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<jats:sec><jats:title>Background:</jats:title><jats:p> Total ankle arthroplasty (TAA) is advocated over ankle arthrodesis to preserve ankle motion (ROM). Clinical and gait analysis studies have shown significant improvement after TAA. The role and outcomes of TAA in stiff ankles, which have little motion to be preserved, has been the subject of limited investigation. This investigation evaluated the mid- to long-term functional outcomes of TAA in stiff ankles. </jats:p></jats:sec><jats:sec><jats:title>Methods:</jats:title><jats:p> A retrospective study of prospectively collected functional gait data in 33 TAA patients at a mean of 7.6 (5-13) years postoperatively used 1-way analysis of variance and multivariate regression analysis to compare among preoperative and postoperative demographic data (age, gender, body mass index, years postsurgery, and diagnosis) and gait parameters according to quartiles of preoperative sagittal ROM. </jats:p></jats:sec><jats:sec><jats:title>Results:</jats:title><jats:p> The stiffest ankles had a mean ROM of 7.8 degrees, compared to 14.3 degrees for the middle 2 quartiles, and 21.0 degrees for the most flexible ankles. Patients in the lowest quartile (Q1) also had statistically significantly lower step length, speed, max plantarflexion, and power preoperatively. Postoperatively, they increased step length, speed, max plantarflexion, and ankle power to levels comparable to patients with more flexible ankles preoperatively (Q2, Q3, and Q4). They had the greatest absolute and relative increases in these parameters of any group, but the final total ROM was still statistically significantly the lowest. </jats:p></jats:sec><jats:sec><jats:title>Conclusion:</jats:title><jats:p> Preoperative ROM was predictive of overall postoperative gait function at an average of 7.6 (range 5-13) years. Although greater preoperative sagittal ROM predicted greater postoperative ROM, the stiffest ankles showed the greatest percentage increase in ROM. Patients with the stiffest ankles had the greatest absolute and relative improvements in objective function after TAA, as measured by multiple gait parameters. At intermediate- to long-term follow-up, patients with stiff ankles maintained significant functional improvements after TAA. </jats:p></jats:sec><jats:sec><jats:title>Level of Evidence:</jats:title><jats:p> Level III, comparative study. </jats:p></jats:sec>

<jats:sec><jats:title>Background:</jats:title><jats:p> Distal metatarsal osteotomy has been used to alleviate plantar pressure caused by anatomic deformities. This study’s purpose was to examine the effect of minimally invasive floating metatarsal osteotomy on plantar pressure in patients with diabetic metatarsal head ulcers. </jats:p></jats:sec><jats:sec><jats:title>Methods:</jats:title><jats:p> We performed a retrospective case series of prospectively collected data on 32 patients with diabetes complicated by plantar metatarsal head ulcers without ischemia. Peak plantar pressure and pressure time integrals were examined using the Tekscan MatScan prior to surgery and 6 months following minimally invasive floating metatarsal osteotomy. Patients were followed for complications for at least 1 year. </jats:p></jats:sec><jats:sec><jats:title>Results:</jats:title><jats:p> Peak plantar pressure at the level of the osteotomized metatarsal head decreased from 338.1 to 225.4 kPa ( P &lt; .0001). The pressure time integral decreased from 82.4 to 65.0 kPa·s ( P &lt; .0001). All ulcers healed within a mean of 3.7 ± 4.2 weeks. There was 1 recurrence (under a hypertrophic callus of the osteotomy) during a median follow-up of 18.3 months (range, 12.2-27). Following surgery, adjacent sites showed increased plantar pressure and 4 patients developed transfer lesions (under an adjacent metatarsal head); all were managed successfully. There was 1 serious adverse event related to surgery (operative site infection) that resolved with antibiotics. </jats:p></jats:sec><jats:sec><jats:title>Conclusion:</jats:title><jats:p> This study showed that the minimally invasive floating metatarsal osteotomy successfully reduced local plantar pressure and that the method was safe and effective, both in treatment and prevention of recurrence. </jats:p></jats:sec><jats:sec><jats:title>Level of Evidence:</jats:title><jats:p> Level III, retrospective case series of prospectively collected data. </jats:p></jats:sec>

<jats:sec><jats:title>Background:</jats:title><jats:p> Achilles sleeve avulsion, a relatively rare disorder, is characterized by sleeve-shaped injury extending from the calcaneus, located near the tendon insertion site. Unlike midsubstance tears of the Achilles tendon, end-to-end repair is difficult because less soft tissue is preserved distally. Open repair with transosseous sutures or suture anchors is currently favored. The purpose of this study was to evaluate the technical feasibility and functional outcomes of ultrasonography-guided Achilles sleeve avulsion repair. </jats:p></jats:sec><jats:sec><jats:title>Methods:</jats:title><jats:p> From November 2009 to April 2018, 21 patients with Achilles sleeve avulsions (mean age, 57.8 years; range, 25-82 years) who underwent repair by the same surgeon were retrospectively reviewed. The repair was achieved through a stab wound under ultrasonographic guidance. Two parallel Bunnell-type sutures were crossed over the proximal stump and tied with sutures from suture anchors fixed in the calcaneal tuberosity. </jats:p></jats:sec><jats:sec><jats:title>Results:</jats:title><jats:p> The mean operative time was 44 minutes, and the mean wound size was 1.5 cm. The patients were allowed to walk freely on postoperative week 6 with using high-ankle shoes. At postoperative 2 years’ follow-up, the American Orthopaedic Foot &amp; Ankle Society score significantly improved from 70.9 to 97.1 ( P &lt; .05); similarly, their 12-item Short Form Health Survey scores improved significantly ( P &lt; .05). Only 2 patients had superficial wound infections, which resolved with wound care and oral antibiotics. </jats:p></jats:sec><jats:sec><jats:title>Conclusion:</jats:title><jats:p> Our ultrasonography-guided surgical technique for Achilles sleeve avulsions provided excellent soft tissue visualization and availability as well as minimized the wound length to achieve good postsurgical outcomes. </jats:p></jats:sec><jats:sec><jats:title>Level of Evidence:</jats:title><jats:p> Level IV, retrospective case series. </jats:p></jats:sec>

<jats:sec><jats:title>Background:</jats:title><jats:p> The modified Broström (MB) procedure has long been the mainstay for the treatment of chronic lateral ankle instability (CLAI). Recently, suture tape (ST) has emerged as augmentation for this repair. The clinical benefit of such augmentation has yet to be fully established. The purpose of this study was to determine if ST augmentation provides an advantage over the traditional MB. </jats:p></jats:sec><jats:sec><jats:title>Methods:</jats:title><jats:p> Adult patients were identified for inclusion in the study based on indications for primary lateral ligament reconstruction for CLAI. The primary outcome measure was time to return to preinjury level of activity (RTPAL). Secondary outcome measures included complications, ability to participate in an accelerated rehabilitation protocol (ARP), patient-reported outcomes (PROs), and visual analog pain scale (VAS). A total of 119 patients with CLAI were enrolled and randomized to the MB (59 patients) or ST (60 patients) treatment arm. </jats:p></jats:sec><jats:sec><jats:title>Results:</jats:title><jats:p> Average RTPAL was 17.5 weeks after MB and 13.3 weeks after ST ( P &lt; .001). At 26 weeks, 12.5% of patients in the MB group and 3.6% of patients in the ST group had not managed RTPAL ( P = .14). The complication rate was 8.5% in the MB group vs 1.7% in the ST group ( P = .12). Four patients in the MB group failed to complete the ARP vs 1 in the ST group ( P = .144). </jats:p></jats:sec><jats:sec><jats:title>Conclusion:</jats:title><jats:p> Results from this multicenter, prospective, randomized trial suggest that ST augmentation allows for earlier RTPAL than MB alone. ST augmentation may support successful accelerated rehabilitation and did not result in increased complications or morbidity. </jats:p></jats:sec><jats:sec><jats:title>Level of Evidence:</jats:title><jats:p> Level II, prospective comparative study. </jats:p></jats:sec>

<jats:sec><jats:title>Background:</jats:title><jats:p> We aimed to report surgical outcomes and analyze prognostic factors of medial toe excision for polysyndactyly of the fifth toe. </jats:p></jats:sec><jats:sec><jats:title>Methods:</jats:title><jats:p> We reviewed the details of 139 consecutive patients who underwent surgery for postaxial polydactyly of the foot from 2009 to 2018. Among these, 83 patients (90 feet) with polysyndactyly of the fifth toe, treated by medial toe excision (between the duplicated toes) and reconstruction of the fourth web space using a dorsal rectangular flap, were included. The toe alignment and stability were restored by chondroplasty and soft tissue balancing without an osteotomy. A full-thickness skin graft was performed in 52 feet. The mean age at surgery was 27.1 ± 17.5 months and the mean duration of follow-up was 42.8 ± 24.9 months. </jats:p></jats:sec><jats:sec><jats:title>Results:</jats:title><jats:p> At the last follow-up, a relatively small size of the reconstructed toe was observed in 19 feet (19/90, 21.1%). Proximal duplication level (metatarsal or proximal phalanx type) and preoperative hypoplasia of the remaining toe were related to the small postoperative size. Valgus deformity of the remaining toe was observed in 2 feet (2/90, 2.2%). We observed 17 cases with delayed healing or early postoperative wound infection. Among these, 7 cases (7/90, 7.8%) showed postoperative thickening or advancement of the web, which was not observed in cases without wound problems. No cases had functional disturbance or pain. </jats:p></jats:sec><jats:sec><jats:title>Conclusion:</jats:title><jats:p> The overall surgical outcomes were satisfactory without an osteotomy. Patients with a proximal duplication level or preoperative hypoplasia of the remaining toe should be informed of its possible small size postoperatively. </jats:p></jats:sec><jats:sec><jats:title>Levels of Evidence:</jats:title><jats:p> Level IV, retrospective case series. </jats:p></jats:sec>

<jats:sec><jats:title>Background:</jats:title><jats:p> Popliteal nerve blocks reduce pain and markedly improve postoperative outcomes during foot and ankle surgery; however, several potential complications may arise from nerve block procedures. The purpose of this study was to investigate local infiltration analgesia with ketorolac as a convenient alternative for pain relief. </jats:p></jats:sec><jats:sec><jats:title>Methods:</jats:title><jats:p> A total of 80 patients scheduled for hindfoot arthrodesis were randomly allocated to one of 2 anesthetic groups: a spinal block augmented with either a popliteal nerve block (n = 40) or local ketorolac and Marcaine infiltration (n = 40). Clinical assessment included postoperative visual analog scale (VAS) pain scores at 4, 8, 12, 24, and 48 hours, total morphine consumption, time to incision (time in operating room to incision), operative time, length of hospital stay, and complications. </jats:p></jats:sec><jats:sec><jats:title>Results:</jats:title><jats:p> Despite similar morphine consumption between groups ( P = .28), VAS scores were significantly lower at 24 hours (1.6 ± 2.2 cm vs 2.7 ± 3.0 cm, P = .01) and 48 hours (0.2 ± 0.7 cm vs 1.0 ± 1.5 cm, P &lt; .01) after surgery using local ketorolac injection. Although time from entry into the operating room to incision was also reduced after local ketorolac injection (19.0 ± 5.3 minutes vs 31.4 ± 14.6 minutes, P &lt; .001), the length of operative time ( P = .38), hospital stay ( P = .43), and number of complications ( P = .24) were similar between groups. </jats:p></jats:sec><jats:sec><jats:title>Conclusion:</jats:title><jats:p> Ketorolac local injection provided effective pain control in hindfoot arthrodesis and markedly reduced VAS pain scores up to 48 hours after surgery compared with popliteal nerve block. In addition, ketorolac local injection also reduced time in the operating room compared with popliteal nerve blockade. </jats:p></jats:sec><jats:sec><jats:title>Level of Evidence:</jats:title><jats:p> Level 1, randomized controlled trial. </jats:p></jats:sec>

<jats:sec><jats:title>Background:</jats:title><jats:p> Modern total ankle arthroplasty (TAA) prostheses are uncemented press-fit designs whose stability is dependent on bone ingrowth. Preoperative insufficient bone density reduces initial local stability at the bone-implant interface, and we hypothesized that this may play a role in periprosthetic osteolysis. We aimed to investigate the preoperative bone density of the distal tibia and talus and compare these in patients with and without osteolysis. </jats:p></jats:sec><jats:sec><jats:title>Methods:</jats:title><jats:p> We enrolled 209 patients (218 ankles) who underwent primary TAA using the HINTEGRA prosthesis. The overall mean follow-up duration was 66 (range, 24-161) months. The patients were allocated into 2 groups according to the presence of periprosthetic osteolysis: the osteolysis group (64 patients, 65 ankles) and nonosteolysis group (145 patients, 153 ankles). Between the 2 groups, we investigated and compared the radiographic outcomes, including the Hounsfield unit (HU) value around the ankle joint and the coronal plane alignment. </jats:p></jats:sec><jats:sec><jats:title>Results:</jats:title><jats:p> HU values of the tibia and talus measured at 5 mm from the reference points were higher than those at 10 mm in each group. However, comparing the osteolysis and nonosteolysis groups, we found no significant intergroup difference in HU value at every measured level in the tibia and talus ( P &gt; .05). Concerning the coronal plane alignment, there were no significant between-group differences in the tibiotalar and talar tilt angles ( P &gt; .05). </jats:p></jats:sec><jats:sec><jats:title>Conclusion:</jats:title><jats:p> Patients with osteolysis showed similar preoperative bone density of the distal tibia and talus compared with patients without osteolysis. Our results suggest that low bone density around the ankle joint may not be associated with increased development of osteolysis. </jats:p></jats:sec><jats:sec><jats:title>Level of Evidence:</jats:title><jats:p> Level III, retrospective cohort study. </jats:p></jats:sec>

<jats:sec><jats:title>Background:</jats:title><jats:p> Nonunion rates in hind or midfoot arthrodesis have been reported as high as 41%. The most notable and readily modifiable risk factor that has been identified is smoking. In 2018, 14.4% of the UK population were active smokers. We examined the effect of smoking status on union rates for a large cohort of patients undergoing hind- or midfoot arthrodesis. </jats:p></jats:sec><jats:sec><jats:title>Methods:</jats:title><jats:p> In total, 381 consecutive primary joint arthrodeses were identified from a single surgeon’s logbook (analysis performed on a per joint basis, with a triple fusion reported as 3 separate joints). Patients were divided based on self-reported smoking status. Primary outcome was clinical union. Delayed union, infection, and the need for ultrasound bone stimulation were secondary outcomes. </jats:p></jats:sec><jats:sec><jats:title>Results:</jats:title><jats:p> Smoking prevalence was 14.0%, and 32.2% were ex-smokers. Groups were comparable for sex, diabetes, and body mass index. Smokers were younger and had fewer comorbidities. Nonunion rates were higher in smokers (relative risk, 5.81; 95% CI, 2.54-13.29; P &lt; .001) with no statistically significant difference between ex-smokers and nonsmokers. Smokers had higher rates of infection ( P = .05) and bone stimulator use ( P &lt; .001). Among smokers, there was a trend toward slower union with heavier smoking ( P = .004). </jats:p></jats:sec><jats:sec><jats:title>Conclusion:</jats:title><jats:p> This large retrospective cohort study confirmed previous evidence that smoking has a considerable negative effect on union in arthrodesis. The 5.81 relative risk in a modifiable risk factor is extremely high. Arthrodesis surgery should be undertaken with extreme caution in smokers. Our study shows that after cessation of smoking, the risk returns to normal, but we were unable to quantify the time frame. </jats:p></jats:sec><jats:sec><jats:title>Level of Evidence:</jats:title><jats:p> Level III, retrospective cohort study. </jats:p></jats:sec>

<jats:sec><jats:title>Background:</jats:title><jats:p> Total ankle arthroplasty (TAA) is known to be a reliable operative option for end-stage rheumatoid arthritis. However, higher risk of postoperative complications related to chronic inflammation and immunosuppressive treatment is still a concern. With the use of a newer prosthesis and modification of anti-rheumatic medications, we compared clinical outcomes after TAA between patients with osteoarthritis and rheumatoid arthritis. </jats:p></jats:sec><jats:sec><jats:title>Methods:</jats:title><jats:p> Forty-five patients with end-stage osteoarthritis (OA group) and 19 with rheumatoid arthritis (RA group) were followed for more than 3 years after 3 component mobile-bearing TAA (Zenith<jats:sup>TM</jats:sup>). Perioperative anti-rheumatic medications were modified using an established guideline used in total hip and knee arthroplasty. Clinical evaluations consisted of American Orthopaedic Foot &amp; Ankle Society (AOFAS) scores, Foot and Ankle Outcome Score (FAOS), and Foot and Ankle Ability Measure (FAAM). </jats:p></jats:sec><jats:sec><jats:title>Results:</jats:title><jats:p> In the preoperative and postoperative evaluation at final follow-up, there were no significant differences in AOFAS, FAOS, and FAAM scores between 2 groups. Despite statistical similarity in total scores, the OA group showed significantly better scores in FAOS sports and leisure (mean, 57.4 ± 10.1) and FAAM sports activity (mean, 62.5 ± 13.6) subscales than those in the RA group (mean, 52.2 ± 9.8, P = .004; and 56.4 ± 13.2, P &lt; .001, respectively). There were no significant differences in perioperative complication and revision rates between 2 groups. </jats:p></jats:sec><jats:sec><jats:title>Conclusion:</jats:title><jats:p> Patients with end-stage ankle RA had clinical outcomes comparable to the patients with OA, except for the ability related to sports activities. In addition, there were no significant differences in early postoperative complication rates, including wound problem and infection. </jats:p></jats:sec><jats:sec><jats:title>Level of Evidence:</jats:title><jats:p> Level III, prognostic, prospective comparative study. </jats:p></jats:sec>

<jats:sec><jats:title>Background:</jats:title><jats:p> Suture buttons have been used for isolated Lisfranc ligament (ILL) fixation. However, no study has reported on its clinical and radiologic outcomes. </jats:p></jats:sec><jats:sec><jats:title>Methods:</jats:title><jats:p> In this retrospective comparative study, patients with ILL injuries were divided into 2 groups according to the treatment method: 32 conventional screw group and 31 suture button group. The clinical and radiologic outcomes at preoperation, 6 months and 1 year postoperation, and last follow-up period were measured. Plantar foot pressure was measured at postoperative month 6 months. Postoperative complications at the last follow-up were evaluated. </jats:p></jats:sec><jats:sec><jats:title>Results:</jats:title><jats:p> The suture button group showed better American Orthopaedic Foot &amp; Ankle Society midfoot scale ( P &lt; .001) and visual analog scale ( P &lt; .001) scores compared with the conventional screw fixation group at the postoperative month 6 period before screw removal. However, no significant difference in clinical outcome between the 2 groups was found at postoperative year 1 or last follow-up. No differences in radiologic outcomes were found between the 2 groups. Plantar foot pressure was significantly elevated in the conventional screw group at the great toe and first metatarsal head area compared with the contralateral foot just before screw removal. Recurrent Lisfranc joint diastasis was found in a single case in the conventional screw group and 2 cases in the suture button group. </jats:p></jats:sec><jats:sec><jats:title>Conclusion:</jats:title><jats:p> Suture button fixation in the treatment of ILL injuries may provide comparable fixation stability and clinical outcome with conventional screw fixation in the early postoperative period. </jats:p></jats:sec><jats:sec><jats:title>Level of Evidence:</jats:title><jats:p> Level III, retrospective case-control study, therapeutic. </jats:p></jats:sec>