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Moving to New Jersey from Philadelphia was stressful, but at least Jada has found Ms. Marianne's Academy of Dance, where she can continue to dance ballet. She's not sure that the other girls at the Academy welcome her, and when she sprains her ankle in practice she's sure that the whole universe is against her.

Purpose The purpose of this study is to propose recommendations for the treatment of patients with chronic lateral ankle instability (CAI) based on expert opinions. Methods A questionnaire was sent to 32 orthopaedic surgeons with clinical and scientific experience in the treatment of CAI. The questions were related to preoperative imaging, indications and timing of surgery, technical choices, and the influence of patient-related aspects. Results Thirty of the 32 invited surgeons (94%) responded. Consensus was found on several aspects of treatment. Preoperative MRI was routinely recommended. Surgery was considered in patients with functional ankle instability after 3–6 months of non-surgical treatment. Ligament repair is still the treatment of choice in patients with mechanical instability; however, in patients with generalized laxity or poor ligament quality, lateral ligament reconstruction (with grafting) of both the ATFL and CFL should be considered. Conclusions Most surgeons request an MRI during the preoperative planning. There is a trend towards earlier surgical treatment (after failure of non-surgical treatment) in patients with mechanical ligament laxity (compared with functional instability) and in high-level athletes. This study proposes an assessment and a treatment algorithm that may be used as a recommendation in the treatment of patients with CAI. Level of evidence V.

Submission Type: Ankle Instability Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Measurement of lateral talar subluxation (LTS) is proposed in the literature as an adjunct and perhaps superior metric to medial clear space (MCS) for distinguishing intact versus disrupted medial restraints in SER-variant ankle fractures. Arbitrary cutoff values have been explored for dichotomizing increased compared to normal LTS. The present study sought to elucidate normative data for LTS which can assist with treatment decision-making for SER fractures. The objectives of this investigation were as follows: (1) define the mean LTS value in a population with normal ankle anatomy; (2) define the mean LTS value with subanalyses according to biological sex and ankle side; (3) compare mean LTS to mean values for existing radiographic measurement tools of MCS and superior clear space (SCS). Methods: Adult patients (aged 19 and over) seen in consultation at a foot and ankle orthopaedic outpatient office over a 2.5 year period without a primary pathology of the ankle joint were considered eligible. Patients were included provided x-rays had been obtained of separate bilateral weight-bearing films with a mortise view. Exclusion criteria consisted of evidence of prior trauma, prior operative intervention or concurrent degenerative changes to the ankle joint, as well as inadequate imaging technique. Radiographic measurements of LTS, MCS and SCS were retrospectively performed by two independent observers with overall mean values calculated. Subanalyses offering comparisons based on biological sex and ankle side were performed using a two-sample unpaired t-test and descriptive statistics, respectively. Assessment of intrarater and interrater reliability was facilitated by producing intraclass correlation coefficients (ICC). Results: Data from 120 patients were included (88 with adequate bilateral ankle views; 106 with left and 102 with right ankle radiographs). The population mean age was 55.23 [±13.28 SD] years, with 78.3% being female. Mean measurements were: LTS 1.09 [±0.76 SD; range 0-3.70] mm, MCS 2.36 [±0.50 SD; range 1.42-4.23] mm, and SCS 3.23 [±0.47 SD; range 2.08-4.48] mm. Ankle side subanalysis showed mean LTS of 0.97 [±0.91 SD] mm for the right and 1.21 [±0.93 SD] mm for the left, with no significant difference evident. There was no significant difference in mean LTS for female (1.07 [±0.78 SD]) versus male (1.16 [±0.74 SD]) patients. Mean ICC for LTS was 0.64 for intrarater and 0.56 for interrater reliability representing moderate agreement. Conclusion: Our investigation generated a mean normative LTS value of 1.09 mm, expanding upon limited literature on this measurement tool in uninjured ankles by using a sample of sufficient size. Only 1.2% of initial LTS measurements by the two observers were > 4.0 mm, suggesting this previously proposed cutoff should provide an effective threshold for detecting increased LTS. The current study newly demonstrated that a single LTS cutoff may be generalizable regardless of biological sex or ankle side. However, our work found achieving reliable LTS values presented a greater challenge compared to other commonly applied measurement tools, namely MCS.

Submission Type: Other Research Type: Level 4 – Case series Introduction/Purpose: Controlled ankle motion (CAM) boots are commonly and increasingly used after orthopaedic injury or in the post-operative setting. However, the use of a CAM boot is not benign, and pressure injury is a concern. The incidence of complications related to prefabricated pneumatic braces is on the rise. “Floating” the heel (no direct contact) has been studied and is important for pressure injury prevention in lower extremity plaster splints. Dermal arteriolar capillaries collapse with a pressure of 32mmHg, but no biomechanical studies have measured posterior heel contact pressures nor described the significance of floating the heel in a rigid CAM boot. This study aims to quantify baseline contact pressures of the posterior heel and assess the efficacy of floating the heel in a CAM boot. Methods: Twenty legs from ten healthy subjects were analyzed. A pressure transducer was positioned over the posterior heel to measure peak contact pressure in a CAM boot with the heel both resting flat and when elevated with a pillow under the calf and ankle. Both absolute pressures and relative pressure improvements were recorded. Results: With the posterior heel in the CAM boot resting flat, no leg reached a pressure below the critical 32mmHg threshold. However, when the heel was floating freely, 55% (11/20) of legs achieved contact pressures below 32mmHg. The average contact pressure with the heel floating was 40mmHg, indicating a 53% improvement in pressure reduction compared to the heel resting down. Conclusion: Prolonged used of a CAM boot should be undertaken with some degree of caution due to the risk of pressure-related complication. Patients must be counseled to float the heel when at rest. Frequent skin assessment and position changes are recommended to detect signs of impending pressure injury in the posterior heel. In cases where rigid immobilization is not essential, alternative orthoses that offload the heel should be considered, especially in those with neurogenic compromise, specifically the neuropathic patient and those with prolonged regional peripheral nerve blocks.

Submission Type: Ankle Fractures Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Various techniques are used to repair the distal tibiofibular syndesmosis. While traditionally performed with syndesmotic screws, recent techniques including the Syndesmosis TightRope® XP (TightRope, Arthrex) and InternalBrace™ (IB, Arthrex) have been developed to optimize natural flexibility and movement of the syndesmosis. It remains unclear whether syndesmotic fixation technique impacts complication rates and outcomes. This study aims to determine which repair technique results in the fewest complications and best functional outcomes as measured by Patient Reported Outcome Measurement Information System (PROMIS) computerized adaptive tests (CATs) of physical function (PF) and pain interference (PI). To our knowledge, this is the largest retrospective study comparing PROMIS scores between these syndesmotic fixation techniques. We hypothesized that Tightrope and IB would reduce complications and improve PROMIS scores compared to screws. Methods: 782 patients who underwent ankle fracture surgery at a single institution between January 2016-December 2021 were reviewed retrospectively. Two foot and ankle fellowship-trained orthopaedic surgeons independently reviewed all radiographs, determined fixation technique, and assessed complications at final follow-up. Multiple extremity injuries, open fractures, and pilon variants were excluded. 328 patients with syndesmotic ruptures were sent post-operative questionnaires. 159 patients with minimum one-year follow-up were analyzed for complications. 70 patients who completed PROMIS CATs were analyzed for functional outcomes. Due to rarity of complications and perfect separation in the data, we were unable to use statistical tests to compare complication incidence across techniques. The Kruskal-Wallis test compared PROMIS scores across repair types. Analysis of PROMIS scores had 80% power to detect large effect sizes (Cohen’s f = 0.40) with a 0.05 significance level but was underpowered for small and medium effects. PROMIS scores were modeled by repair technique using linear regression. Results: 62/159 patients underwent syndesmotic fixation with screw placement, 59/159 with Tightrope, and 38/159 with IB. Overall complication rates with syndesmotic screw fixation were 12.9% (8/62): 8.1% (5/62) degenerative joint disease (DJD), 0% end-stage arthritis, 1.6% (1/62) syndesmotic malreduction, 4.8% (3/62) syndesmotic malunion. Overall complication rate in Tightrope was 1.7% (1/59): 1.7% (1/59) DJD. IB had no radiographic complications. Mean PF was 50.38±9.39 screw, 53.87±9.70 Tightrope, and 52.18±13.08 IB (p=0.71). Mean PI was 49.28±8.22 screw, 47.91±8.80 Tightrope, and 49.15±10.46 IB (p=0.79). Compared to screws, adjusted models demonstrated mean PF 4.00 points greater for Tightrope (p=0.17) and 2.94 points greater for IB (p=0.34). Adjusted models for PI revealed mean scores of 2.05 points less for Tightrope (p=0.42) and 1.23 points less for IB (p=0.65) compared to screws. Conclusion: Our findings indicate that syndesmotic fixation with the Tightrope and IB reduce radiographic complications compared to screws. While this study was underpowered to detect small or medium effect sizes and thus was unable to demonstrate statistically significant differences in PROMIS scores, the higher PF and lower PI for Tightrope and IB compared to screws may reach statistical significance in larger sample sizes. Nevertheless, differences in PF scores in the adjusted model suggest that Tightrope and IB improve PF compared to screw, reaching the lower end range of the minimal clinically important difference for this outcome measure reported in the literature.

Submission Type: Other Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: There is great interest in orthobiologics as surgical adjuvants to decrease rates of complications, including non-union, and time to fusion. While there are a limited number of studies investigating the role of orthobiologics in healing following foot and ankle fusion procedures, there is an even greater lack of large studies investigating the use of allographic or autographic adjuvants as compared to those procedures without. As such, the purpose of this study is to compare the outcomes of patients receiving crushed cancellous allograft, autograft, or no biological adjuvant to determine if there is a difference in complications and time to fusion following foot and ankle arthrodeses. Methods: A multi-institutional retrospective review was conducted of 296 patients with minimum 6-month follow-up, undergoing arthrodesis by one of four fellowship-trained foot and ankle orthopaedic surgeons from 2016-2022. Patients underwent ankle (n=74), subtalar (ST) (n=124), midfoot (n=154), or forefoot (n=27) fusions. Data collected included demographics, medical history, orthobiologics used, postoperative complications, readmission and reoperation rates. 58 (19.6%) cases used no biological adjuvant, 224 (75.7%) used allograft, and 14 (4.7%) used autograft. Union was defined as bridging bone on three joint quadrants on AP and lateral radiographs, or greater than 50% bridging bone of the joint space on computed tomography (CT). The overall cohort was majority female (58.4%) with a mean age 56.49 (range 18-81) years, BMI 31.96 (range 16.16-56.17) kg/m2 and follow-up duration 1.43 (range 0.50-5.96) years. Results: The allograft cohort was significantly older (p=.019) with significantly higher rates of cardiac disease (p <.001) and hypertension (p=.006), the no graft group had significantly lower BMI (p <.001). Allograft was used at a statistically significantly higher rate in ST (p <.001) and ankle fusions (p=.044) while forefoot fusions had a higher rate of no graft use (p <.001). The overall union rate was 88.9% and mean time to fusion 153.41±102.36 days, with no significant difference between cohorts. Similarly, there was no statistically significant difference in rate of postoperative infection, reoperation, or revision following fusion procedures regardless of graft usage. Conclusion: Joints treated with no biological adjuvant, allograft, or autograft demonstrated equivalent fusion rates in this large study. Additionally, there was no difference in the rate of postoperative adverse outcome regardless of graft usage. These findings should be considered by providers and patients alike when considering the use of biological adjuvants in foot and ankle fusion procedures.

Submission Type: Ankle Arthritis Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Re-establishing anatomic ankle and foot alignment is critical to optimize clinical outcomes and longevity of total ankle replacement (TAR). The foot and ankle offset (FAO) is a semiautomatic 3D biometric weight-bearing computed tomography (WBCT) measurement that represents the relationship between the tripod of the foot and the center of the ankle joint. Notably, FAO correlates with increased need of additional procedures in TAR. Yet to our knowledge, no study has utilized FAO to quantify the extent to which TAR can improve alignment in the absence of foot realignment procedures. Our study aims to evaluate associations between preoperative and postoperative FAO and coronal radiograph Tibiotalar Alignment (TTA) for TAR. We hypothesize that TAR alone may significantly improve FAO in patients with ankle deformity. Methods: This study is a single-institution retrospective review of prospectively collected data from primary TARs from March 2022 – November 2023 that obtained preoperative and postoperative (between 4 months and 1 year postoperatively) WBCT scans. Patients who underwent concomitant foot realignment procedures (foot osteotomy or fusion) at the time of primary TAR were excluded. There were 85 ankles that underwent primary TAR during the study period who obtained preoperative and postoperative WBCT scans and radiographs. Excluding 23 ankles with concomitant foot realignment procedures and 7 ankles with inadequate scans, there were 55 ankles included for analysis. Patients were classified as varus, neutral or valgus using the cutoff of 5 degrees for TTA and based on the classification described by Lintz for FAO. Correlation between changes in TTA and FAO was addressed by Pearson`s correlation test. Linear regression was used to investigate the association between changes in TTA with changes in FAO. Results: Changes in TTA had a strong positive correlation (PCC 0.832, p < .0001) with changes in FAO. Every 1 degree of increase in TTA pre to post is associated with 0.367 unit increase in FAO pre to post (R^2 0.693, p < 0.0001). In terms of TAR ability to improve FAO, there was a median pre to post FAO change of 2.66 [-0.11, 5.86] for the varus pre-op FAO group and of − 4.69 [-7.52, -2.985] for the valgus pre-op FAO group. Postoperatively, 80% of patients that had pre-op varus FAO remained varus, while 59% that had pre-op neutral FAO persisted neutral and 22% that had pre-op valgus FAO stayed valgus. 98% of patients had neutral post TTA, confirming coronal alignment improvement with TAR. Conclusion: In this study, with each 1-degree change in TTA, there was a 0.367 change in FAO with a strong positive correlation between the 2D and the 3D measurements. TAR was able to improve FAO in patients with tibiotalar deformity and a more powerful change was noticed in valgus alignment. After TAR, patients with pre-op varus FAO are most likely to remain varus, while patients with valgus pre-op FAO are most likely to improve to neutral FAO. Understanding how FAO changes after TAR can help surgeons predict when an additional procedure could be necessary.

Although several arthroscopic procedures for lateral ligament instability of the ankle have been reported recently, it is difficult to augment the reconstruction by arthroscopically tightening the inferior extensor retinaculum. There is also concern that when using the inferior extensor retinaculum, this is not strictly an anatomical repair since its calcaneal attachment is different to that of the calcaneofibular ligament. If a ligament repair is completed firmly, it is unnecessary to add argumentation with inferior extensor retinaculum. The authors describe a simplified technique, repair of the lateral ligament alone using a lasso-loop stitch, which avoids additionally tighten the inferior extensor retinaculum. In this paper, it is described an arthroscopic anterior talofibular ligament repair using lasso-loop stitch alone for lateral instability of the ankle that is likely safe for patients and minimal invasive. Level of evidence Therapeutic study, Level V.

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: End-stage subtalar osteoarthritis in the context of Progressive Collapsing Foot Deformity (PCFD) is usually treated through subtalar joint (SJ) arthrodesis. In this study we set out to assess the changes occurring at the ankle joint after Anterolateral Arthroscopic Subtalar Arthrodesis (ALAPSTA). Methods: In this retrospective study, we evaluated pre- and post-operative (at 6 months) weight bearing computed tomography (WBCT) images of patients diagnosed with PCFD with a degenerated SJ (2A according to PCFD classification) and/or peritalar subluxation (2D) with or without associated flexible midfoot and/or forefoot deformities (1B, 1C and 1E) which underwent ALAPSTA as a standalone procedure between 2017 and 2020. Hindfoot alignment was assessed using multiple measurements. Distance Mapping (DM) at the ankle joint (divided in 9 regions) allowed to assess changes in terms of joint interaction between pre and postoperative images. Results: Out of 94 PCFD treated, thirtythree feet (33 patients, median age 62) were included in the study. Hindfoot alignment significantly improved, with a median Foot and Ankle Offset significantly decreased from 9.3 to 4 points (p< 0.001). We found a significant increase in mean distances occurring posterolaterally at the ankle (from 4.5 mm (SD 1.2) to 5.4 mm (SD 1.5), p< 0.001) along with a significant decrease occurring anteromedially (from 9.1 mm (SD 1.2) to 8.3 mm (SD 1.4), p< 0.001). In the three anterior regions there was a significant reduction of the mean distance between surfaces (all p= or < 0.01) while in two of the three posterior regions the distance between the tibia and talus significantly increased (p< 0.01). Conclusion: In patients diagnosed with PCFD undergone ALAPSTA, we observed significant changes in terms of interaction between the articular surfaces at the ankle joint, demonstrating a an external rotation and dorsiflexion on the talus in keeping with a ‘re-saddling’ effect over the calcaneus achieved through the procedure.