Dorsal calcaneal wedge removal in zadek osteotomy: A cadaveric study

BACKGROUND

Insertional Achilles tendinopathy (IAT) is a common pathology with multiple surgical interventions available for treatment. The Zadek, dorsal closing wedge calcaneal osteotomy (ZO) has been demonstrated to be effective treatment of IAT. There have been various recommendations in the literature as to what measurement of wedge removal should be considered ideal to produce greatest postoperative range of motion (ROM), thus postoperative biomechanical potential. Accordingly, the purpose of this cadaveric study was to assess the range of motion achieved after various measurements of wedge removal by ZO.

METHODS

The ZO was performed on six cadaveric specimens. A 7.5 mm and 15 mm wedge osteotomy was marked and sequentially completed on each specimen. Lateral fluoroscopic imaging was utilized to take preoperative and postoperative ROM measurements for each osteotomy. Dorsiflexion (DF) and plantarflexion (PF) ROM arcs were measured for each wedge size and compared by t-test. Effect sizes were calculated by Cohen's d analysis.

RESULTS

Maximal DF was 110.87 ± 12.97 deg in the pre-osteotomy state. Removal of a 7.5 mm wedge improved DF by 8 deg to a mean 102.93 ± 13.81 deg (p = 0.08). Removal of a 15 mm wedge improved DF by 16 deg to a mean 95.96 ± 11.41 deg (p = 0.003). Cohen's d and effect size calculation demonstrated a 7.5 mm wedge to have a small effect on DF, while a 15 mm wedge had a medium effect (0.29, 0.52 respectively). Maximal PF did not change significantly amongst the pre-osteotomy, 7.5 mm wedge, or 15 mm wedge positions. ICC was 0.96.

CONCLUSION

Based on the results presented in this study, removal of a 15 mm wedge with ZO yields significant and greater improvement in ROM than a 7.5 mm wedge. We hope the current study will better inform preoperative planning for ZO.

STUDY TYPE

Prospective Cadaver Study.

LEVEL OF EVIDENCE

V.

Percutaneous vs Open Zadek Osteotomy for Treatment of Insertional Achilles Tendinopathy and Haglund's Deformity: A Systematic Review

Background

Percutaneous Zadek osteotomy (ZO) has emerged as a surgical treatment of insertional Achilles tendinopathy (IAT) over the last decade. Existing literature is limited regarding the comparison of this approach with the more established, open ZO technique. This systematic review aims to evaluate and compare the current data on open vs percutaneous ZO approaches to help set evidence-based guidelines.

Methods

A systematic literature search was performed using the keywords (Zadek osteotomy) OR (Keck and Kelly osteotomy) OR (dorsal closing wedge calcaneal osteotomy) OR (Haglund Deformity) OR (Haglund Syndrome) OR (Insertional Achilles Tendinopathy) and MeSH terms Osteotomy, Calcaneus, Syndrome, Insertional, Achilles tendon, and Tendinopathy. Our search included the following databases: PubMed, Embase, and the Cochrane Library. The PRISMA protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2009 to 2024 and included the use of open or percutaneous approaches of ZO for the treatment of IAT with at least a 12-month follow-up. The MINORS score criteria were used to evaluate the strength and quality of studies.

Results

A total of 17 studies were reviewed, including 611 subjects and 625 ZO procedures. Of these procedures, 81 (11%) subjects had a percutaneous and 544 (89%) subjects had an open ZO. The mean follow-up time was 16.1 months for patients treated with percutaneous ZO and 36.1 months for patients treated with open ZO. Both open and percutaneous studies included in this review showed postoperative improvements in AOFAS, FFI, VISA-A, and VAS scores in patients with IAT. The reported complication rate was 5.8% among patients treated with percutaneous ZO and 10.2% among patients treated with open ZO.

Conclusion

Percutaneous ZO is an emerging approach with substantially fewer documented cases compared with the open ZO. Both percutaneous and open ZO appear to be relatively effective treatments for insertional Achilles tendinopathy with Haglund's deformity. The lower complication rates reported for percutaneous ZO is encouraging. Further investigation with more subjects undergoing percutaneous ZO is clearly needed.

How Have Patient Out-of-pocket Costs for Common Outpatient Orthopaedic Foot and Ankle Surgical Procedures Changed Over Time? A Retrospective Study From 2010 to 2020

BACKGROUND

Out-of-pocket (OOP) costs can be substantial financial burdens for patients and may even cause patients to delay or forgo necessary medical procedures. Although overall healthcare costs are rising in the United States, recent trends in patient OOP costs for foot and ankle orthopaedic surgical procedures have not been reported. Fully understanding patient OOP costs for common orthopaedic surgical procedures, such as those performed on the foot and ankle, might help patients and professionals make informed decisions regarding treatment options and demonstrate to policymakers the growing unaffordability of these procedures.

QUESTIONS/PURPOSES

(1) How do OOP costs for common outpatient foot and ankle surgical procedures for commercially insured patients compare between elective and trauma surgical procedures? (2) How do these OOP costs compare between patients enrolled in various insurance plan types? (3) How do these OOP costs compare between surgical procedures performed in hospital-based outpatient departments and ambulatory surgical centers (ASCs)? (4) How have these OOP costs changed over time?

METHODS

This was a retrospective, comparative study drawn from a large, longitudinally maintained database. Data on adult patients who underwent elective or trauma outpatient foot or ankle surgical procedures between 2010 and 2020 were extracted using the MarketScan Database, which contains well-delineated cost variables for all patient claims, which are particularly advantageous for assessing OOP costs. Of the 1,031,279 patient encounters initially identified, 41% (427,879) met the inclusion criteria. Demographic, procedural, and financial data were recorded. The median patient age was 50 years (IQR 39 to 57); 65% were women, and more than half of patients were enrolled in preferred provider organization insurance plans. Approximately 75% of surgical procedures were classified as elective (rather than trauma), and 69% of procedures were performed in hospital-based outpatient departments (rather than ASCs). The primary outcome was OOP costs incurred by the patient, which were defined as the sum of the deductible, coinsurance, and copayment paid for each episode of care. Monetary data were adjusted to 2020 USD. A general linear regression, the Kruskal-Wallis test, and the Wilcoxon-Mann-Whitney test were used for analysis, as appropriate. Alpha was set at 0.05.

RESULTS

For foot and ankle indications, trauma surgical procedures generated higher median OOP costs than elective procedures (USD 942 [IQR USD 150 to 2052] versus USD 568 [IQR USD 51 to 1426], difference of medians USD 374; p < 0.001). Of the insurance plans studied, high-deductible health plans had the highest median OOP costs. OOP costs were lower for procedures performed in ASCs than in hospital-based outpatient departments (USD 645 [IQR USD 114 to 1447] versus USD 681 [IQR USD 64 to 1683], difference of medians USD 36; p < 0.001). This trend was driven by higher coinsurance for hospital-based outpatient departments than for ASCs (USD 391 [IQR USD 0 to 1136] versus USD 337 [IQR USD 0 to 797], difference of medians USD 54; p < 0.001). The median OOP costs for common outpatient foot and ankle surgical procedures increased by 102%, from USD 450 in 2010 to USD 907 in 2020.

CONCLUSION

Rapidly increasing OOP costs of common foot and ankle orthopaedic surgical procedures warrant a thorough investigation of potential cost-saving strategies and initiatives to enhance healthcare affordability for patients. In particular, measures should be taken to reduce underuse of necessary care for patients enrolled in high-deductible health plans, such as shorter-term deductible timespans and placing additional regulations on the implementation of these plans. Moreover, policymakers and physicians could consider finding ways to increase the proportion of procedures performed at ASCs for procedure types that have been shown to be equally safe and effective as in hospital-based outpatient departments. Future studies should extend this analysis to publicly insured patients and further investigate the health and financial effects of high-deductible health plans and ASCs, respectively.

LEVEL OF EVIDENCE

Level III, economic and decision analysis.

Evaluating ChatGPT Performance on the Orthopaedic In-Training Examination

Background

Artificial intelligence (AI) holds potential in improving medical education and healthcare delivery. ChatGPT is a state-of-the-art natural language processing AI model which has shown impressive capabilities, scoring in the top percentiles on numerous standardized examinations, including the Uniform Bar Exam and Scholastic Aptitude Test. The goal of this study was to evaluate ChatGPT performance on the Orthopaedic In-Training Examination (OITE), an assessment of medical knowledge for orthopedic residents.

Methods

OITE 2020, 2021, and 2022 questions without images were inputted into ChatGPT version 3.5 and version 4 (GPT-4) with zero prompting. The performance of ChatGPT was evaluated as a percentage of correct responses and compared with the national average of orthopedic surgery residents at each postgraduate year (PGY) level. ChatGPT was asked to provide a source for its answer, which was categorized as being a journal article, book, or website, and if the source could be verified. Impact factor for the journal cited was also recorded.

Results

ChatGPT answered 196 of 360 answers correctly (54.3%), corresponding to a PGY-1 level. ChatGPT cited a verifiable source in 47.2% of questions, with an average median journal impact factor of 5.4. GPT-4 answered 265 of 360 questions correctly (73.6%), corresponding to the average performance of a PGY-5 and exceeding the corresponding passing score for the American Board of Orthopaedic Surgery Part I Examination of 67%. GPT-4 cited a verifiable source in 87.9% of questions, with an average median journal impact factor of 5.2.

Conclusions

ChatGPT performed above the average PGY-1 level and GPT-4 performed better than the average PGY-5 level, showing major improvement. Further investigation is needed to determine how successive versions of ChatGPT would perform and how to optimize this technology to improve medical education.

Clinical Relevance

AI has the potential to aid in medical education and healthcare delivery.

Republication of "Treatment of Hallux Valgus Deformity Using a Suture Button Device: A Preliminary Report"

Background

Hallux valgus (HV) is commonly treated with proximal or distal first metatarsal osteotomy. Despite good correction, these procedures have inherent risks such as malunion, nonunion, metatarsal shortening, loss of fixation, and avascular necrosis. Suture button fixation has been used for HV treatment. It avoids the risks of corrective osteotomies while maintaining reduction of the intermetatarsal angle (IMA). The goal of this study was to assess the radiographic and functional outcomes of patients undergoing HV correction with a distal soft tissue procedure and proximal suture button fixation.

Methods

The authors retrospectively reviewed the charts and radiographs of 22 patients who had undergone HV correction using a distal soft tissue correction and proximal fixation with a miniature suture button device (Mini TightRope; Arthrex, Inc, Naples, FL). Mean follow-up was 27.7 months. The IMA, hallux valgus angle (HVA), and sesamoid station were measured on radiographs obtained preoperatively as well as in the immediate postoperative period and at final follow-up. Preoperative and postoperative Short Form-36 (SF-36) and Foot and Ankle Ability Measure (FAAM) scores were collected. Postoperative complications, and any additional operative procedures performed were also recorded.

Results

The mean preoperative IMA and HVA were 16.9 and 32.6 degrees, respectively. The mean immediate postoperative IMA was 5.2 degrees (P < .0001) and the mean HVA was 9.8 degrees (P < .0001). At final follow-up, the mean IMA was 8.2 degrees (P < .0001) and the mean HVA was 16.7 degrees (P < .0001). The average change in HVA from preoperative to final follow-up was 16.0 degrees and the average change in IMA from preoperative to final follow-up was 8.6 degrees (P < .0001). Sesamoid station assessment at the 2-week follow-up showed that 22 patients (100%) were in the normal position group; at final follow-up, 17 patients (77%) had normal position and 5 patients (23%) had displaced position. Although there were no clinically symptomatic recurrences, asymptomatic radiographic recurrence was noted in 5 patients (23%) who had a final HVA >20 degrees. All components of the FAAM and the SF-36 showed improvement from preoperative to final follow-up, although these changes were not statistically significant. Three patients experienced complications, including an intraoperative second metatarsal fracture, a postoperative second metatarsal stress fracture, and a postoperative deep vein thrombosis.

Conclusion

The use of a distal soft tissue procedure in conjunction with proximal suture button fixation is a safe and effective procedure for treating symptomatic HV deformity. Our results show that this technique can correct the IMA, HVA, and sesamoid station without the need for osteotomy.

Level of evidence

Level IV.

Opioid Usage After Hallux Valgus Correction Surgery

BACKGROUND

Given the lack of objective data on opioid use and the difficulty of addressing a patient's postoperative pain, we sought to quantify patient's narcotic use after hallux valgus surgery. The purpose of our study was to determine the average quantity and type of postoperative opioids consumed after hallux valgus surgery and to assess potential predictive factors for increased opioid consumption.

METHODS

At the preoperative visit, patients were consented and completed a demographical questionnaire. Data were collected from the operative record, 2, 6, and 12-week postoperative visits. Type and number of pills prescribed were recorded as well as number of pills consumed at each postoperative visit. A logistic regression was performed to determine the average quantity consumed postoperatively and any statistically significant correlations.

RESULTS

The average number of opioid pills collectively consumed at the 2-week and 12-week postoperative visit was 20 and 23, respectively. At the 2-week postoperative visit, only patient body mass index (BMI) showed a correlation with increased opioid use.

CONCLUSION

Patients consumed an average of 23 of 40 (57.5%) narcotic pain pills prescribed after hallux valgus reconstruction surgery through the 12-week postoperative period. Owing to the opioid epidemic and potential for narcotic diversion, surgeons should counsel their patients on proper nonopioid postoperative pain management.

LEVEL OF EVIDENCE

II Therapeutic.

Summary Report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's Symposium on Targets for Osteoarthritis Research: Part 1: Epidemiology, Pathophysiology, and Current Imaging Approaches

This first of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey the state of scientific knowledge related to incidence, diagnosis, pathologic mechanisms, and injection treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 3, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Part 1 overviews areas of epidemiology and pathophysiology, current approaches in imaging, diagnostic and therapeutic injections, and genetics. Opportunities for future research are discussed. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the needs of patients that suffer from arthritis of foot and ankle. The foot and ankle contain a myriad of interrelated joints and tissues that together provide a critical functionality. When this functionality is compromised by OA, significant disability results, yet the foot and ankle are generally understudied by the research community. Level of Evidence: Level V - Review Article/Expert Opinion.

Summary Report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's Symposium on Targets for Osteoarthritis Research: Part 2: Treatment Options

This second of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey current treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 10, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Topics were chosen by meeting organizers, who then identified and invited the expert speakers. Part 2 overviews the current treatment options, including orthotics, non-joint destructive procedures, as well as arthroscopies and arthroplasties in ankles and feet. Opportunities for future research are also discussed, such as developments in surgical options for ankle and the first metatarsophalangeal joint. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the importance to patients of addressing the foot and ankle with improved basic, translational, and clinical research.

LEVEL OF EVIDENCE

Level V, review article/expert opinion.

Hallux Valgus with Increased DMAA Correction by Modified Lapidus Procedure

Category:

Bunion; Midfoot/Forefoot

Introduction/Purpose:

Hallux valgus is one of the most common deformities treated by orthopedic foot and ankle surgeons. Hallux valgus can frequently present with an increased distal metatarsal articular angle (DMAA), which may require correction in addition to treating the hallux valgus deformity. Many surgical procedures can correct hallux valgus with an increased DMAA with varying levels of success. Thus, we investigate the efficacy of the modified Lapidus procedure, a triplanar correction, in correcting the DMAA in hallux valgus surgery.

Methods:

A retrospective chart review was performed on patients who underwent the hallux valgus reconstruction with a modified Lapidus procedure between April 26th, 2018 and November 19th, 2020. Exclusion criteria included any patient undergoing hallux valgus correction not receiving a modified Lapidus procedure and patients with inadequate follow up. Hallux valgus angle (HVA), intermetatarsal angle (IMA) and DMAA were measured on pre-operative, immediate post-operative and at final follow up weight bearing radiographs.

Results:

The study included a total of 99 cases of modified Lapidus procedure for hallux valgus on 85 subjects with an average follow up of 5.4 months. On radiologic assessment, the average DMAA decreased from 17.72 +- 6.18 degrees pre-operatively to 9.19 +- 5.19 degrees immediately post-operatively (p < 0.0001) and 9.79 +- 4.62 degrees at the final follow up (p < 0.0001). The average HVA decreased from 31.34 +- 10.39 degrees pre-operatively to 13.34 +- 6.16 degrees immediately post-operatively (p < 0.0001) and 15.05 +- 7.43 degrees at final follow up (p < 0.0001). Lastly, the IMA decreased from 14.99 +- 3.82 pre-operatively (p < 0.0001) to 4.66 +- 2.59 immediately post-operative and 6.62 +- 3.46 degrees at final follow up (p < 0.0001). The rate of recurrence was 3.03%.

Conclusion:

The modified Lapidus procedure is an effective procedure in correcting the HVA, IMA, and DMAA in hallux valgus surgery without the need for additional distal or proximal metatarsal osteotomies. Surgeons should consider this technique in patients with moderate to severe hallux valgus deformity who may require correction of their DMAA.

Tranexamic Acid in Foot and Ankle Surgery: A Topical Review and Value Analysis

Tranexamic acid (TXA) has become a commonly used perioperative intervention in total joint arthroplasty, shoulder and knee arthroscopy, and spinal procedures in order to minimize blood loss, hematoma formation, hemarthrosis, and wound healing complications. There is a potential role for TXA use in foot and ankle procedures, with limited studies suggesting a potential benefit in minimizing postoperative wound complications and blood loss without an increased risk of thromboembolic events. In light of the profound clinical and financial impact of TXA use in other orthopaedic subspecialties and the early successes in foot and ankle surgery, we aim to provide more information about TXA and its use in foot and ankle surgery. Therefore, the purpose of this review is to perform a comprehensive literature review on the topic of TXA use in foot and ankle procedures in order to describe the pertinent available literature on the use of TXA in orthopaedic surgery and its implications specifically in foot and ankle surgery. It is our aim to identify potential benefits and shortcomings in the available evidence on TXA use for foot and ankle surgery in hopes to (1) best inform foot and ankle surgeons where beneficial and safe and (2) inspire further research on this topic as it relates to clinical management for foot and ankle patients.Levels of Evidence: Level IV.

Tranexamic Acid in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

Hemarthrosis after anterior cruciate ligament (ACL) reconstruction procedures can delay rehabilitation and have toxic effects on the cartilage and synovium. Tranexamic acid is widely used in adult reconstruction procedures; however, its use in ACL reconstruction is a novel topic of study.

PURPOSE

To analyze the available literature on hemarthrosis, pain, functional outcomes, and complications after administration of tranexamic acid in ACL reconstruction procedures.

STUDY DESIGN

Meta-analysis.

METHODS

A literature search was performed to retrieve randomized controlled trials examining the use of tranexamic acid at the time of ACL reconstruction procedures. The studied outcomes included postoperative joint drain output, hemarthrosis grade, visual analog scale scores for pain, range of motion, Lysholm score, postoperative rates of deep venous thrombosis, and pulmonary embolism. Outcomes were pooled to perform a meta-analysis.

RESULTS

Five prospective randomized controlled trials met inclusion criteria for analysis. Four studies administered intravenous tranexamic acid in bolus or infusion form before ACL reconstruction, while 2 studies administered tranexamic acid via intra-articular injection. Specifically, tranexamic acid was administered intravenously (preoperative 15-mg/kg bolus 10 minutes before tourniquet inflation with or without 10 mg/kg/h for 3 hours postoperatively) or intra-articularly (10 mL [100 mg/mL] intraoperatively), and 1 study consisted of tranexamic acid administration in combined intravenous and intra-articular forms (15-mg/kg bolus 10 minutes before tourniquet inflation and intra-articular 3 g 10 minutes before tourniquet deflation). Tranexamic acid use in ACL reconstruction cases resulted in a mean reduction of 61.5 mL in postoperative drain output at 24 hours (95% CI, -95.51 to -27.46; P = .0004), lower hemarthrosis grade (P < .00001), improved Lysholm scores, and reduction in visual analog scale scores for pain (-1.96 points; 95% CI, -2.19 to -1.73; P < .00001) extending to postoperative week 6. Range of motion was improved in the immediate postoperative period, and the need for joint aspiration within 2 weeks was reduced (P < .001). There was no difference in venous thromboembolic event rate between the experimental and control groups.

CONCLUSION

The use of intravenous tranexamic acid in ACL reconstruction surgery results in reduced joint drain output and hemarthrosis and improved pain scores and range of motion in the initial postoperative period without increased complications or thromboembolic events.

Hallux Valgus Deformities: Preferred Surgical Repair Techniques and All-Cause Revision Rates

INTRODUCTION

Hallux valgus is a commonly treated condition by foot and ankle surgeons with more than 200 different described correction techniques. Recurrence rates range from 5% to 50%, with increasing support of the theory that arthrodesis procedures may have a lower recurrence rate than osteotomies. Arthrodesis procedures to the first metatarsophalangeal (MTP) joint or tarsometatarsal (TMT) joint for correction of hallux valgus deformity are becoming more commonly utilized. The purpose of this study is to investigate the surgical incidence and revision rates of hallux valgus deformities corrected by arthrodesis compared to osteotomy in the state of South Carolina.

METHODS

The South Carolina Revenue and Fiscal Affairs Office was queried from 2000 to 2017 to identify all surgically treated hallux valgus deformities. Data extraction included patient demographics, ICD-9 diagnoses, CPT procedure codes, and dates of surgery. A logistic regression model was used for statistical inference.

RESULTS

A total of 22 199 feet had surgical treatment for hallux valgus during this time period, with 20 422 (92.0%), 592 (2.7%), and 1185(5.3%) receiving an osteotomy, arthrodesis, or other procedure at initial treatment, respectively. There was an all-cause revision rate of 5.6% in the osteotomy group and 6.4% in the arthrodesis group. Demographic factors such as female sex, white race, and surgery pre-2010 were associated with higher revision rates. Multiple comorbidities were correlated with higher revision rates such as tobacco use, hypothyroidism, osteoarthritis, recurrent dislocations, hallux rigidus, lesser toe deformities, metatarsus varus, and talipes cavus.

CONCLUSION

Despite the recent increase in arthrodesis procedures for the treatment of hallux valgus deformity, our results suggest that osteotomy procedures are more commonly performed and there is no difference in all-cause revision surgery. However, there are multiple patient demographics and comorbidities that are associated with higher rates of revision surgery and should be considered and discussed during the preoperative planning period.

LEVEL OF EVIDENCE

Level IV.

Minimally Invasive Dorsal Cheilectomy and Hallux Metatarsal Phalangeal Joint Arthroscopy for the Treatment of Hallux Rigidus

Background:

Hallux rigidus (HR) is a common source of forefoot pain and disability. For those who fail nonoperative treatment, minimally invasive dorsal cheilectomy (MIDC) is an increasingly popular alternative to the open approach with early positive results. Early failures may be due to lose bone debris from the MIDC as well as other intra-articular pathology that cannot be addressed with MIDC alone. Metatarsophalangeal (MTP) arthroscopy can be used in addition to MIDC to assess the joint after MIDC and address any intra-articular pathology while still maintaining the benefits of minimally invasive surgery. We report our clinical outcomes following MIDC combined with MTP arthroscopy.

Methods:

From November 2017 to July 2020, a retrospective analysis of all MIDC cheilectomies with MTP arthroscopy performed by the 2 senior authors was done. Wound complications, infections, revision rates, need for future surgery, conversion to fusion rates, pre- and postoperative range of motion, visual analog scale (VAS) scores, time to return to normal shoe, intraoperative arthroscopic findings, and operative time were collected. Follow-up average was 16.5 months (range 3-33 months).

Results:

A total of 20 patients were included with an average follow-up of 16.5 months. The average VAS score improved from 7.05 preoperatively to 0.75 postoperatively ( P < .05). Average range of motion in dorsiflexion increased from 32 to 48 degrees ( P < .05) and plantarflexion increased from 15 to 19 degrees plantarflexion ( P < .05). All patients were weightbearing as tolerated immediately after surgery in a postoperative shoe and transitioned to a regular shoe at average of 2.1 weeks. We had no wound infections, wound complications, revision surgeries, tendon injuries or nerve damage. One patient required conversion to a fusion 3 years after the index procedure. Average tourniquet time was 30.39 minutes (range 17-60 minutes) and total average operating room time was 59.7 minutes (range 40-87 minutes). On arthroscopic evaluation of the MTP joint after MIDC, 100% of patients had bone debris, 100% had synovitis, 10% had loose bodies, and 30% had large cartilage flaps within the joint.

Conclusion:

MIDC and first MTP joint arthroscopy for treatment of hallux rigidus provide improved pain relief with minimal complications while still maintaining the benefits touted for minimally invasive operative procedures. Additionally, we have shown a high rate of intra-articular debris along with intra-articular pathology such as synovitis, loose chondral flaps, and loose bodies that exist after MIDC. This combined procedure has the potential for improving patient outcomes and may minimize risk of future revision surgeries compared with MIDC alone.

Level of Evidence:

Level IV, case series study.

Surgical Strategies: Necrotizing Fasciitis of the Foot and Ankle Treated With Dermal Regeneration Matrix for Limb Salvage

Although necrotizing fasciitis is a life-threatening entity that needs expeditious treatment, cases involving the lower extremity are less commonly encountered than in the upper extremity. Surgical intervention is often required and likely lead to amputation (below-knee or above-knee) vs debridement in the lower extremity.Coverage options in the foot and ankle after serial debridements can present many challenges for limb salvage. Patients are often left with large soft tissue defects requiring coverage with a subsequent increase in relative morbidity. Treatment options for coverage in these cases include negative-pressure wound therapy, split-thickness skin grafting, free flap coverage, or higher-level amputation. In the diabetic population, who present with a lower extremity necrotizing infection, limb salvage is often a challenge given the multiple comorbidities associated with these patients including peripheral vascular disease, immunocompromised state, and neuropathy. Optimal treatment strategies for these necrotizing infections in the foot and ankle remain uncertain.We offer a technique tip for utilization of a dermal regeneration matrix to allow coverage of large soft tissue defect with exposed tendon and/or bone without the need for free flap coverage or higher-level amputation, thus allowing for an additional limb salvage option.Level of Evidence: Level V, expert opinion.

18-Year Operative Incidence and Cost Analysis of the Treatment of Adult Acquired Flatfoot Deformity

Background:

Adult acquired flatfoot (AAFD) is commonly treated by foot and ankle surgeons. Despite how commonly this disease presents, its incidence and economic impact have yet to be defined. We hypothesized that the operative incidence of AAFD and its economic burden would increase over the time period 1996 to 2014.

Methods:

The South Carolina database was queried for data from acute care and ambulatory surgery centers. Bivariate descriptive statistics were used to analyze the data. Operative incidence was calculated and demographics and medical comorbidities of patients who progressed to operative intervention were analyzed. Costs associated with operative care episodes were calculated to determine the economic burden.

Results:

A total of 1299 patients underwent AAFD corrective surgery between 1996 and 2014. Patients who underwent surgery for AAFD were most likely to be white, female, and in their fourth, fifth, and sixth decade of life. Operative incidence for AAFD rose from 0.26 per 100 000 covered lives in 1996 to 3.04 in 2014. The total health care costs associated with patients who underwent surgery for AAFD increased from $57 395.33 in 1996 to $6 859 723.60 in 2014.

Conclusions:

This data demonstrate that patients most commonly undergoing operative intervention for AAFD were white, female, and in their fourth, fifth, or sixth decade of life. There has been a significant increase in operative incidence, which may help direct attention to further exploration of outcome data in these patient populations, associated treatment costs, and preventative treatment options.

Level of Evidence:

Level III, retrospective comparative study.

Return to Sports and Activity After Total Ankle Arthroplasty and Arthrodesis: A Systematic Review

BACKGROUND

There is no consensus regarding participation in sports and recreational activities following total ankle replacement (TAR) and ankle arthrodesis (AA). This systematic review summarizes the evidence on return to sports and activity after operative management with either TAR or AA for ankle osteoarthritis (OA).

METHODS

A literature search of MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was performed. Risk of bias of included studies was assessed using Methodological Index for Non-Randomized Studies (MINORS) criteria. Included studies reported sport and activity outcomes in patients undergoing TAR and AA, with primary outcomes being the percentage of sports participation and level of sports participation.

RESULTS

Twelve studies met inclusion criteria for analysis. There were 1270 ankle procedures, of which 923 TAR and 347 AA were performed. The mean reported patient age was 59.2 years and the mean BMI was 28 kg/m². The mean follow-up was 43 months. Fifty-four percent of patients were active in sports preoperatively compared with 63.7% postoperatively. The mean preoperative activity participation rate was 41% in the TAR cohort, but it improved to 59% after TAR, whereas the preoperative activity participation rate of 73% was similar to the postoperative rate of 70% in the AA cohort. The most common sports in the TAR and AA groups were swimming, hiking, cycling, and skiing.

CONCLUSION

Participation in sports activity was nearly 10% improved after operative management of ankle OA with TAR and remains high after AA. The existing literature demonstrated a large improvement in pre- to postoperative activity levels after TAR, with minimal change in activity after AA; however, AA patients were more active at baseline. The most frequent postoperative sports activities after operative management of ankle OA were swimming, hiking, cycling, and skiing. Participation in high-impact sports such as tennis, soccer, and running was consistently limited after surgery. This review of the literature will allow patients and foot and ankle surgeons to set evidence-based goals and establish realistic expectations for postoperative physical activity after TAR and AA.

LEVEL OF EVIDENCE

Level III, systematic review.

Plantar Medial Avulsion Fracture of the Calcaneus With Acute Tarsal Tunnel: Case Report and Technique Tip

Level of Evidence: Level V, expert opinion.

Does the Use of Locking Screws Decrease the Rate of Hardware Removal in Ankle Fractures?

Background. While biomechanical characteristics of locking screw fixation versus traditional plating has been studied extensively in orthopaedic literature, clinical outcome studies are lacking. The goal of this study was to evaluate the efficacy and complications rate of locking versus traditional nonlocking screws in complex ankle fractures employing distal fibula internal fixation with 1/3 semitubular small fragment plates. Methods. A retrospective review was performed between January 2010 and June 2013 of all patients in whom internal fixation of the fibula in an ankle fracture (open or closed) was performed using only 1/3 semitubular small fragment fibular plates. Patient characteristics, fracture patterns, specific screw choice that were placed in the most distal 2 fibular plate holes (either locking or nonlocking), infectious wound complications, and concomitant syndesmotic injury and the need and corresponding purpose for hardware removal were recorded. Results. A total of 135 patients were found to meet inclusion criteria and were analyzed for this study. Of the patients with locking screws, 25 of 98 (25%) elected to have hardware removed, while 13 of 37 (35%) of those with nonlocking screws elected hardware removal. This did not reach statistical significance (P = .30). There was no statistically significant difference between the groups with regards to age, smoking status, body mass index, diabetes, or use of syndesmotic screw fixation. There was no significant difference in loss of fixation, infection, or other surgical complications in between the groups. Conclusions. There was no significant decrease in the rate of hardware removal with the use of 1/3 tubular locking versus nonlocking plates in the treatment of distal fibula fractures. Despite these screws locking flush to the plate, the hardware is equally symptomatic in both groups. There was no significant difference in the rate of complications between the 2 groups and our data suggest that the added expense of using locking screws routinely when fixing lateral malleolar fractures should be carefully considered, especially if the fracture pattern does not warrant locking technology. Levels of Evidence: Prognostic, Level III.

Biomechanical Comparison of Achilles Tendon Pullout Strength Following Midline Tendon-Splitting and Endoscopic Approaches for Calcaneoplasty

BACKGROUND

Calcaneoplasty is a common procedure performed for the management of Haglund's syndrome when nonoperative management fails. Midline tendon-splitting and endoscopy are 2 common approaches to calcaneoplasty. Studies have suggested that an endoscopic approach may allow earlier return to activity and superior outcomes, but there are no biomechanical or clinical studies to validate these claims. The goal of this study was to quantify and compare Achilles tendon pullout strength following midline tendon-splitting and endoscopic calcaneoplasty in cadaveric specimens.

METHODS

Twelve match-paired cadaveric specimens were randomly divided into 2 groups: endoscopic and midline tendon-split. Following calcaneoplasty, fluoroscopy was used to match bone resection and the Achilles was loaded to failure in a mechanical testing system. A paired-samples t test was conducted to compare bone resection height, bone resection angle, load to failure, and mode of failure.

RESULTS

The endoscopic approach yielded a 204% greater postsurgical pullout strength for the Achilles tendon than the midline tendon-split (1368 ± 370 N vs 450 ± 192 N, respectively) (P < .05). There were no differences in resection angle or resection height. All specimens failed due to bone or tendon avulsion.

CONCLUSION

Endoscopic calcaneoplasty had more than 3 times greater pullout strength than the midline tendon-splitting approach.

CLINICAL RELEVANCE

This may allow earlier return to functional rehabilitation following endoscopic calcaneoplasty, but further studies are needed to determine if these differences are clinically significant. Further understanding of the time-zero biomechanics following calcaneoplasty may provide guidance regarding postoperative management with respect to surgical approach.

Treatment of Hallux Valgus Deformity Using a Suture Button Device: A Preliminary Report

Background:

Hallux valgus (HV) is commonly treated with proximal or distal first metatarsal osteotomy. Despite good correction, these procedures have inherent risks such as malunion, nonunion, metatarsal shortening, loss of fixation, and avascular necrosis. Suture button fixation has been used for HV treatment. It avoids the risks of corrective osteotomies while maintaining reduction of the intermetatarsal angle (IMA). The goal of this study was to assess the radiographic and functional outcomes of patients undergoing HV correction with a distal soft tissue procedure and proximal suture button fixation.

Methods:

The authors retrospectively reviewed the charts and radiographs of 22 patients who had undergone HV correction using a distal soft tissue correction and proximal fixation with a miniature suture button device (Mini TightRope; Arthrex, Inc, Naples, FL). Mean follow-up was 27.7 months. The IMA, hallux valgus angle (HVA), and sesamoid station were measured on radiographs obtained preoperatively as well as in the immediate postoperative period and at final follow-up. Preoperative and postoperative Short Form-36 (SF-36) and Foot and Ankle Ability Measure (FAAM) scores were collected. Postoperative complications, and any additional operative procedures performed were also recorded.

Results:

The mean preoperative IMA and HVA were 16.9 and 32.6 degrees, respectively. The mean immediate postoperative IMA was 5.2 degrees ( P < .0001) and the mean HVA was 9.8 degrees ( P < .0001). At final follow-up, the mean IMA was 8.2 degrees ( P < .0001) and the mean HVA was 16.7 degrees ( P < .0001). The average change in HVA from preoperative to final follow-up was 16.0 degrees and the average change in IMA from preoperative to final follow-up was 8.6 degrees ( P < .0001). Sesamoid station assessment at the 2-week follow-up showed that 22 patients (100%) were in the normal position group; at final follow-up, 17 patients (77%) had normal position and 5 patients (23%) had displaced position. Although there were no clinically symptomatic recurrences, asymptomatic radiographic recurrence was noted in 5 patients (23%) who had a final HVA >20 degrees. All components of the FAAM and the SF-36 showed improvement from preoperative to final follow-up, although these changes were not statistically significant. Three patients experienced complications, including an intraoperative second metatarsal fracture, a postoperative second metatarsal stress fracture, and a postoperative deep vein thrombosis.

Conclusion:

The use of a distal soft tissue procedure in conjunction with proximal suture button fixation is a safe and effective procedure for treating symptomatic HV deformity. Our results show that this technique can correct the IMA, HVA, and sesamoid station without the need for osteotomy.

Level of evidence:

Level IV.

The Role of 3D Reconstruction True-Volume Analysis in Osteochondral Lesions of the Talus: A Case Series

BACKGROUND

Evaluation and management of osteochondral lesions of the talus (OLTs) often warrant advanced imaging studies, especially in revision or cases with cystic defects. It is possible that orthopedic surgeons may overestimate the size and misinterpret the morphology of OLT from conventional computed tomography (CT), thereby influencing treatment strategies. The purpose of this study was to determine the utility of a novel means to estimate the true-volume of OLTs using 3D reconstructed images and volume analysis.

METHODS

With Institutional Review Board approval, an institutional radiology database was queried for patients with cystic OLTs that failed previous microfracture, having compatible CT scans and magnetic resonance imaging (MRI) between 2011 and 2016. Fourteen patients met inclusion criteria. Of these, 5 cases were randomly selected for 3D CT reconstruction modeling. Ten orthopedic surgeons independently estimated the volume of these 5 OLTs via standard CT. Then 3D reconstructions were made and morphometric true-volume (MTV) analysis measurements of each OLT were generated. The percent change in volumes from CT were compared to MTVs determined from 3D reconstructive analysis.

RESULTS

On average, the volume calculated by conventional CT scanner grossly overestimated the actual size of the OLTs. The volume calculated on conventional CT scanner overestimated the size of OLTs compared to the 3D MTV reconstructed analysis by 285% to 864%.

CONCLUSIONS

Our results showed that conventional measurements of OLTS with CT grossly overestimated the size of the lesion. The 3D MTV analysis of cystic osteochondral lesions may help clinicians with preoperative planning for graft selection and appropriate volume while avoiding unnecessary costs incurred with overestimation.

LEVEL OF EVIDENCE

Level IV, case series.

Gravity Reduction View: A Radiographic Technique for the Evaluation and Management of Weber B Fibula Fractures

BACKGROUND

While various radiographic parameters and application of manual/gravity stress have been proposed to elucidate instability for Weber B fibula fractures, the prognostic capability of these modalities remains unclear. Determination of anatomic positioning of the mortise is paramount. We propose a radiographic technique, the Gravity Reduction View (GRV), which helps elucidate non-anatomic positioning and reducibility of the mortise.

METHODS

The patient is positioned lateral decubitus with the injured leg elevated on a holder with the fibula directed superiorly. The x-ray cassette is placed posterior to the heel, with the beam angled at 15° of internal rotation to obtain a mortise view. Our proposed treatment algorithm is based upon the measurement of the medial clear space (MCS) on the GRV versus the static mortise view (and in comparison to the superior clear space (SCS)) and is based on reducibility of the MCS. A retrospective review of patients evaluated utilizing the GRV was performed.

RESULTS

26 patients with Weber B fibula fractures were managed according to this treatment algorithm. Mean age was 50.57 years old (range:18-81, SD=19). 17 patients underwent operative treatment and 9 patients were initially treated nonoperatively. 2 patients demonstrated late displacement and were treated surgically. Using this algorithm, at a mean follow-up of 26 weeks, all patients had a final MCS that was less than the SCS (final mean MCS 2.86 mm vs. mean SCS of 3.32) indicating effectiveness of the treatment algorithm.

CONCLUSIONS

The GRV is a radiographic view in which deltoid competency, reducibility and initial positioning of the mortise are assessed by comparing a static mortise view with the appearance of the mortise on the GRV. We have proposed a treatment algorithm based on the GRV that we found it useful in our patients in guiding treatment and achieving anatomic mortise alignment.

Determining Measurement Error for Bohler's Angle and the Effect of X-Ray Obliquity on Accuracy

BACKGROUND

Bohler's angle (BA) is the most commonly utilized radiographic measurement in the study of calcaneus fractures and has been shown to be prognostic in nature. Therefore, it is critical that the measurement of BA be accurate as both therapeutic and prognostic information relies on it. Oblique lateral radiographs can be a cause of error in BA measurements. However, measurement error and the effects of X-ray beam obliquity on BA have not been established in the literature. The purpose of this study was to determine measurement error and understand the effects of X-ray beam's obliquity on the measurement of BA.

METHODS

A cadaver specimen was imaged using a C-arm to obtain a perfect lateral radiograph of the ankle and slightly oblique lateral views in the anterior, posterior, cephalad, and caudad directions in 5° increments (21 images). Metallic beads were then placed on the anterior calcaneal process, posterior facet, and the superior aspect of the posterior tuberosity, and the same 21 images were then obtained. The metallic beads placed on the reference radiographs allowed the authors to accurately measure BA for each image and served as reference for the corresponding test radiographs. Thirty-four orthopaedic staff members participated in the study and used DICOM measurement tool to measure BA on each of the 21 test radiographs. The measurements were then compared to the measurements of BA from the reference radiographs to determine error in measurement.

RESULTS

A total of 714 different measurements were obtained. Average measurement error was 6° (95% confidence interval = -4° to 15°). The difference between the observed BA measurements compared to the true BA measurements increased with increasing X-ray obliquity.

CONCLUSIONS

Measurement error for BA is ±6° and increases most with cephalad oblique radiographs. Orthopaedic surgeons' ability to accurately measure BA significantly decreases with increasing obliquity of the lateral radiograph.

LEVELS OF EVIDENCE

Level V: Cadaver bench study.

Gravity Reduction View

Category:

Trauma

Introduction/Purpose:

The determination of stability and ultimate need for operative stabilization of Weber B fibula fractures largely depends on the presence of a competent deltoid ligament. While various radiographic parameters and the application of manual or gravity stress have been proposed to elucidate instability, the prognostic capability of these modalities remains unclear. Given that a recent study found no difference between operative and nonoperative treatment for stress-positive Weber B ankle fractures, the value of stress views is questionable; what may be ultimately more important is the determination of anatomic positioning of the mortise. We propose a novel view, the Gravity Reduction View (GRV), which helps elucidate non-anatomic positioning and reducibility of the mortise. We also propose a treatment algorithm based on the use of the GRV.

Methods:

To obtain the GRV, the patient is positioned in lateral decubitus with the injured fibula directed upward and elevated with a leg holder. The x-ray cassette is placed posterior to the heel, with the beam angled at 15˚ of internal rotation to obtain a mortise view. Our treatment algorithm is based upon the measurement of the medial clear space (MCS) on the GRV versus the static mortise view. If the MCS on GRV remains wide or decreases, surgery is recommended as the GRV confirms a non- anatomic mortise. If the MCS remains within normal limits on the static and GRV views, a trial of nonoperative treatment with immobilization and repeat radiographs in 1-2 weeks is undertaken. If the MCS is normal on repeat weightbearing x-rays, the patient is treated conservatively; if increased, surgery is recommended. To further assess mortise stability, the MCS is compared to the superior clear space (SCS).

Results:

23 patients with Weber B distal fibula fractures were managed according to this treatment algorithm. The mean age was 49.1 years old (range: 18-74). Of these patients, 15 underwent operative treatment and 10 patients were initially treated nonoperatively, although 2 patients demonstrated late displacement and were treated surgically. Using this algorithm, all patients had a final MCS that was less than the SCS (final mean MCS for patients treated operatively or nonoperatively 2.85 mm vs. mean SCS of 3.34), indicating effectiveness of the treatment algorithm.

Conclusion:

The Gravity Reduction View is a novel radiographic view in which deltoid competency, reducibility and initial anatomic positioning of the mortise are assessed by comparing a static mortise view with the appearance of the mortise on the reduction view (GRV). We have developed a treatment algorithm based on the GRV and have found it to be predictive of mortise alignment and useful in guiding treatment.

Arthroscopically Assisted Versus Standard Open Reduction and Internal Fixation Techniques for the Acute Ankle Fracture

BACKGROUND

Ankle fractures represent one of the most common orthopaedic injuries requiring operative treatment. Although open reduction and internal fixation (ORIF) of ankle fractures leads to good results in most patients, poor functional outcomes continue to be reported in some patients for whom anatomic reduction was achieved. It has been theorized that these lesser outcomes may in part be due to a component of missed intra-articular injury that reportedly ranges between 20% and 79%, although to date the true explanation for this subset of lower functional outcomes remains unknown. Such concerns have recently spawned novel techniques of arthroscopically assisted ankle fracture assessment in hopes of enabling better detection and treatment of concomitant intra-articular ankle injuries. The purpose of this systematic review was to summarize the literature comparing standard ORIF to arthroscopically assisted ORIF (AAORIF) for ankle fractures.

METHODS

A systematic review of the English literature was performed using the PubMed database to access all studies over the last 50 years that have documented the functional outcomes of acute ankle fracture management using either a traditional ORIF or an AAORIF technique in the adult population. Relevant publications were analyzed for their respective Levels of Evidence as well as any perceived differences reported in operative time, outcomes, and complications.

RESULTS

A total of only 14 ORIF and 4 AAORIF papers fit the criteria for review. There is fair quality (grade B) evidence to support good to excellent outcomes following traditional ORIF of malleolar fractures. There is fair-quality (grade B) evidence that ankle arthroscopy can be successfully employed for identification and treatment of intra-articular injuries associated with acute ankle fractures, but insufficient (grade I) evidence examining the functional outcomes and complication rates after treatment of these injuries and little documentation that this approach portends any improvement in patient outcome over historical techniques. There is also insufficient (grade I) evidence from 2 prospective randomized studies and 1 case-control study to provide any direct comparative data on functional outcomes, complication rates or total operative time between AAORIF and ORIF for the treatment of acute ankle fractures.

CONCLUSIONS

Ankle arthroscopy is a valuable tool in identifying and treating intra-articular lesions associated with ankle fractures. The presence of such intra-articular pathology may lead to the unexpectedly poor outcomes seen in some patients who undergo surgical fixation of ankle fractures with otherwise anatomic reduction on postoperative radiographs; the ability to diagnose and address these lesions therefore has the potential to improve patient outcomes. To date, however, currently available literature has not shown that treatment of these intra-articular injuries provides any improvement in outcomes over standard ORIF, and few prospective randomized controlled studies have been performed comparing these 2 operative techniques-rendering any suggestion that AAORIF improves clinical outcomes over traditional ORIF difficult to justify. Further research is indicated for what may be a potentially promising surgical adjunct before we can advocate its routine use in these patients.

LEVEL OF EVIDENCE

Level II, systematic review.

Operating Room Time Savings with the Use of Splint Packs: A Randomized Controlled Trial

BACKGROUND

The most expensive variable in the operating room (OR) is time. Lean Process Management is being used in the medical field to improve efficiency in the OR. Streamlining individual processes within the OR is crucial to a comprehensive time saving and cost-cutting health care strategy. At our institution, one hour of OR time costs approximately $500, exclusive of supply and personnel costs. Commercially prepared splint packs (SP) contain all components necessary for plaster-of-Paris short-leg splint application and have the potential to decrease splint application time and overall costs by making it a more lean process. We conducted a randomized controlled trial comparing OR time savings between SP use and bulk supply (BS) splint application.

METHODS

Fifty consecutive adult operative patients on whom post-operative short-leg splint immobilization was indicated were randomized to either a control group using BS or an experimental group using SP. One orthopaedic surgeon (EMB) prepared and applied all of the splints in a standardized fashion. Retrieval time, preparation time, splint application time, and total splinting time for both groups were measured and statistically analyzed.

RESULTS

The retrieval time, preparation time and total splinting time were significantly less (p<0.001) in the SP group compared with the BS group. There was no significant difference in application time between the SP group and BS group.

CONCLUSION

The use of SP made the process of splinting more lean. This has resulted in an average of 2 minutes 52 seconds saved in total splinting time compared to BS, making it an effective cost-cutting and time saving technique. For high volume ORs, use of splint packs may contribute to substantial time and cost savings without impacting patient safety.

Ankle Arthritis: You Can't Always Replace It

End-stage arthritis of the tibiotalar joint is disabling and causes substantial functional impairment. End-stage arthritis of the tibiotalar joint is often the residual effect of a previous traumatic injury. Nonsurgical treatment for end-stage arthritis of the ankle includes bracing, shoe wear modifications, and selective joint injections. For patients who fail to respond to nonsurgical modalities, the two primary treatment options are arthroplasty and arthrodesis. Each treatment option has strong proponents who argue the superiority of their treatment algorithm. Although there is no ideal treatment for ankle arthritis, there are high-quality studies that help guide treatment in patients of varying demographics. Many inherent risks are linked with each treatment option; however, the risks of greatest concern are early implant loosening after arthroplasty that requires revision surgery and the acceleration of adjacent joint degeneration associated with arthrodesis.

Posterior Facet Settling and Changes in Bohler's Angle in Operatively and Nonoperatively Treated Calcaneus Fractures

BACKGROUND

Patients with calcaneus fractures often exhibit settling of the posterior facet with a corresponding decrease in Bohler's angle (BA) following either operative or nonoperative treatment. Both injury BA and postoperative BA have been shown to be prognostic for outcomes; however, the demographic and surgeon-specific factors that may contribute to settling have not been critically examined in the literature. The purpose of this study was to identify these causative factors.

METHODS

234 patients with intra-articular calcaneus fractures were analyzed. All patients had preoperative plain radiographs, at least 5 months of orthopedic follow-up, and computed tomography scanning performed. BA was measured on the injury radiographs for all patients. For operatively treated patients, BA was measured on the immediate postoperative radiographs and compared with the last available radiograph. For nonoperatively treated patients, BA was measured on the last available radiograph. All patients were fully weightbearing at the time of final follow-up but not on initial radiographs due to their recent injury. Demographic data including age, gender, energy of injury mechanism, tobacco use, diabetes, osteoporosis, rheumatoid arthritis, and substance/alcohol abuse were retrospectively collected. Fractures were classified using the Essex-Lopresti and Sanders classifications. Time to full weightbearing was documented, as were any reports of noncompliance with weightbearing restrictions. For patients treated operatively, type of fixation (calcaneal-specific perimeter plate, nonperimeter plate, screw fixation), use of locking screws, use of bone graft or graft substitutes, and the number of screws supporting the posterior facet were documented.

RESULTS

There was a statistically significant amount of settling within the operative and nonoperative groups, but there was no statistically significant difference in settling of BA between the groups. The average settling of BA for the operative and nonoperative group was 8 degrees. Age greater than 50 years, diabetes, and alcohol abuse were all statistically significant and independent predictors of BA settling irrespective of treatment.

CONCLUSION

The amount of BA settling between the operative and nonoperative group was not significant and showed an average decrease of 8 degrees in each group. However, the amount of settling that we found, irrespective of treatment, increased with patient age, alcohol abuse, and diabetes.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.