Fractures of the talus are life-changing events. The talus is of vital importance to normal gait. Given its importance, great care is needed in diagnosing and treating these injuries. The threshold for operative treatment and accurate anatomic reduction should be low. Surgical tenets include the avoidance of extensive subperiosteal dissection to minimize vascular disruption. The complications with injuries to the talus are extensive and include avascular necrosis (AVN). Although AVN can prove to be a devastating sequela from this injury, it occurs less frequently than posttraumatic arthritis.

Posterior ankle impingement is typically seen in athletes, primarily dancers and soccer players, secondary to dynamic and repetitive push-off maneuvers and forced hyperplantarflexion. Posterior ankle impingement results from chronic, repetitive trauma to the posterior ankle capsule, flexor hallucis longus tendon, and/or os trigonum. It is important to perform a thorough workup by isolating and testing the posterior compartment muscles and obtaining proper imaging with radiographs to identify any osseous abnormalities and MRI to evaluate the soft tissue structures. Nonsurgical treatment includes activity modification, physical therapy, and steroid injections.

Ankle syndesmosis injuries include isolated ligamentous rupture, as well as fractures with ligamentous injury. These injuries can significantly affect athletes in all sports, and lead to prolonged recovery and return to sport. Adequate evaluation and diagnosis of these injuries are imperative for treatment and return to play. Many can be treated nonoperatively, but operative treatment is indicated in fractures with syndesmosis disruption and ligamentous injuries with instability. Anatomic reduction and fixation of these injuries will allow functional rehab and return to sport.

Heterotopic ossification (HO) is a known sequela in total ankle arthroplasty. The purpose of this study was to determine the radiographic incidence of HO in fourth-generation total ankle implants including the INFINITY, CADENCE, and VANTAGE. Radiographs were assessed for the incidence and location of HO in each implant using the modified Brooker classification. Seventy-one patients were included. There were 41 INFINITY, 16 CADENCE, and 14 VANTAGE implants. The average radiographic follow-up was 19.7 months. The incidence of HO was 69.0%. Overall, the HO was Class I in 31 cases (63.3%); Class II in 7 cases (14.3%); Class III in 10 cases (20.4%); and Class IV in 1 case (2.0%). For INFINITY; n = 33 patients (80.5%), CADENCE; n = 8 patients (50%); VANTAGE n = 8 patients (57.1%). When comparing INFINITY with CADENCE/VANTAGE, there was a statistically significant difference in presence of HO (P = 0.01). When comparing INFINITY with CADENCE, there was a statistically significant difference in presence of HO (P = 0.04). In the 33 cases of INFINITY with HO, 30 had neutral or posterior coverage, and in 4 cases, the prosthesis did not extend to the posterior tibial cortex (P = 0.005). This study demonstrates a continued high rate of HO with 3 fourth-generation ankle implants in the short term, although many were Class 1 and posterior. The INFINITY had a higher overall incidence of HO. Adequate posterior cortical coverage did not play a role in radiographic presence of HO. Further research is warranted with longer-term follow-up to determine the clinical and radiographic significance of HO. Level of Evidence: Level III: Retrospective comparative

Ankle arthroplasty is a viable treatment option for end-stage ankle arthritis and has shown improvements in pain relief, motion, as well as function and gait. Newer generation total ankle prostheses have improved instrumentation and surgical techniques, as well as minimal bone resection on both the tibia and talus. The purpose of this systematic review was to determine the short-term clinical success of the INFINITY total ankle, including the common complications and rate of revision with this prosthesis. We performed a systematic review of electronic databases that included reported complications and revisions using this prosthesis. Complications were recorded according to the Glazebrook classification. Six total published studies with clinical outcomes and complications and 432 prostheses were included. The weighted mean follow-up was 24.5 months and weighted mean patient age was 62.3 years. There were 43 (10.0%) total complications—9 low grade, 16 medium grade, and 18 high grade. There were 26 total revision procedures (6.0%). Revisions were mostly performed for deep infection, aseptic loosening, and subsidence. When including deep infections, the overall implant survivorship was 94%. When excluding the 8 deep infections requiring revision, implant survivorship was 96%. The INFINITY has acceptable short-term complication and revision rates. This fourth-generation prosthesis compares to prior reported studies with earlier generation ankle implants in the short term. Level of Evidence: IV

The Lapidus arthrodesis is a powerful procedure for the correction of hallux valgus with metatarsus primus varus. Yet, first ray instability may persist despite correction of the primary deformity with 2 crossed screw fixation. A third screw is often utilized as the additional point of fixation for noteworthy residual transverse plane motion, but it is not without potential complications. The suture and button fixation device may be an appropriate alternative to the third screw construct. This retrospective cohort study identified clinical / radiographic outcomes and complication rates following a third point of fixation with either a screw or suture and button fixation device in patients undergoing a modified Lapidus arthrodesis. One surgeon performed all of the Lapidus procedure with a third screw while the other surgeon performed all with a suture and button fixation device. Of 136 consecutive patients who underwent a modified Lapidus arthrodesis, 83 (61%) patients required a third point of fixation for satisfactory stabilization of the first ray. Surgical technique was similar between the 2 surgeons; however, one utilized the suture and button fixation device method (n = 36), while the other used a third screw for fixation (n = 47). Many of the clinical outcomes, radiographic results, and the union rate were similar between the 2 methods. Nineteen (40%) complications occurred in the third screw group compared to 6 (17%) in the suture and button fixation device group. However, the third screw group demonstrated 100% maintenance of deformity correction at 1 year versus 95% in the suture and button fixation device group. Although fixation with a suture and button fixation device was associated with fewer complications, a larger study is necessary to determine if these variations are statistically significant.

Ankle fractures with syndesmosis disruption present a challenge for foot and ankle surgeons. After open reduction internal fixation (ORIF), conventional postoperative treatment requires a period of immobilization and non-weightbearing, which if prolonged, can be detrimental to patients. The purpose of this case series is to present outcomes of early weightbearing after ankle fracture ORIF requiring syndesmosis stabilization using a dynamic fixation device. Thirty consecutive patients from August 2019 to July 2021 were included. Medical records and radiographs were reviewed to determine patient and surgical characteristics, postoperative complications, and reduction maintenance. Surgical treatment consisted of ORIF of malleolar fractures and stabilization of the syndesmosis with a Tightrope® XP (Arthrex Inc., Naples, FL). The mean age was 49 years. Mean BMI was 28.8. There were 24 supination-external rotation and 6 pronation-external rotation injuries. Twenty-six patients had syndesmosis fixation with a single implant, and 4 patients had syndesmosis fixation with two implants. The average time to weightbearing in a walking boot was 9.7 days. Average follow up was 13 months. One patient developed early postoperative saphenous neuritis, which resolved with conservative measures. There were no infections, malunions or nonunions, and all patients maintained fracture and syndesmosis reduction. In conclusion, the Tightrope® XP provides a safe and effective method for treatment of ankle fractures with syndesmosis disruption and supports early weightbearing after ORIF in an active healthy population. The results of this study are comparable to prior studies and show there is a low risk of complication and need for routine removal of implants.

This document was created to serve as one of a series of clinical consensus statements (CCS) sponsored by the American College of Foot and Ankle Surgeons® (ACFAS) ( 1 Dayton P DeVries JG Landsman A Meyr AJ Schweinberger M. American College of Foot and Ankle Surgeons® clinical consensus statement: perioperative prophylactic antibiotic use in clean elective foot surgery. J Foot Ankle Surg. 2015; 54: 273-279 Google Scholar , 2 Fleischer AE Abicht BP Baker JR Boffeli TJ Jupiter DC Schade VL. American College of Foot and Ankle Surgeons® clinical consensus statement: risk, prevention, and diagnosis of venous thromboembolism disease in foot and ankle surgery and injuries requiring immobilization. J Foot Ankle Surg. 2015; 54: 497-507 Google Scholar , 3 Meyr AJ Mirmiran R Naldo J Sachs BD Shibuya N. American College of Foot and Ankle Surgeons' clinical consensus statement: perioperative management. J Foot Ankle Surg. 2017; 56: 336-356 Google Scholar , 4 Mirmiran R Bush T Cerra MM Grambart S Kauschinger E Younger M Zychowicz M. Joint clinical consensus statement of the American College of Foot and Ankle Surgeons® and the American Association of Nurse Practioners®: etiology, diagnosis, and treatment consensus for gouty arthritis of the foot and ankle. J Foot Ankle Surg. 2018; 57: 1207-1217 Google Scholar , 5 Schneider HP Baca J Carpenter B Dayton P Fleischer AE Sachs BD. American College of Foot and Ankle Surgeons® clinical consensus statement: diagnosis and treatment of adult acquired infracalcaneal heel pain. J Foot Ankle Surg. 2018; 57: 370-381 Google Scholar , 6 Piraino JA Theodoulou MH Ortiz J Peterson K Lundquist A Hollawell S Scott RT Joseph R Mahan KT Bresnahan PJ Butto DN Cain JD Ford TC Knight JM Wobst GM. American College of Foot and Ankle Surgeons® clinical consensus statement: appropriate clinical management of adult-acquired flatfoot deformity. J Foot Ankle Surg. 2020; 59: 347-355 Google Scholar , 7 Shibuya N McAlister JE Prissel MA Piraino JA Joseph RM Theodoulou MH Jupiter DC. Consensus statement of the American College of Foot and Ankle Surgeons: diagnosis and treatment of ankle arthritis. J Foot Ankle Surg. 2020; 59: 1019-1031 Google Scholar , 8 Naldo J Agnew P Brucato M Dayton P Shane A. ACFAS clinical consensus statement: acute Achilles tendon pathology. J Foot Ankle Surg. 2021; 60: 93-101 Google Scholar ). It is important to appreciate that consensus statements do not represent clinical practice guidelines, formal evidence reviews, recommendations, or evidence-based guidelines. Instead, a CCS reflects information synthesized from an organized group of experts based on the best available evidence. Still, it also may contain, and to some degree embraces, opinions, uncertainties, and minority viewpoints. A CCS should open the door to discussion on a topic, as opposed to providing definitive answers.

Osteomyelitis of the foot and ankle is a challenge to treat and creates a significant demand on both the patient and the healthcare system. The purposes of this study were to determine the microorganisms associated with foot and ankle osteomyelitis, to evaluate the change in methicillin-resistant Staphylococcus aureus (MRSA) between 2005 and 2010, and to determine the relationship between these infecting organisms and patient comorbidities. The medical records for 302 patients diagnosed with osteomyelitis of the foot and ankle, 151 in 2005 and 151 in 2010, were randomly selected and evaluated. The authors reviewed the demographics, comorbidities, microorganism(s) confirmed with bone biopsy and culture, location, and use of antibiotics before bone biopsy. Gram-positive bacteria were the most prevalent, composing 81.9% of the isolates in 2005 and 59.6% in 2010. Methicillin-sensitive Staphylococcus aureus was the most common in both cohorts. Conversely, the incidence of MRSA statistically decreased from 28.3% to 10.6% from 2005 to 2010 (p < .0001). Gram-negative bacteria were found in 39.5% of the 2005 isolates and 31.8% of those from 2010. Pseudomonas sp. was the most common gram-negative bacteria. Patients with peripheral vascular disease had a significantly higher incidence of gram-negative bacteria (odds ratio 2.1, 95% confidence interval, 1.3 to 3.6, p = .003). The results of this study reveal that MSSA was the most common bacteria, incidence of MRSA decreased between the 2005 to 2010, and patients with peripheral vascular disease have a significantly higher incidence of gram-negative bacteria.

Traditional postoperative care after open reduction internal fixation (ORIF) of unstable ankle fractures with syndesmotic instability includes non-weightbearing for 6 to 8 weeks. However, prolonged non-weightbearing may be detrimental. The goal of this case series was to assess the outcomes of early protected weightbearing after operative treatment of acute ankle fractures with syndesmotic instability requiring screw stabilization. Fifty-eight consecutive patients, treated from January 2006 to January 2013, met the inclusion criteria with a minimum follow up of 1 year. Electronic medical records and radiographs were reviewed for patient and surgical characteristics, postoperative complications, and maintenance of reduction. Patients initiated walking at an average of 10 days (range 1 to 15) postoperatively. Surgical treatment consisted of operative reduction with standard fixation devices and 1 or 2 trans-syndesmotic screws that purchased 4 cortices. All 58 patients maintained correction after surgery when allowed to weightbear early in the postoperative recovery. Five complications (8.6%) occurred in the 58 patients, which included 3 superficial infections (5.2%) and 2 cases (3.4%) of neuritis. The maintenance of reduction and low complication rate in this study support the option of early protected weightbearing after ankle fracture ORIF with trans-syndesmotic fixation.

In an attempt at limb salvage for patients with peripheral arterial disease, revascularization is often performed prior to pedal amputation. The purpose of this study was to evaluate the association between proximal arterial lesions, based on Trans-Atlantic Inter-Society Consensus aortoiliac, femoropopliteal, and infrapopliteal classifications, and healing pedal amputations post endovascular revascularization. Patients with revascularization up to 90 days prior to pedal amputation with a minimum of 12 months postoperative follow-up were included. Each level of proximal disease was subdivided into Trans-Atlantic Inter-Society Consensus classifications A through D, which range in severity from a single short stenosis or occlusion to more complex stenoses and chronic total occlusion. For comparison, we categorized A and/or B lesions into Group 1 and C and/or D lesions into Group 2. The frequency of proximal lesions was recorded as either isolated, bi-level, or multilevel disease. Chi-square and Fisher's exact tests were used to compare categorical variables. Of the 310 patients, there were a total of 68 aortoiliac, 256 femoropopliteal, and 172 infrapopliteal lesions; 140 patients had isolated lesions, 154 had bi-level disease, and 16 had multilevel disease. Although not statistically significant, patients in Group 1 (A and/or B lesions) had higher proportion of failed amputation compared to Group 2 (C and/or D lesions) in either aortoiliac (84.4% vs 15.6%, p = .17), femoropopliteal (61.2% vs 38.8%, p = .72), or infrapopliteal (57.3% vs 42.7%, p = .44). Bi-level disease showed a higher proportion of failure (50.6%) compared to isolated lesions (43.8%) and multilevel disease (5.6%), (p = .86). To our knowledge, this is the first study to evaluate the association between Trans-Atlantic Inter-Society Consensus arterial lesions and incisional healing of pedal amputations. Despite our belief, there was no correlation between patients with simple, isolated lesions compared to either complex arterial lesions or multilevel disease in healing pedal amputations.

There has been a growing trend toward endovascular intervention to improve peripheral flow in patients with peripheral arterial disease. To date, there is no clear consensus regarding timing of lower-extremity amputations after revascularization. The purpose of this study was to evaluate the effects of timing between endovascular intervention and minor lower-extremity amputations and its influence on wound healing and limb loss within 1 year. A secondary purpose was to evaluate the impact of restoring in-line flow on healing rates. A total of 310 patients who underwent endovascular intervention and a minor lower-extremity amputation within 90 days were included in the study. Healing rates were defined as optimal, delayed, or failure. There was a statistically significant difference between patients with optimal healing to delayed healing and amputation ≥30 days after endovascular intervention (p = .037). We found no difference in healing rates in regard to amputation timing when examining patients who ultimately healed versus patients who failed to heal (p = .6717). Absence of in-line flow (p = .0177), male sex (p = .0090) and diabetes mellitus (p = .0076) were statistically significant factors for failing to heal. Presence of infection (p ≤ .0001) and wound dehiscence (p ≤ .001) were also associated with a failure to heal. End-stage renal disease trended toward significance for failing to heal (p = .065). Amputation-free survival at 1 year after endovascular intervention and pedal amputation was 76.8% (n = 238). Our findings suggest that in the absence of infection, performing minor lower-extremity amputations 15 to 60 days after endovascular intervention may allow for improved healing. Absence of in-line flow, male sex, diabetes mellitus, postoperative infection, and wound dehiscence are significant factors for failure.

The indications for arthroscopy have expanded over the years. Arthroscopic-assisted open reduction internal fixation in the setting of acute trauma is gaining popularity with foot and ankle surgeons. It serves to facilitate direct visualization of fracture fragments and allows for precise articular reduction with minimal soft tissue insult. Current evidence reports a high incidence of chondral injury with ankle fractures. Arthroscopy performed at the time of open reduction internal fixation allows for joint inspection and potential treatment of these posttraumatic defects.

Many surgical procedures have been described for Achilles tendon pathology; however, no overwhelming consensus has been reached for surgical treatment. Open repair using a central or paramedian incision allows excellent visualization for end-to-end anastomosis in the case of a complete rupture and detachment and reattachment for insertional pathologies. Postoperative wound dehiscence and infection in the Achilles tendon have considerable deleterious effects on overall functional recovery and outcome and sometimes require plastic surgery techniques to achieve coverage. With the aim of avoiding such complications, foot and ankle surgeons have studied less invasive techniques for repair. We describe a percutaneous approach to Achilles tendinopathy using a modification of the Bunnell suture weave technique combined with the use of interference screws. No direct end-to-end repair of the tendon is performed, rather, the proximal stump is brought in direct proximity of the distal stump, preventing overlengthening and proximal stump retraction. This technique also reduces the suture creep often seen with end-to-end tendon repair by providing a direct, rigid suture to bone interface. We have used the new technique to minimize dissection and exposure while restoring function and accelerating recovery postoperatively.