Acute compartment syndrome of the foot remains a controversial topic. The diagnosis, management, and reported sequelae remain largely supported by low level evidence and expert opinion. Ischemic plantar flexion contractures resulting in cavus and claw toe deformities, acute and chronic neuropathic pain, sensory deficits and paresthesias, neuropathic ulceration, and odynohyperkeratosis are sequelae of both conservative and operative management of acute compartment syndrome of the foot. Further research on the outcomes of acute fasciotomy versus delayed management is necessary to support therapeutic strategies. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Introduction: We aimed to assess the quality and content of websites addressing orthopaedic conditions affecting older adults, emphasizing osteoporosis and fragility fracture. Methods: Ten diagnoses were chosen. The transparency of information was assessed via the Health On the Net (HON) score; information content was assessed via diagnosis-specific grading templates. A total of 140 websites (14 per diagnosis) were reviewed by three raters. HON scores and information quality were compared by diagnosis, website type, and website source. The correlation between HON score and information quality score was calculated. Results: Most websites were commercial (59.3%). Cronbach alpha for Hall scores exceeded the a priori threshold of 0.7. Analysis proceeded using averages across raters. HON score was significantly associated with higher content scores (r = 0.56; P < 0.0001). Content scores ranged from 21.1 to 59.4. Content scores differed significantly by diagnosis (P = 0.0008) and website source (P < 0.0001). Discussion: The quality and content of websites is highly variable for osteoporosis and fragility fracture diagnoses. Patients should be encouraged to access reputable sites, including sites displaying a HON seal. Academic and medical specialty societies demonstrate opportunity for improvement of their own websites and might be able to lead efforts to increase accessibility of high-quality content.

Category: Ankle Arthritis Introduction/Purpose: Treatment of the failed total ankle arthroplasty (TAA) is challenging, and historically arthrodesis was advocated as the salvage treatment of choice. Currently, there is limited available literature reporting on options and outcomes of revision arthroplasty despite the persistent relatively high failure rate ranging from 10-23% within the first ten years after primary TAA. Early published outcomes of intramedullary-referencing implants for primary TAA have shown improvement in clinical outcomes and radiographic parameters, sustained correction of coronal deformity, and excellent survivorship with few associated complications. The purpose of this study is to report the clinical and radiographic outcomes of revision TAA using an intramedullary-referencing implant. Methods: We reviewed a consecutive series of 24 cases (14 female and 10 male; median age, 57.9 (28.2-74.6) years; median BMI, 31 (19.4-40.2)) between 2008 to 2015 in which a failed TAA underwent revision using InBone, an intramedullary-referencing, fixed-bearing, two-component total ankle system. Demographic, radiographic, and functional outcome data were collected preoperatively, immediately postoperatively, and at the most recent follow up. The primary outcome was implant survival defined by no reoperation for subsidence/loosening or revision of the implant. Secondary outcomes included radiographic (coronal and sagittal component alignment, osteolysis, and subsidence) and functional (American Orthopaedic Foot & Ankle Society [AOFAS] score and foot function index [FFI]) outcome data. Results: Twenty-four patients underwent revision TAA with intramedullary-referencing with 87.5% implant survival at average follow up of 30.4 months. Revision was performed most commonly for aseptic talar subsidence (45.8%) or implant loosening (tibia, 12.5%; talus, 16.7%). Following revision, three (12.5%) patients required reoperation for talar subsidence or loosening at average 37.7 months. Progression of osteolysis of the tibia, talus, and fibula was observed in 14 (58%), 4 (17%), and 6 (25%) of patients, respectively, although osteolysis was present preoperatively in 17 (70.1%), 9 (37.5%), and 10 (41.7%), respectively. Subsidence of the tibial and talar components was observed in 8 (33%) and 9 (38%) patients, respectively. Clinically, the average AOFAS and FFI score were 72 (57-100) and 27.1 (11.8-82.9), respectively. Conclusion: Early results of intramedullary-referencing revision TAA demonstrated improved patient-reported outcomes and maintenance of radiographic outcomes at an average follow-up of 30 months. Additionally, early results of revision arthroplasty after failed TAA were similar to those after primary arthroplasty. Aseptic talar subsidence or loosening were the main postoperative complications which required reoperation. Revision arthroplasty utilizing an intramedullary-referencing implant is a viable option for the failed TAA.

Heterotopic ossification after total ankle arthroplasty (TAA) is a known sequela and has been reported to contribute to reduced range of motion and poor functional outcomes. However, conflicting results have been reported in the literature. The present study documents the incidence of heterotopic ossification for a novel fourth-generation fixed-bearing 2-component prosthesis and reports a systematic review of the literature. We reviewed the incidence and functional outcome of consecutively enrolled patients who underwent primary Infinity TAA between 2013 and 2015 in a prospective observational study. Preoperative and postoperative radiographic and functional outcome data were collected. A systematic review was also conducted investigating all published studies between 1998 and 2018 reporting the incidence of heterotopic ossification after TAA. The incidence of heterotopic ossification was 70.5% in the 61 patients who underwent primary TAA in the case series. There was no association between heterotopic ossification and American Orthopaedic Foot and Ankle Society (AOFAS) score, foot function index (FFI), visual analogue scale (VAS), and ankle osteoarthritis scale (AOS). Sixteen studies on 1339 TAA implants were included. The overall incidence of heterotopic ossification after TAA was 66.0% at average 3.6 years (range 22.2% to 100%). Four studies (299 ankles) did not address functional outcomes. Eleven studies (960 ankles) reported no association between heterotopic ossification and functional outcomes. One study (80 ankles) reported a statistically significant difference in range of motion (7°) and AOFAS score (7 points). In conclusion, although the incidence of heterotopic ossification after TAA is considerable, there is insufficient literature to suggest that heterotopic ossification after TAA impacts range of motion or functional outcome.

RECOMMENDATION:Transfer of synovial aspirate in blood culture bottles, obtaining deep biopsy of tissues and bone, obtaining multiple samples, increasing incubation period of cultures, and the use of molecular techniques for culture negative cases are some of the strategies that can help improve the ability to isolate the causative organism(s) in infections of foot and ankle.LEVEL OF EVIDENCE:Moderate.DELEGATE VOTE:Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

RECOMMENDATION:Two-stage exchange arthroplasty is recommended in the majority of cases following infected TAA. One-stage arthroplasty is only indicated in a limited patient population with acute infection, preoperatively identified low-virulence organisms, and low-risk patient factors.LEVEL OF EVIDENCE:Consensus.DELEGATE VOTE:Agree: 92%, Disagree: 8%, Abstain: 0% (Super Majority, Strong Consensus).

RECOMMENDATION:There is no universal algorithm for addressing the infected ankle or subtalar arthrodesis. A potential algorithm created by consensus is.LEVEL OF EVIDENCE:Consensus.DELEGATE VOTE:Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Aims. This study presents the first report of clinical and radiographic outcomes of the Infinity Total Ankle System (Wright Medical, Memphis, TN) with minimum 2-year follow-up. Patients and Methods. The first 67 consecutive patients who underwent primary total ankle arthroplasty (TAA) with the Infinity system at 2 North American sites between August 2013 and May 2015 were reviewed in a prospective, observational study. Demographic, radiographic, and functional outcome data were collected preoperatively, at 6 to 12 months postoperatively, and annually thereafter. Results. The overall implant survival rate was 97% (65 of 67 implants) at a mean follow-up of 35.4 months (27 to 47 months). Two cases underwent talar component revision for aseptic loosening. Six of the 67 cases (9%) required a nonrevision reoperation. Mean Foot Function Index and Ankle Osteoarthritis Scale scores at latest follow-up improved from preoperative by 21.6 ( P < .0001) and 34.0 ( P < .0001), respectively. No radiographic loosening of any talar or tibial components was identified in the 65 nonrevised cases. Conclusion. Early clinical and radiographic outcomes with the Infinity TAA are promising and compare favorably to those reported for both fixed- and mobile-bearing third-generation TAA designs, even when used in cases with deformity and increased case complexity. Levels of Evidence: Level IV

Background Perioperative myocardial infarctions and cardiac complications are leading causes of mortality after noncardiac surgery. In an effort to improve patient safety, the Surgical Care Improvement Project (SCIP) implemented guidelines concerning administration of β-blockers therapy aimed to reduce cardiac complications. Methods The Nationwide Inpatient Sample was queried for 759,819 elective total knee arthroplasties performed from 2003 to 2011. Incidence of cardiac complications, mortality, and risk factors for cardiac complications was determined before and after SCIP implementation. Results The incidence of cardiac events after total knee arthroplasty remained stable at 9%. The incidence and mortality of postoperative stroke, myocardial infarction, and cardiac arrest significantly decreased. Mortality after cardiac complications decreased by 50%. Conclusion After the implementation of SCIP guidelines, there was a greater than 50% reduction in mortality and a significant decrease in fatal postoperative stroke, heart failure, and cardiac arrest.

Category: Ankle, Ankle Arthritis, Basic Sciences/Biologics Introduction/Purpose: Despite improvements in newer-generation total ankle arthroplasty (TAA) implants, relatively high wound-healing complication rates continue to be reported with the anterior ankle incision. Only 66% heal without wound-healing complications, 25% have minor complications requiring local care and/or oral antibiotics, and 9% experience major complications requiring reoperation (Raikin et al., 2010). Recently, multiple regenerative adjuncts have been investigated to reduce postoperative complications by enhancing local healing factors and reducing risk of infection. The relatively novel use of adjunctive therapy utilizing cryopreserved amniotic membrane modulate wound healing by down-regulating inflammation and scar formation (Hanselman et al., 2015). The purpose of our study is to determine whether the local application of cryopreserved amniotic membrane wound allograft may enhance soft tissue wound healing of the TAA anterior ankle incision. Methods: Patients with symptomatic ankle arthritis who failed conservative management underwent TAA by two senior foot and ankle surgeons at single tertiary hospital. Both senior surgeons were present and involved in all surgeries, and all patients underwent the same procedure as indicated by their pathology, postoperative regimen, and rehabilitation protocol. At skin closure, patients were either allocated to the treatment or control group strictly by the designated primary attending. The skin closure of the treatment group was performed in standard fashion with local application of cryopreserved amniotic membrane to the extensor retinacular layer and no allograft was used for the control group. Demographics, sagittal and coronal correction, and patient comorbidity information was collected. The primary outcome was time to skin healing as determined by suture removal and surgical site skin apposition without evidence of granulation tissue or eschar. Secondary outcomes were skin dehiscence, local wound care, and use of antibiotics. Results: Local application of amniotic membrane allograft significantly decreased overall time to skin healing (40 days to 28.5 days, p=0.0377). There were no reoperations for wound complications in either group. However, there was a trend in decreased dehiscence (13% to 6%, p=0.29) and antibiotic prescription (23% to 9%, p=0.09). There was no significant difference in treatment versus control group with respect to body mass index, sagittal or coronal correction, sex, history of smoking, prior arthrodesis, or primary or revision. There was a significantly higher percentage of patients with history of diabetes who received amniotic membrane than those who did not receive the adjunct therapy (20% versus 2%, p=0.01). Conclusion: Regenerative technology using local application of cryopreserved amniotic membrane allograft may enhance TAA outcomes by decreasing time to healing. Although there was a trend in decreased dehiscence and antibiotic usage, larger randomized controlled trials are necessary to determine whether local application of cryopreserved amniotic membrane allograft may enhance soft tissue wound healing and ultimately reduce the incidence of devastating soft tissue complications.