Background: Total ankle arthroplasty (TAA) has continued to increase in popularity as a treatment for ankle arthritis. Despite popularity, continual updates to implant designs strive for improved outcomes which has led to different implant design changes including an extended-length tibial tray to offer more distal tibia cortical coverage. The purpose of this study was to compare radiographic findings (tibial component subsidence, tibial component loosening, heterotopic ossification [HO]) and patient-reported outcome measures (PROMs) between 2 age-, gender-, and body mass index–matched TAA groups. Methods: This study was a retrospective review of TAA patients matched into 2 groups: group 1 patients received the extended tibial tray implant, and group 2 received the standard tibial tray implant. Pre- and postoperative lateral radiographs and PROMs (Veterans-RAND 12 [VR-12] Item Health Survey, Ankle Osteoarthritis Scale [AOS], visual analog scale [VAS], and patient satisfaction) were analyzed. Results: Seventy-eight patients were allocated to each group. The mean age was 66.7 years in group 1 and 66.9 years in group 2, with a mean follow-up of 44.6 months and 50.7 months, respectively. There were no significant differences between the groups for pre- and postoperative PROMs. Group 1 had higher patient satisfaction with overall care (95.4 vs 89.8, P = .019). Radiographically, the rate of HO formation was significantly lower in group 1 (38.5% vs 62.8%, P < .001), and group 1 also had greater plantarflexion ( P = .096) and significantly less dorsiflexion ( P = .008). Conclusion: Results appear to indicate that using TAA implants with an extended-length tibial tray is associated with more complete distal tibia cortical coverage, a numerically lower but statistically nonsignificant rate of tibial component subsidence, less heterotopic ossification formation, a trend toward greater postoperative plantarflexion, and higher patient satisfaction with overall care. Level of Evidence: Level III, retrospective cohort study.

BACKGROUND:Total ankle arthroplasty (TAA) is increasingly used as a motion-preserving alternative to ankle arthrodesis for end-stage ankle disease. The Salto Talaris fixed-bearing prosthesis was designed to enhance joint kinematics while minimizing bone resection and reducing complications seen in earlier implant generations. This study reports midterm clinical outcomes, including survivorship, complications, reoperation and failure rates in a large, single-surgeon cohort. METHODS:A retrospective review was conducted of 1121 primary TAAs performed in 1023 patients (98 bilateral) between May 2008 and December 2022. Patients with a minimum of 2-year clinical follow-up were included and any patients who failed or passed away before then were accounted for. Data included demographics, comorbidities, preoperative ankle diagnosis, ancillary procedures, intra- and postoperative complications, and patient-reported outcomes measures (PROMs). Complications were identified and then classified by the Glazebrook system (low-, medium-, high-grade). Reoperations and revisions were coded according to the Canadian Orthopaedic Foot and Ankle Society reoperations coding system. RESULTS:The mean age at the index TAA surgery was 65.5 (range, 28.7-94.4) years, with osteoarthritis being the most common diagnosis. The average follow-up was 5.5 (range, 2-17.2) years. Key PROMs showed statistically significant improvements from preoperative to latest follow‑up (Veterans RAND 12-Item Health Survey physical component summary, +10.1 [95% CI 8.83-10.77]; Ankle Osteoarthritis Scale [AOS] pain, -29.2 [95% CI 25.43-29.72]; AOS disability, -32.8 [95% CI 29.32-33.80]; visual analog scale for pain, -36.8 [95% CI 32.6-40.7]; all P < .001). Implant survivorship was 94.6% at the time of this report. A total of 240 ankles (21.4%) experienced at least 1 complication. Secondary reoperations occurred in 134 ankles (12.0%), with 61 ankles failing (5.4%) and leading to a revision TAA, conversion to arthrodesis, or an explant to antibiotic spacer. Most failures were due to high-grade complications including aseptic loosening (22/61) and deep infection (19/61). Among the failed ankles, 2 patients ultimately underwent a below-the-knee amputation. CONCLUSION:In this large cohort, the Salto Talaris TAA was associated with improvements in patient-reported quality of life, activity, and pain, and showed high survivorship with relatively low failure (5.4%) and reoperation (12.0%) rates at an average of 5.5 years after index surgery.

BACKGROUND:Optimal fixation methods for syndesmosis injuries remain debated. The anterior-inferior tibiofibular ligament (AITFL) is critical for syndesmosis stability. The purpose of this study was to biomechanically evaluate a suture button (SB) repair of syndesmosis injuries augmented with the tails of the SB construct vs an AITFL suture augmentation, and to measure the effect of deltoid ligament repair in limiting ankle external rotation (ER). METHODS:This controlled laboratory study used 13 cadaveric lower-leg specimens with robotic forces of 10 Nm internal and external torque under 750 N of axial compression. Each specimen underwent 8 testing surgical states: (1) native/uninjured; (2) sectioned syndesmosis with a sectioned interosseous ligament, AITFL, and posterior-inferior tibiofibular ligament; (3) fully sectioned including deep deltoid ligament; (4) syndesmosis repair with SB construct; (5) added AITFL repair using suture tails repair (SB+tails); (6) added deltoid repair with AITFL tails and syndesmosis repairs (SB+tails+deltoid repair); (7) AITFL augmentation with syndesmosis repair (SB+AITFL augmentation); and (8) additional deltoid repair with AITFL augmentation and syndesmosis repair (SB+AITFL augmentation+deltoid). RESULTS:The SB+AITFL tails repair and SB+AITFL augmentation both had significantly decreased ankle ER (2.25° [1.43°, 3.06°], P < .001, and 2.34° [1.47°, 3.21°], P < .001, respectively) and decreased internal rotation (IR) (2.26° [1.38°, 3.15°], P < .001, and 2.12° [1.13°, 3.10°], P < .001, respectively) compared to the fully sectioned state. No significant differences were observed between these constructs for either ER or IR (P > .99). Additional deltoid repair significantly decreased ER (SB+tails: 0.93° [0.04°, 1.81°], P = .038, SB+ AITFL augmentation: 0.69° [0.35°, 1.02°], P < .001), but not IR (SB+tails: P > .99, SB+AITFL augmentation: P > .99). CONCLUSION:Both the SB+AITFL tails and SB+AITFL augmentation demonstrated improvements in ankle stability over SB alone; with the numbers available, no significant difference between these methods could be detected. However, no repair construct fully restored external ankle rotation to the native state. The deltoid suture repair added medial stability to both SB+AITFL tails and SB+AITFL augmentation. All absolute differences between constructs were small (fractions of a degree or millimeter), and findings should be interpreted accordingly. STUDY DESIGN:Controlled laboratory studyClinical Relevance:This study found that, in this cadaveric model, augmenting the AITFL using either method in addition to suture button placement and open deltoid repair was associated with ankle stability approaching preinjury values across most biomechanical measures tested.

Background: Instability and collapse of the medial longitudinal arch and structural incompetence of the first ray have been linked to various conditions of the foot. These include progressive collapsing foot deformity (PCFD), hallux valgus (HV), and midfoot osteoarthritis (OA). More recently, an innovative approach combining the biomechanical advantages of the modified Lapidus procedure and Cotton osteotomy were described in the literature. The aim of this study was to determine the midterm outcomes following first-tarsometatarsal plantarflexion bone block arthrodesis with a precontoured allograft wedge (first-TMT PFBB arthrodesis). Methods: A retrospective review was performed of consecutive patients who underwent this procedure between 2020 and 2023 with an average 2-year follow-up. Patients were assessed for radiographic union/nonunion based on weightbearing CT (WBCT) by 3 independent fellowship-trained orthopaedic foot and ankle surgeons. Patient-reported outcomes (PROs) including Patient-Reported Outcome Measures Information System (PROMIS) and Foot and Ankle Ability Measure (FAAM) activities of daily living (ADL) were collected pre- and postoperatively. Patients were excluded if diagnosed with Charcot arthropathy/neuropathy or underwent an extended medial column arthrodesis. Results: A total of 61 patients were identified as having a first-TMT PFBB arthrodesis procedure, 49 patients (52 feet) met inclusion criteria. The average allograft wedge was 9 mm (range, 5-14) mm. Fourteen feet (26.9%) underwent at least 1 revision surgery. Nonunion occurred in 22 feet (42.3%) in 40.8% of patients. Additionally, new-onset plantar first-MTP/sesamoid overload pain occurred in 8 feet (15.4%).Conclusion: Given the observed high nonunion rate (42%) and revision rate (27%), this technique should be approached with caution. We believe patient selection and counseling regarding potential postoperative complications including high reoperation and nonunion rates as well as the potential to overlengthen or overcorrect first-ray positioning resulting in sesamoid overload symptoms are important to consider before proceeding with first-TMT plantarflexion allograft bone block arthrodesis.

Background: Early results of the fixed-bearing total ankle arthroplasty (TAA) have demonstrated improvement in patient-reported outcome measures (PROMs) for patients with end-stage ankle arthritis. The purpose of this study is to update the previously reported PROMs for the largest cohort of US patients undergoing modern fixed-bearing TAA with the Salto Talaris implant. Methods: A retrospective review was completed of 300 consecutive patients who underwent implantation with 321 modern fixed-bearing TAA by a single surgeon. PROMs were collected prior to surgery, at 3 and 6 months, and yearly thereafter. Collected outcome measures included Veterans RAND 12-Item Health Survey (VR-12), Ankle Osteoarthritis Scale (AOS), and visual analog pain scale (VAS). Presurgical and latest available follow-up (>2 years) PROMs were compared using a mixed effect linear regression with significance level alpha = 0.01 using a Bonferroni-adjusted significance threshold to account for testing across the 5 PROMs. Results: Of the 321 TAAs, an updated 300 procedures (282 patients) had a minimum 2-year follow-up. The average follow-up was 75.3 (range, 24-193.9) months. The mean physical VR-12 score increased significantly from prior to surgery to latest follow-up, while mental VR-12 scores did not (P < .001 and P = .608, respectively). AOS pain and disability scores and VAS pain scores improved significantly (P < .001). Clinical significance of PROMs was assessed using previously reported minimal clinically important differences (MCIDs), and the average changes in VR-12 physical composite score, AOS Pain and Disability scores, and VAS scores from preoperation to latest follow-up were all greater than the respective MCID values. Conclusion: At midterm follow-up, fixed-bearing TAA with the Salto Talaris implant was associated with improvement in quality of life, pain, and disability. Level of Evidence: Level IV, case series.

BACKGROUND:The indications for deltoid ligament (DL) repair in ankle fractures with widened medial clear space (MCS) remain controversial. Many authors report no difference in long-term functional outcomes, whereas others report persistent MCS widening and higher malreduction rates without DL repair. This study compares DL repair to no repair exclusively in surgically treated bimalleolar equivalent Weber C fibula fractures. METHODS:This was a retrospective chart review of surgically treated Weber C lateral malleolus fractures with syndesmosis stabilization, with associated DL injury (bimalleolar equivalent). Patients with associated posterior or medial malleolus fractures, Weber B or A fractures, fibula fixation constructs other than plate and screws, follow-up less than 12 months, and revisions were excluded. Those meeting the inclusion criteria were split into 2 groups: DL repair vs no repair. Collected data included patient demographics, surgical procedures performed, and outcome measures. Primary outcomes measured postoperative oblique MCS and valgus talar tilt angle (TTA). Secondary outcomes included fracture union, complications, and patient-reported outcome measures (PROMs). RESULTS:Seventy-seven fractures were included; 48 underwent DL repair whereas 29 did not. The mean follow-up was 28.9 months. Most study outcomes within each group had a statistically significant postoperative improvement. The valgus TTA in the repair vs no repair groups was 0.1 ± 0.9 vs 1.3 ± 2.0 degrees, respectively (P < .001). The MCS in the repair vs no repair groups was 3.5 ± 0.6 vs 3.8 ± 1.3 mm, respectively (P = .169). There were statistically significant differences in favor of DL repair in postoperative Veterans RAND-12 Item Health Survey physical subscale (P = .025) and Foot and Ankle Ability Measure activities of daily living subscale (P = .044) scores. There were no complications or revision surgeries directly related to DL repair. CONCLUSION:The DL repair group had superior functional outcomes and ankle coronal plane alignment in comparison to no repair. There were no complications or revisions related directly to the deltoid repair. These results support consideration of DL repair in bimalleolar equivalent Weber C ankle fractures to improve functional outcomes and coronal plane alignment.

Category: Hindfoot; Other Introduction/Purpose: Progressive collapsing foot deformity (PCFD) remains a challenging condition for foot and ankle surgeons to treat. While there exists more clarity on the treatment for end-stage rigid deformities involving PCFD, there is still significant debate over different surgical treatment options for the flexible collapsing foot. Common surgical corrections for flexible PCFD include the 'All-American Procedure' popularized by Manoli in the 1990s. Isolated talonavicular (TN) arthrodesis has also been described for the treatment of flexible PCFD. The primary objective of this study was to evaluate clinical and radiographic outcomes in patients with AAFD treated with isolated tri-planar corrective TN arthrodesis. A secondary objective was to establish whether there is a correlation between radiographic outcomes and clinical outcomes. Methods: Fifty-four patients (59 feet) from July 2013 to October 2020 with flexible PCFD underwent surgical treatment with isolated TN arthrodesis. Patients with other arthrodesis or hindfoot osteotomies were excluded. Concomitant gastrocnemius lengthening and toe deformity correction procedures were not an exclusion criterion. Weight-bearing radiographs were performed pre- and postoperatively, with Meary angle (or lateral talo-first metatarsal angle) and calcaneal pitch measured on lateral view. The degree of TN coverage on antero-posterior (AP) radiographs were measured with the TN coverage angle and the degree of first ray angular deformity was measured using Simmon angle (or AP talo-first metatarsal angle). Angles were measured by a foot and ankle fellow. The Foot & Ankle Ability Measure (FAAM) and Veterans-Rand 12 Item Health Survey (VR- 12) were used to clinically evaluate the patient. Results: Thirty-seven females and seventeen males were evaluated with a mean age 61 years at the time of surgery and an average length of follow up of 19 months. There were significant improvements in deformity correction found in this study. Radiographically, the lateral radiographs demonstrated Meary angle correction from 27 degrees pre-operatively to 9 degrees post- operatively (p<0.001) and calcaneal pitch improving from 15 degrees pre-operatively to 18 degrees post operatively (p<.001). AP radiographic analysis demonstrated TN coverage angle improving from 35 degrees pre-operatively to 5 degrees post-operatively (p<0.001) and Simmon angle improving from 20 degrees pre-operatively to 6 degrees, post-operatively (p<.001). The only statistically significant improvement in clinical outcomes was in the FAAM score (pre-operative score 48.48, post-operative score 58.45 (p<.001)). Conclusion: Isolated TN arthrodesis is a viable option for multi-planar deformity correction in patients with flexible PCFD. Not only did it provide significant improvements in radiographic alignment, it also provided improved functional outcomes as demonstrated on FAAM scores. Comparative studies with other surgical treatment techniques such as the 'All-American Procedure' should be performed to determine which is the best technique for patients with flexible PCFD.

BACKGROUND:Sesamoid pathology can lead to significant pain and disability both with activities of daily living and high-impact athletic movements. Sesamoidectomy is a widely used procedure for patients who fail conservative treatment measures. Traditional dorsal or plantar approaches for sesamoidectomy have shown to successfully alleviate pain, but complications were reported. A proposed alternative medial approach using a burr may provide many advantages compared with traditional approaches. This study presents patient outcomes and complications for this technique. METHODS:This was a retrospective chart review of patients undergoing sesamoidectomy (tibial, peroneal, or both) using a burr through a medial approach to the sesamoid metatarsal articulation. Data collected included patient demographics, radiographic analysis, and outcomes: Veterans Rand 12 Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), visual analog scale (VAS), patient satisfaction, and complications. RESULTS:Twenty-seven patients (29 feet) were included. The mean age was 38.4 years followed up for a mean of 30.9 months. VR-12 physical component improved from 35.98 ± 7.86 to 51.34 ± 8.01 (P < .001), FAAM ADL and sport improved from 58.33 ± 16.61 to 83.27 ± 18.28 (P < .001) and 26.37 ± 20.31 to 63.75 ± 29.74 (P < .001), respectively. Patient satisfaction with the treatment was 80.59% ± 27.06%. The overall complication rate was 11 (37.9%) whereas the overall reoperation rate was 4 (13.7%) of 29 feet. Complications included 1 arthrofibrosis, 1 flexor hallucis longus subacute rupture, and 1 asymptomatic hallux valgus. There were no sesamoid excision revisions. CONCLUSION:Sesamoidectomy using a medial approach with a burr provided significantly improved short-term functional outcomes, 80% patient satisfaction rate, with a relatively acceptable complications rate including 20% persistent pain. The medial approach is familiar to orthopaedic foot and ankle surgeons, provides adequate exposure, and eliminates the possibility of a painful plantar scar while avoiding disruption of the plantar plate, flexor hallucis brevis tendon, and ligamentous structures attached to the sesamoids. Larger studies with long-term follow-up from other centers are needed.

Category: Ankle; Trauma Introduction/Purpose: The indications of deltoid ligament repair in ankle injuries with widened medial clear space in the absence of medial malleolus fracture remain controversial. Many authors reported no difference in long-term functional outcomes, while others reported persistent medial clear space widening and higher malreduction when deltoid ligaments went without repair. This malreduction can lead to chronic ankle instability and pain. Talar shift as little as 1mm is reported to lead to a 49% increase in ankle joint pressure, a detrimental factor for developing post-traumatic ankle arthritis. The purpose of this study was to compare deltoid ligament repair to no repair in a homogenous group of surgically treated isolated Weber C fibula fractures exclusively. Methods: A retrospective chart review of prospectively collected data was carried out to identify consecutive surgically treated Weber C lateral malleolus fractures and syndesmosis stabilization with associated deltoid ligament injury between February 2013-December 2023. Associated posterior/medial malleolus fractures other than avulsions, Weber A/B fractures, fibula fixation constructs besides plate and screws, Charcot neuropathy, pes planovalgus with incompetent deltoid ligament, and revisions were excluded. Those meeting inclusion criteria were split into two groups: deltoid ligament suture repair vs. no repair. Collected data included demographics, smoking and diabetes status, surgical procedure and patient reported outcome measures (PROMs).. Primary outcomes were oblique medial clear space (MCS) and valgus talar tilt angle (TTA) on weightbearing radiographs. All radiographs were independently reviewed by a fellowship trained foot and ankle orthopedic surgeon. Secondary outcomes were fracture union, complications, reoperations, and PROMs: Foot and Ankle Ability Measure (FAAM), Veterans-Rand 12 (VR12) General Health Survey, visual analog pain scale (VAS). Results: Seventy-nine fractures were included; 49 underwent deltoid ligament repair while 30 did not. The mean follow-up was 18.5 months. There was a statistically significant post-op improvement in most study outcomes within the groups. The valgus TTA in the repair vs no repair groups were 0.1±0.9 vs. 1.2±2.1 degrees, respectively (p=0.007). The MCS in the repair vs. no repair groups was 3.5±0.6 vs. 3.9±1.4mm, respectively (p=0.107). There were no statistically significant differences between deltoid repair and no repair groups in post-operative VR12 MCS (p=0.194), VR12 PCS (p=0.077), VAS (p=0.231), FAAM ADL (p=0.109), FAAM sport (p=0.314), or patient satisfaction (p=0.33). The union rate was 100% in the repair vs. 96% in the no repair groups (p=0.163). There were no complications related to repairing the deltoid ligament. Conclusion: Deltoid ligament repair led to a superior ankle coronal alignment in comparison to no repair. There were no complications or revisions related to the medial approach and repairing the deltoid ligament. While there were trends toward better functional outcomes with deltoid ligament repair, this did not reach statistical significance. Long term studies may be required before recommending deltoid ligament repair as the gold standard in isolated Weber C fractures. Meanwhile, we recommend valgus stressing the ankle at the end of the procedure and decide whether deltoid repair is needed on individual basis. Outcomes of deltoid repair group vs no deltoid repair group.

With ankle replacements gaining popularity and documented good functional outcomes, there is an increasing number of patients inquiring about the possibility of converting an ankle fusion to a replacement. This could be due to pain, limited function, or increasing adjacent joint arthritis. There is an increasing body of evidence in the literature that a conversion to a replacement is possible and that the outcomes are positive. There are also absolute contradictions for a conversion. An absent fibula, pain of unknown origin, and recent infection fall in this category. Long-term follow-up is needed to see if conversions of ankle fusions to replacements have the same functional results and longevity as primary replacements.

Background: Total ankle arthroplasty (TAA) continues to be investigated as a primary treatment for end-stage ankle arthritis. The objective of this study is to report mid- to long-term results of the Salto Talaris TAA using prospectively collected patient-reported outcomes and implant survival rates with 4- to 13-year follow-up.Methods: This was a retrospective study of prospectively collected data from 2 multicenter cohort studies from 3 centers. Three hundred fourteen subjects who received a Salto Talaris TAA from 2005 to 2015 were included in the study. Follow-up ranged 4-13 years following index procedure. Outcomes included 36-Item Short Form Health Survey (SF-36) mental and physical component summary scores, pain scores, and adverse events including additional surgeries, revision, or removal of components.Results: Significant improvements were seen in pain and physical function scores at 2-year follow-up and were generally maintained through most recent follow-up. The survival rate of the prosthesis was >95% (n = 30/32 at >10 years, n = 272/282 at 4.5-10 years). Thirteen patients (4.1%) underwent revision or removal of their prosthesis. Time to revision ranged from 2 months to 6.5 years following the index procedure. Twenty-two patients (7.0%) had additional surgery that did not involve revision or removal of components.Conclusion: Treatment of end-stage ankle arthritis with this implant provided patients with improved pain and functional outcome scores at mid- to long-term follow-up. The significant improvements reported at 2-4 years appeared to endure through the extended follow-up period.Level of Evidence: Level III, retrospective cohort study.

Background: Low-energy stage II Lisfranc injuries are rare, and treatment can be operative or nonoperative based on a surgeon’s assessment of midfoot stability. No previously published patient-reported outcome measures (PROMs) data for Lisfranc injuries isolates purely ligamentous stage II injuries. The purpose of this study was to analyze PROMs for patients who underwent operative management of stage II Lisfranc injuries. Methods: Thirty-nine patients (39 feet) with confirmed Nunley-Vertullo stage II Lisfranc injuries between May 2012 and February 2022 were identified through a retrospective chart review. PROMs that were analyzed were the visual analog scale (VAS) pain scale, Veterans RAND 12-Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), and patient satisfaction. Results: Thirty-two open reduction internal fixations (ORIFs) and 7 fusions were performed. The mean latest follow-up was 44.6 (range, 12-92) months. There were 2 complications (5%, 2/39) that required a revision procedure. Twenty-six patients (67%, 26/39) underwent secondary surgery to remove retained hardware. The mean time to hardware removal was 3.97 (range, 2.70-7.47) months. The overall mean patient satisfaction score with overall medical care including clinical visits and interactions with medical staff personnel was 93.6/100. All PROMs (VAS, VR-12, FAAM) demonstrated statistically significant improvement ( P < .05) from preoperative (injury) values to latest follow-up postinjury values. Conclusion: Patients who were treated surgically with stage II purely ligamentous Lisfranc injuries via the methods used were found to mostly undergo hardware removal and have high levels of overall satisfaction with their process of medical care. Level of Evidence: Level IV, retrospective case series.

Percutaneous tibial neuromodulation is a medical guideline recommended therapy for treating symptoms of overactive bladder. Stimulation is delivered to the tibial nerve via a thin needle placed percutaneously for 30 min once a week for 12-weeks, and monthly thereafter. Studies have shown that this therapy can effectively relieve symptoms of overactive bladder; however, the frequent office visits present a barrier to patients and can impact therapy effectiveness. To mitigate the burden of frequent clinic visits, small implantable devices are being developed to deliver tibial neuromodulation. These devices are implanted during a single minimally invasive procedure and deliver stimulation intermittently, similar to percutaneous tibial neuromodulation. Here, we describe the implant procedure and design of a pivotal study evaluating the safety and effectiveness for an implantable tibial neuromodulation device. The Evaluation of Implantable Tibial Neuromodulation (TITAN 2) pivotal study is a prospective, multicenter, investigational device exemption study being conducted at up to 30 sites in the United States and enrolling subjects with symptoms of overactive bladder.

Category: Midfoot/Forefoot; Sports Introduction/Purpose: Patients with pathology of the sesamoids can have significant pain and disability both with activities of daily living and high impact athletic movements. Sesamoidectomy is a widely used procedure for patients who fail conservative treatment measures. Traditional dorsal or plantar approaches for sesamoidectomy have shown to successfully alleviate pain but complications are noted, including hallux varus deformity, painful plantar incision, and clawing of the hallux. Additionally, the dorsal approach is technically difficult because of poor visualization, which can lead to unnecessary disruption of important plantar ligamentous structures. An alternative medial approach using a bur provides many advantages compared to traditional approaches. Methods: This was a retrospective chart review of patients undergoing sesamoidectomy using a bur with a medial approach to the sesamoid metatarsal articulation. Data collected included patient demographics, radiographic analysis, and outcomes: Veterans Rand 12 Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), Visual Analog Scale (VAS), patient satisfaction, and complications. Results: In patients (10 feet) with an average age of 36.5 (range, 13-77) years were analyzed. Six patients underwent medial sesamoidectomy, three underwent lateral sesamoidectomy, and one patient underwent excision of both medial and lateral sesamoids using a bur. The average latest follow up was 11.9 months. Scores were improved from pre-operatively to most recent follow-up for VR-12 Physical (29.43 vs 53.86), FAAM ADL (48.8 vs 94.1 points), FAAM Sports (7.8 vs 87.4 points), and VAS (57.8 vs 8.6). Patient satisfaction with the treatment was 96.4%. There were zero complications or additional procedures performed. Conclusion: In this series, sesamoidectomy utilizing a medial approach with a bur provided excellent pain relief, zero complications, and significantly improved outcome scores at early follow up. The medial approach is familiar to orthopedic foot and ankle surgeons, provides adequate exposure, and eliminates the possibility of a painful plantar incision. Furthermore, this technique allows for maintenance of the plantar plate, flexor hallucis brevis (FHB) tendon, and all other ligamentous structures that attach to the sesamoids. Larger studies with longer term follow up are needed to further our knowledge on this surgical technique.

The most reliable reconstruction for chronic ankle ligament instability continues to be debated. The conventional Broström is widely used, but there are limitations to the technique. By virtue of the tissue repair a conservative rehabilitation approach is advocated, and there is an increasing concern that the repair does not match the strength of the native ligament. That begs the question of whether an augmentation is needed and if it is done, how does it affect the native ligament repair and how does it stand up over time? This chapter will discuss these questions as well as our current approach to lateral ligament reconstruction.

Category: Trauma; Ankle Introduction/Purpose: Ankle fractures are among the most common fractures in the body and it can affect not only professional athletes but also lower activity level and sedentary patients. The standard treatment for displaced fractures is open reduction and internal fixation. Even though the management for Weber B and C fractures is well stablished in the literature, deltoid ligament repair is still debatable. Medial ligament instability is a result of deltoid ligament failure and usually leads to valgus deformity of the ankle and severe morbidity over time. The primary objective of this study is to analyze clinically and radiographically, patients with Weber C fractures and deltoid ligament injury who were submitted to fibular fracture and syndesmotic fixation, associated with deltoid ligament repair. Methods: Forty one patients who had Weber C fractures with deltoid ligament lesion from January 2013 to December 2019 had their medical records and X-Rays reviewed by a fully trained foot and ankle surgeon. The patients were between 14 and 69 years old and had their medial clear space wider than 4mm on initial X-Rays (our criteria for deltoid ligament lesion). Patients with Weber A or B, diabetics and with previous surgeries on the ankle were excluded. Patients were submitted to open anatomic reduction and fixation of the fibula, the syndesmosis was fixed with dynamic fixation system and the deltoid was reattached to the tip of the medial malleolus with one suture anchor. Medial Clear Spcace, Tibiofiluar clear space and Tibiofibular overlap were measuresd on weight bearing X-Rays done on the last follow up visit. FAAM sports Subscale17 and VR12 were used to evaluate clinical status of our patients. Results: Forty one patients were analyzed on this series after 22 months on average. The mean age at operation was 37.7 years old. There were 32 males and 9 females. Mental and Physical VR-12 scores went from 56 and 37 pre-operatively to 57 and 50 on their final evaluation. Activity Daily Living and Sports FAAM scores improved from 27 and 7 to 19 and 88 respectively. Post- operative mean medial clear space was 3mm, and mean tibio-fibular clear space was 5mm. The average tibio-fibular overlap percentage was 46%. Patient's overall satisfaction rate was 86.7%. Conclusion: Weber C fractures with Deltoid ligament lesion can be successfully treated with anatomic reduction, syndesmotic fixation (dyanamic systems) and open deltoid repairs. Patients show excellent reduction parameters on weight-bearing X-Rays and good clinical outcomes after a minimum 12 months follow up. Comparative studies with and without deltoid ligament repair should be performed to compare two techniques. Weight-bearing CT scan could be used in future studies for more accurate evaluation of the syndesmotic reduction and medial clear space.

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) has continued to increase in popularity as a treatment modality for ankle arthritis. Despite this increased popularity, continual updates to implant designs strive for improved outcomes. This has led to different implant design changes including an extended length tibial tray to offer more distal tibia cortical coverage. This study compares the rates of tibial component subsidence, tibial component loosening, heterotopic ossification (HO) formation, average post-operative range of motion (ROM), and patient reported outcome measures (PROMs) between two matched groups of patients who underwent TAA with Salto Talaris extended tibial tray components with full distal tibia cortical coverage and a group who underwent TAA with Salto Talaris traditional tibial tray components without full tibia cortical coverage. Methods: Patients who underwent TAA between January 2019 and February 2021 with Salto Talaris implants (Smith & Nephew, Memphis, TN) were included for review. Patients were matched into two groups for age, gender, and Body Mass Index (BMI). Group 1 consisted of patients who received TAA with the extended tibial tray implant and full distal tibia cortical coverage and Group 2 consisted of patients who received the standard tibial tray implant without full distal tibia cortical coverage. Preoperative and postoperative radiographs were analyzed for the presence of subsidence, loosening, HO formation. ROM was measured utilizing plantarflexion and dorsiflexion weight-bearing lateral radiographs. PROMs were also analyzed including the Veterans- RAND 12 (VR-12) Item Health Survey, Ankle Osteoarthritis Scale (AOS), Foot and Ankle Ability Measure (FAAM), Visual Analog Score (VAS), and Patient Satisfaction. Results: Sixty-one patients (36 males; 25 females) were matched between the two groups. The mean age was 66.9 years in Group 1 and 67.1 years in Group 2, with a mean follow-up of 15.6 months and 22.1 months, respectively. Mean BMI was 30.6 in Group 1 and 30.5 in Group 2. The post-operative VR-12 Physical score was significantly higher in Group 1 (49.2 vs 45.1, P=0.025). Group 1 also had a significantly lower post-operative VAS pain score (11.1 vs 21.2, P=0.012) as well as patient satisfaction (93.8 vs 85.2, P=0.018). Radiographically, the rate of subsidence was significantly lower in Group 1 (0% vs 16.4%, P=0.001) as well as the rate of HO formation (26.2% vs 67.2%, P<0.001). Group 1 had significantly greater post-operative plantarflexion (17.7 degrees vs 14.0 degrees, P=0.018). Conclusion: Early short-term results appear to indicate that utilizing TAA implants with an extended length tibial tray with full distal tibia cortical coverage is associated with less subsidence, less heterotopic ossification formation, greater post-operative plantarflexion, less pain and higher patient satisfaction. Future analysis with longer-term follow up as well as a larger patient cohort may help shed even more light into the efficacy of this new implant design.