid gland was performed after fixation of his pilon fracture. Subsequently, he developed an increasing lucency in the calcaneus and symptoms of pain and erythema months after the calcaneus pin had been removed. The osteomyelitis was treated with surgical debridement and 3 months of itraconazole once cultures had definitively grown T. rubrum.

A biomechanical evaluation of locked plating for distal fibula fractures in an osteoporotic sawbone model.

BACKGROUND: Supination external rotation (SER) injuries are commonly fixed with a one third tubular neutralization plate. This study investigated if a combination locked plate with additional fixation options was biomechanically superior in osteoporotic bone and comminuted fracture models. METHODS: Using an osteoporotic and a comminuted Sawbones model, SER injuries were fixed with a lag screw for simple oblique fibula fractures, and either a one third tubular neutralization plate or a locking plate. Samples were tested in stiffness, peak torque, displacement at failure, and torsion fatigue. RESULTS: There was no statistically significant difference in biomechanical testing for fractures treated with a lag screw and plate. For comminuted fractures, locked plating demonstrated statistically significant stiffer fixation. CONCLUSION: A combination locked plate is biomechanically superior to a standard one third tubular plate in comminuted SER ankle fractures. There was no biomechanical superiority between locked and one third tubular plates when the fracture was amenable to a lag screw.

Venous Thromboembolism in Outpatient Elective Foot and Ankle Procedure Patients Who Is at Risk?

BACKGROUND: Venous thromboembolism (VTE) is a rare but potentially serious complication following elective foot and ankle (F&A) procedures. The absence of guidelines for thromboprophylaxis in elective procedures underscores the importance of identifying patients at risk. This study aimed to identify key risk factors of VTE in patients who underwent elective foot and ankle (F&A) operations. METHODS: Data was collected from the IBM MarketScan Database (2009-2019) for patients >18 years old without prior VTE who underwent elective F&A procedures. Patients were divided into 3 groups based on region of operation (forefoot, mid/hindfoot, lower leg/ankle). VTE incidence (including deep vein thrombosis and/or pulmonary embolism) was recorded 30 and 90 days postprocedure. Risk factors for VTE were identified through multivariate logistic regression. RESULTS: Among the 301 256 patients who underwent elective F&A procedures, the overall 90-day incidence of VTE was 0.95%. The findings revealed that 31.9% of VTE incidents occurred within the first 2 weeks after operation, and 29.2% still occurred after 6 weeks. Analysis of the anatomical region of operation demonstrated that the lowest rate of 90-day VTE was amongst patients undergoing forefoot procedures (0.70%). There was a higher risk for VTE in patients undergoing midfoot/hindfoot procedures (1.22%, OR = 1.81) and lower leg/ankle procedures (1.76%, OR = 2.31). Additional risk factors for VTE included thrombophilia (4.02%, OR = 3.37), male sex (1.30%, OR = 1.47), increasing age (1.02% age 65+, OR = 1.41), and a high Charlson Comorbidity Index (1.12%, OR < 0.82 for scores <5). CONCLUSION: This study identifies the incidence and timing for VTE after elective F&A procedures. Furthermore, this study defines the risk factors associated with increased odds of VTE after elective F&A procedures. These findings are helpful in educating patients about a continued risk for VTE throughout the 90-day postoperative period and beyond. These results can also be utilized to stratify patients who need thromboprophylaxis based on the individual risk level. LEVEL OF EVIDENCE: Level III: Retrospective cohort study.

Weightbearing Computed Tomography Can Accurately Detect Subtle Lisfranc Injury.

BACKGROUND: Early detection of Lisfranc injury is critical for improving clinical outcomes, but diagnosing subtle injury can be difficult. Weightbearing computed tomography (WBCT) allows evaluation of such injuries in 3 dimensions (3D) under physiologic load. This study aimed to assess the utility of 1-, 2-, and 3-dimensional measurements on WBCT to diagnose subtle injury in isolated ligamentous Lisfranc injuries. METHODS: Ten cadaveric specimens underwent WBCT evaluation of the Lisfranc joint complex in the intact state and subsequently with sequential sectioning of the dorsal Lisfranc ligament and interosseous Lisfranc ligament (IOL) to create subtle Lisfranc injury, and finally after transectioning of plantar Lisfranc ligament (PLL) to create the injury conditions for complete ligamentous Lisfranc injury. Measurements under static vertical tibial load of 80 kg were performed on WBCT images including (1) Lisfranc joint (medial cuneiform-base of second metatarsal) volume, (2) Lisfranc joint area, (3) C1-C2 intercuneiform area, (4) C1-M2 distance, (5) C1-C2 distance, (6) M1-M2 intermetatarsal distance, (7) first tarsometatarsal (TMT1) alignment, (8) second tarsometatarsal (TMT2) alignment, (9) TMT1 dorsal step-off distance, and (10) TMT2 dorsal step-off distance. RESULTS: In the subtle Lisfranc injury state, Lisfranc joint volume and area, C1-M2 distance, and M1-M2 distance measurements on WBCT significantly increased, when compared with the intact state (P values .001 to .014). Additionally, Lisfranc joint volume and area, C1-M2 distance, M1-M2 distance, TMT2 alignment, and TMT2 dorsal step-off measurements were increased in the complete Lisfranc injury state. Of all measurements, C1-M2 distance had the largest area under the curve (AUC) of 0.96 (sensitivity = 90%; specificity = 90%), followed by Lisfranc volume (AUC = 0.90; sensitivity = 80%; specificity = 80%) and Lisfranc area (AUC = 0.89; sensitivity = 80%; specificity = 100%). CONCLUSION: In a cadaveric model we found that WBCT scan can increase the diagnostic accuracy for subtle Lisfranc injury. Among the measurements, C1-M2 distance exhibited the highest level of accuracy. The 2D joint area and 3D joint volume also proved to be accurate, with 3D volume measurements of the Lisfranc joint displaying the most significant absolute difference between the intact state and increasing severity of Lisfranc injury. These findings suggest that 2D joint area and 3D joint volume may have potential as supplementary measurements to more accurately diagnose subtle Lisfranc injuries. CLINICAL RELEVANCE: WBCT may help surgeons detect subtle Lisfranc injuries.

Lateral Ankle Ligament Repair Is Not Only for Young Patients: Trends in Incidence and Demographics.

The purpose of this study was to examine the changes in annual incidence and patient population undergoing lateral ankle ligament repair (LALR) for the surgical treatment of chronic ankle instability. The IBM Watson Health MarketScan Database was queried for patients who underwent LALR from January 2009 to December 2019 based on CPT code 27698. Volume and incidence per 100 000 population were determined for annual sums, gender, age, and geographical regions based on population estimates from the United States Census Bureau. Future annual volumes were statistically projected with linear regression modeling to the year 2032. Overall, 160 457 LALR procedures were identified in the database from 2009 to 2019. Annual incidence increased 76.6% from 3.46 to 6.11 cases per 100 000 population, while estimates of annual volumes are projected to increase 61.5% from 19 829 to 32 033 procedures to the year 2032. Interestingly, the greatest increase in incidence was observed among patients above 70 years old, which might suggest older patients are staying active longer and desiring elective procedures to maintain their activity levels. As the incidence of LALR increases in older patients, more research will be needed to understand the unique surgical considerations and risk factors impacting patient-reported outcomes.Level of Evidence: Level IV.

Association of First Metatarsal Phalangeal Joint Fusion for Hallux Rigidus With Patient-Reported Pain and Mental Health Outcomes in Patients Taking Psychotropic Medications.

Background: Limited literature examines the relationship between surgical outcomes in chronic foot and ankle conditions and concurrent psychiatric care. The present study aimed to investigate patient-reported and surgical outcomes of patients treated for a psychiatric disorder undergoing first metatarsophalangeal (MTP) fusion for hallux rigidus. We hypothesized that patients on psychotropic medications would have greater subjective pain preoperatively and less improvement in physical and mental functionality postoperatively when compared with nonmedicated patients. Methods: A single-center, retrospective review of prospectively collected data was conducted on 92 patients undergoing first MTP fusion with a preoperative diagnosis of hallux rigidus from 2015 to 2019. At their preoperative, 6-month postoperative, and 1-year postoperative visits, patients were administered visual analog pain scale (VAS) and 36-Item Short Form Health Survey (SF-36) functionality surveys. Patients were subsequently identified by chronic use of psychotropic medication preoperatively and grouped for analysis (MED, n = 42; NO MED, n = 50). Results: Postoperative mean VAS pain scores were lower for all studied patients at 6 months (VAS = 1.6 ± 2.3) and 1 year postoperatively (VAS = 1.1± 1.8) relative to the preoperative visit (VAS = 4.7 ± 2.8) (P ≤ .0001 and P ≤ .0001, respectively). No differences in mean VAS pain scores nor SF-36 physical component summary scores were detected at preoperative, 6-month, or 1-year visits between NO MED and MED groups. Mean SF-36 mental component summary scores for those in the MED group were lower at preoperative (NO MED = 83.8, MED = 71.8, P = .006) and 6-month postoperative (NO MED = 86.1, MED = 72.7, P = .037) visits than those in the NO MED group, a trend not observed at the 1-year postoperative mark (NO MED = 84.1, MED = 76.8, P = .228). There were no observed differences in operative time (P = .219), tourniquet time (P = .359), nor time to full weightbearing (P = .512) between MED and NO MED groups. Additionally, no differences in postoperative complication rates were observed between groups. Conclusion: In patients treated with psychotropically active medications with hallux rigidus, MTP Fusion appears to be a reasonable treatment choice with similar outcomes for patients requiring psychotropically active medications to the outcomes of those patients not requiring psychotropically active medications. Level of Evidence: Level III, retrospective comparative study.

Body Mass Index (BMI) Cutoffs and Racial, Ethnic, Sex, or Age Disparities in Patients Treated With Total Ankle Arthroplasty.

Background: The rising prevalence of obesity among American adults has disproportionately affected Black adults and women. Furthermore, body mass index (BMI) has historically been used as a relative contraindication to many total joint arthroplasty (TJA) procedures, including total ankle arthroplasty. The purpose of this study was to investigate potential disparities in patient eligibility for total ankle arthroplasty based on race, ethnicity, sex, and age by applying commonly used BMI cutoffs to the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Methods: Patients in the ACS-NSQIP database who underwent TAA from 2011 to 2020 were retrospectively reviewed in a cross-sectional analysis. BMI cutoffs of <50, <45, <40, and <35 were then applied. The eligibility rate for TAA was examined for each BMI cutoff, and findings were stratified by race, ethnicity, sex, and age. Independent t tests, chi-squared tests, and Fisher exact tests were performed to compare differences at an α = 0.05. Results: A total of 1215 of 1865 TAA patients (65.1%) were included after applying the exclusion criteria. Black patients had disproportionately lower rates of eligibility at the most stringent BMI cutoff of <35 (P = .004). Hispanic patients had generally lower rates of eligibility across all BMI cutoffs. In contrast, Asian American and Pacific Islander patients had higher rates of eligibility at the BMI cutoffs of <35 (P = .033) and <40 (P = .039), and White non-Hispanic patients had higher rates of eligibility across all BMI cutoffs. Females had lower eligibility rates across all BMI cutoffs. Ineligible patients were also younger compared to eligible patients across all BMI cutoffs. Conclusion: Stringent BMI cutoffs may disproportionately disqualify Black, female, and younger patients from receiving total ankle arthroplasty. Level of Evidence: Level III, retrospective cross-sectional study.

Risk Factors for Prolonged Opioid Use After Ankle Fracture Surgery.

BACKGROUND: The incidence of ankle fractures is increasing, and risk factors for prolonged opioid use after ankle fracture fixation are unknown. Accordingly, the purpose of this study was to investigate risk factors that lead to prolonged opioid use after surgery. METHODS: The Truven MarketScan database was used to identify patients who underwent ankle fracture surgery from January 2009 to December 2018 based on CPT codes. Patient characteristics were collected, and patients separated into 3 cohorts based on postoperative opioid use (no refills, refills within 6 months postoperative, and refills within 1 year postoperatively). The χ2 test and multivariate analysis were performed to assess the association between risk factors and prolonged use. RESULTS: In total, 34 691 patients were analyzed. Comorbidities most highly associated with prolonged opioid use include 2+ preoperative opioid prescriptions (odds ratio [OR] = 11.92; P < .001), tobacco use (OR = 2.03; P < .001), low back pain (OR = 1.81; P < .001), depression (OR = 1.48; P < .001), diabetes (OR = 1.34; P < .001), and alcohol abuse (OR = 1.32; P < .001). CONCLUSION: Opioid use after ankle fracture surgery is common and may be necessary; however, prolonged opioid use and development of dependence carries significant risk. Identifying those patients at an increased risk for prolonged opioid use can aid providers in tailoring their postoperative pain regimen. LEVELS OF EVIDENCE: Prognostic, Level III.

Complications of Lesser Toe Surgery: How To Avoid Them before Surgery and How To Assess and Treat Them When They Have Occurred.

Complications following lesser toe surgery are challenging to manage. The keys to treatment of any of these conditions are, first, to try to avoid them through identification of patient- and surgeon-related variables that contribute to their development and, second, following the occurance of a complication, to understand what can and cannot be corrected with surgical and nonsurgical management. This review provides a comprehensive assessment of current literature, demonstrates best practices and approaches to lesser toe complications, and provides an illustration of clinical examples.

Preoperative Depression is Associated With Increased Complications Following Ankle Fracture Surgery.

BACKGROUND: The effects of preoperative depression following ankle fracture surgery remains unknown. The purpose of this study is to investigate the relationship between preoperative depression and outcomes following ankle fracture surgery. METHODS: This retrospective study used the Truven MarketScan database to identify patients who underwent ankle fracture surgery from January 2009 to December 2018. Patients with and without a diagnosis of preoperative depression were identified based on International Classification of Diseases (ICD) codes. Chi-squared and multivariate analyses were performed to determine the association between preoperative depression and postoperative complications following ankle fracture surgery. RESULTS: In total, 107,897 patients were identified for analysis, 13,981 of whom were diagnosed with depression (13%). Preoperative depression was associated with the increased odds for postoperative infection (odds ratio [OR]: 1.33, confidence interval [CI]: 1.20-1.46), wound complications (OR: 1.13, CI: 1.00-1.28), pain-related postoperative emergency department visits (OR: 1.58, CI: 1.30-19.1), 30-day and 90-day readmissions (OR: 1.08, CI: 1.03-1.21 and OR: 1.13, CI: 1.07-1.18), sepsis (OR: 1.39, CI: 1.12-1.72), and postoperative development of complex regional pain syndrome (OR: 1.46, CI: 1.18-1.81). CONCLUSION: Preoperative depression is associated with increased complications following ankle fracture surgery. Further studies are warranted to investigate the degree to which depression is a modifiable risk factor. LEVEL OF EVIDENCE: 3.

The Rise of Total Ankle Arthroplasty Use: A Database Analysis Describing Case Volumes and Incidence Trends in the United States Between 2009 and 2019.

BACKGROUND: Ankle arthrodesis has been the mainstay treatment for end-stage ankle arthritis. The popularity of total ankle arthroplasty (TAA) has been on the rise due to improved implant design and postoperative outcomes. The purpose of this study was to describe the basic epidemiology and trends of annual procedure volumes and incidence in the general American population as well as in different population subgroups from 2009 to 2019. We hypothesize that the incidence of TAA has significantly risen while the median length of hospital stay has decreased nationwide. METHODS: The IBM MarketScan database was queried for patients who underwent TAA from January 2009 to December 2019 based on Current Procedural Terminology coding. Population estimates from the US Census Bureau were used to calculate the annual incidence of TAA. Procedural volume and incidence were calculated for annual sums, gender, age subgroups, inpatient and outpatient TAA, as well as in four statistical geographic regions in the United States. Median length of hospital stay was calculated and trended annually for inpatient TAA. RESULTS: A total of 41,060 primary TAAs were identified in the database from 2009 to 2019, in which 52.5% were performed in males. Annual volumes increased by 136.1%, from 2180 to 5147 procedures nationwide. Incidence reported per 100 000 population increased by 120.8%. Both inpatient and outpatient procedures have increased, by 242.5% and 86.6%, respectively. Median length of hospital stay decreased from 3 days in 2009 to 1 day in 2019 and did not differ between genders. Growth in incidence was demonstrated in males and females above the age of 54 years with the largest growth in annual incidence found between 65 and 74 years. Incidence rose in the South and West of the United States by 111.8% and 136.5%, respectively. CONCLUSION: We found that annual volumes and incidence rates of primary TAA has increased between 2009 and 2019. Although both inpatient and outpatient surgery have become more frequent, inpatient volumes and incidence have increased almost 3 times more than those of outpatient surgery. Length of hospital stay decreased over the study years. When adjusted for the same study period, the cumulative annual growth rates of TAA were found to be 2 times greater than total knee arthroplasty and 3.6 times greater than total hip arthroplasty. LEVEL OF EVIDENCE: Level III, retrospective database review.

Preoperative Depression Influences Outcomes Following Total Ankle Arthroplasty.

INTRODUCTION: Total ankle arthroplasty (TAA) is increasing in incidence. While preoperative depression is known to affect outcomes following other procedures, its effect on outcomes following TAA are unknown. Therefore, the purpose of this study was to investigate this relationship. METHODS: This is a retrospective cohort study using the Nationwide Readmission Database (NRD). All patients undergoing TAA were included. Two cohorts (those with and without preoperative depression) were created. Logistic regression was then performed to assess the contribution of a preoperative diagnosis of depression on rates of 90-day complications, while controlling for patient demographic and comorbid data. RESULTS: Overall, 8047 patients were included, of whom, 11.4% (918) were depressed. Compared to patients without depression, patients with depression had increased odds of the following: nonhome discharge (OR 1.61, 95% CI 1.31-1.98), extended length of stay (>2 days; OR 1.34, 95% CI 1.15-1.57), prosthetic complication (OR 1.39, 95% CI 1.10-1.74), wound complication (OR 1.59, 95% CI 1.11-2.29), prosthetic joint infection (OR 1.82, 95% CI 1.06-3.15), superficial surgical site infection (OR 1.62, 95% CI 1.02-2.58), and medical complication (OR 1.32, 95% CI 1.03-1.68). DISCUSSION: Depression in patients undergoing TAA is common and is associated with increased health care utilization and complications following surgery. The modifiability of depression should be investigated with future studies. LEVELS OF EVIDENCE: Prognostic, Level III: Comparative study.

Effect of Obesity on Patient-Perceived Outcomes After First Metatarsophalangeal Joint Arthrodesis.

BACKGROUND: While first metatarsophalangeal joint (MTPJ) arthrodesis is a common and effective procedure, there is a paucity of studies examining obesity's effect on outcomes of 1st MTPJ arthrodesis. This study's purpose was to evaluate patient-reported outcomes following 1st MTPJ arthrodesis in obese versus non-obese patients. METHODS: A retrospective cohort study of 94 patients undergoing first MTPJ fusion over the age of 18 with a diagnosis of hallux valgus or hallux rigidus was performed. Surgical and postoperative outcomes were examined preoperatively and at 6 and 12 months follow-up via Visual Analog Pain scale (VAS), and Short Form 36 (SF-36) surveys, and data were stratified into 2 patient groups: BMI < 30 (n = 62, mean age 63.9 ± 9.1 and ≥ 30 (n = 32, mean age 61.9 ± 8.4). RESULTS: Average overall VAS and SF-36 physical component scores improved significantly at 6 months (P < .001, .006) and 1 year postoperative visits (P < .001, .007) with no differences in survey scores, outcomes, or complications between weight groups. CONCLUSION: Our study showed first MTPJ fusion improves short-term pain and physical quality-of-life in arthritic obese and non-obese patients without differences in nonunion, complications, or patient-reported measures. LEVEL OF EVIDENCE: Level III, Prognostic, Case-Control Study.

Non-emergent Conditions of the Ankle, Hindfoot, and Midfoot in Elderly Patients Are as Mobility Limiting as Congestive Heart Failure.

BACKGROUND: Mobility limitations are well linked to increased morbidity and mortality. Older patients with chronic pathologies of the foot and ankle can suffer from significant mobility limitations; however, the magnitude of limitation experienced by this cohort is not well characterized. Conversely, the effects of congestive heart failure (CHF) on patient mobility are routinely assessed via the New York Heart Association (NYHA) classification. New York Heart Association classification is determined by a patient's physical activity limitation and is strongly correlated to functional status. We hypothesized that non-emergent conditions of the foot and ankle would be as mobility limiting as CHF. METHODS: Life-Space Mobility Assessments (LSAs) were prospectively collected from orthopaedic patients at their preoperative visits and from CHF patients at a cardiology clinic. Patients over the age of 50 years were included in this study. Congestive heart failure patients NYHA class II or greater were included. The non-emergent foot and ankle cohort included Achilles tendonitis, ankle joint cartilage defects, ankle arthritis, subtalar arthritis, and midfoot arthritis. Patient demographics and LSA scores were analyzed using Mann-Whitney U and chi-squared tests. RESULTS: A total of 96 elderly, non-emergent foot and ankle operative patients and 45 CHF patients met inclusion criteria. All medical comorbidities, except smoking status, were significantly more prevalent in the CHF cohort. No statistical difference was observed between CHF and preoperative foot and ankle LSA scores (56.1 vs 62.4, P = .320). Life-Space Mobility Assessment scores in the foot and ankle cohort were significantly improved relative to CHF patients, at 6-month and 1-year postoperative visits (P = .028, P < .0001, respectively). CONCLUSION: Non-emergent ankle, hindfoot, and midfoot pathology is associated with similar mobility limitation to that of NYHA class II and III CHF. Older patients undergoing elective foot and ankle procedures exceeded the mobility of CHF patients at 6 months post-operation, and the mobility gains persisted at 1-year post-operation. LEVELS OF EVIDENCE: Level II: Prospective cohort study.