Category: Arthroscopy; Ankle; Hindfoot; Sports Introduction/Purpose: Posterior ankle and hindfoot arthroscopy (PAHA) is a well described procedure used for treating posterior ankle impingement syndrome (PAIS). Os trigonum and trigonal process (Stieda) are common etiologies and diagnosis is typically made by radiographs, CT, or MRI. However, these static tests may not detect associated soft tissue and other bony pathologies, which are often dynamic. Physical examination and Ultrasound (US) are dynamic. US can be limited by depth. Traditional open treatment may not allow visualization and appreciation for these associated pathologies. PAHA is dynamic providing at least 8X magnification with full visualization of the posterior ankle and subtalar joints. The primary aim of this study is to report the incidence of associated pathologies seen with os trigonum or Stieda impingement when treated with PAHA. Methods: A retrospective case series of patients who underwent PAHA for PAIS due to trigonal impingement between January 2011 and September 2016 were reviewed. Surgeries were performed by three fellowship-trained orthopedic foot and ankle surgeons in 251 patients. Exclusions were those having concomitant open posterior procedures, other indications for PAHA (e.g., OCL, subtalar fusion) or other PAIS etiology (e.g., soft tissue impingement). After exclusions, 112 patients were studied, with a mean age of 30.5 (12-70) and a BMI of 29.93 (SD 9.23). Demographic data was collected along with pre and postoperative diagnosis, arthroscopic findings, type of impingement, location of the disorder, associated procedures, and anatomical etiologies. Trigonal impingements were allocated as os trigonal or Stieda and subgrouped as isolated, with other impingement lesions +/- FHL disorders. Differences between groups with isolated trigonal impingement and those with associated pathologies were determined by distribution comparison. Wilcoxon test was used to compare subgroups. Results: From the 112 cases, 75 were os trigonum and 37 Stieda. Isolated trigonal disorders accounted for 16% of the total PAIS patients (n=18). Those cases having pathologies other than trigonal impingement had a mode of 3 (1-5) additional pathologies with 41% of the treated cases having 3 or more adjunctive findings needing treatment during posterior arthroscopy. Flexor hallucis longus (FHL) disorders were found in 68% of cases, subtalar problems in 44%, and transverse posterior inferior tibiofibular ligament (tPITFL) in 19%. A 58% proportion of associated pathologies was observed when FHL disorders were not considered. Significant differences were noted when comparing os trigonum and Stieda subgroups (FHL: 29% to 18%, p<0.001; FHL and others: 34% to 59%, p=0.046; other findings: 14% to 16%, p=0.025). Conclusion: Our study described a high prevalence of associated pathological structures involved with a trigonal disorder leading to PAI in a large cohort. Trigonal bone (os trigonum or Stieda) was found to cause impingement in isolation in a small proportion of cases (16%). Even when the FHL is removed from the equation, 58% of the total patients still presented other associated impingement pathologies. This should alert surgeons when considering removing trigonal impingement especially with an open approach. Open approaches may limit the visualization and assessment of associated posterior ankle and subtalar pathoanatomy, thus possibly overlooking concomitant causes of PAIS.

Category: Ankle Arthritis; Hindfoot Introduction/Purpose: Tibio-talo-calcaneal (TTC) arthrodesis is usually a salvage procedure to address several hindfoot and ankle conditions. Non-union rate after TTC fusion is variably reported 3.4% - 48%. The aims of this study were to describe the outcomes and complications of this procedure and to determine potential risk factors associated with non-union. Methods: In this IRB-approved retrospective cohort study, we used the following codes (28705,28725 and 27870) to search the medical records for all patients who underwent TTC fusion between 2006-2022. All relevant demographic data, surgical indications, surgery details (type of the graft, type of the implant, and surgical approach, associated procedures), post-operative course (complications and union rate) and follow-up duration were extracted. Descriptive statistics were performed, and continuous variables were described using median (interquartile range) and categorical variables were described using frequency (%) and mean (standard deviation, SD). Patients and surgery characteristics were compared between united and non-united cases using Wilcoxon Rank Sum Tests for continuous variables and Chi-squared or exact tests, as appropriate, for categorical variables. Analyses were performed using SAS statistical software version 9.4 (SAS Institute Inc., Cary, NC). Results: Fifty-one patients (53 feet) were included in the study. Long hindfoot fusion nails were used in 51 cases.Ten cases were routinely dynamized 8-10 weeks after surgery. In 24 (45.3%) patients, morselized allograft was combined with infuseTM and reamer irrigation aspiration autograft (RIA). In 20 (37.7%) patients, morselized allograft was combined with infuseTM only. There were 6 non-union cases (11.3%). When comparing patients and surgery characteristics between non-union versus union group, smoking (P = 0.0150) and routine dynamization (P= 0.0297) were higher in the non-union group. No difference in union rates between different types of graft. Frequency of other complications is listed in (Figure 1). Follow up duration was 27.2 months (range 4-108 months). Conclusion: TTC fusion achieves good union rate (88.68%), however it carries a relatively high risk of complications. Routine dynamization of the TTC nail at 8-10 weeks could be a risk factor for non-union. Smoking was also associated with a high non- union rate.

Commentary: Important review article on the current literature and status of ankle arthroplasty in the US. It outlines all of the current FDA approved prostheses. Also reviews literature on utilization and cost comparisons to ankle fusion

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Background: The use of posterior ankle and hindfoot arthroscopy (PAHA) has been expanding over time. Many new indications have been reported in the literature. The primary objective of this study was to report the rate of PAHA complication in a large cohort of patients and describe their potential associations with demographical and surgical variables. Methods: In this IRB-approved retrospective comparative study, patients who underwent posterior ankle and/or hindfoot arthroscopy in a single institution from December 2009 to July 2016 were studied. Three fellowship-trained orthopaedic foot and ankle surgeon performed all surgeries. Demographic data, diagnosis, tourniquet use, associated procedures, and complications were recorded. To investigate a priori factors predictive of neurologic complication after PAHA, univariate and multivariable logistic regression was utilized. Where appropriate, sparse events sensitivity analysis was tested by fitting models with Firth log-likelihood approach. Results: A total of 232 subjects with 251 surgeries were selected. Indications were posterior ankle impingement (37%), flexor hallux longus disorders (14%), subtalar arthritis (8%), and osteochondral lesions (6%). Complications were observed in 6.8% (17/251) of procedures. Neural sensory lesions were noted in 10 patients (3.98%), and wound complications in 4 ankles (1.59%). Seven neurologic lesions resolved spontaneously and 3 required further intervention. In a multivariable regression model controlled for confounders, the use of accessory posterolateral portal was the significant driver for neurologic complications (odds ratio [OR] 32.19, 95% CI 3.53-293.50). Conclusion: The complication rate in this cohort that was treated with posterior ankle and/or hindfoot arthroscopy was 6.8%. Most complications were due to neural sensorial injuries (sural 5, medial plantar nerve 4, medial calcaneal nerve 1 ) and 3 required additional operative treatment. The use of an accessory posterolateral portal was significantly associated with neurologic complications. The provided information may assist surgeons in establishing diagnoses, making therapeutic decisions, and instituting surgical strategies for patients that might benefit from a posterior arthroscopic approach. Level of Evidence: Level III, retrospective comparative study.

BACKGROUND:Somatic nerve pain is one of the most common complications following surgery of the foot and ankle but may also arise following traumatic injury or chronic nerve compression. The sural nerve is a commonly affected nerve in the foot and ankle; it is at risk given the proximity to frequently used surgical approaches, exposure to crush injuries, and traction from severe ankle inversion injuries. The purpose of this study is to investigate the outcomes of sural nerve neurectomy with proximal implantation for sural neuromas (SN) and chronic sural neuritis (CSN).METHODS:Patients that underwent neurectomy with proximal implantation (20 muscle, 1 adipose tissue) by 2 foot and ankle specialists for isolated SN- and CSN-related pain at a single tertiary institution were included. Demographic data, baseline outcomes including 36-Item Short Form Health Survey (SF-36), Foot and Ankle Ability Measure (FAAM), and visual analog scale (VAS) were recorded. Final follow-up questionnaires using Patient Reported Outcomes Measurement Information System (PROMIS) lower extremity function, pain interference (PI), and neuropathic pain quality, FAAM, and VAS were administered using REDCap. Perioperative factors including neuropathic medications, diagnostic injections, the use of collagen wraps, and perioperative ketamine were collected from the medical record. Descriptive statistics were performed and potential changes in patient-reported outcome measure scores were evaluated using Wilcoxon signed-rank tests.RESULTS:The 21 patients meeting inclusion criteria for this study had a median age of 47 years (interquartile range [IQR], 43-49) and had median follow-up duration of 33.7 months (IQR, 4.5-47.6). Median FAAM activities of daily living score improved from 40.6 (38.7-50.7) preoperatively to 66.1 (53.6-83.3) postoperatively, P = .032. FAAM sports scores improved from 14.1 (7.8-21.9) to 41.1 (25.0-60.9) postoperatively, P = .002. VAS scores improved from a median of 9.0 (8.0-9.0) to 3.0 (3.0-6.0), P < .001. At final follow-up, patients reported PROMIS lower extremity function score median of 43.8 (35.6-54.9), PROMIS neuropathic pain quality score of 54.1 (43.6-61.6), and PROMIS PI of 57.7 (41.1-63.8). Patients with both anxiety and depression reported less improvement in pain and physical. Other perioperative factors lacked sufficient numbers for statistical analysis.CONCLUSION:Sural nerve neurectomy and proximal implantation (20 muscle, 1 adipose) provided significant improvement in pain and function for patients with sural neuromas and chronic sural neuritis at median follow-up of 33.7 months. Anxiety and depression were associated with significantly poorer outcomes following surgery. Patients with CRPS as well as recent nicotine use tended to report less improvement in pain and worse function after surgery, although this sample size was too limited for statistical analysis of these variables. Further research is needed to identify the ideal surgical candidates and perioperative factors to optimize patient outcomes.LEVEL OF EVIDENCE:Level IV, retrospective case series.

Background: This study aimed to assess the preferred operative treatment for patients over the age of 60 with end-stage ankle arthritis and perspectives on total ankle replacement (TAR) among American Orthopaedic Foot & Ankle Society (AOFAS) members. Associated factors were analyzed for potential contraindications among members with different levels of experience. Method: A questionnaire containing 6 questions was designed and sent to 2056 members of the AOFAS. Responses were received from 467 orthopaedic surgeons practicing in the United States (76%), Canada (5%), and 26 other countries (20%). Participants were grouped for response comparisons according to country as well as experience level. Differences in contraindications were compared using χ2 tests or exact tests. Results: Respondents practicing in the United States and surgeons who perform 11 or more TARs per year tended to recommend operative treatments favoring TAR and displayed recognition of its increasing role (P < .05). Overall, respondents felt that 41% of typical patients over 60 years old with end-stage arthritis would be best treated with TAR. Talus avascular necrosis, morbid obesity (body mass index >40 kg/m2), and poorly controlled diabetes with neuropathy were most recognized as the absolute contraindications to TAR. Surgeon’s experience affected the consideration of these clinical factors as contraindications. Conclusions: Total ankle replacement has a substantial and increasing role in the treatment of end-stage ankle arthritis in patients over the age of 60. Absolute and potential contraindications of the procedures were indicated from a cross-sectional survey of AOFAS members. Surgeons more experienced with total ankle replacement felt more comfortable employing it in a wider range of clinical settings. Level of Evidence: Level III, therapeutic.

Category: Ankle; Midfoot/Forefoot; Trauma; Other Introduction/Purpose: Peripheral nerve injury or entrapment is a common complication following surgery in the foot and ankle region. The superficial peroneal nerve is particularly at risk following ankle arthroscopy and lateral approaches to the ankle or fibula. Symptoms can result in intense pain and significant disability for patients. The purpose of this study is to investigate the outcomes of superficial peroneal nerve neurolysis and neurectomy. Methods: All patients were identified who underwent operative treatment by two foot and ankle specialists for superficial peroneal nerve related pain. Exclusion criteria included patients under the age of 18, prisoners, those who underwent concomitant osseous procedures, and less than 6-week follow-up. Demographic data, baseline outcomes including FFI, SF-36, FAAM, and VAS were recorded. Final follow-up questionnaires using PROMIS measures and FAAM were administered using REDCap. Results: 55 patients were included in this study with a mean age of 43.0 years (IQR, 33.0-48.0). At a median follow-upof 6.8 months (IQR 1.2-20.2 months), VAS improved from a median of 9.0 (IQR 6.0-9.0) preoperatively to 2.0 (IQR 0.00-5.0) after surgery, p < 0.05. Patients reported a median VAS improvement of 4.0 (IQR 2.0-7.0). At final follow-up patients reported PROMIS lower extremity function score median of 58.6 (IQR 45.2-58.6), PROMIS neuropathic pain quality score of 42.9 (IQR 37.2-55.5), and PROMIS pain interference of 50.5 (IQR 41.1-57.0). Worker's compensation claims were independently associated with significantly poorer post-operative function measured using FAAM ADL (58.58 WC vs 74.86 non-WC, p<0.02) and higher post- operative VAS scores (4.46 WC vs 2.36 non-WC, p<0.01). ). Patients with current or recent tobacco use within 3 months leading up to surgery reported significantly higher post-operative VAS pain scores compared to nonsmokers (4.54 vs 2.47, p<0.02). Conclusion: Neurectomy or neurolysis has potential to significantly improve somatic pain for entrapment or neuroma formation of the superficial peroneal nerve. Tobacco use as well as worker's compensation claims were associated with significantly poorer outcomes. Further studies are needed to optimize perioperative management and surgical techniques for these patients.

Category: Ankle; Hindfoot Introduction/Purpose: Somatic neuropathy is a common complication following foot and ankle surgery, trauma, or compression due to entrapment. Symptoms can be intense and debilitating. The Sural nerve is commonly affected and is at risk due to the location and proximity to frequently used surgical approaches. The purpose of this study is to investigate the outcomes of sural nerve neurolysis and neurectomy with intramuscular burial for sural neuritis. Methods: IRB approval was obtained, and patients were identified who underwent operative treatment by two foot and ankle specialists for sural nerve related pain. Exclusion criteria included patients under the age of 18, prisoners, those who underwent concomitant osseous procedures, and less than 6-week follow-up. Demographics and preoperative outcomes including FFI, SF-36, FAAM, and VAS were recorded. Final follow-up questionnaires using PROMIS measures and FAAM were administered using REDCap. Results: The 25 patients meeting inclusion criteria for this study had a median age of 47 (interquartile range [IQR], 43 to 49) and had median follow-up of 33.7 months (IQR, 4.5 -73.2). Median FAAM ADL improved from 40.8 (IQR 38.1-51.3) preoperatively to 59.5 (IQR 47.6-76.2) postoperatively, p=0.032. FAAM Sports scores improved from 15.6 (IQR 9.4-21.9) to 31.3 (IQR 25.0-56.3) postoperatively, p=0.002. VAS scores improved from a median of 9.0 (IQR 7.0-9.0) to 4.5 (3.0-6.0), p<0.0001. At final follow-up patients reported PROMIS lower extremity function score median of 46.7 (IQR 36.7-51.2), PROMIS neuropathic pain quality score of 51.5 (IQR 45.5-60.2), and PROMIS pain interference of 55.7 (IQR 41.1-63.7). Patients with current or recent nicotine use, depression, anxiety, and complex regional pain syndrome (CRPS) prior to surgery reported poorer outcomes. Conclusion: Neurectomy with burial or neurolysis can significantly improve symptoms for sural neuritis secondary to neuroma or nerve entrapment. Tobacco use, depression and anxiety are associated with poorer outcomes following surgery. Further research is needed to More clearly identify patients at risk for worse outcomes and perioperative factors that could allow interventions to optimize patient outcomes.

Treatments of Achilles tendinopathy continue to evolve. The body of literature is inadequate to provide a comprehensive guide to evaluation and treat failed surgeries. Issues related to failed surgical treatment may be divided into infection/wound issue, mechanical failure, and persistent pain. Awareness of the potential problems described in this article will allow surgeons to have a foundation in clinical assessment and making accurate diagnoses. Various surgical treatment options are available and should be executed carefully to treat individualized patient conditions.

Category: Ankle Arthritis; Ankle; Trauma Introduction/Purpose: Ankle osteoarthritis (AO) is an incapacitating condition for patients and a substantial burden for medical assistance. It is well known that the vast majority of AO occurs as a sequela of previous trauma. However, it is currently unknown what types of injuries of the foot and ankle most commonly lead to end-stage arthritis. Therefore, the purpose of this study was to investigate the etiology of end-stage ankle osteoarthritis in all patients who underwent ankle fusion or replacement at a tertiary care center over 20 years. We hypothesized that the most common injury patterns would correspond to low-energy lesions. Methods: The electronic medical record was queried using current procedural terminology (CPT) codes for ankle fusion or ankle replacement to identify all patients who underwent either of these procedures at a single tertiary academic center over 20 years. Etiologies were broadly grouped as Pilon/Plafond fracture, ankle fracture, talus fracture, tibia fracture, single or recurrent sprains, infection/septic joint, systemic disorder (Charcot arthropathy, rheumatoid arthritis, hemophilic arthropathy), and idiopathic/primary osteoarthritis. Each fracture pattern was then subclassified using commonly accepted classification systems by two independent observers in addition to the grade of arthritis at the time of fusion or replacement. Reliability among readers was assessed by Kleiss kappa. Normative data were analyzed by ANOVA and comparison among groups and methods by Student's T- test. Results: A total of 533 patients were included in this study. The initial injury patterns were broadly classified as pilon/plafond (65), ankle (173), sprains (110), talus (17), tibia (22), tibiotalar dislocation without fracture (1). Other identified etiologies included rheumatoid arthritis (18), Charcot arthropathy (11), progressive collapsing foot deformity (21), septic arthritis (5), and cavovarus (6). The average time interval between the initial injury and definitive treatment for end-stage arthritis was 558 days. Ankle fractures classified as 44C1 (14,1%), 44B3 (10.6%), 44B2 (9.3%) followed by pilon 43C3 (6.5%) and 43C1 (4.1%) were the most prevalent subclassification found in the fractures group. Conclusion: The primary etiology for AO is secondary due to trauma. A history of ankle sprains and instability was found in 20.6%. Fractures corresponded to 54,6% of our cohort, ankle fractures producing most of these lesions. When considering the subtype of injury, ankle fractures with a 44C1 and a 44B3 classification were the more frequent presentation. These findings could support the argument that complex low-energy rotational traumas do not carry a benign course. Comprehension of the AO etiology scenario may guide prevention policies and specific primary treatment guidelines to diminish disease impact on the population and health care system.

Category: Ankle Arthritis Introduction/Purpose: The long term outcome of total ankle replacement is contingent on restoring the anatomic tibiotalar alignment of the ankle joint. Prior studies have mainly looked at the effect of coronal and hindfoot alignment of TAR on outcome and failure with few studies focusing on the effect of sagittal tibiotalar alignment. From these, we know that sagittal alignment has a greater impact on joint mechanics and that proper positioning of the talar component in the sagittal plane results in greater postoperative pain relief and better functional outcome, especially ankle range of motion. The goal of this study was to define a sagittal radiographic value that predicts failure in TAR. Methods: We analyzed the data of a retrospective patient cohort of consecutive TAR patients, which were treated from 2004 and 2011. Patients with two types of prosthesis were included, Salto Talaris (fixed bearing) and STAR (mobile bearing). All measurements were completed by two blinded observers, including the sagittal distal tibial articular angle (sDTAA), the lateral talar station (LTS) and the talar component inclination angle (γ angle). A total of 90 patients were included, 51 were male and 39 female patients. Seventy-seven patients received a Salto and 13 patients a STAR prosthesis. The average age was 63.7 years. Results: The mean sDTAA was 83.9 degrees and the mean γ angle was 21 degrees, both without significant difference in the two different prosthesis designs. A significant association (p=0.03) between post-op LTS as a continuous variable per unit increase and clinical failure was demonstrated, which included all the revision cases, with an odds ratio of 1.25. In addition a significant association (p=0.03) between increased LTS and sDTAA change of >5°, which is indicative of anterior subsidence, was shown. This was associated with an odds ratio of clinical TAR failure of 1.27. Conclusion: The abnormal radiographic post-op lateral talar station appears to predict clinical TAR failure and correlates with the abnormal sDTAA; the anterior translated talus loads the anterior tibia leading to anterior subsidence of the prosthesis. Limitation of this study is the inclusion of two different types of prosthesis designs.

Category: Ankle; Ankle Arthritis; Other Introduction/Purpose: Weightbearing computed tomography (WBCT) is a reliable and precise modality for the measurement and analysis of bone position in the foot and ankle, as well as associated deformities. WBCT to assess three dimensional relationships among bones allowed the development of new measurements, as the Foot and Ankle Offset (FAO), which has high inter-rater and intra-rater reliability. This study reports our institution's experience utilizing WBCT for the care of foot and ankle patients by describing its utility across different orthopedic diseases in improving diagnostic assessment, aiding surgical planning, and expanding the use for objective clinical follow-up. Methods: The medical records of consecutive patients with various foot and ankle disorders that underwent WBCT examination as part of the standard of care at a single institution between November 2014 and August 2020 were retrospectively reviewed. Patient factors, including body mass index (BMI), sex, and patient comorbidities were collected. 3D coordinates for calculation of FAO were harvested using the Multiplanar Reconstruction (MPR) views were calculated from the obtained exams. Descriptive statistics were performed with Shapiro-Wilk test and the Anderson-Darling tests. Results: 1175 feet and ankles (820 patients) had a WBCT performed over the studied 68 months. 53% of the subjects were male and 47% female. 588 of the acquisitions were from the right side (50.04%) and 587 from the left side (49.96%). Diabetes was present in 15.47% of, Rheumatic diagnoses in 4.52% and smoking habits in 44.10% of patients. Mean BMI of the sample was found to be 32.47 (32.03-32.90, 95% CI). The mean Foot and Ankle Offset (FAO) encountered in the study's population was 2.43 (2.05- 2.82, 95% CI; min -30.8, max 37.65; median 2.39). Conclusion: This study contains the largest cohort of WBCTs with accompanied FAO measurements to date, which can aid with establishing a new baseline FAO measurement for multiple pathological conditions. Acquiring WBCTs resulted in more specific diagnoses for patients with foot and ankle complaints. The ability to utilize WBCT for presurgical planning, its capability to provide a 3D reconstruction of patient anatomy, and use for assessment of advanced relational foot and ankle measurements, like FAO, demonstrate how WBCT may serve as a remarkable utility in clinical practice and has become a standard of care in our practice at the University of Iowa.

Category: Hindfoot; Other Introduction/Purpose: There remains a controversy for treatment of subtalar joint arthritis. Both open and arthroscopic techniques have been reported for successful treatment of subtalar arthritis; however, there is a little evidence to report prospective comparative outcomes between the two techniques. The purpose of this study was to compare clinical and functional outcomes including complications between the two techniques. Methods: A prospective, randomized collected data of 54 consecutive patients who were diagnosed with isolated subtalar joint arthritis and underwent either open (27 patients) or posterior arthroscopic (27 patients) subtalar arthrodesis between 2015 and 2019 in 2 institutions. A minimum follow-up to be included in the study was 12 months (mean, 24.2 months; range, 12 to 41 months). The primary outcome was union time. The secondary outcomes included visual analogue scale (VAS), Short Form-36 (SF-36), and FAAM, union rate, time to return to activity of daily living, sports, work, and complications. Pre- and post-operative SF-36, FAAM, and pain (Visual Analog Scale) were obtained and compared between the two groups using independent t-test and the same group with paired t-test. Results: There were 54 patients (42 male and 12 female) with mean age of 43.7 years (range, 21-68 years) and mean BMI of 25.7 kg/m2 (range, 18.3-33.6 kg/m2). Both techniques demonstrated significant improvement of post-operative functional outcomes (VAS, SF-36, and VAS (p < 0.001 all)) compared to pre-operative period; however, there was no significant difference between the two groups. The secondary outcomes between open and arthroscopic groups were time to return to activity of daily living (8.4 vs 10.8 weeks), works (10.6 vs 12.9 weeks), sports (24.9 vs 32.7 weeks), time to union using CT scan (9.4 vs 12.8 weeks), union rate (100% versus 96.3%), and complications included painful hardware (18.5% vs 22.2%), paresthesia (0 vs 7.4%), and no infection in both groups. Conclusion: Both open and arthroscopic techniques were demonstrated significant improvement in terms of functional outcomes as measured with the FAAM, SF-36, and VAS in patients with subtalar joint arthritis. Although there was no significant difference of short-term of functional outcomes measurement and complications, arthroscopic technique was better in term of fasten recovery time and time to union.

Background: Workers’ compensation (WC) has been associated with poor outcomes following a variety of injuries and surgeries, but rates of subsequent pain or injury (SPI) following surgery have not been studied. The purpose of this study was to investigate the rates, locations, and risk factors of SPI in WC patients and non-WC patients who underwent the same surgeries. Methods: With institutional review board approval, records from foot or ankle surgery performed by author P.P. from 2009 to 2015 were obtained. A retrospective chart review was performed on all WC and non-WC patients with at least 1 Current Procedural Terminology code of interest. SPI was defined as a new injury at a different anatomical location occurring 2 months to 2 years after the index surgery. Chi-square and 2-tailed t tests were used to compare risk factors and rates of SPI in both groups. Results: The WC population had higher rates of SPI than the non-WC population. Specifically, 13 of 56 WC patients (23.2%) vs 12 of 165 non-WC patients (7.3%) reported SPI (P = .001). The hip, knee, and contralateral foot and ankle were common areas of SPI in both groups. Legal representation and increased age were risk factors for SPI in the WC population. Specifically, 10 of 13 WC patients with SPI had legal representation vs 16 of 43 WC patients without SPI (P = .02). Female sex was a risk factor for SPI in the non-WC population. Conclusions: WC patients had higher rates of subsequent pain or injury than non-WC patients. Legal representation was a risk factor for SPI in the WC population. Level of Evidence: Level III, comparative series.

Background:Treatment of diabetes costs the United States an estimated $245 billion annually; one-third of which is related to the treatment of diabetic foot ulcers (DFUs). We present a safe, efficacious, and economically prudent model for the outpatient treatment of uncomplicated DFUs.Methods:77 patients (mean age = 54 years, range 31 to 83) with uncomplicated DFUs prospectively enrolled from September 2008 through February 2012. All patients received an initial sharp debridement by one of two orthopaedic foot and ankle fellowship trained surgeons. Ulcer dressings, offloading devices, and debridement procedures were standardized. Patients were evaluated every two weeks by research nurses who utilized a clinical management algorithm and performed conservative sharp wound debridement (CSWD).Results:Average time to clinical healing was 6.0 weeks. There were no complications of CSWD performed by nurses. The sensitivity for the timely identification of wound deterioration was 100%, specificity = 86.49%, PPV = 68.75% and NPV = 100% with an overall accuracy of 89.58%. The estimated cost savings in this model by having nurses perform CSWD was $223.26 per encounter, which, when extrapolated to national estimates, amounts to $1.56 billion to $2.49 billion in potential annual savings across six to ten-week treatment periods, respectively.Conclusion:CSWD of DFUs by nurses in a vertically integrated multidisciplinary team is a safe, effective, and fiscally responsible clinical practice. This clinical model on a national scale could result in significant healthcare savings. Surgeons and other licensed independent practitioners would have more time for evaluating and treating more complex and operative patients; nurses would be practicing closer to the full extent of their education and training as allowed in most states.Level of Evidence: III.