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Category: Midfoot/Forefoot Introduction/Purpose: The Modified Lapidus arthrodesis is a historically established surgical technique for treatment of hallux valgus, providing quality patient outcomes and reproducible results. Addition of a transverse first to second intermetatarsal screw spanning the base of the metatarsals in this procedure can increase stability. However, no study evaluates the radiographical parameters following application of this intermetatarsal screw fixation to procedures without first to second intermetatarsal screw fixation. The purpose of this study was to assess the quality of radiographic parameters between individuals receiving a first to second intertarsal screw fixation to those that did not receive intermetatarsal screw fixation following a non-saw cut Modified Lapidus procedure. Methods: A retrospective review was performed on 74 patients that underwent a Modified Lapidus arthrodesis between 2016- 2020 at a single institution. Preoperative indications for the procedure included first ray instability, first ray hypermobility, hallux abductovalgus, and metatarsal primus elevatus. Inclusion criteria consisted of skeletally mature patients undergoing non sawcut Modified Lapidus procedure. Patients that received the procedure due to a traumatic event or patients with concomitant second metatarsal arthrodesis were excluded. Review of patient's charts was performed. Basic demographics data, implant type, and radiographic parameters including intermetatarsal angle (IMA) and first metatarsal length were obtained from preoperative as well as postoperative films. Results: A total of 74 patients who underwent a Modified Lapidus arthrodesis were included in the study. A group of 43 patients received the Modified Lapidus arthrodesis with the addition of a first to second intermetatarsal screw fixation compared to a group of 31 patients who only received the Modified Lapidus arthrodesis procedure. The average IMA in all patients prior to surgery was 13°. The patients who received intermetatarsal screw fixation had significantly higher IMA reductions between preoperative and postoperative films than those who did not receive the intermetatarsal screw (-8.41° vs. -5.78°, p=.005). The difference in first metatarsal length on preoperative and postoperative films was less in patients who received the screw fixation but this was not statistically significant. Conclusion: The Modified Lapidus procedure is a commonly used procedure to treat hallux valgus. The results of this study found that the addition of a first to second intermetatarsal significantly reduced the IMA when compared to individuals who did not receive the screw construct. These findings will help surgeons further delineate if an intermetatarsal screw is required and how it will contribute to the radiographic parameters of interest.

Category: Ankle Introduction/Purpose: Isolated lateral malleolus fractures are a common ankle fracture that a foot and ankle surgeon will encounter. Retrograde intramedullary fixation for unstable lateral malleolus fractures has become a viable option for patients at higher risk for potentially devastating wound complications. The aim of this cadaveric study was to assess the relative risk of injuring adjacent anatomic structures with percutaneous implantation of an intramedullary fibular screw for lateral malleolus fractures to minimize iatrogenic injury. Methods: Seven fresh-frozen below-the-knee cadaver specimens were used for this study. Prior to investigations, specimens were inspected with fluoroscopic radiographs for preexisting pathology or prior surgical intervention. Lateral dissection of the lateral malleolus was performed after screw placement to determine the proximity of the peroneus longus (PL), peroneus brevis (PB), and sural nerve (SN) to the inserted hardware. The mean, standard deviation, and range for distances were calculated for all structures. Analysis of variance (ANOVA) was used to determine statistical significance. Results: Percutaneous intramedullary fibular screw placement was performed in seven specimens, six females and one male, with an average age of 79.3 +- 8.1 years. Amongst the seven specimens, only one resulted in an injury to a structure of interest (sural nerve). The peroneus longus and peroneus brevis were not injured in any of the specimens. Table 1 shows the average distance between the guidewire and each structure of interest. Conclusion: This study shows the potential risks to lateral structures when placing an intramedullary fibular screw for unstable lateral malleolus fractures. We suggest that orthopedic surgeons exercise caution when performing critical steps of the procedure to minimize avoidable injury to structures of importance that may increase the morbidity of the patient.

Category: Midfoot/Forefoot Introduction/Purpose: Lisfranc injuries are a relatively common midfoot injury involving the tarsometatarsal (TMT) joint. Surgical fixation typically involves open reduction with internal fixation or primary arthrodesis of the joint(s). The standard surgical approach to the TMT joint involves two dorsal incisions however, a recent study has suggested the use of a modified single dorsal incision approach. The goal of this paper is to compare the total surface area of the joint that can be prepared for primary arthrodesis of the TMT using the standard vs modified single dorsal approach. Methods: Ten fresh frozen below-the-knee cadaver specimens were randomly assigned to receive either the standard or modified dorsal single incision operative approach to the TMT joint. Prior to initiating the study, specimens were inspected with fluoroscopic radiographs for preexisting pathology or prior surgical intervention. The joint surface was visualized and then underwent articular preparation as for a joint fusion. After adequate joint preparation, the TMT joint was disarticulated and the surface was photographed for image analysis. Using ImageJ, articular joint surface preparation areas were measured by two blinded reviewers. to assess the joint surface preparation and this was compared by surgical approach. Results: After ImageJ and Mann-Whitney U statistical analysis, there was no significant difference in the amount of joint prepared when comparing the standard versus modified dorsal approach for the first three TMT joints (p= 0.548, p=0.310, p= 0.548). The percentage of joint preparation utilizing the standard dorsal approach versus the modified dorsal approach for TMT joints one through three are as follows (percentages utilized are listed as the median value with its correlating range): First TMT- 67.6% (range 26%) by the standard approach versus 71.7% (range 9%) by the modified dorsal approach, second TMT- 67.9% (range 24%) versus 65.7% (range 12%), and third TMT- 65.9% (range 42%) versus 59.6% (range 24%). Table 1 summarizes our results between each operative approach. Conclusion: With our findings, we demonstrate that a modified single dorsal approach to the Lisfranc joint provided comparable joint preparation for primary arthrodesis as the standard dual incision approach. However, the modified dorsal approach may be beneficial in that it avoids creating a skin bridge which has potential for necrosis with the standard two incision approach. The authors believe the comparable joint preparation combined with its potential to alleviate soft tissue complications make the modified dorsal approach a viable surgical approach for a TMT arthrodesis.

Category: Trauma; Ankle Introduction/Purpose: Pilon fractures are difficult injuries to manage as they are typically associated with extensive soft tissue damage. Although staged management of external fixation followed by open reduction and internal fixation is often used to prevent additional soft tissue damage and its associated complications, rates of nonunion remain high in this patient population. The purpose of this study is to evaluate and identify factors associated with increased rates of nonunion following operative fixation of pilon fractures. Methods: A retrospective review of all operatively managed pilon fractures at a single level 1 trauma center from 2014 to 2019 was performed. Minimum six-month follow-up was required for inclusion. Patients with skeletal immaturity or amputation prior to definitive fixation were excluded. Patients were grouped based on presence or absence of nonunion, which was defined as lack of bridging bone in at least 3 of 4 cortices and the presence of pain with ambulation at six-month follow-up. Demographics, injury and operative characteristics, and surgical outcomes were compared between the two groups. Results: Among the 279 patients meeting inclusion criteria, 48 developed nonunion at 6-month follow-up (17.2%). Average follow-up was 3.2 years. Patients with nonunion had significantly higher rates of open fractures (50.0% vs. 22.1%, p<0.001) and more required skin grafts (14.6% vs. 5.6%, p=0.029), muscle flap coverage (12.5% vs. 2.6%, p=0.002), and bone grafting (25.0% vs. 3.9%, p<0.001) compared to controls. Those who developed nonunion had significantly lower rates of medial column fixation (43.8% vs. 67.5%, p=0.002) and higher rates of surgical site infection (45.8% vs. 7.8%, p<0.001). Rates of AO/OTA 43C fractures (70.8% vs. 52.4%) and fractures treated with plates overlapping the site of external fixation (39.5% vs. 26.6%) were higher in the nonunion group, but did not reach statistical significance (p=0.064 and p=0.098). There were no significant differences in demographics, mechanism of injury, Gustilo-Anderson classification, associated ipsilateral lower extremity injuries, surgical approach, or type of fixation between the two groups. Conclusion: In the present study, pilon fractures were found to have a nonunion rate of 17.2% at six-month follow-up. Nonunion was associated with the presence of open fracture, need for soft tissue coverage or bone grafting, and surgical site infection. Medial column fixation was associated with a lower rate of nonunion in these fractures.

Category: Trauma; Ankle Introduction/Purpose: Pilon fractures are complex injuries that most commonly result from high-energy trauma. The extensive soft tissue damage and high rates of associated infection seen in these injuries remains a challenging concern for surgeons. The purpose of this study is to identify risk factors associated with surgical site infection (SSI) following operative management of pilon fractures. Methods: A retrospective review of all operatively managed pilon fractures at a single level 1 trauma center from 2014 to 2019 was performed. Minimum six-month follow-up and skeletal maturity was required for inclusion. Patients with amputation prior to definitive fixation were excluded. SSI consisted of superficial (defined as infection resolving with oral antibiotics) and/or deep infections (defined as return to the operating room for debridement with positive cultures). Patients were grouped based on presence or absence of SSI. Demographics, injury and operative characteristics, and surgical outcomes were compared between the two groups. Results: A total of 279 patients met inclusion criteria for the study, with 40 patients developing SSI (14.3%). Average follow-up was 3.2 years. Patients that developed SSI had a significantly higher proportion of open fractures (47.5% vs 23.4%, p=0.003); however, there were no significant differences in Gustilo-Anderson classification or open wound location compared to controls. The SSI group required significantly higher rates of skin grafts (25.0% vs 4.2%, p<0.001) and muscle flap coverage (20.0% vs 1.7%, p<0.001). Average operative time was significantly longer in the SSI group (283.1 vs. 222.3 minutes, p=0.002). Patients with SSI displayed significantly higher rates of nonunion at six-month follow-up compared to those without SSI (55.0% vs 10.9%, p<0.001). There were no significant differences in mechanism of injury, AO/OTA fracture classification, associated ipsilateral lower extremity injuries, bone grafting, surgical approach, or presence of medial column fixation between the two groups. Conclusion: The present study showed that SSI after pilon fractures can lead to significant morbidity, with 55% of patients having nonunion at six months. Risk factors for SSI in these patients included open fracture, need for soft tissue coverage, and longer operative times. Future multicenter studies are needed to further investigate risk factors for SSI after operative management of pilon fractures.

Category: Hindfoot; Trauma Introduction/Purpose: Calcaneus fractures are common injuries to the hindfoot. The safety of in-patient versus outpatient treatment in patients with calcaneus fractures remains unclear. The aim of the present study was to assess differences in wound complications and readmissions in operative calcaneus fractures treated with open reduction and internal fixation (ORIF) in an in- patient versus outpatient setting. Methods: Patients undergoing ORIF for calcaneus fractures from 2012 to 2020 were reviewed. Inclusion criteria were age greater than 18 years and an operative calcaneus fracture treated with the sinus tarsi approach (STA). Exclusion criteria consisted of a minimum of three months follow-up, open calcaneal fractures or fracture dislocations, inpatients with polytrauma, and patients without a preoperative computed tomography (CT) scan. A total of 113 patients met inclusion criteria with 24 (21%) managed inpatient and 89 (79%) managed as outpatient. The primary outcomes were deep infection defined as return to the operating room for debridement with positive cultures and readmissions. Secondary outcomes included implant related pain and unplanned return to the operating room. Results: Inpatients had a higher percentage of ASA classification 3&4 patients (58.3% vs 29.2%, p=0.008). Outpatients had a longer delay in days between injury and definitive fixation (mean 8 (8.9 SD, 0-31 range) vs. 14 (12.4 SD, 0-91 range) days, p=0.009). There were no statistically significant differences in the incidence of deep infections (8.3% vs. 4.5%, p=.606), implant related pain (8.3% vs. 15.7%, p=.516), return to the operating room (16.7% vs. 15.7%, p=1.0) or readmissions (4.2% vs. 3.4%, p=1.0) between inpatient and outpatient groups including in binary logistic regression models (p>.3 for all). In our retrospective study of patients undergoing operative repair of isolated calcaneus fractures with STA, there was no increased risk of wound complications or readmissions when calcaneus fractures were treated in an outpatient setting. Conclusion: In our retrospective study of patients undergoing operative repair of isolated calcaneus fractures with STA, there was no increased risk of wound complications or readmissions when calcaneus fractures were treated in an outpatient setting.

Category: Basic Sciences/Biologics; Midfoot/Forefoot Introduction/Purpose: Iatrogenic cutaneous nerve injury is the most common complication encountered in foot and ankle surgery with limited evidence to inform surgeons on neuroprotective techniques. The purpose of this study was to assess risk for injury to the dorsomedial cutaneous nerve (DCN) during insertion of percutaneous interfragmentary screws used in metatarsophalangeal (MTP) arthrodesis. Methods: Ten mid-tibia fresh frozen cadaver specimens were obtained for execution of this study. All cadavers were grossly and radiographically inspected for any evidence of existing pathology or prior operative intervention. Percutaneous placement of interfragmentary screw in both distal to proximal and proximal to distal fashion was performed. Only the skin was incised before reaming and screw placement. After screw placement, dissection of the great toe was conducted. The distance between the screws and the DCN was obtained. The DCN was also inspected for injury. Results: A total of 10 cadavers were included. The average age of our population was 64 (+- 12.6). Males represented 80% of our included specimens. Injury to the DCN was not reported using the proximal to distal screw fixation. The mean distance from the dorsal cutaneous nerve using proximal to distal interfragmentary screw fixation was 7.45+- 3.85 mm compared to 4.30+-2.71 mm in the distal to proximal screw. Distal to proximal screw fixation was associated with 10% risk of nerve injury with no nerve injuries occurring at the site of proximal to distal screws. Conclusion: In our cadaver study, proximal to distal screw fixation seems to offer neuroprotection in the setting of MTP arthrodesis. The DCN is known to have many anatomic variants, and DCN injuries can be a pretext for painful neuroma formation. Surgeons should consider careful dissection to the joint capsule in effort to decrease the risk of neurogenic injury when placing interfragmentary screws in MTP arthrodesis.

Category: Basic Sciences/Biologics; Hindfoot; Other Introduction/Purpose: Talonavicular (TN) joint arthrodesis is a common procedure for end stage arthritis. There are two common operative approaches used to expose the TN joint for articular preparation, the medial and dorsal. Classically, the medial approach has been the preferred method of TN joint fusion, but recent arguments have been made for the use of the dorsal approach. Articular surface preparation is a key tenant required for any joint fusion. To date no physical preparation studies have been done to compare the two approaches in terms of articular surface preparation. Methods: Ten fresh frozen cadaver specimens were obtained. Fluoroscopic radiographs were used to rule out any pre-existing pathology of the talonavicular joint. Specimens were assigned to receive either a dorsal or medial operative approach to the talonavicular joint. After joint preparation, the talonavicular joint was disarticulated and the amount of articular surface preparation was recorded using ImageJ software. Results: A total of 8 male and 2 female specimens were utilized with an average age of 64.5 +- 13.1. The dorsal approach had a higher average percentage of talar, navicular, and total talonavicular joint surface prepared. When examining joint surface area preparation regardless of approach used, the talar head was significantly less prepared than the navicular. The inter-observer correlation coefficient was excellent for both navicular and talar surface area prepared. Conclusion: The amount of articular surface preparation in the dorsal approach was consistently higher on average. Given the high rate of nonunion in isolated talonavicular and triple arthrodesis, surgeons should be aware that the dorsal approach may offer an increased amount of articular surface preparation. Our study adds to the growing body of evidence supporting the investigation and use of the dorsal approach when attempting talonavicular arthrodesis.

Category: Ankle; Trauma Introduction/Purpose: Subtalar fracture dislocations are a rare hindfoot injury with relatively little evidence to inform surgeons about outcomes and risk factors for complications. Some previously documented poor prognostic factors include lateral and complicated dislocations, total talar extrusions, and concomitant fractures. The mechanism of injury often results from high energy trauma and has been reported as severe inversion (medial dislocation) or eversion (lateral dislocation) of the foot. The purpose of this study was to assess the risk factors associated with deep infection after operative treatment of subtalar fracture dislocations. Methods: A retrospective cohort study at a single level 1 trauma center was performed to identify patients who had operative treatment of a subtalar fracture dislocation over an 11 year period (2008-2019). Patients were identified by review of the electronic health record and data collected included patient demographics, injury characteristics, and treatment choices. Deep infection was defined as return to the operating room for debridement. Minimum follow-up for inclusion was 3 months. Descriptive analyses (means, medians, standard deviations, ranges, frequency distributions) were used to assess and describe the group. Chi-square tests of association and independent-sample t tests were used to assess differences between the infected group and those without infection. Results: A total of 154 met criteria for this study. The most common associated fractures were talus (47%) and calcaneus (33%). Approximately every 1 in 8 patients (12.3%) patients developed a deep infection. The infected group was older (47.2 vs 39.5 years, p=0.03). Tobacco users were found to have a significantly higher rate of postoperative deep infection (74 vs 34%, aOR=7.4, 95% CI, 2.3-24.1, p=0.001). There was a significantly higher proportion of infection in patients with Gustilo-Anderson type 3 open fractures (32 vs 12%, aOR=5.7, 95% CI, 1.6-20.3, p=0.007). The infected group had a higher proportion of below the knee amputation (47 vs 1%, p<0.001). Conclusion: Infection after operative management of subtalar fracture dislocations can be devastating, with 47% of infected patients requiring amputation. Risk factors for infection after subtalar fracture dislocation include older age, smoking, type 3 open fracture, and freshwater contamination. Ultimately demographic and injury characteristics seem to drive the risk of infection in subtalar fracture dislocations.

Category: Trauma Introduction/Purpose: The purpose of this study was to evaluate union of talar neck fractures with critical bone defects treated acutely with autologous tibial bone graft during primary osteosynthesis. We hypothesized that acute autografting leads to reliable union rates. Methods: A case series at a Level I trauma center was performed to identify patients who underwent open reduction and internal fixation of talar neck fracture with proximal tibial autograft between 2015 and 2018. Inclusion criteria were age greater than 18 years and displaced talar neck fracture with critical bone defect treated with tibial autograft. Critical bone defect was defined as a gap greater than 5mm in the sagittal plane and greater than 1/3 of the width of the talar neck in the coronal plane. Post-operative foot CT scans were obtained for all patients to assess for union. Primary outcome was union and secondary outcomes were malunion, avascular necrosis, post-traumatic arthritis, and patient-reported outcomes (PRO) including PROMIS (Patient Reported Outcomes Measurement Information System), Foot and Ankle Measurements: Activity of Daily Living and Sports (FAAM ADL/Sports), Visual Analogue Scale for feet (VAS), Foot Function Index (FFI), and Short Form-36 (SF-36). Results: Twelve patients were included in the series. The average age was 34 years (17-59). The Hawkins classification of the fractures were four type II (33%) and eight type III (67%). Five fractures (42%) were extruded tali. Four fractures (33%) were open fractures, all being type III fractures. Union was achieved in eleven patients (92%). Nonunion occurred in one patient (8%), who had an open, extruded talus fracture and was a heavy smoker. Avascular necrosis occurred in 11 patients (92%). Ten patients (83%) had radiographic tibiotalar post-traumatic arthritis (PTA), and 12 patients (100%) developed subtalar PTA. Average PROMIS score was 37 (32-45) and average FAAM ADL and Sports was 61 (31-87) and 31 (0-71), respectively. Average VAS was 5 (0-10) and average FFI was 49 (7-89). SF-36 scores showed fair to poor outcomes in the majority of patients. Conclusion: Tibial autograft in primary osteosynthesis of comminuted talar neck fractures with critical bone defects leads to reliable union rates and is an operative strategy that should be considered when treating these difficult fractures. Despite high union rates, secondary outcomes of AVN, PTA, and below-average PRO still occurred in the majority of patients.