State of the Art: Foot and Ankle Surgery


Poster Num First name Last name Field Title of the abstract Co-author 1 Co-author 2 Co-author 3 Co-author 4 Co-author 5 Abstract
P001 Nicole Abdul Forefoot An investigation of the damage to flexor tendons incurred by different proximal phalangeal closing wedge osteotomy techniques in cadaveric feet Mr David Townshend Mr Rajesh Kakwani Background Minimally invasive surgery (MIS) for hammer toe correction has become increasingly popular in the United Kingdom. The proximal phalangeal closing wedge osteotomy component of hammer toe correction can be performed by passing the burr via a plantar incision through the flexor tendons (transtendinous) or passing the burr adjacent to the flexor tendons (paratendinous). Aim To investigate damage to the flexor tendons by transtendinous and paratendinous techniques in cadaveric feet. Method Institutional approval was granted. Alternating between right and left feet of 8 donors, MIS proximal phalangeal osteotomies were performed transtendinous (n=24) and paratendinous (n=24) using the 2nd, 3rd and 4th toes. Osteotomies were performed by 2 experienced surgeons using a 2mmx8mm wedge burr. Toes were then dissected by and independent observer to assess damage to the flexor tendons. Results Using the paratendinous technique, significantly more damage to the flexor tendons was noted compared to the transtendinous technique (47% vs 4%, p<0.05). The position of the osteotomy at or distal to the metaphyseal/diaphyseal junction was assessed. There was a significant difference in flexor tendon damage in the paratendinous group when the osteotomy was sited at the junction compared to more distally (67% versus 27%, p<0.05). There was no significant difference accordingly to site using the transtendinous technique (7% versus 1%, p>0.05). Conclusion The least damage to the flexor tendon in MIS proximal phalangeal osteotomy is achieved with a transtendinous technique regardless of osteotomy site. The most damage to the flexor tendon occurs with a paratendinous technique at the metaphyseal/diaphyseal junction.
P002 Mahmoud Abouzied Forefoot Outcome of modified oblique Keller capsular interposition arthroplasty for treatment of hallux rigidus El morsy Mohammed ashour El karamany Mamdouh Risk Ahmed Shawkt Background: The controversy about the treatment of hallux rigidus exist in the high grades of the disease. Arthrodesis of the first MTP joint which is the main stay treatment of advanced hallux rigidus has its own problems and limitations. Aim: The purpose of the study was to assess the results of modified Keller capsular interposition arthroplasty in management of hallux rigidus. Patients and methods: Between December 2014 and June 2016, a prospective study was conducted involving twenty patients who underwent modified oblique Keller capsular interpositional arthroplasty for hallux rigidus. Inclusion criteria of the study included patients with hallux rigidus grade 3 and 4 according to Coughlin and Shurans classification, after failure of conservative treatment for at least 6 weeks. Exclusion criteria included Patients with systemic inflammatory diseases, patients with trophic ulcer or impaired sensation, previous surgery or fractures in the hallux, together with patients who refused to join the study Results: The average follow-up period was 22.16 months (range, 12 to 36). At final follow-up, average postoperative VAS for pain improved significantly from 5.65±1.09 to 1.5±1.1 (p<0.00001). The average postoperative active dorsiflexion range improved significantly from 10.85±3.25 to 22.85±4.96 (P<0.001). The average postoperative AOFAS score improved from 57.85±9.24 points preoperatively to 89.2±4.8 (P<0.001). Conclusion: The simple and cheap technique used in the current case series, presented modified oblique Keller interposition arthroplasty as a treatment modality for advanced hallux rigidus with overall favorable outcome results and low complications.
P003 Paweł Adamczyk Reconstructive Interposition arthroplasty using collagen matrix in hallux rigidus- a case series Grzegorz Adamczyk Mateusz Dawidziuk Maciej Miszczak Background : End stage arthrosis of first metatarsophalangeal joint (MTP I) can be treated operatively by cheilectomy, resection arthroplasty, metatarsal or phalangeal osteotomy, arthrodesis, implant (silastic, partial or total joint replacement) arthroplasty or interposition arthroplasty. The aim of the study was to investigate mid-term outcome of interposition arthroplasty using collagen matrix. Methods: 9 feet were operated in 8 patients (mean age 54,6 years ; 4 left and 5 right) using Chondrogide Collagen Matrix (Geistlich), mean follow up was 26 months. Patients’ satisfaction and functional outcomes were measured using American Orthopedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale (AOFAS MTP I- IPJ), Visual Analog Scale for Pain (VAS), weightbearing x-rays in AP and lateral view, MTP I ROM measurements and all answered the question if they had today’s knowledge they would have decided to have surgery once again. Results: Mean AOFAS MTP I-IPJ Scale result was 80,9 (SD 10,5), VAS 12,1% (SD 13,0), all Patients answered that having today’s knowledge they would have decided to go to surgery again. None of operated MTP I joints needed and underwent another surgery and non was lost in the follow-up. Conclusions: Interposition arthroplasty of MTP I is effective procedure in treating hallux rigidus. Patients are satisfied and it allows to keep a range of motion in MTP I and possibility of carrying out revision procedures like fusion or implant arthroplasty if needed in future.
P004 Yui Akiyama Ankle Hiflex Foot Gear improves Quality of life in patients with osteoarthritis of the ankle Takaaki Hirano Hiroyuki Mitsui Hisateru Niki Purpose Hiflex Foot Gear (HFG) is a custom-made polyethylene ankle–foot orthosis developed to permit slight mobility of the ankle while providing adequate ankle support. The purpose of this study was to validate the hypothesis that HFG improves the quality of life in patients with ankle osteoarthritis. Subjects and methods Ten ankles from eight patients diagnosed with ankle osteoarthritis , prescribed an HFG, and observed for follow-up for at least 3 months were included in this study. The patients’ mean age was 69.9 years. Clinical evaluations were made before and 3 months after wearing the orthosis. JSSF scale and SAFE-Q were used for making evaluations (a paired t-test). Results JSSF scores improved from 55.1 points at baseline to 71.4 points after wearing the HFG (p < 0.001). In SAFE-Q, Pain, physical function and daily life, social functions and general health and well- being improved and shoe- related remained unchanged. Discussion Our results revealed that wearing the HFG improved pain in patients with severe ankle osteoarthritis. Retained flexibility in the ankle range of motion was believed to be the factor underlying improvements in physical function and daily life, social functions, and general health and well- being. HFG is a potential option for conservative therapy in patients who cannot obtain sufficient pain control during the preoperative waiting period or in those who do not wish to undergo surgery.
P005 Jirun Apinun Ankle Exposure of talar dome in different force directions of noninvasive ankle distraction Chotetawan Tanavalee Ian Winson William Harries Steve Hepple Background Non-invasive ankle distraction is beneficial in exposing the ankle joint during anterior arthroscopy. The described methods of distractor application during surgery in the literature are varied. Aim To determine the relationship between the direction of distraction force and talar dome exposure. Method Non-invasive ankle distraction was performed on 32 ankles in different direction of distraction force (upward 30, parallel, downward 30, and downward 60 angled to the leg) Radiographic images were obtained. Anterior tibiotalar space (ATTS), posterior tibiotalar space (PTTS), talar exposure angle (TEA), and tibiotalar angle (TTA) were measured. Statistical analyses were performed. Result With more downward direction of the distraction force, there were an increase in ATTS (from 3.18 to 4.72 mm, P < 0.05 in every paired group), a decrease in PTTS (from 3.20 to 1.79 mm, P < 0.05 in every paired group), an increase in TEA (from 54.18-64.43, P < 0.05 in every paired group except between 30 upward group compared with parallel group and 30 downward group compared with 60 downward group), and an increase in TTA (from 135.12 to 146.98, P < 0.05 in every paired group except between 30 upward group compared with parallel group). Conclusion Degree of the talar dome exposure is related to the direction of distraction force applied during the ankle arthroscopic surgery. More downward direction of distraction force is required for more central talar lesion. However, lesion located posterior than 60 TEA may not be possible to access through anterior arthroscopy even with ankle distraction applied.
P006 Alessio Bernasconi Hindfoot The role of arthroereisis of the subtalar joint for flatfoot in children and adults: a review of the literature Francois Lintz Nazim Mehdi Francesco Sadile BACKGROUND: Subtalar arthroereisis has been reported as a minimally invasive, effective and low-risk procedure in the treatment of flatfoot mainly in children but also in adults. AIM: We performed a critical review of the scientific literature in order to define the role of arthroereisis in the treatment of flatfoot based on recent evidence. METHOD: Searching on PubMed, Scopus and EMBASE, we retrieved all relevant articles dealing with the subtalar arthroereisis in both adults and children. We focused on the current state of understanding about this topic and tried to quantify the evidence available. „„RESULTS: Subtalar arthroereisis has been described as a standalone or adjunctive procedure.„ Different devices for subtalar arthroereisis are currently used throughout the world associated with soft-tissue and bone procedures, depending on the surgeon rather than on standardised or validated protocols.„ Sinus tarsi pain is the most frequent complication, often requiring removal of the implant. „„CONCLUSION: To date, poor-quality evidence is available in the literature (Level IV and V), with only one comparative non-randomised study (Level II) not providing strong recommendations. Long-term outcome and complication rates (especially the onset of osteoarthritis) are still unclear.
P007 Tomasz Bienek Forefoot Basal open osteotomy of first metatarsal ( open- wedge I MTO) as a compliment to hallux metatarso- phalangeal ( I MTP) arthrodesis in severe hallux valgus deformity. Wojciech Klon Background: I MTP arthrodesis is performed, among others, in severe hallux valgus deformity treatment. However, in some cases, correction of adductus I metatarsal with isolated arthrodesis can be insufficient. Aim: The aim is evaluation of effectiveness of open- wedge I MTO as a compliment to MTP I arthrodesis in severe hallux valgus deformity treatment. Method 42 patients ( 38 females, 4 males), aged mean 64 y.,operated due to hallux valgus deformity between 01.01.2015-31.12.2016 at Orthopedics Ward of Oswiecim hospital. Exlusion criteria: revision surgery. 19 patients had performed isolated MTP I arthrodesis ( group A) and 23 – combined MTP I arthrodesis and open- wedge I MTO ( group B). Clinical evaluation included AOFAS scale ( prior and 6 months after surgery). Radiological evaluation contains HVA and IMA ( prior and 6 months after surgery), and additionally metatarsal adductus angle ( MAA – Engel) on preoperative X- ray. Results Non- union was found in two patients ( 1 – group A and 1- group B). Patients in both groups showed improvement in AOFAS scale and on X ray results ( in both groups – not statistically significant). Patients with incresased MAA often have additional open- wedge I MTO performed, ( statistically significant p<0,05), but have still bigger HVA postoperatively ( statistically significant p<0,05) Conclusion Open- wedge I MTO may be a compliment of I MTP arthrodesis, when isolated arthrodesis is not sufficient for I MT adductus correction. Its regards especially patients with increased initial MAA.
P008 Carlo Biz Basic Science The fasciacytes: A new cell devoted to fascial gliding regulation. Carla Stecco Caterina Fede Ilaria Fantoni Raffaele De caro Pietro Ruggieri Background: Hyaluronan occurs between deep fascia and muscle, facilitating gliding between these two structures, and also within the loose connective tissue of the fascia, guaranteeing the smooth sliding of adjacent fibrous fascial layers. It also promotes the functions of the deep fascia. Aim: in this study a new class of cells in fasciae is identified, which we have termed fasciacytes, devoted to producing the hyaluronan‐rich extracellular matrix. Methods: Synthesis of the hyaluronan‐rich matrix by these new cells was demonstrated by Alcian Blue staining, anti‐HABP (hyaluronic acid binding protein) immunohistochemistry, and transmission electron microscopy. Strong expression of HAS2 (hyaluronan synthase 2) mRNA by these cells was detected and quantified using real time RT‐PCR. Results: This new cell type has some features similar to fibroblasts: they are positive for the fibroblast marker vimentin and negative for CD68, a marker for the monocyte‐macrophage lineage. However, they have morphological features distinct from classical fibroblasts and they express the marker for chondroid metaplasia, S‐100A4. Conclusion: The authors suggest that these cells represent a new cell type devoted to the production of hyaluronan. Since hyaluronan is essential for fascial gliding, regulation of these cells could affect the functions of fasciae so they could be implicated in myofascial pain. This article is protected by copyright. All rights reserved.
P009 Carlo Biz Forefoot Functional and radiographic outcomes of hallux valgus correction by mini-invasive surgery with Reverdin-Isham and Akin percutaneous osteotomies: a longitudinal prospective study with a 48-month follow-up. Michele Fosser Miki Dalmau Pastor Marco Corradin Filippo Zonta Pietro Ruggieri Background: Minimally invasive surgery (MIS) represents one of the most innovative surgical treatments of Hallux Valgus (HV). However, long-term outcomes remain a matter of discussion. Aim: The purpose of this longitudinal prospective study was to evaluate radiographic and functional outcomes in patients with mild-to-severe HV who underwent Reverdin-Isham and Akin percutaneous osteotomy. Methods: Eighty patients with mild-to-severe symptomatic HV were treated by MIS. Clinical evaluation was assessed pre-operatively, as well as at 3 and 12 months after surgery and at final follow-up of 48 months, using the AOFAS Hallux grading system. Computer-assisted measurement of antero-posterior radiographs was taken pre-operatively, as well as at 3 and 12 months after surgery and at 48-month follow-up, analysing: IMA, HVA, DMAA and the tibial sesamoid position. Patient satisfaction was assessed using the Visual Analogue Score (VAS). Statistical analysis was carried out using the paired t-test (p < 0.05). Results: The mean AOFAS score was 87.15 points at the final follow-up of 48 months, and the VAS score was 8.35/10. The postoperative radiographic assessments showed a statistically significant improvement. The mean corrections of each angular value at the last follow-up were as follows: IMA 3.90°; HVA 12.50°; DMAA 4.72°; and a tibial sesamoid position of 1.10. The articular surface was congruent in 77 (96.25%) cases and incongruent only in 3. Complete healing of the osteotomies was achieved in all series at 3-month follow-up. Conclusion: Minimally invasive surgery with Reverdin-Isham and Akin percutaneous osteotomy is a safe, effective and reliable procedure for correction of mild-to-moderate HV.
P010 Carlo Biz Trauma Early Radiographic and Clinical Outcomes of Minimally Displaced Proximal Fifth Metatarsal Fractures: Cast Vs Functional Bandage Giacomo de Guttry Miki Dalmau Pastor Marco Zamperetti Alberto Gasparella Pietro Ruggieri Background and Aim: The purpose of this non-randomized retrospective study was to investigate outcomes of minimally displaced, proximal 5MTB fractures, treated by a below-knee walking cast or a functional elasticated bandage with a support of a flat hard-soled shoe. Method: a consecutive patient series was divided into two groups: the cast group (CG) and the functional group (FG). The subjects were radiologically and clinically evaluated according to Mehlhorn and Lawrence-Botte classification, and AOFAS Midfoot score, respectively. Results: 154 patients were followed up for a median of 15 months (range 12-24). There was no significant difference (p > 0.05) among the outcomes of each fracture pattern regarding the treatment choice. However, an earlier return to sports was noted in the FG, while Type-3 fractures achieved the worst results. Conclusion: Type-1 and 2 minimally displaced 5MTB proximal fractures can be successfully treated conservatively without weight-bearing restriction and without benefit of a cast with respect to a functional elasticated bandage.
P011 Carlo Biz Infection Minimally Invasive Distal Metatarsal Diaphyseal Osteotomy (DMDO) for the Treatment of Chronic Plantar Diabetic Foot Ulcers: A Prospective Cohort Study. Stefano Gastaldo Miki Dalmau Pastor Marco Corradin Andrea Volpin Pietro Ruggieri Background and Aims: The aims of this prospective study were first to evaluate the safety and effectiveness of minimally invasive Distal Metatarsal Diaphyseal Osteotomies (DMDO) for treating a consecutive series of diabetic patients with chronic plantar diabetic foot ulcers (CPDFUs), and second to assess their clinical-functional and radiographic outcomes. Method: A consecutive series of patients affected by diabetes mellitus with CPDFUs, not responsive to previous non-operative management, underwent DMDO. The CPDFUs were evaluated using the University of Texas Diabetic Wound Classification System. Demographic parameters of patients, AOFAS scores, VAS scores, healing times, and complications were recorded. Maestro’s criteria and bone callus formation were analyzed radiologically. Statistical analysis was carried out (p < 0.05). Results: Thirty consecutive enrolled patients with a mean age of 66.7 (range 53-75) years, presented 35 CPDFUs with a mean diameter of 16.3 mm and a mean duration of 10.3 months. The most frequent grade of the UTDWC was IIIB (42.9%). All ulcers recovered at a mean healing time of 7.9 ± 4.0 (range 4-17) weeks. AOFAS scores improved significantly from 55.3 to 81.4 points (p < 0.001). At a mean follow-up of 25.3 months (18-71), no cases of ulcer recurrence were recorded, while a major complication, a wound infection, required longer healing time. Conclusion: Minimally invasive DMDO is a safe and effective method in promoting CPDFU healing, regardless of the grade of severity, by the reduction of the high plantar pressure under the metatarsal heads; secondly, this technique improves functional and radiographic outcomes with few complications.
P012 Carlo Biz Trauma Long-term radiographic and clinical-functional outcomes of isolated, displaced, closed talar neck and body fractures treated by ORIF: the timing of surgical management. Nicolò Golin Michele De Cicco Nicola Maschio Ilaria Fantoni Pietro Ruggieri Background and Aim: the main purpose of this retrospective case series study was to evaluate long-term radiographic and clinical outcomes of a series of patients with diagnosis of isolated, displaced, closed talar neck or body fractures treated by ORIF. Secondly, it was aimed to verify the influence of the location of talar fractures on the outcomes, the prognostic value of the Hawkins sign, whether operative delays promote avascular necrosis (AVN) and if the fractures require emergent surgical management. Methods: 31 patients underwent ORIF at our institution. The injuries were divided between neck and body fractures, which were classified according to Hawkins and Sneppen. Radiographic assessment focused on reduction quality, bone healing, Hawkins sign and osteoarthritis development. Clinical-functional scores (AOFAS; MFS; FFI-17; SF-36) and VAS were determined, and statistical analysis was performed. Results: 27 patients were included with an average follow-up period of 83.2 months. There were 9 neck and 19 body fractures. Their reduction resulted anatomical in 22 cases, and all reached radiographic consolidation after a mean period of 3.4 months. The Hawkins sign was observed in 9 cases. With a 0-11 day surgical timing interval, more than 60% of the patients obtained good or fair results with different scores, while 18 were completely satisfied. Conclusion: satisfactory clinical results were achieved. Talar fracture location did not influence the outcomes, the Hawkins sign was confirmed as a positive prognostic factor, and operation timing did not influence AVN development. Hence, these injuries do not require emergent surgical management by ORIF.
P013 Peter Bock Hindfoot Inter- and Intraobserver Reliability of Radiologic Flatfoot Parameters before and after Surgery Michel Chraim Michael Pittermann Stefan Rois Background A variety of radiological parameters are used to evaluate flatfoot deformity. There is variability in the measurements of those parameters. Aim We asked: (1) Which of the 11 measured parameters have the best inter- and intraobserver reliability in a standardized radiologic setting? (2) Are post-operative assessments as reliable as pre-operative? (3) What are the identifiable sources of variability? Method AP and lateral weigth bearing radiographs of 38 feet were evaluated before and after flatfoot repair surgery by 3 observers with variable experience in foot surgery (A: 10 years; B: 3 years; C: third-year orthopaedic resident) for 11 parameters. Inter-observer and intra-observer reliability was calculated. Results Preoperative inter-observer reliability was high for 4/11, moderate for 5/11 and low for 2/11 parameters. Postoperative inter-observer reliability was high for 4/11, moderate for another 5/11 and low for 2/11 parameters. Intra-observer reliability was excellent for 11/11 pre-operative parameters (observer A and B) and for 8/11 parameters (observer C). Intra-observer reliability was excellent for 10/11 post-operative parameters (observer A and B) and 8/11 parameters (observer C). Conclusion Following parameters can be recommended for the pre- and postoperative evaluation of flatfoot deformity: ap: talo-navicular coverage angle; lateral: talo-metatarsal I angle, calcaneal pitch angle, cuneiform-medial height (high interobserver reliability); and ap: talo-metatarsal II angle; lateral: talo-calcaneal angle, tibio-calcaneal angle (moderate interobserver reliability). For more experienced observers (A,B) we additionally recommend the ap talo-metatarsal I angle (moderate reliability). The pre- and postoperative statuses did not change inter- and intraobserver reliability for the majority of parameters. As source of variability we found observer experience and the definition and ability to measure the parameters themselves.
P014 Bernardo Brandao Forefoot Comparative study assessing sporting ability after Arthrodesis and Cartiva hemiarthroplasty for treatment of hallux rigidus Edmund Poh Anna Fox Anand Pillai Background: Arthrodesis and Cartiva synthetic cartilage implant (SCI) are accepted treatments for hallux rigidus. Although good functional outcomes have been reported for both procedures, there is little data available on post-operative sporting ability for these patients. Aim: To compare sporting ability after Arthrodesis and Cartiva SCI hemiarthroplasty of the first metatarsophalangeal joint. Methods: Patients at a single centre with symptomatic hallux rigidus who underwent Arthrodesis or Cartiva SCI hemiarthroplasty were identified. Sporting ability was assessed using the Foot & Ankle Ability Measure (FAAM) sports questionnaire. First metatarsophalangeal joint arthritis was radiographically graded according to the Hattrup and Johnson (HJ) classification. Results: 42 Arthrodesis and 16 Cartiva patients were included in this study. Mean ages for this cohort were 64 and 58 respectively with a follow-up time of 19 and 17 months respectively. Arthrodesis patients consisted of 6.8% HJ1, 40.9% HJ2 and 52.3% HJ3 and Cartiva SCI patients 37% HJ2 and 63% HJ3 with no HJ1 patients. Mean post-operative FAAM scores were 80.9% for Arthrodesis and 78.6% for Cartiva SCI. Mann-Whitney U testing revealed no statistically significant difference between Arthrodesis and Cartiva SCI (p>0.3). Comparing age (<55 and >55) and gender matched cohorts revealed no statistically significant results. Conclusions: Our results suggest that both Arthrodesis and Cartiva SCI result in similar post-operative sporting ability. More research with larger cohorts and longer follow up is indicated. Initial results of Cartiva SCI are favourable and comparable to Arthrodesis.
P015 Bernardo Brandao Forefoot Cartiva Synthetic Cartilage Implant Hemiarthroplasty vs Osteotomy of the Second Metatarsal Head Anna Fox Anand Pillai Background: Cartiva synthetic cartilage implants (SCI) have been designed for treatment of conditions affecting the second metatarsal head. Osteotomies are regularly performed for the treatment of conditions affecting the second metatarsal head such as Freiburg's disease. A comparative study between these two procedures has not yet been performed. Aim: To compare the efficacy of Cartiva SCI hemiarthroplasty and Osteotomy for the treatment of conditions affecting the second metatarsal head. Methods: Patients at a single centre with symptomatic conditions affecting the second metatarsal head who received Cartiva SCI or a primary Osteotomy were identified, and patient-reported outcomes were evaluated using MOXFQ and the FAAM questionnaires. Results: 6 Cartiva and 7 Osteotomy patients were identified. 3 of the 6 patients, 2 Freiburg's disease and 1 Osteochondral defect, had revisions to Weil osteotomies at a mean 13 months post-operatively and were excluded. Cartiva SCI did not impede revision to osteotomy. The remaining 3 Cartiva patients at mean 18 months post-op had improved MOXFQ Index and 3 Domain scores. Pain was the domain most improved (13 points). Mean FAAM scores at 18 months post-op improved by 31%. The Osteotomy group at mean 27 months post-op had improved MOXFQ Index and 3 Domain scores. Walking/Standing was the domain most improved (54 points). Mean FAAM scores at 27 months post-op improved by 26%. Conclusions: Second metatarsal head osteotomies result in high functional outcomes and should be the mainstay of treatment, especially in conditions affecting the vascular supply of the metatarsal head.
P016 Bernardo Brandao Forefoot Cartiva Synthetic Cartilage Implant Hemiarthroplasty of the Second Metatarsal Head Anna Fox Anand Pillai Background: Cartiva synthetic cartilage implants (SCI) have been designed for treatment of conditions affecting the second metatarsal head. At present, current literature fails to explore the functional outcomes of such a procedure for the second metatarsal. Aim: To study the efficacy of Cartiva SCI hemiarthroplasty for the treatment of conditions affecting the second metatarsal head. Methods: Patients at a single centre with symptomatic conditions affecting the second metatarsal head received Cartiva SCI procedures and were identified. Pre-operative and post-operative patient-reported outcomes were evaluated using the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale and the Manchester-Oxford Foot Questionnaire (MOXFQ). Results: 6 female patients were followed up for an average of 19 months post-operatively. 3 of the 6 patients, 2 Freiburg's disease and 1 Osteochondral defect, had revisions to Weil osteotomies at a mean 13 months post-operatively and were excluded. Cartiva SCI did not impede revision to osteotomy. The remaining 3 patients, 1 Freiburg's disease and 2 arthritis, at mean 18 months post-operatively had improved MOXFQ Index score (23) and 3 Domain scores of Walking/Standing (29), Pain (42) and Social Interaction (25). Mean FAAM scores at 18 months post-op improved by 31% (65%-96%). Conclusions: Cartiva SCI can be utilised for treatment of conditions affecting the second metatarsal head in selected patients with intact vascular supply without risk of impeding revision to osteotomy. There was a 50% revision rate in patients who suffered a vascular injury to the metatarsal head.
P017 Bernardo Brandao Forefoot Cartiva Synthetic Cartilage Implant Hemiarthroplasty for Treatment of Hallux Rigidus Anna Fox Anand Pillai Background: The Cartiva synthetic cartilage implant (SCI) has been licenced for use in management of symptomatic hallux rigidus in several countries including the UK. Objectives: To study the efficacy of the use of Cartiva synthetic cartilage implant hemiarthroplasty in the treatment of hallux rigidus. Methods: Patients at a single centre with symptomatic hallux rigidus who underwent Cartiva SCI implant procedure were identified. First metatarsophalangeal joint arthritis was radiographically graded according to the Hattrup and Johnson (HJ) classification. Pre-operative and post-operative patient-reported outcomes were evaluated using the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale and the Manchester-Oxford Foot Questionnaire (MOXFQ). Results: 50 patients (13M, 37F) (33R and 17L) were followed up for an average of 13 months (min=2, max=30). 13 patients suffered from HJ2/moderate arthritis and 37 patients with grade HJ3/severe arthritis. Wilcoxon matched-pairs signed-rank test was used to identify statistically significant results as determined by a p value of <0.05. Post-operative mean FAAM scores showed statistically significant improvement (p<0.0001). Patients reported a 45% increase in functionality during activities of daily living after surgery. There was an average improvement in MOXFQ Index scores of 28 points, which were shown to be statistically significant (p<0.0001). MOXFQ Domain score showed statistically significant improvements in all 3 domains (p<0.02). Conclusions: Our study shows excellent post-operative results with a statistically significant improvement in functional outcomes. Pain in particular was significantly reduced by the use of Cartiva SCI. Durability and survivability of the implant will continue to be studied in this cohort.
P018 Marcus Brookes Ankle An audit of early functional outcome of Brostrom lateral ligament reconstruction Rumina Begum David Townshend Rajesh Kakwani Rajesh Kakwani Background: Patient reported outcomes measures (PROMS) have become increasingly more important in assessing the outcome of surgery, particularly for foot and ankle procedures. Many scoring systems have been utilised in the current literature including American Orthopaedic Foot and Ankle score (AOFAS) and the Manchester Oxford Foot Questionnaire (MOXFQ). More recently, a more sophisticated tool, the Sports Athlete Foot and Ankle Score has been developed to assess function and pain relating to activity in more detail. Methods: We carried out a retrospective audit of 30 patients who underwent Brostrom reconstruction between 2014-2015. Preoperative PROMS questionnaires were completed in clinic and post op forms were sent by post at 6 months. Questionnaires were made up of a combination of scoring systems including EQ -5D, MOX FQ, AOFAS and SAFAS. Results: Out of 30 patients, 20 had both set of pre and post op forms completed. The average age of the population was 31 years and 60% were male, with a third of the group (6 patients) being military personnel. 12/20 (60%) of patients reported the overall outcome of surgery as excellent, with the remainder rating it as good or fair. Average post-operative scores showed an improvement across all the scoring systems including mean AOFAS, which increased from 36 (pre-op) to 47 (post op). Furthermore, SAFAS scores improved in each domain: symptoms; 11 pre-op increased to 23 post-op, pain; 21 improved to 40, daily living; 24 to 29 with the steepest increase in sports; from 7 to 33. Conclusion: Whilst all scores improved in assessing outcomes after Bostrom reconstruction, SAFAS has shown to highlight more specific changes relating to physical activity and may prove to be the scoring system of choice when evaluating outcome in the younger population who have a higher level of function.
P019 Arne Burssens Hindfoot Clinical and Radiological Outcome after a Medial Calcaneal Osteotomy Assessed by Weightbearing CT Stefan Clockaerts Sara De Boey Kristien Vuylsteke Weightearing CT International Study Group Tim Leenders Background: The influence of a radiographic correction after a medial calcaneal osteotomy (MCO) on the clinical outcome remains under-investigated. Aim: To assess the association between the clinical and radiological outcome. Methods: Seventeen patients with a mean age of 44,5 years (range 18–66 yrs) were prospectively included in pre-post study design. MCO was indicated in a stage II adult acquired flat foot deformity (N=15) and a post-traumatic valgus deformity (N=2). Clinical outcome was assessed by visual analogue scale (VAS) and Foot and Ankle Outcome Score (FAOS) at 1 year post-op. Radiographic parameters obtained from the weightbearing CT included the hindfoot angle (HA), navicular height (NH) and Méary angle (MA). Results: The mean pre-operative VAS of 7.2 ± 1.5 and FAOS of 77 ± 13.7 improved post-operatively towards a mean VAS of 3.1 ± 2.5 and mean FAOS of 42 ± 18.9, which showed to statistically different (p<0,001). The mean HA = 13.9° of valgus, NH=26.5mm, MA=15.7° preoperatively and improved towards a mean HA= 4.9 ° of valgus, NH=31.1mm, MA=13.8° post-operatively, which showed to be statistically different (p<0,05), except for the MA (p=0.07). The highest correlation was moderate and found between the VAS and HA improvement (r=0.61). Conclusion: This study demonstrates an effective improvement of both the clinical and radiological outcome. The best association with the clinical results was found for the HA correction. This information emphasis the importance of obtaining a HA improvement during surgery for an AAFD stage II.
P020 Arne Burssens Ankle Templating of Acute and Chronic Syndesmotic Ankle Lesions in Weightbearing and Nonweightbearing CT Hannes Vermue Alexej Barg Nicola Krähenbühl Weightbearing CT International Study Group Kris Buedts Background: Diagnosis and surgical treatment of syndesmotic ankle injuries remains challenging due to the limitations of 2D imaging. Aim: To develop a reproducible method to quantify the displacement of syndesmotic lesions based on computed 3D imaging. Methods: Fifteen patients with a unilateral syndesmotic lesion were retrospectively included. Bilateral imaging was performed by a weightbearing CT in case of a high ankle sprain (N=12) and by non-weightbearing CT in case of a fracture associated chronic malreduced syndesmotic lesion (N=3). The healthy ankle was used as template after being mirrored and superimposed on the contralateral ankle (Fig1a). The following anatomical landmarks of the distal fibula were computed: the apex malleolis lateralis, anterior and posterior tubercle. The change in position of these landmarks relative to the stationary, healthy fibula was used for quantification (Fig1b, c). A control group of N=7 was used (Fig1d). Results: The main findings demonstrated a statistically significant difference between the mean mediolateral diastasis (M=1.60mm, SD=0.85), mean external rotation (M=4.68 degrees, SD=2.74) of the sprained group and mean mediolateral diastasis (M=0.88mm, SD=0.86), mean shortening (M=1.31mm, SD= 0.59) of the fracture group compared to the control group (P<.05). Conclusion: This study shows an effective method for quantifying a unilateral syndesmotic lesion of the ankle. Applications in clinical practice could improve diagnostic accuracy and aid in pre-operative planning by determining which correction needs to be achieved to have the fibula correctly reduced in the syndesmosis.
P021 Arne Burssens Ankle Intrinsic Anatomical Risk Factors in High Ankle Sprains Determined by Computed 3D CT Analysis Hannes Vermue Laurens De Cock Weightbearing CT International Study Group Kris Buedts Emmanuel Audenaert Background: High ankle sprains (HAS) cause subtle lesions in the syndesmotic ligaments of the distal tibiofibular joint (DTFJ). Current intrinsic anatomical parameters of the DTFJ are determined based on 2D imaging and uncertainty remains whether they differ in a HAS patients. Aim: Radiographic incisura fibularis parameters will be determined in 3D and compared in a healthy vs sprained group. Methods: Ten patients with a mean age of 42,56 (SD = 15,38) that sustained a HAS and twenty-five control subjects with a mean age of 47,44 (SD = 6,55) were retrospectively included. The slices obtained from CT analysis were segmented to have a 3D reconstruction. The following DTFJ anatomical parameters were computed using CAD software: incisura height (Fig. 1a (h)), incisura width-depth ratio (Fig. 1b (w/d)), incisura angle, and incisura-tibia ratio. Results: The mean incisura heigth in the group of patients with HAS was 30,81 mm (SD = 3,17) compared to 36,10mm (SD = 5,27) in the control group which showed a significant difference (P < 0.05). The mean incisura width-depth ratio in the sprained group was 6.38 (SD = 1.32) compared to 5.47, (SD = 1.01) in the control group, which showed a significant difference (P < 0.05). The other DTFJ anatomical parameters showed no significant difference. Conclusion: This study shows a significant difference in both incisura height and incisura width-depth ratio between HAS patients and control subjects. These parameters could be used to identify potential anatomical intrinsic risk factors in sustaining a HAS.
P022 Jarrett Cain Diabetes Local delivery of opioid antagonist on diabetic fracture healing Michelle B. Titunick Ian S. Zagon Patricia McLaughlin BACKGROUND: Complications associated with the diabetes include increased incidence of fracture healing, delayed fracture healing, delayed osteoblasts cell replication, decreased angiogenesis, migration and/or osteoblast cell differentiation. The cellular events involved in bone healing are adversely affected by diabetes; however, can be modulated by the Opioid Growth Factor (OGF) – OGF receptor (OGFr) is an inhibitory peptide that downregulates DNA synthesis in a tissue nonspecific manner. Diabetes is associated with elevated serum levels of OGF and dysregulation of the OGFr leading to multiple complications related to healing, sensitivity, and regeneration. AIM: This study explores the presence and function of the OGF-OGFr axis in bone tissue from type 1 diabetic rats examining intact and fractured femurs during early phases of the repair process METHOD: Seven-week-old Sprague Dawley rats were injected with streptozotocin (40mg/kg i.p.) to induce T1D; other rats received buffer only and served as controls. After one month, hyperglycemia rats underwent surgery to produce a fracture at the distal third of the femur. Four diabetic rats received opioid antagoinist (naltrexone) and calcium sulfate and all remaining rats received calcium sulfate with water only. X-rays were taken immediately after surgery and after rats were euthanized on post-surgery; femur and tibia were collected for protein isolation, western blot analysis along with frozen or paraffin-embedded for histological analysis RESULTS: Immunofluorescence indicated approximately 90% increase in opioid growth factor receptor expression in diabetic femurs compared to age-matched normal femurs. Western Blotting also suggested an increase in the receptor protein in diabetic bones relative to normal bone. TRAP staining for osteoclasts was greater in control and opioid antagonist-treated diabetic fractures when compared to the number of osteoclasts in vehicle-treated diabetic fractured femurs. Safranin O stained sections revealed approximately more bone in opioid growth receptor antagonist-treated diabetic bone fractures than in vehicle-treated bone fractures CONCLUSION: These data support our hypothesis that expression levels of OGFr are dysregulated in the bone of diabetic patients leading to complications in bone healing. Moreover, modulation of the OGF-OGFr pathway with receptor antagonists restored some aspects of bone healing. With further study, these preliminary results support the role of the OGF-OGFr axis in treatment of diabetic bone healing. New therapies to target dysregulation of the OGF-OGFr regulatory pathway in diabetes would provide a safe and effective disease-modifying treatment for delayed bone healing.
P023 Jarrett Cain Hindfoot 3-D Morphometric Analysis of Talocalcaneal Joint in Stage II Posterior Tibial Tendon Dysfunction Evan Roush BS Eric Lukosius MD K.C. Walley MD Allen Kunselman MA Gregory Lewis PhD INTRODUCTION: Posterior Tibial Tendon Dysfunction (PTTD) is common disorder that can lead to changes in function during the gait cycle due to decreased arch, increased hindfoot valgus, and forefoot abduction. These kinematic changes can have a structural impact on the joints throughout the foot. While previous studies have evaluated anatomical three-dimensional (3D) position of the subtalar joint, the purpose of this study was to perform morphological analysis of the anterior, middle and posterior facets in patients with stage II posterior tibial tendon dysfunction compared to normal controls. METHODS: Clinical computed tomography images from 10 matched feet (i.e., 10 normal and 10 stage II PTTD) were obtained and used for 3D reconstruction in Mimics software (Materialise). From the3D reconstructions, morphometric evaluations of the subtalar joint were completed including 3D anatomic point placement and measurements of the length and width of the anterior, middle and posterior facets (Fig. 1) by 3 independent evaluators. Evaluators were blinded to experimental groups and to one another’s measurements. A linear mixed-effects model was used to assess the differences between control and PTTD subtalar joints with respect to morphometric measurements (mm). The concordance correlation coefficient (CCC) was used to assess the agreement between the 3 evaluators with respect to their recorded morphometric measurements per location (e.g., anterior, middle, posterior). RESULTS: Although the mean distance of the length and width of the middle facet trended higher in the stage II PTTD compared to controls, this difference was not statistically significant (Table 1). Similarly, there was no difference detected between control and PTTD with respect to morphometric measurements in the anterior and posterior facets (Table 1). The agreement among the 3 evaluators with respect to morphometric measurements was the strongest in the length and width of the middle facets. CONCLUSION: Stage II posterior tibial tendon dysfunction has been shown to cause increase subtalar joint kinematics, joint contact pressure and based on the study, a strong trend toward morphological changes of the subtalar joint in particular the middle facet. Further studies are needed with weight bearing CT scans in correlation with advance stages of posterior tibial tendon dysfunction.
P024 Sandra Catalán Amigo Trauma Acute Achilles tendon ruptura. Open versus percutaneous surgery. Morphological study. Background: Acute Achilles tendon ruptures are a common injury and the incidence is increasing. The treatment could be grouped in conservative, open and percutaneous surgery. The percutaneous surgery is likely a good option in front of the open surgery, because of less minor complications and similar incidence of reruptures. Aim: The purpose of this study was to evaluate the Achilles tendon morphological changes after percutaneous and open surgery. Method: There were two groups in the clinical study, one was treated with percutaneous surgery and the other one, with open surgery. Patients in this prospective randomized study were evaluated by means of morphological, clinical and functional evaluation at 3, 6 and 12 months. The morphological changes were assessed by magnetic resonance (MRI) and ultrasound. Results: Regarding MRI and ultrasound, the most frequent findings were heterogeneity and thickening of the tendon without clinical meaning. Thinning of the tendon was associated with reruptures and worse functional scores. One re-rupture occurred in each of the groups, and one partial sural nerve injury occurred in the percutaneous group, without significant differences between both groups. There were statistically significantly more complications with percutaneous repair. Conclusions: In the present study, no significant morphological differences have been found using MRI and ultrasound between both treatments, in terms of healing quality and tendon thickness. Global complications are more frequent in the percutaneous surgery group.
P025 Giovanni Cautiero Hindfoot Percutaneous medializing calcaneal osteotomy: our experience. Catani Ottorino Sergio Fabrizio Zanchini Fabio BACKGROUND. Idiopathic flatfoot is a common problem for both adolescents and young adults. They require surgical treatment when conservative treatments failed despite in some cases idiopathic flatfoot resolves spontaneously. Surgical treatment should aim to restore the physiological arch support and ensure correct foot support by restoring the mechanical tripod between the heel, head of the first and the fifth metatarsal. Although there are several surgical proposals for the treatment of this pathology the indications, the timing and the procedures performed remain controversial. AIM. Our treatment proposal includes a medializing osteotomy with percutaneous technique sometimes combined with a sinus tarsi arthroereisis in severe painful flatfoot cases (III-IV grade) unresponsive to conservative therapies. METHOD. We treated 20 feet of 20 patients (13 males, 7 females) with a mean age of 26 years. Patients not responsive to conservative treatment were included. Mean follow-up was 18 months. Patients were evaluated with AOFAS score and X-ray evaluation was performed at 1, 6 and 12 months. Patients wore a pinstriped boot for 30 days after surgery and then observed at 20 days for partial weigh bearing. Fifty days after surgery, full weight bearing is allowed. RESULTS. All patients underwent heel medialization osteotomy with percutaneous technique and sinus tarsi arthroereisis. The osteotomy was maintained with two cannulated screws in all patients. The AOFAS score increased significantly from 63.7 to 96.6. No surgical complications were observed at follow up. All patients were satisfied with the treatment. CONCLUSION. Percutaneous medializing osteotomy of the heel, sometimes combined with sinus tarsi arthroereisis, allows correction of painful adult flatfoot with satisfactory preliminary results and could become a valid alternative to open technique.
P026 Paolo Ceccarini Infection Profile vs Tubular Plate in Unimalleolar or Bimalleolar Fractures: is There a Real Difference in wound complications? Rosario Petruccelli Enrico Leonardi Julien Teodori Giuseppe Rinonapooli Auro Caraffa Background and aim: The aim of our study is to compare two types of plates, one third tubular plate and LCP distal fibula plate, evaluating the clinical outcome and the skin complications associated with their use. Methods: The present study is a retrospective single-center study, carried out between the January 1st 2012 and December 31st 2015. We collected the data of 122 consecutive unimalleolar or bimalleolar fractures treated by internal fixation for a closed, displaced distal closed fibular fracture. Exclusion criteria were : 1) open ankle fractures, 2) trimalleolar fractures, 3) previous ankle fractures 4) severe venous insufficiency, 5) ankle osteoarthritis previous to surgery, 6) associated ankle dislocation. After this selection, 93 patients were included in our study and assigned in two groups, based on using of different implant : in group A 48 patients were treated with one-third tubular and in group B 45 patients were treated with LCP distal fibula plate. There were no significant differences in the baseline characteristics. Patients received the same surgical procedure and the same post-operative care, then they were radiologically evaluated at 1-3-12 months and clinical examination was made at 24 (range 15-36) months using AOFAS clinical rating system. Categorical data, grouped into distinct categories ,were evalueted using Chi-square test. We considered a p value < 0.05 as statistically significant. Results: At the final 24-month follow-up a comparison between the two groups showed no statistical significant differences in reduction accuracy and bone union ratio at radiological examination. The wound complications rate of the overall study group was 7.6%.There were no statistical differences in the rate of wound complications between the two groups. There were no differences between both group in percentage of hardware removal at follow-up (overall 5.4%). In the group A occurred 1 deep infection , 2 superficial infection ,no wound dehiscence; in group B occured 1 deep infection, 1 superficial infection and 2 wound dehiscence. There were no statistical differences in the rate of wound complications between the two groups ( p=0.70 ;Fisher exact test). Conclusions: Our study has shown no difference in radiographic bone union rate, no significant differences in terms of clinical outcomes, in time of bone reduction and wound complication rate between the LCP distal fibula plate and conventional one-third tubular plate. RCT or metanalasys are in this case useful to improve scientific evidence and give more information for the correct surgical treatment of ankle fractures.
P027 CHLOE XIAOYUN CHAN Forefoot TWO YEAR OUTCOMES OF MINIMALLY INVASIVE HALLUX VALGUS SURGERY Jonathan Zhi-Wei GAN Hwei Chi CHONG Inderjeet Rikhraj SINGH Sean Yung Chuan NG Kevin KOO Background and aim: We report our experience with the Minimally Invasive Chevron Akin (MICA) technique for correcting Hallux Valgus, and evaluate its effectiveness and associated complications. Method: We performed a retrospective case series of 13 feet with mild to moderate symptomatic hallux valgus treated surgically from July 2013 to December 2014, with at least 48-months follow-up. Patients were assessed pre-operatively and post-operatively with radiographical measurements (Hallux Valgus Angle (HVA) and Intermetatarsal Angle (IMA)) and clinical scores (American Orthopaedic Foot and Ankle Society (AOFAS), 36-Item Short Form Health Survery (SF-36), Visual Analog Scale (VAS)). Comparisons were made between the findings pre-operatively and at least 2 years post-operatively. Results: Mean HVA and IMA decreased from 30.4° and 13.9° to 10.9° and 10.2° respectively (p<0.05). The mean AOFAS score improved from an average of 59.0 to 93.7 (p<0.05). All patients reported a VAS score of 0 post-operatively, and all 4 chosen SF-36 domains had significant improvements (p<0.05). Complications included 2 feet which required early re-operation due to mobility at the osteotomy site, 1 feet with post-operative superficial infection, 1 feet with stiffness, and 1 feet with paresthesia. Conclusion: The MICA technique is a safe and effective method in the surgical correction of mild to moderate hallux valgus deformity given the positive radiological and clinical outcomes 2-years post-surgery. Its continued use is justified. Further studies are warranted to analyze the long-term results, and compare the efficacy with open techniques.
P028 Angelo Chessa Forefoot Outcomes of hallux valgus correction by minimally invasive distal osteotomy F.Cerri E.Raimondo M. Da Gama Malcher A.Colombo L.Pietrogrande Background Surgical correction of first metatarsal deformities consist nowadays in more than 130 different operative techniques. Use of minimally invasive surgical techniques are increasing due to the reduced incidence of complications, early weight bearing load, shorter hospital stay. Minimally Invasive Distal Osteotomy is used in mild or moderate cases of hallux valgus Aim We decided to evaluate the radiological an clinical outcome of patients treated with minimally invasive distal osteotomy. Method A total of 69 consecutive patients treated with PDO technique for hallux valgus correction from 2015 to 2017 in San Paolo Hospital in Milan, Italy, were included in this retrospective review. Surgery were performed in day-hospital regimen; weight bearing was allowed after surgery with talus shoe; taping has been renovated weekly and K wire has been removed 6 weeks after surgery. Outcomes assessed included radiological parameters and clinical evaluation using the American Orthopedic Foot and Ankle Society (AOFAS) score, and complication rate. Results All patients showed an overall correction of the radiological angles, changing from a HVA of 30.95° and a IMA of 12.2° preoperatively to 11.2° and 5.8° postoperatively, respectively; and a PASA of 24.5° and a DASA of 12.7° preoperatively to a PASA of 11.3° and a DASA of 7.1° postoperatively. The overall postoperative AOFAS Score was 87.3. Personal satisfaction valued with Coughlin Score was obtained in 90% of patients, 58% of them were very satisfied. Bone healing has been reached in all patients. We had no complications. Conclusion In our experience PDO is confirmed to be an effective and safe surgical technique for treating mild or moderate hallux valgus deformities. It can reduce complications rate related to bone exposure, it shorten in-hospital stay and, in our experience, always lead to a correction of the deformity.
P029 Hyun Choi Trauma Syndesmosis fixation in unstable ankle fractures using a partially threaded 5.0 mm cannulated screw SEUNG YEOL LEE SEUNGBUM KOO KYOUNG MIN LEE SangYeop Shin Byeong-Seop Park Background: No general consensus has been reached regarding the optimal fixaftion methods for ankle syndesmosis injuries. Aim: To evaluate the radiographic outcomes of syndesmosis injuries treated with a partially threaded 5.0 mm cannulated screw. Methods: This study included 58 consecutive patients with syndesmosis injuries concurrent with ankle fractures who had undergone operative fixation with a partially threaded 5.0 mm cannulated screw to repair the syndesmosis injury. There were 45 male and 13 female patients, with a mean age of 39.9 ± 14.4 years. Radiographic indices, including the medial clear space, tibiofibular overlap, tibiofibular clear space, and fibular position on the lateral X-ray, were measured on the preoperative, immediately postoperative, and final follow-up radiographs. The measurements were compared between the injured and intact ankles. Results: Preoperative radiographic indices, including the medial clear space, tibiofibular overlap, tibiofibular clear space, and fibular position on the lateral X-ray, were significantly different between the injured and intact ankles. The medial clear space of the injured ankle was significantly wider than that of the intact ankle preoperatively and became narrower immediately postoperation. Finally, the medial clear space was not significantly different between the injured and intact ankles at the final follow-up (p=0.522). No screw breakage or refractures were observed. Conclusions: A 5.0 mm partially threaded cannulated screw effectively restored and maintained the normal relationship between the tibia and fibula within the ankle mortise with little risk of complications. This appears to be an effective alternative technique to treat syndesmosis injuries concurrent with ankle fractures.
P030 Jun Young Choi Forefoot Minimally invasive surgery for young female patients with mild-to-moderate juvenile hallux valgus deformity Jin Soo Suh Dong Joo Lee Background: We aimed to compare the clinical and radiographic outcomes of minimally invasive surgery (MIS) and distal chevron metatarsal osteotomy (DCMO) for young female patients with mild-to-moderate juvenile hallux valgus deformity. Methods: We retrospectively reviewed the radiographs and clinical findings of young female patients with mild-to-moderate juvenile hallux valgus who underwent MIS (25 feet) or DCMO (30 feet). In 12 of 25 MIS feet, 2.0-mm bio-absorbable pins were used as an additional fixation device crossing the osteotomy site, and 1.4-mm Kirschner wires were used in the remaining 13 feet. Results: Radiographic and clinical parameters preoperatively and at the final follow-up were not significantly different between the 2 groups. There were no significant differences in the increments of hallux valgus angle (HVA), distal metatarsal articular angle, medial sesamoid position, first metatarsal length, metatarsal length index, or relative second metatarsal length. Two MIS subgroups according to the additional fixation device showed no significant differences in HVA, the first to second intermetatarsal angle lateral translation ratio, or plantar offset at the final follow-up. Conclusions: MIS for young female patients with mild-to-moderate juvenile hallux valgus deformity had similar radiographic and clinical outcomes compared to DCMO. Regarding additional fixation crossing the osteotomy site, both temporary Kirschner wires and absorbable pins showed no radiographic differences in terms of correction maintenance.
P031 Jun Young Choi Forefoot Factors influencing medial sesamoid arthritis in patients with hallux valgus deformity: Magnetic resonance imaging evaluation Jin Soo Suh Dong Joo Lee Background: We aimed to evaluate the magnetic resonance imaging (MRI) findings of hallux valgus deformity, and assess the severity of and identify the factors that influence the arthritic changes in the first metatarsophalangeal (MTP) and medial sesamoid-metatarsal (mSM) joints. Methods: We reviewed and compared weight-bearing radiographs and MR images of 524 feet of 415 patients who underwent hallux valgus correction. On MRI, the degrees of the arthritic changes in the first MTP and mSM joints were categorized into 5 classes. Multiple regression analysis was performed to identify the factors affecting the arthritic changes. Results: A significant correlation was found between age (P < 0.001), degree of arthritic changes in the first MTP and mSM joints on MRI, and Coughlin and Shurnas’ hallux rigidus grade. Furthermore, medial sesamoid position on forefoot axial radiograph was significantly correlated with mSM joint arthritis. Conclusions: MRI provides more accurate assessment of the arthritic changes in the first MTP and mSM joints.
P032 Jun Young Choi Forefoot Shortening proximal chevron metatarsal osteotomy for patients with a hallux valgus deformity with advanced arthritis Jin Soo Suh Dong Joo Lee Aim: To correct hallux valgus deformities in patients with advanced arthritis of the first metatarsophalangeal joint, we designed a new chevron-type shortening osteotomy technique that could be used to correct valgus deformities at the proximal metatarsal level, as well as shorten and lower the metatarsal, in a one-time procedure. Methods: Sixteen feet in 16 patients with a minimum of 18 months follow-up who underwent shortening proximal chevron metatarsal osteotomy (PCMO) for a hallux valgus deformity with advanced arthritic change between January 2014 and March 2016 were retrospectively evaluated in this study. chevron osteotomies with 20 degrees of plantarward obliquity at the proximal metatarsal level were made at 5-mm intervals for simultaneous valgus correction and metatarsal shortening. An additional Weil osteotomy of the second metatarsal was performed in all feet Results: Patients’ mean age was 57.88±6.55. The deformity was satisfactorily corrected due to the operation. The first metatarsal was shortened by approximately 8.75 mm, while the relative length of the second metatarsal did not differ significantly postoperatively (P = .179). The relative second metatarsal height, as seen on forefoot axial radiographs, was maintained constantly, with no significant difference (P = .215). No painful plantar callosity or transfer metatarsalgia under the second metatarsal head was observed postoperatively. Conclusion: Shortening PCMO for hallux valgus deformities with advanced arthritic change showed a good result regarding deformity correction and pain relief. Appropriate lowering and an additional Weil osteotomy effectively prevented postoperative pain and painful callosity under the second metatarsal head.
P033 Jun Young Choi Forefoot Analysis of congenital postaxial polydactyly of the foot using magnetic resonance imaging Jin Soo Suh Dong Joo Lee Background: Operation of the postaxial polydactyly of the foot was generally performed when the patients’ ages reached 1 year old. Aim: We aimed to evaluate magnetic resonance imaging (MRI) findings for congenital postaxial polydactyly of the foot. Methods: 347 feet of 288 patients who underwent congenital postaxial polydactyly correction were divided into five subtypes according to the radiographic shape of the deformity origin –widened metatarsal head, bifid, fused duplicated, incompletely duplicated or completely duplicated. We assessed MRI to figure out whether radiographic unrevealed areas were fused or separated. MRI was also used for the cases with the radiographic phalangeal aplasia. Results: With MRI, Huge variations were noted for radiographic unrevealed area. Fusion or separation at the base or head of the affected bone between original and extradigit was seen regardless of the subtype. MRI was also effective to reveal phalangeal aplastic area. Conclusion: MRI evaluation for congenital postaxial polydactyly of the foot was useful to figure out the exact anatomical status of radiographic unrevealed area.
P034 Jun Young Choi Effect of wearing shoes Effects of wearing shoes on the feet: Radiographic comparison of middle-aged partially shod Maasai women’s feet and regularly shod Maasai and Korean women’s feet Jin Soo Suh Dong Joo Lee Background: Maasai tribe members walk long distances daily either barefoot or wearing traditional shoes made from recycled car tires, without any foot ailments. Aim: To figure out the characteristic of their feet, we designed a radiographic comparative study of middle-aged partially shod Maasai women’s feet and regularly shod Maasai and Korean women’s feet. Method: Weight bearing radiographs of bilateral foot and ankle joints from 20 healthy middle-aged bush-living partially shod (PS) Maasai women were obtained. Same number of radiographs from 20 urban-living regularly shod (RS) Maasai and 20 Korean women were obtained and compared. The hallux valgus angle, the first to second intermetatarsal angle, talonavicular coverage angle, talo-first metatarsal angle, Meary angle, naviculo-cuboidal overlap, and the medial cuneiform height were measured to establish the degree of pes plano-valgus and hallux valgus deformity. Results: On comparing PS and RS Maasai groups radiographically, the talonavicular coverage angle, talo-first metatarsal angle, and naviculo-cuboidal overlap were significantly greater in the PS Maasai group, whereas hallux valgus angle, the first and second intermetatarsal angle, Meary angle, and the medial cuneiform height were greater in the RS Maasai and Korean group. Conclusion: Regularly wearing shoes would protect the feet from pes plano-valgus deformity, despite potentially contributing to hallux valgus deformity.
P035 Dong-il Chun Hindfoot Arthroscopic findings in patients were diagnosed with sinus tarsi syndrome Chul Hyun Park Background: Sinus tarsi syndrome is a poorly understood disease and etiology of this condition is not clearly understood. Recently, some authors have proposed that talocalcaneal impingement caused by accessory anterolateral talar facet (AALTF) could be a cause of sinus tarsi syndrome. Aim: The purposes of this study were to evaluate the pathologic findings of subtalar arthroscopy in patients were diagnosed as sinus tarsi syndrome and to evaluate the relationships between AALTF and sinus tarsi syndrome. Method: Seventeen cases (15 patients) who underwent surgeries for the sinus tarsi syndrome were reviewed. The mean follow-up period was 18.6 months, and the mean age was 31.9 years. The previous trauma history, duration of the symptom, and arthroscopic findings were analyzed. The clinical results were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and the visual analogue scale (VAS). Results: All patients had trauma before the pain began. The mean duration of the symptom was 12.3 months. Arthroscopic findings showed synovitis in all patients in spite of difference of severity, AALTF in 16 cases (94.1%), partial tear of the interosseous talocalcaneal ligament in 10 (58.8%), soft-tissue impingement in 7 (41.2%), and arthrofibrosis in 2 (11.8%). The AOFAS ankle-hindfoot score was significantly improved from 73 (62~77) preoperatively to 93 (67~100) postoperatively. The VAS was decreased from 6 (5~7) preoperatively to 1 (0~5) postoperatively. Conclusion: Talocalcaneal impingement caused by AALTF should be considered as a cause of the chronic sinus tarsi pain.
P036 Iban Clares Moreno Forefoot Digital planning of forefoot surgery. Interrater reliability by using two different software Josep Torrent Gómez BACKGROUND Preoperative planning is commonly performed for many foot and ankle procedures. Standard planning software (RAIM JAVA®) is available at all working local station of our hospital. In addition, we have a specific orthopaedic pre-operative planning software (TraumaCad®) that enables surgeons to accurately template patient images, take measurements, and simulate the expected result prior to surgery. AIM The purpose of the present study is to determine the preoperative digital planning accuracy for standard and specific systems in the measurement of the intermetatarsal angle. We want to estimate inter- and intraobserver variability. METHODS Two orthopaedic surgeons measured 50 digital weight bearing foot radiographs on separate days using the standard and specific systems (two measurements for each system). The intraclass correlation coefficient (ICC) summarized the overall accuracy and precision of the measurement process relative to subject variation. RESULTS All observers demonstrated good intra-observer reliability and there was good inter-observer reliability for each set of readings taken. The intraclass correlation coefficient for RAIM JAVA measurements was 0’90 for observer A and 0’86 for observer B; and for TraumaCAd measurements was 0’93 for observer A and 0’96 for observer B. In addition, the interobserver intraclass correlation coefficient was 0’86 for RAIM JAVA® and 0’92 for TraumaCad®. CONCLUSIONS There was strong correlation between all measurements. Standard digital planning has been shown to be a valuable tool for measuring the intermetatarsal angle. We consider there is insufficient evidence to recommend specific software for current angle measurements.
P037 Iban Clares Moreno Trauma 2 cases of failed treatment of Maissonneuve fracture. Tips and tricks for syndesmotic screw fixation Josep Torrent Gómez BACKGRAOUND Maisonneuve fractures are a combination of high fibular and medial malleolar fractures with a disruption of the tibiofibular syndesmosis ligaments. Although injuries to ankle syndesmosis are numerous, methods of diagnosis and treatment remain controversial. Furthermore, intraoperative assessment of the accuracy of reduction of the fibula in the incisura using fluoroscopy is difficult. AIM We report 2 cases of Maissonneuve fracture treated with syndesmotic screw fixation who required reoperation during the first days after surgery. Iatrogenic syndesmosis malreduction can still occur despite adequate intraoperative fluoroscopy. We want to describe how to avoid malreduction by presenting these 2 cases and summarizing current literature. METHOD A 41-year-old man and 38-year-old woman suffered a Maissonneuve fracture treated with syndesmotic screw fixation. We highly suspected malreduction in the postoperative X-ray control, and computed tomography was carried out to complete the study. Both patients underwent a revision surgery, obtaining a proper reduction and performing syndesmotic fixation. RESULTS Multiple articles have described malreduction after operative treatment in up to 50% of the cases. Some considerations can be used to help us guide reduction like to establish anatomic relationships such as tibiofibular clear space and overlap along with medial clear space in anteroposterior and mortise radiographs. Variations in angulation of clamp placement to hold syndesmotic reduction affects malreduction of the syndesmosis. In addition, it is important to avoid overcompression of the syndesmosis. CONCLUSION Knowledge of the technical details regarding intraoperative reduction methods and reduction assessment can minimize the risk of syndesmotic malreduction and improve patient outcomes.
P038 Nuno Côrte-Real Ankle Endoscopic Flexor Hallucis Longus Transfer For Treatment Of Achilles Tendon Desinsertion - Case Report Miguel Duarte Silva Patrícia Wircker Rafael Dias João Caetano João Figueiredo Acute Achilles tendon ruptures usually occur in male patients between 30 and 40 years old that are episodic athletes. The incidence of reruptures after primary surgical treatment is highly variable and there are various salvage surgical procedures, usually open techniques. We present a case of a female patient, 45 years old, admitted in our institution after right ankle trauma. She had history of right Achilles tendon rupture surgically repaired eleven years before. At observation, the patient had local pain and ankle dorsiflexion was affected with a positive Thompson sign. A MRI was performed confirming the existence of a complete rupture of the distal portion of the Achilles tendon, 2 mm above its calcaneal insertion. The patient was then proposed for surgical treatment. Intraoperatively it was observed that the Achilles tendon had lost its calcaneal insertion. A flexor hallucis longus transfer using a two portal endoscopic technique was performed. The flexor hallucis longus tendon is harvested inside the retromalleolar groove and transferred to a calcaneal tunnel immediately in front of the Achilles tendon footprint and fixed with an interferencial screw. The ankle was immobilized in equinus for 4 weeks. After this period, physiotherapy was made for 6 months. After this time regeneration of the tendon is observed and functional recovery with ability to do single leg heel rise and a ATRS of 92. This is a case of uncommon Achilles tendon desinsertion on an already diseased tendon which was surgically treated using an endoscopic flexor hallucis longus tendon transfer technique. As far as we know, it is the first report of the use of this technique on this type of lesion.
P039 Cesar de Cesar Netto Forefoot The use of synthetic polyvinyl alcohol hydrogel implants in the lesser metatarsal heads. Is it safely doable? A cadaveric Study. Alexandre Leme Godoy-Santos Taylor Cabe Lauren Roberts Jonathan Deland Mark Drakos Background/Aim: Study's objective was to evaluate the average dimensions of lesser metatarsal heads using CT scans and anatomical measurements, the maximum reaming size and the largest possible implant dimensions that could be safely used in each metatarsal head Methods: Ten below-knee cadaveric specimens used. Lesser metatarsal heads dimensions were measured in CT images and in anatomical dissections. Surgical procedures were performed by a single observer. The heads of all metatarsals were exposed. Sequential reaming with 1mm increments was then performed. The thickness of the surrounding bone rim (dorsal, plantar, medial and lateral) was measured using a precision caliper after each sequential ream. Based on the maximum reamer size used, either the 10 mm or 8mm implant was inserted. Any fracture, failure of the metatarsal head or instability of the implant was recorded. Results: CT and anatomical measurements demonstrated significant correlation (ICC=0.85 and 0.63 respectively). The heads of the 2nd metatarsal demonstrated significantly increased width when compared to the other lesser metatarsals. The 5th metatarsal heads demonstrated significantly decreased height. The width of the metatarsal heads was the only factor that significantly influenced the maximum reaming size achieved and the size of the implant introduced. Please see attached file for more results. Conclusion: 10mm synthetic polyvinyl alcohol hydrogel implants could be inserted safely in only 20% of the 2nd metatarsal heads. 8mm implants could be inserted in approximately 50% of the 2nd, 3rd and 4th metatarsal heads. The use of 6mm implants is probably safer and needs to be investigated.
P040 Cesar de Cesar Netto Ankle Ankle Fusion Percutaneous Home Run Screw Fixation: technical aspects and soft tissue structures at risk Alexandre Leme Godoy-Santos Martim Pinto Jackson Rucker Staggers Sameer Naranje Ashish Shah BACKGROUND/AIM Percutaneous positioning of a screw directed from the posterolateral tibial metaphysis into the talar neck ("home-run screw") during ankle fusions is technically demanding. The objective of this study was to identify the number of attempts necessary for a perfect positioning of the screw and the neurovascular and tendinous structures at risk. METHODS Eleven cadaver limbs were used. Guide wires (3.2mm) were percutaneously placed into the distal posterolateral aspect of the leg, under fluoroscopic guidance, with the ankle held in neutral position. Mal positioned pins were not removed. The number of guide wires needed to achieve an acceptable positioning of the implant was noted. After dissection, we evaluated neurovascular and tendinous injuries, and measured the shortest distance between the guide pins and the soft-tissue structures, using a precision digital caliper. RESULTS Mean number of guide wires needed to achieve acceptable positioning of the implant was 2.09 (SD 0.83, range 1 - 4). Distances between the closest guide pin and soft-tissue structures were: Achilles tendon 6.90mm (SD 3.74mm); peroneal tendons 9.65mm (SD 3.99mm); sural neurovascular bundle 0.97mm (SD 1.93mm); posteromedial neurovascular bundle 14.26mm (SD 4.56mm). Sural bundle was in contact with the guide pin in 5/11 specimens (45.5%) and transected in 3/11 specimens (27.3%). CONCLUSION Placement of percutaneous ankle fusion home-run screws is technically demanding and multiple guide pins are needed. Our study showed that important tendinous and neurovascular structures are in close proximity with the guide pins and that the sural bundle is injured in approximately 73% of the cases.
P041 Cesar de Cesar Netto Trauma Intraoperative Tap Test for Syndesmotic Instability: A cadaveric study Alexandre Leme Godoy-Santos Martim Pinto Jackson Rucker Staggers Sameer Naranje Ashish Shah Introduction Precise diagnosis of distal tibiofibular syndesmotic injury is challenging. Tibiofibular clear space (TFCS) identified on radiographic imaging is considered the most reliable indicator of the injury. The Cotton test is the most widely used intraoperative technique to evaluate the syndesmotic integrity although it has limitations. We advocate for a novel intra-operative test using a 3.5 mm cortical tap. Methods TFCS was assessed in nine cadaveric specimens using three sequential fluoroscopic images. First image was taken prior to the application of the tap test representing the intact and non-stressed state. Then, a 2.5mm hole was drilled distally on the lateral fibula, and a 3.5mm cortical tap was then threaded in the hole. The tap test involved gradually advancing the blunt tip against the lateral tibia, providing a tibiofibular separation force (intact, stressed). This same stress was then applied after all syndesmotic ligaments were released (injured, stressed). Results We found excellent intra-observer (0.97) and inter-observer (0.98) agreements. Significant differences were found in the paired comparison between the groups (p6mm as diagnostic for syndesmotic instability, the tap test demonstrated a 96.3% sensitivity and specificity, a 96.3% PPV and NPV and a 96.3% accuracy in diagnosing syndesmotic instability. Conclusions Our study showed that syndesmotic instability test using a 3.5mm blunt cortical tap is a simple, accurate and reliable technique to demonstrate significant differences in the TFCS when injury was present. It could represent a more controlled and stable alternative to the most used Cotton test.
P042 Cesar de Cesar Netto Forefoot First Tarsometatarsal Joint Shape and Orientation: Can We Trust in Our Radiographic Findings? Alexandre Leme Godoy-Santos Martim Pinto Jackson Rucker Staggers Sameer Naranje Ashish Shah Background/Aim Purpose of this study was to assess whether the shape and angulation of the first tarsometatarsal (TMT) joint are affected by the positioning of the foot and orientation of the x-ray beam. METHODS Ten adult cadaveric specimens used. A radiolucent loading apparatus was built, allowing positioning of a plantigrade foot and controlled angulation of 5o, 10 o, 15o and 20o in dorsiflexion, plantarflexion, inversion and eversion. Fluoroscopic images were obtained of each cadaveric specimen in all seventeen different positions, with the x-ray beam perpendicular to the floor and aiming to the base of the 1st metatarsal. Two blinded observers independently measured the 1st tarsometatarsal (TMT) joint angle, in the different possible foot positioning. RESULTS Mean value for 1st TMT joint angle was 112.92o±6.89o. Values were significantly different between the cadaveric specimens (p<.0001), ranging from 96.7o-129.98o. There was a tendency for increased valgus angulation when positioned in neutral, plantarflexion and inversion and decreased valgus with dorsiflexion and eversion. Regarding the shape of the distal articular cartilage of the medial cuneiform, joints with flat configuration showed significantly increased 1st TMT joint angle when compared to curved surfaces (115.9o vs. 110.7o, p<.0001). There was also a tendency for flattening of the joint in dorsiflexion and inversion. CONCLUSION Our study found that radiographic shape and angulation of the first TMT joint are affected by foot positioning and x-ray beam orientation. Clinical usefulness of 1st TMT radiographic anatomical characteristics is limited and should not influence decision in treating patients with 1st TMT clinical instability.
P043 Cesar de Cesar Netto Forefoot Instability of the First Ray and Hallux Valgus in Patients with Adult Acquired Flatfoot Deformity (AAFD): A Weightbearing CT Study Andrew Roney Guilherme Honda Saito Alessio Bernasconi Lauren Roberts Scott J Ellis Background/Aim Longitudinal arch collapse and first ray instability represent landmarks for adult acquired flatfoot deformity (AAFD), and have been linked to the development and progression of hallux valgus (HV). The purpose of this study was to assess the correlation between hallux valgus severity and foot collapse indicators using WBCT measurements, in patients with AAFD. Methods Retrospective comparative study, 108 patients with stage II AAFD, 36 men and 72 women, mean age of 54.4 (range, 20-78) years, had WBCTs evaluated by 2 blinded and independent observers. Readers assessed multiple variables: 1-2 intermetarsal angle, hallux valgus angle, talocalcaneal angle in the axial plane, talus-first metatarsal angle in the axial and sagittal planes, hindfoot alignment angle, hindfoot moment arm, navicular- and medial cuneiform-floor distance and talonavicular uncoverage angle. P-values <0.05 were considered significant. Results Intra- and interobserver reliability ranged from (0.65-0.99). Means and standard deviations for IM and HV angles were 11.3°±3.7° and 17.6°±13.4°, respectively. These angles significantly correlated with each other. Most of the AAFD measurements evaluated were significantly associated with either increased IM or HV angles. IM angle correlated with increased talocalcaneal (26.0°±10.3°), talus-first metatarsal (19.0°±13.6°), and hindfoot alignment angles (22.3°±12.9°). HV angle correlated with medial cuneiform-floor distance (15.1mm±5.5mm), talus-first metatarsal angle in the axial plane and sagittal plane (15.7°±8.8°, p=0.0351), talonavicular uncoverage angle (17.8°±13.9°). Conclusion This is the first study to confirm the association between AAFD, first ray instability and hallux valgus deformity using WBCT images. We found that stage II flatfoot patients indeed have increased intermetatarsal and HV angles.
P044 Cesar de Cesar Netto Hindfoot Foot Alignment in Basketball and American Football Elite Athletes. Are they different? Alessio Bernasconi Andrew Roney Lauren Roberts Francois Lintz Martin O'Malley Background/Aim The purpose of this study was to assess different WBCT measurements of hindfoot and forefoot alignment in injured high-level football and basketball players. We hypothesized that specific patterns of hindfoot alignment and height of the longitudinal arch of the foot could be identified. Methods Retrospective comparative study included 80 professional male athletes - 47 basketball and 33 American football players from College, NBA and NFL leagues - that underwent WBCT as part of the clinical investigation for different injuries. WBCTs images were evaluated by a blinded board-certified foot and ankle orthopedic surgeon. Multiple measurements used for assessment of hindfoot valgus and longitudinal arch height were assessed: foot and ankle offset (%), calcaneal offset (mm), hindfoot alignment angle (°), navicular and medial cuneiform-floor distances (mm), forefoot arch angle (°), inferior talar-superior talar angle (°), and subtalar horizontal angle (°). Results A summary of demographic characteristics and measurement’s distributions is given in table 1. No significant differences were found between basketball and American football elite athletes when comparing the mean values of measurements evaluated (mean differences): foot and ankle offset (0.26%), calcaneal offset (0.58mm), hindfoot alignment angle (0.73°), navicular-floor (0.35mm) and medical cuneiform-floor distances (0.38mm), forefoot arch angle (0.74°), inferior talar–superior talar angle (0.83°) and subtalar horizontal angle (0.1°). Conclusion Although we didn’t find significant differences in foot alignment when comparing basketball and American football professional athletes, the results of our study highlight some of the important foot alignment parameters and establish distributions in an extreme but important population.
P045 Cesar de Cesar Netto Hindfoot Hindfoot Alignment in Stage II Adult-Acquired Flatfoot Deformity: Can Clinical Evaluation Predict Radiographic Measurements? Grace Kunas Anca Marinescu Dylan Soukup Lauren Roberts Scott J Ellis Background and Aim: Purpose of this study was to evaluate the correlation between radiographic and clinical evaluation of hindfoot alignment in patients with stage II adult-acquired flatfoot deformity (AAFD). Methods: Twenty-nine patients (30 feet) with stage II AAFD, 17 men and 12 women, mean age of 51 (range, 20 to 71) years, were prospectively recruited. Radiographic parameters were measured by two blinded and independent readers: hindfoot alignment angle (HAA) and hindfoot moment arm (HMA). Clinical photographs of hindfoot alignment were taken, in three different vertical camera angulations (0, 20 and 40 degrees). Pictures were assessed by the same readers for standing tibiocalcaneal angle (STCA) and resting calcaneal stance position (RCSP). Results: We found almost perfect intra- (range, 0.91-0.99) and interobserver reliability (range, 0.74-0.98) for all measures. Mean value and confidence interval (CI) for RCSP and STCA were 10.78 degrees (CI: 10.09-11.47) and 12.55 degrees (CI: 11.71-13.40), respectively. Position of the camera didn’t influence clinical alignment (p>.05). Average HMA was 18.74mm (CI: 16.34-21.14mm) and mean HAA was 23.54 degrees (CI: 21.08-25.99). Clinical and radiographic hindfoot alignment were found to significantly correlate (p
P046 Laurens De Cock Forefoot Good Results after First Metatarsophalangeal Joint Fusion Using Kirschner Wires with Incorporation of the Sesamoids into the Fusion. Arne Burssens Dominique Spaepen Peter Mertens Kris Buedts Background: First metatarsophalangeal (MTP) joint fusion is a commonly performed procedure for a variety of pathologies of the first MTP joint. Many fixation constructs for first MTP joint fusion have been described. A trend toward more costly fixation methods is being observed. The senior author uses two crossed Kirschner (K)-wires and incorporates the sesamoids into the fusion. Aim: The primary purpose of this study was to evaluate the non-union rate of our technique. Methods: A retrospective review of all first MTP joint fusions performed by the senior author was performed, using the archived records of operations performed from 2008 until 2014. All patients had undergone incorporation of their sesamoids into the fusion. Patients were excluded if other fixation methods than two crossed K-wires were used or if they were diagnosed with rheumatoid arthritis. Results: A total of 91 feet in 79 patients met the inclusion criteria. The rate of union was 97.8% (2 non-unions). The mean age was 59 years and mean follow-up period was 58 months. Postoperative the mean Visual Analog Scale (VAS) for pain was 1.3 and mean AOFAS hallux score was 77 out of 90. Conclusion: This present study suggests that a less costly fixation using two crossed K-wires for first MTP joint fusion can lead to a high incidence of fusion in carefully selected patients. To our knowledge, this study reports on the largest patient group to date, to evaluate the radiographic and functional results after first MTP joint fusion, using two crossed K-wires and incorporation of the sesamoids into the fusion.
P047 Laurens De Cock Forefoot Correction of Intermetatarsal Angle as Result of First Metatarsophalangeal Fusion: Are there Predictive Factors Contributing to the Correction? Willem-Jan Vleugels Kris Buedts Geoffrey Vandeputte Sander Wuite Giovanni Matricali Introduction: Fusion of the first metatarsophalangeal joint (MTPJ) is a commonly performed treatment of first ray deformities. Although the effect of first MTPJ fusion on reduction of Intermetatarsal angle (IMA) is well described, our purpose was to find radiographic parameters that could predict this reduction. Materials and methods: We retrospectively reviewed our database for first MTPJ fusions performed on feet with a preoperative IMA greater than fourteen degrees. On standard radiographs the following measurements were performed: IMA, hallux valgus angle (HVA) and length of the first and second metatarsal. Translation at the base of the metatarsal and translation in the MTPJ fusion was measured together with position of the sesamoids. There was a recording of the fixation method. In order to identify independently associated predictors for IMA correction, a backward selection procedure was applied retaining variables with p < 0,05, using a linear regression model with IMA correction as continuous outcome variable. Results: We included 71 feet in our analysis and the mean preoperative IMA was 16.11 degrees with a mean reduction of 3.96 degrees after surgery. Four independently associated predictors for IMA correction were found (p < 0.05): An increase in preoperative IMA and medial translation at the base of the first metatarsal increased the chance of IMA reduction. Translation of the phalanx lateral in relation to the metatarsal head in the fusion, a dorsal plate or crossed screws as fixation method in comparison to Iofix decreased the chance of IMA reduction. Discussion: IMA and translation at the base of the first metatarsal can preoperatively predict IMA reduction after first MTPJ fusion. Surgeons should fuse the first MTPJ without translation in the fusion and position the phalanx maximally medial in relation to the metatarsal head.
P048 Baljinder Dhinsa Forefoot FIRST METATARSOPHALANGEAL FUSION USING JOINT SPECIFIC DORSAL PLATE WITH INTERFRAGMENTARY SCREW AUGMENTATION; CLINICAL AND RADIOLOGICAL OUTCOMES Ahmed Latif Benjamin Lau Laila Hussain Ali Abbasian Background Arthrodesis of the first metatarsophalangeal joint (1st MTPJ) is a recognised technique for the treatment of hallux rigidus, severe hallux valgus, failed 1st MTPJ surgery, instability and traumatic arthritis. It is not clear whether one fixation method is superior to others, however biomechanical studies have suggested that the combination of a lag screw and a dorsal plate conveys the greatest stability. Aim This study reports the outcome of a plating system that incorporates a lag compression screw within a low profile titanium plate which is positioned dorsal to the joint with a predetermined contour. Methods This is a prospective cohort study of 40 consecutive primary 1st MTPJ arthrodesis procedures performed between August 2013 and November 2016. All the procedures were performed by a consultant foot and ankle surgeon, and each patient had the same postoperative rehabilitation protocol. Results All patients achieved clinical union by 6 weeks and radiological union was confirmed on plain radiographs between 6 - 16 weeks. Infection was not observed in any case. The mean MOXFQ and EQ5D scores were significantly improved at final follow up (range, 3 to 42.1 months). One case of hardware removal was reported for prominence of the plate tip. Conclusion First MTPJ fusion utilising the anchorage cross plate achieved consistently satisfactory results with a reliable and reproducible MTPJ position and a 100% union rate. The complication rates were close to zero with only 2.5% (1/40) rate of hardware removal.
P049 Baljinder Dhinsa Forefoot The management of dorsal peroneal nerve compression in the midfoot Laila Hussain Sam Singh Background The foot and ankle specialist will frequently encounter patients with dorsal midfoot pain in clinic. In the presence of midfoot pain and/or paraesthesia, nerve entrapment must be considered. Aim The authors aim to report the outcome of a case series of patients who underwent surgical release of the deep peroneal nerve (DPN). Methods Between 2011-2017, a single surgeon operated on seven patients with a diagnosis of DPN entrapment. A retrospective review of the patient's clinical notes was performed, including the operative findings. Results The average age at presentation was 47 years (range, 31-70 years), and the left foot was affected in four cases. In all cases the patient presented with dorsal midfoot pain, with three cases associated with paraesthesia. The mean follow up was 25 months (range, 4-70 months), with six of the patients discharged with their pre-operative symptoms settled. One patient who had good immediate pain relief following DPN neurolysis, extensor halluces breveis tendon resection and reduction of exostosis developed recurrence of the neuropathic pain at five years. Despite non-operative management the symptoms did not settle and exploration of the DPN was performed. Conclusion The anatomical position of the DPN, and its site of compression, may vary however it can be localised by a positive Tinel's sign and targeted injection with local anaesthetic. All the patients that underwent surgical exploration and decompression had a good outcome, with one patient requiring further neurolysis for impingement.
P050 Baljinder Dhinsa Trauma Fractures of the Anterior Process of the Calcaneum; a review and proposed treatment algorithm. Ahmed Latif Roland Walker Ali Abbasian Diane Back Sam Singh Aim To assess the mechanism and configuration of these fractures, perform a literature review and develop a treatment algorithm. Methods A comprehensive literature search was performed. Following inclusion and exclusion criteria, 23 studies were available for analysis. Results Delay in diagnosis is common and has a negative impact on outcome. If an APC fracture is suspected; anteroposterior, lateral and oblique plain radiographs should be requested. Further investigation with computed tomography or magnetic resonance imaging is indicated if plain radiographs are inconclusive and patient remains symptomatic. Non-operative measures are usually adequate for most undisplaced fractures, however surgical intervention maybe required for large, intra-articular fractures in the acute setting and for non-union. Conclusions A treatment algorithm is suggested that may help with the diagnosis and management of these injuries.
P051 Elvira Di Cave Ankle Osteochondral lesions of talus treated with biphasic bioresorbable scaffold (TruFit Plug®): 6- to 8-year follow-up Lorenzo Marcellini, MD Pierluigi Versari, MD David Luzon, MD BACKGROUND: The ideal treatment of osteochondral lesions of the talus (OLT) is debatable. The TruFit plug has been investigated as a potential treatment method for osteochondral defects. This is a biphasic scaffold designed to stimulate cartilage and subchondral bone formation. The purpose of this retrospective study was to investigate the long-term functional and MRI outcomes of the TruFit Plug for the treatment of OLT. METHODS: We evaluated 12 consecutive patients treated from March 2007 to April 2009 for OLT. Clinical examination included the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score and the visual analog scale (VAS) for pain. MRI scans were optained pre-treatment and at last follow-up. The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was used to assess cartilage incorporation. RESULTS: Mean follow-up was 7.5 years (range, 6.5 to 8.7 years). The average age was of 38.6 years (range, 22 to 57 years). The sex ratio between males and females was 3:1 (9 males, 3 females). The mean AOFAS score improved from a preoperative score of 47.2 ± 10.7 to 84.4 ± 8 (p< 0.05). According to the postoperative AOFAS scores 1 case obtained excellent results, 9 were classified as good, and 2 were fair. VAS score improved from a preoperative value of 6.9 ± 1.4 points to 1.2 ± 1.1 points at last follow-up (p< 0.05). The MOCART score for cartilage repair tissue on postoperative MRI averaged 61.1 points (range, 25-85 points). CONCLUSIONS: The long-term results suggest that the technique of Trufit Plug for OLT is safely and demonstrates good post-operative scores including improvement of pain and function, with discordant MRI results. However, randomized controlled clinical trials comparing TruFit Plug with an established treatment method are needed to improve synthetic biphasic implants as therapy for osteochondral lesions.
P052 Xiaojun Duan Ankle Application of 3D PrintedPersonalized Guide in Arthroscopic Ankle Arthrodesis Peng He Huaquan Fan Fuyou Wang Liu Yang Background: Ankle arthrodesis is an effective treatment for end-stage ankle arthritis, which often requires to keep the ankle joint to the functional position with screws. The accurate positioning of Kirschner wire plays an important role in ankle arthrodesis. Aim: The purpose of this study was to accurately drill the Kirschner wire with the help of the 3D printed personalized guide, and to evaluate the feasibility of the 3D technology as well as the outcome of the surgery. Method: Patients’ DICM data of ankle via CT examination were introduced into the MIMICS software, and the personalized guides were designed at the surgeon’s discretion. The guides, which were made with polylactic acid (PLA) as the raw material by the 3D printing technology, were sterilized with ethylene oxide before surgery. After routine arthroscopic debridement of the residual cartilage, two 2mm Kirschner wires were drilled with the help of the guides; the C-arm X-ray fluoroscopy was used to confirm the position of wires before applying the cannulated screws. The patients who underwent ankle arthrodesis during Jan 1, 2014 to Jun 30, 2016were divided into two groups. The experimental group adopted the 3D printed personalized guides, while the control group received traditional method, i.e., drilling the Kirschner wires according to the surgeon’s experience. The time of completing the procedure of drilling the Kirschner wires to correct position were compared in the two groups. Regular follow-ups were conducted to statistically analyze the differences of the ankle fusion time and AOFAS scores between the two groups. Results: 3D printed personalized guides based on patients’ ankle CT data were successfully prepared. A total of 29 patients were enrolled, with 15 in the experimental group and 14 in the control group. It took 2.2 ± 0.8 minutes for completing the procedure of drilling the Kirschner wires to correct position in the experimental group and 4.5 ± 1.6 minutes in the control group (P<0.01). No obvious complications occurred in the two groups during and after the surgery. Postoperative radiographs confirmed bony fusion in all cases. There were no significant differences in the fusion time and AOFAS scores 1 year postoperatively between the two groups (Student's t test). Conclusion: The application of 3D printed personalized guide in assisting the accurate drilling of Kirschner wire in ankle arthrodesis can shorten the operation time and reduce the intraoperative radiation to surgeons and patients. This technique does not affect the surgical outcome.
P053 Xiaojun Duan Hindfoot Arthroscopically assisted anterior treatment of symptomatic large talar bone cyst Background: The symptomatic cystic lesions of the talus are rare. Traditional operations usually do not provide visualization to reveal the deep structure of the lesion and can cause cartilage damage or other severe traumatic injury. Aim: This study presents an innovative technique to reach the cystic lesion without talar cartilage damage, then remove the lesion and fill defect with bone graft assisted by anterior arthroscopy, and evaluates its safety and reliability for future study. Method: Seven cases of talar bone cyst were included. Standard anteromedial and anterolateral portals were established to observe the ankle; then the distal end of the medial approach was moderately enlarged to 2-3 centimeter. The biopsy of cyst was obtained under arthroscope; the cyst wall was abraded and the sclerotic rim was drilled. Arthrocare radiofrequency ablation was performed to prevent recurrence. The defect was tightly impacted with autologous or allograft cancellous bone. American Orthopaedic Foot and Ankle Society (AOFAS) score were done regularly during the follow-ups, and radiological assessment and CT scan were applied to observe the efficacy at 1 year postoperatively. Results: All cysts in these series of cases were located in the medial talus. Two cases were impacted with grafted autogenous iliac bone into talar defect, and 5 cases with allograft cancellous bone. CT scan confirmed that the cysts were healed and no signs of recurrence was found in all patients at 1 year postoperatively. The mean AOFAS score increased from preoperative 65 points to postoperative 91 points with statistical significance (p<0.01). There were no complications and reoperations postoperatively. Conclusion: Arthroscopically assisted anterior treatment with autologous or allograft bone graft is an effective method for symptomatic large talar bone cyst.
P054 Xiaojun Duan Ankle Arthroscopic arthrodesis for ankle arthritis without routine bone graft Liu Yang Background: Ankle arthrodesis is considered by many to be the standard operative treatment for end-stage ankle arthritis. Aim: The purpose of this study was to perform the new technique application for ankle joint surface and determine the outcome for the union rates of ankle arthroscopic arthrodesis. Methods: A total of 79 patients with posttraumatic arthritis, primary osteoarthritis, and rheumatoid arthritis were treated by ankle arthroscopic arthrodesis between May 2007 and December 2013. Our surgical indication was deformity less than 15 °measured by weight-bearing radiographs. Firstly, the remaining articular cartilage was removed with different curettes and shavers. Then the new technique (microfracture) was done at tibiotalar surfaces. Finally the ankle was fixed with two cannulated percutaneous screws. The wound healing, complications, postoperative radiographs, and AOFAS score were evaluated. Results: The average follow-up time was 33 months (range 25-58 months). No bone grafting and a fusion rate of 100% was achieved. The average fusion time was 12.1 weeks. One patient developed superficial infection at two weeks and it was cured by non- surgical treatment. No deep infections, deep venous thrombosis, or revision surgery were observed. Screws had been removed in four patients because of prominence. One patient had fusion the subtalar joint because of arthritis at 5 years postoperatively. In the lastest follow-up, radiographic signs of developed or progressing arthritis were observed in 9 patients at subtalar joint and in 4 patients at talonavicular joint. At 1-year follow-up, the mean AOFAS ankle/hindfoot score had increased to 84 from a mean preoperative value of 38 (P<0.01). Conclusions: Arthroscopic arthrodesis provides surgeons with an alternative to traditional open techniques for the management of severe ankle arthritis. Preparation of the joint surface with microfracture has been demonstrated to increase the union rate of arthroscopic ankle arthrodesis, while bone graft and other promoting substance are not necessary to be routinely used.
P055 Hani El-Mowafi Reconstructive Foot Deformity Correction. Is there a window for Prevention, Enhance the healing, and decrease the recurrence rate of the planter ulceration? Yasser Kandil Ahmed El-Hawary Background: Diabetic foot ulcers (DFUs) are among the most serious and devastating complications of 
diabetes. Patients with active DFUs suffer from a lowered quality of life as great as that 
of amputee. Bony deformity secondary to diabetic Charcot arthropathy is a leading cause in development of diabetic foot ulcers (DFUs). Aim: Our goal is to define the role of correction of the foot deformity in managing diabetic foot ulcers and to evaluate the results of healing of plantar ulcer. Material and Methods: A series of 20 patients, (5 forefoot, 11 midfoot and 4 hindfoot ulcers). All plantar ulcers were treated by operative correction of foot deformity without excision of the ulcer. Results: The mean follow up was 34.7±19.2 (range, 12-72) months. All the plantar ulcers healed in an average time of 5.5±0.9 weeks. There were 2 cases ulcer recurrence. The mean AOFAS Score was improved significantly from 31.63 ± 7.2 to 69.7±8.3 (p < 0.05). Conclusion: Analysis of the foot deformity biomechanically and correcting the foot mechanics is the corner stone in treatment of DFUs. Plantar ulcers should be left to heal spontaneously after correction of bony deformity. Rrecent guidelines for management of DFUs should clearly include orthopaedic management for correction of bony deformity as a primary step in dealing with Prevention, help the healing and decrease the rate of the recurrence of DFUs.
P056 Mohammed Elsayed Forefoot Early Functional outcome following surgical reconstruction in patients with a delayed presentation of TURF toe injury Amit Chauhan Prasad Karpe Rajiv Limaye Background: Turf toe is a sprain of the MTPJ due to a hyperextension injury of a dorsi flexed toe and a plantar-flexed foot against a ground surface with the contribution of some axial loading. The plantar-plate complex is designed to resist dorsiflexion of the first MTPJ and the degree of damage depends on the overall severity of the injury and forces to the joint. Aim and Method: A prospective analysis to assess patient outcomes and complications in a consecutive series of patients who underwent surgical treatment for turf toe by a single foot and ankle surgeon. Outcome was measured using the Manchester- Oxford foot questionnaire (MOxFQ). Results: The study included 7 patients with turf toe injury. The MOxFQ scoring system showed statistically significant improvement in all three domains (walking/ standing, pain and social interaction). The MOxFQ summary index score showed a clinically and statistically significant improvement from a mean of 70.3 (median 67.2) preoperatively to 23.4 (median 25.0) following the repair (median improvement 48.3, P = 0.022). The mean time to return to normal activity after the surgery was 4.0 months (median 3.0 months) and none of the patients had any complications or recurrence. Conclusion: Management of turf toe involves correct diagnosis and careful selection of candidates for surgery. This study demonstrates that excellent functional outcomes can be obtained with surgical treatment of turf toe.
P057 Mohammed Elsayed Ankle Mid-term outcomes following Supra-malleolar Osteotomies as a treatment for eccentric ankle osteoarthritis Amit Chauhan Prasad Karpe Rajiv Limaye Background: Surgical treatments for ankle osteoarthritis have been limited to arthrodesis or ankle replacement. Supramalleolar osteotomy provides a joint-preserving option for patients with eccentric osteoarthritis of the ankle. Aim and Method: Prospective review to evaluate radiological and functional outcomes in patients following supramalleolar osteotomy between 2010 and 2015. Osteotomy was the primary surgical procedure in all patients after failure of nonoperative measures. Pre-operative standing antero-posterior and Saltzman view radiographs were taken to evaluate degree of malalignment requiring correction. Radiological and clinical outcomes were assessed at 3, 6, 12, 18 and 24 months post-operatively. Radiographs were reviewed for time of union. Patients were assessed on an outpatient basis for ankle range of motion as well as outcomes using AOFAS scores. Results: 17 patients over a 7 year period. Mean follow-up was 37.7 months (range 23-75). Radiological union occurred at a range of 8-10; there were no cases of nonunion. The pre-operative AOFAS scores for patients ranged from 15 – 40 and post- operative scores ranging from 74 – 92, Paired student t-test comparing pre-operative to post-operative scores gives 52.7 improvement, confidence interval of 49.0 to 56.5, P = 0.0001 statistically significant (student t-test, 52.7, CI = 49.0 - 56.5, P = 0.0001). Conclusion: Supramalleolar osteotomy is a viable joint preserving option for patients with eccentric osteoarthritis of the ankle. It preserves motion, redistributes forces away from the affected compartment and corrects malalignment, providing significant symptomatic and functional improvement.
P058 Parag Garg Forefoot First Metatarsophalangeal Joint Arthrodesis Using an Intra-Osseous Post and Lag Screw with Immediate Bearing of Weight PARAG GARG M ALI FAZAL PINAK RAY Background - Arthrodesis is the gold standard procedure for advanced arthrosis of the first metatarsophalangeal joint. Having a strong construct is preferable for allowing immediate bearing of weight which facilitates patient rehabilitation. Plate and screw fixation is currently in favour but this can lead to prominent metalware necessitating removal. Aim - To present the largest reported series of using the IO Fix™ (Extremity Medical, NJ, USA) implant which comprises of an intra-osseous post and lag screw when performing first metatarsophalangeal joint arthrodesis; a device offering stronger fixation than screws alone while theoretically minimizes soft tissue irritation. Method - We conducted a review of 54 (N = 54) feet in 52 patients. All patients had a minimum follow-up of 1 year whose indications were end-stage hallux rigidus (44 feet), severe hallux valgus (8 feet), and rheumatoid arthritis (2 feet). All patients were seen by a chartered physiotherapist preoperatively and fitted with a rigid soled shoe and given crutches. Results - The mean MOXFQ score improved from 46.4 ± 13.3 to 18.4 ± 9.4 (p < 0.001) at latest follow-up. Arthrodesis was achieved in 52 feet (96.3%) at a mean of 61 ± 16 (range 39 to 201) days with non-union observed in 2 feet (3.7%); neither of whom had known risk-factors. Metalware impinging upon soft tissues necessitating removal was observed in 3 feet (5.6%) and there were no cases of loss of position or implant breakage. Conclusion - The IO Fix™ device is safe and effective and provides an alternative method of stabilizing the metatarsophalangeal joint when undertaking arthrodesis surgery.
P059 Albert Ginés-Cespedosa Forefoot IS SF-36 A HELPFUL QUESTIONNAIRE TO MEASURE OUTCOMES IN FOREFOOT SURGERY? Daniel Pérez-Prieto Ferran Corcoll Carrasco Pablo Feito Martínez Gemma González-Lucena Background The SF-36, a self-administered questionnaire, assesses health related quality of life (HRQL) with 36 items divided into 8 dimensions and 2 summary components. It is widely used to analyze the impact of different surgical procedures on patient quality of life. The aim of the study is to analyze the questionnaire’s capacity for detecting changes or the responsiveness of the test in patients after forefoot surgery. Method Eighty-three patients who had undergone forefoot surgery completed the SF-36 and Manchester-Oxford Foot Questionnaire (MOXFQ) prior to the intervention and at one year of surgery. Pain was also assessed through the visual analogue scale (VAS). The ability of the SF-36 to detect changes and their magnitude were evaluated by analyzing the psychometric properties of the test dimensions. For the statistical analysis, the T-test and Effect Size (ES) were used. Results Pre-post differences were statistically significant for the domains: bodily pain (p=0.00), vitality (p=0.002) and mental health (p=0.00). Likewise, the effect size for these 3 domains was moderate: bodily pain (ES> 0.7), vitality (ES> 0.4) and mental health (ES> 0.4). For the rest of the domains the ES was low (ES<0.2). The SF-36 showed a lower responsiveness with respect to MOXFQ (ES> 0.7). The correlation between the bodily pain domain and VAS was moderate ([r]>0.48 p<0.05). Conclusion SF-36 questionnaires present good responsiveness for bodily pain but is less accurate for assessing other types of changes in forefoot surgery patients’ HRQL. The scale’s sensitivity is lower than some self-administered scores like the MOXFQ.
P060 Gemma González-Lucena Forefoot VALIDITY OF THE SPANISH MANCHESTER-OXFORD FOOT QUESTIONNAIRE (MOXFQ) IN PATIENTS THAT UNDERWENT FOREFOOT SURGERY. Daniel Pérez-Prieto Aleix Sala Pujals Elisenda Giménez Valero Albert Ginés-Cespedosa Background The Manchester-Oxford Foot Questionnaire (MOXFQ) has been validated in different languages. Most of those validating works included different kinds of foot and ankle surgery. The aim of this study was to assess the validity of Spanish MOXFQ in patients operated on for forefoot pathologies. Method Eighty-three patients who had undergone forefoot surgery completed the MOXFQ and SF-36 scale prior to surgery and 1-year postoperatively. Pain was also assessed through the visual analogue scale (VAS) as well as the American Orthopedic Foot and Ankle Society (AOFAS) Clinical Rating System. Psychometric properties were assessed for all three MOXFQ dimensions, and for the MOXFQ Index. Results The Spanish MOXFQ demonstrated consistency and reproducibility with Cronbach’s alpha values between 0.77 and 0.95 ([ICCs]>0.95). It showed a moderate correlation between the Walking/standing dimension and the related domains of the SF-36 ([r]>0.43, p <0.05). A high correlation between the Pain dimension and VAS scale ([r]>0.67, p<0.05) was seen. Responsiveness was excellent with effect size >1.5, except for the social domain at 0.7. Conclusion The Spanish version of the MOXFQ showed good psychometric properties in patients with forefoot problems. It should be considered a validated score to be used in these kinds of patients.
P061 Matteo Guelfi Ankle All-inside lateral collateral ligament repair for chronic ankle instability: anatomical study on safety, reliability and reproducibility Stefano Negri Francesc Malagelada Jordi Vega Background: Anatomic structures are at risk of entrapment by the sutures used during arthroscopic all-inside lateral collateral ligament repair. Aim: This study aimed to 1) evaluate the risk of damage to anatomic structures, 2) the anatomical reliability in terms of ligaments reinsertion and reproducibility of the original footprint and 3) the learning curve of this technique. Method: Twelve fresh-frozen unpaired below-knee specimens were used for the study. Two foot and ankle arthroscopists with different level of experience in this arthroscopic technique, performed the repair independently. To simulate a chronic ankle instability the lateral collateral ligament was previously detached with an osteotome through the anterolateral portal. The repair was then performed following a standardized procedure as originally described. After the repair was finalised, an experienced anatomist dissected all the specimens. Results: Dissections revealed no cases of sutures causing entrapment of any of the surrounding anatomic structures. In all specimens (100%) both fascicles of the ATFL were reinserted onto its original footprint. No differences were noted in terms of structures entrapment or ligaments reinsertion site between the 2 surgeons. Conclusions: The all-inside arthroscopic lateral collateral ligament repair is a safe, reliable and reproducible technique. This study has proven that it provides an anatomic repair of both fascicles of the ATFL with minimal risk of entrapment of surrounding anatomical structures by sutures. In addiction it has been shown to benefit from a shallow learning curve, given that the surgeon has a sound level of knowledge of ankle arthroscopy and arthroscopic anatomy.
P062 Naren Gurbani Ankle Arthroscopic Management of Post-Traumatic Arthritis of Ankle and Subtalar Joints Background: Even after optimum management of traumatic joint injuries, prevalence of post-traumatic arthritis is 12 to 15%. In ankles, 70% of arthritic cases are post trauma. Most common management of end stage arthritis of ankle and foot joints is open arthrodesis, with success rate of around 80% Aim: This retrospective study proves that Arthroscopic Ankle and Subtalar arthrodesis has evolved as safer and more effective alternative to open arthrodesis due to preservation of soft tissue envelope. Method: Arthroscopic arthrodesis was performed in 96 ankles and 34 Subtalar joints to treat end stage post-traumatic arthritis. No tourniquet was used and all surgeries were performed on outpatient basis. Preparation of tibio-talar and talo-calcaneal surfaces to subchondral bone was achieved using arthroscopic instruments. Under fluoroscopic guidance, two cannulated screws were inserted from medial and lateral tibial surfaces into talus. For subtalar arthrodesis, a single cannulated screw was used from calcaneum into talus. The screw used is a self-tapping, fully threaded, variable pitch titanium screw with tapered profile and headless design. Postoperative care included non-weight bearing for two weeks followed by incremental weight bearing as tolerated in cam-walker. Results: Average time until union was around eight weeks as determined by serial X-rays. The arthrodesis rate was 95.3% with fewer complications. Conclusions: Incremental compression screw design simplifies surgical technique, reduces risk of incisional complications, provides reliable compression resulting in higher arthrodesis rate in shorter time. A non-invasive soft tissue distracter for ankle and a versatile skeletal distractor for subtalar joint provides adequate distraction
P063 Xing Fu Daniel Hap Ankle Early Results of A Novel Percutaneous Modified Bostrum-Gould Procedure for Lateral Ankle Instability Guan Tzu, Tay Background Many patients with ankle sprains progress to chronic lateral ankle instability despite adequate conservative treatment. The open modified Brostrum-Gould repair technique is widely accepted as the standard for lateral ankle stabilization. Aim We describe a percutaneous modification of the Brostrum-Gould procedure for lateral ankle instability and report its early results. Methods A total of 10 patients underwent the modified Brostrum-Gould procedure in our institution over a period of 6 months. All surgeries were performed by a single fellowship-trained Foot and Ankle surgeon. Our surgical technique involves making a sub-centimeter incision at the anterior aspect of the distal fibula. Dissection is made down to bone and a -loaded suture anchor is placed at the ATFL origin. The sutures are then loaded individually into a trocar needle and passed underneath the remnant ATFL and inferior extensor retinaculum at its distal extent. Percutaneous stab incisions are made to allow retrieval of the sutures which are passed subcutaneously back to the ATFL origin. The two sets of sutures, positioned to recreate the ATFL and CFL, are then secured with the ankle in eversion and plantigrade position. Patients are placed on a short walker boot and 2 to 3 weeks of non-weightbearing post-operatively. Results Follow-up period ranged from 3 to 6 months. Patients were reviewed in the outpatient clinic and administered functional outcome questionnaires (AOFAS ankle-hindfoot and SF-12 scores). The results in our series have been promising, with excellent outcome scores and no complications reported. Conclusion The early results of our modification of the Brostrum-Gould procedure are favourable. Further studies are needed to ascertain the long term outcome of our technique.
P064 Makoto Hirao Reconstructive Use of autologous calcaneal bone grafting and interconnected porous hydroxyapatite ceramic (IP-CHA) for bone transplantation in rheumatoid foot surgery Kosuke Ebina Akira Miyama Yuki Etani Kenji Takami Hideki Yoshikawa Background Cancellous bone grafts from the calcaneus have been used for the foot and ankle as well as iliac bone graft, however there is a sparse report for calcaneal bone transplantation in the field of rheumatoid foot surgery. Aim In this study, safety and usefulness of calcaneal bone grafts, and combination with interconnected porous hydroxyapatite ceramic (IP-CHA) was evaluated in rheumatoid arthritis (RA) foot surgeries. Method Of 6 RA cases, 3 (talo-navicular joint fusion) used a calcaneal bone graft alone, and the remaining 3 cases (subtalar joint and talo-navicular joint fusion) used a combination of calcaneal bone graft and interconnected porous hydroxyapatite ceramic (IP-CHA) augmented with dense calcium hydroxyapatite for subtalar bony defect (1.5-2.0cm) after the correction. Pre and postoperative Japanese Society for Surgery of the Foot (JSSF) RA foot ankle scale scores were obtained for the clinical assessment. As radiographic assessment, Tibio-calcaneal (TC) angle, calcaneal pitch, talo-1st metatarsal angle, and pronated foot index were also evaluated. Results After starting weight-bearing or walking, there was no pain and skin trouble at the fusion and harvesting sites. All cases achieved bony fusion within 6-10 weeks. JSSF RA foot ankle score was improved in all 6 cases. Furthermore, TC angle, talo-1st metatarsal angle, and pronated foot index were also improved at latest follow-up in all cases. Conclusion Autologous bone grafting from the calcaneus was safe and convenient even in rheumatoid foot surgeries. For larger bony defects (1.5-2.0cm), combination use with IP-CHA augmented with dense calcium hydroxyapatite was also useful.
P065 Cristian Indino Ankle Return to sport after arthroscopic Autologous Matrix-Induced Chondrogenesis in patients with osteochondral lesion of the talus. D'Ambrosi Riccardo Manzi Luigi Maccario Camilla Di Silvestri Claudia Angela Usuelli Federico Giuseppe Background Osteochondral talar lesions are common entities in young adults who actively practice sports. Many patients ask to return to the same activity level they had before the onset of symptoms. Aim The aim of the study was to evaluate the return to sport in patients underwent arthroscopic autologous matrix-induced chondrogenesis (AT-AMIC) 2 years after surgery. Method 31 patients of which 64.5% male (average age: 33.9 years old), were included in the study. All patients were assessed with the American Orthopaedic Foot & Ankle Score (AOFAS), physical component score of the 12-Item Short Form Health Survey (PCS-SF-12), HALASI ankle activity score and University of California, Los Angeles (UCLA). Each patient was evaluated pre-operatively and at a minimum follow-up of 24 months after surgery. Results 80.3% of the patients group to the same level of activity before injury. Mean follow-up resulted 44.8 months. Significant differences were observed as regards AOFAS, SF-12, HALASI and UCLA scores at the last follow-up (p<0.001). Conclusion Good percentage of patients were able to return to their pre-injury sport level after arthroscopic autologous matrix-induced chondrogenesis surgery.
P066 Anton Kachesov Forefoot Comparison of two types of osteotomy for correcting of lesser rays in forefoot reconstruction O.B. Nosov Y. El Moudni Background. Correction of lesser toes in forefoot deformity is still challenge for surgeons. Consequences of operation as “floating toes”, deviation of the lesser toes, recurrent metatarsalgia make this problem actual. Aim is to analyze results of Weil osteotomy (WO) compared to the screwed Helal osteotomy (SHO) in patients with transverse flatfoot. Methods. 82 patients (131 feet) with forefoot deformities: hammer toe, subluxation of lesser toes, metatarsalgia were observed prospectively for 1 year. General function and clinical evaluation were determined using, the American Orthopedic Foot and Ankle Society (AOFAS) questionnaire. “Floating toes” were found by examination of the foot. Deviation of lesser toes were measured by Vidar Dicom Viewer. Evaluation of plantar pressure (PP) under the lesser metatarsal heads (LMH) was done using F-scan. Results. In the research were included 78 (125) patients, leaving 4 patients (6 feet) were unavailable. WO with wedge excision and screwing of the lesser rays were done in group 1. Patients of group 2 were underwent Helal osteotomy, transfer point of rotation with screwing (Tab 1). Analysis of PP demonstrated significant decrease of the plantar pressure under the LMH in both groups. Results are presented in Tab.2, Fig 1,2,3. Conclusions. SHO provides to correct lesser toes deviation and prevent “floating toes” after forefoot reconstruction more effectively than WO. Transfer of the point of rotation allows to correct lesser toe position in sagittal and horizontal planes. There was not any significant different between WO and SHO in AOFAS score and PP under LMH.
P067 Yoon-Chung Kim DM foot Blood viscosity as a clinical parameter for DM foot amputation Jae Hoon Ahn Joonyoung Park Yoon Joo Cho Youngseok Moon Jongbin Kim Background Blood viscosity(BV) is the force that counteracts the free sliding of blood layers within the circulation and depends on the internal cohesion between the molecules and the cells. Clinically, BV is a useful parameter in cardiology, neurosurgery and hematology. BV is higher in diabetic patients, however, data from whom experienced bad prognosis including amputation are missing. Therefore, BV should be considered as a clinical parameter from the point of view of foot and ankle surgeon. Aim We investigated the predictability of BV for bad prognosis in diabetic patients. Method Retrospective review of 250 patients who have diabetes, coronary arterial disease(CAD), peripheral arterial disease(PAD), venous insufficiency, peripheral neuropathy, or other intractable lower extremity wounds. BV tests for all patients using a scanning capillary method were performed between January 2017 and February 2018; systolic and diastolic BV data were obtained, separately. ODI(oxygen delivery index) using hematocrit was calculated which reflects tissue hypoxia. Patients’ age, sex, smoking history, blood pressure, blood glucose, glycated hemoglobin(HbA1c) and lipid profiles were investigated as well. Patients’ medication history for antiplatelet/anticoagulant agents and surgical history including minor/major amputation were investigated. All data were statistically analyzed. Results BV and HbA1c were found to be significantly higher in diabetic amputation patients (P < 0.05). As BV were increased, ODI was decreased and hematocrit was increased. Patients who use antiplatelet/anticoagulant agents because of their underlying CAD or PAD showed low BV paradoxically. Conclusion BV can be considered as a clinical parameter for warning sign of diabetic foot amputation.
P068 Tetsuro Kokubo Forefoot Outcome after the surgery for the tarsometatarsal osteoarthritis with hallux valgus Takeshi Hashimoto Introduction Severe hallux valgus has associated with second tarsometatarsal joint (TMT) osteoarthritis (OA), and it is often treated simultaneously, but there are little reports of the outcome of the surgery. Aim The aim of this retrospective study is to investigate the outcome of surgery of hallux valgus with second TMTOA. Method Twenty-three patients with hallux valgus associated with second TMTOA who underwent surgery were 28 feet. For the hallux valgus, we performed the Lapidus procedure 17 feet and the first metatarsal osteotomy 11 feet. For the second TMTOA, 18 feet with TMT fusion, 10 feet without TMT fusion were performed. Before and after the surgery, weightbearing the radiographs of foot were taken and the hallux valgus angle (HVA) and intermetatarsal angle (IMA) was measured. And we get the patient-reported outcome measurement tool; self-administered foot evaluation questionnaire (SAFE-Q) at the last outpatient consultation, and examined the SAFE-Q score. Result Radiographic parameters had improved postoperatively from 45 to 14 degrees in HVA, from 19 to nine degrees in IMA. The SAFE-Q score was 76 (pain), 81 (physical functioning and daily living: PFDL), 69 (social functioning: SF), 60 (footwear), 80 (general health and well-being). Age was correlated the score in PFDL and SF. Adjusted age, the score was significantly lower in PFDL and SF when Lapidus procedure with TMT fusion than without TMT fusion. Conclusion Since the mobility limitation of the TMT may affect the PFDL and the SF, it could be better to avoid combining the Lapidus procedure and TMT fusion.
P069 Matevž Krašna Forefoot Low complication rate in the first metatarsophalangeal joint fusion by using a standardized treatment protocol based on risk assessment and control checkpoints Jurij Štalc Keywords: first metatarsophalangeal joint, fusion, standardized treatment, risk mitigation, complications. Background: Fusion is the golden standard for treatment of end-stage arthritis of the first metatarsophalangeal joint (MTP 1) with known complications and complication rates. Aim: The aim of this retrospective study was to assess a novel treatment protocol for MTP 1 fusion, based on risk identification and mitigation. Methods: Complications of MTP 1 fusion and risk factors for them were identified. Standardized treatment protocol was designed to include risk assessment checkpoints at different stages of patient treatment (preoperatively, intraoperatively and postoperatively). At each checkpoint treatment progression was delayed until the complication risks were minimized. 72 feet in 68 patients (54 female) were treated by this protocol. The average patients’ age was 60 (from 23 to 83) years. Results: The average follow-up was 37 (20 to 60) months. Fusion success rate was 98.6 %; one non-union was revised for deep infection; all patients had satisfactory position of the big toe; one of the patients required revision for IP joint degeneration; surgical material was not removed in any patient. Conclusion: Our results suggest that by using risk mitigation checkpoints during treatment low complication rates of MTP 1 fusion can be achieved.
P070 TSUNG YU LAN Reconstructive Comparison of outcomes of adolescent symptomatic pes valgus treated with calcaneal lengthening and subtalar arthroereisis. Background Flatfoot was described as a low or absent medial longitudinal arch, with hind foot in excess valgus alignment. Calcaneal lengthening and subtalar arthroereisis have been solution in the treatment of symptomatic pes valgus for years. Aim To investigate the clinical and radiographic outcome of calcaneal lengthening and subtalar arthroeresis . Materials and Methods This is a retrospective cohort study. There were 20 feet in calcaneal lengthening group (CL), with mean age 13.3 year old. 47 feet in subtalar arthroereisis group (SA) with mean age 11.4 year old. The follow up was at least one year ( Mean: 15.7 months (12.7~34.7 months)). Radiographic parameters included Meary angle, calcaneal pitch, Talocalcaneal angle. We used AOFAS hind foot score to evaluate clinical outcomes. The radiographic parameters and AOFAS scores showed no statistically difference in both groups. 【Results】 Both groups showed significantly improvement in radiographic parameters and AOFAS score postoperatively (from 70.9 to 98.0 in CL; from 72.0 to 96.1 in SA). No significant difference between both groups in AOFAS score and radiographic parameters preoperatively and postoperatively, except calcaneal pitch (21.2° in CL compared to 17.8° in SA). One patient in CL group had superficial wound infection and one patient in SA group had implant dislodge. Conclusion Both methods could achieve good clinical outcome. In our experience subtalar arthroeresis is less invasive and well tolerated in skeletal immature children. Calcaneal lengthening could be preserved for adolescence whose are skeletal mature.
P071 Seung Yeol Lee Forefoot Natural Progression of Radiographic Indices in Juvenile Hallux Valgus Deformity Soon-Sun Kwon Kyoung Min Lee Aim: We aimed to estimate the annual change of radiographic indices for juvenile hallux valgus (JHV) and analyze factors that influence deformity progression. Methods: Patients aged <15 years with JHV who were followed up for at least 1 year and underwent weightbearing foot radiography were included. The hallux valgus angle (HVA), hallux interphalangeal, intermetatarsal, metatarsus adductus, distal metatarsal articular, anteroposterior talo-first metatarsal, and lateral talo-first metatarsal angles were evaluated. HVA progression rate was adjusted by multiple factors using a linear mixed model, with sex and radiographic measurements as the fixed effects and laterality and each subject as the random effects. Results: In total, of 133 feet from 69 patients were included. HVA and distal metatarsal articular angle both increased by 0.8° per year (p<0.001 and p=0.003, respectively) (Fig). HVA increased by 1.5° per year (p<0.001) in patients <10 years old. Moreover, HVA increased by 0.8° per year (p<0.001) in patients with both HVA<15° and intermetatarsal angle of ≥10° at the initial examination. In patients with HVA ≥15° regardless of the intermetatarsal angle at the initial examination, HVA increased by 0.5° per year (p=0.001). Conclusion: JHV deformity may progress with aging. Most of the deformity progression could occur before the age of 10. Physicians may predict the degree of progression of each radiographic measurement as the patients grow older, up to 15 years of age. Our results could also help physicians to choose the optimal operative treatment strategy for JHV before skeletal maturation.
P072 DOO JAE LEE Ankle Clinical significance and morphological analysis of the os subfibulare using radiologic assessment in patients with chronic lateral ankle instability Dong Yeon Lee Hyuck Soo Shin Jae Hee Lee Background: Although os subfibulare has been associated to various clinical problems in patients with chronic lateral ankle instability (CLAI), there are a few studies on the analysis of morphological characteristics of os subfibulare. Purpose: To analyze morphologic characteristics of os subfibulare and to evaluate the clinical significance of os subfibulare in patients with CLAI. Methods: Among 252 patients who visited our training hospital with the symptom of lateral ankle instability for more than 1 year after sustaining ankle injury, 71 patients with os subfibulare who underwent MRI of the ankle were included in this study. The shape and size of ossicles were measured on a sagittal MRI . The location of the ossicle was classified into 3 zones by relation with the attachment site of the anterior talofibular ligament. The talofibular impingement, in which ossicles impinged to the talar articular surface. Results: The most common shape of ossicles was oval, and the most common site of ossicles was ATFL attach site. 61% of patients showed talofibular joint impingement on axial MRI, whereas 28 cases showed normal congruency of the talofibular joint. 48 cases in 71 patients with CLAI had an enlarged fibular shape instead of a contralateral fibula on simple radiographs. The age; sex; the shape, location, and size of the ossicle and talofibular articular impingement were associated with surgical treatment in statistical analysis Conclusion: We suggest it’s crucial to understand the morphological characteristics of os subfibulare in patients with CLAI and to establish the treatment plan accordingly
P073 Winston Shang Rong Lim Forefoot Simultaneous bilateral hallux valgus surgery: minimally invasive or conventional? Kevin Oon Thien Koo Inderjeet Singh Rikhraj Background Hallux valgus is bilateral in up to 84% of cases. Several studies have demonstrated that simultaneous bilateral correction is as efficacious as unilateral surgery. In the setting of simultaneous bilateral correction, we aim to evaluate if minimally invasive percutaneous surgery (MIS) provides any advantage compared to conventional open surgery. Method A pilot study was conducted using prospectively collected data from 2013 - 2017 on 26 feet (13 patients) undergoing simultaneous MIS correction and 138 feet (69 patients) undergoing simultaneous conventional open surgery. Patients were followed for a minimum of six months. Pre- and post-operative hallux visual analogue score (VAS), American Orthopedic Foot and Ankle Society (AOFAS) score, radiographs and clinical records were reviewed. Results The mean age was 48.1 in the MIS and 54.3 in the open group (P=0.13).There was no difference in the pre-operative mean hallux valgus angle (HVA) (MIS - 28.0 vs Open- 30.4, P = 0.15), or AOFAS score (MIS – 51.3 vs Open – 57.0, P= 0.06). Post-operatively, the mean HVA was significantly lower in the MIS group (MIS- 9.5 vs Open - 12.9, P=0.02). A significantly higher proportion of patients in the MIS group were satisfied with their surgery (88.5% vs 68.3%, p=0.04) with better satisfaction scores (2.46 vs 2.94, P= 0.02). There were no differences in post-operative VAS, AOFAS scores, operative time, length of hospitalization or medical leave and proportion of patients with their expectations of surgery met. Conclusion This study demonstrates that simultaneous bilateral MIS hallux valgus surgery can be considered for patients with bilateral symptomatic hallux valgus.
P074 François LINTZ Forefoot Comparative study of 3D versus 2D first intermetatarsal M1M2 angle measurement using Weight Bearing CT Arne Burssens Alessio Bernasconi Martin O'Malley The Weight Bearing CT International Study Group Cesar de Cesar Netto BACKGROUND Surgical planning based on 2D angular measurements is subject to perspective distortion. Novel weightbearing CT (WBCT) three-dimensional (3D) biometric measurements using coordinate systems may represent a more reliable and accurate evaluation of this deformity. AIM To compare the M1-M2 angle (IMA) obtained from digitally reconstructed radiographs (DRR) versus a set of coordinates from the full WBCT 3D dataset, in patients with hallux valgus (HV) versus healthy controls. MATERIAL This is a multicenter retrospective comparative study of 83 feet (41 HV, 42 controls). Coordinates in three planes (x,y,z) of four different landmark points were harvested: center of the heads and midpoint of the proximal metaphysis of the 1st and 2nd metatarsal. The IMA measurements were performed on DRR images (DRR-IMA). The 3D angles (3D-IMA) and its projection on the weightbearing plane (2D-IMA) were calculated by a 4th, blinded investigator. Intra-observer realiability, intermethod correlation and mean were harvested. RESULTS Intraobserver reliability was excellent for radiographic DRR-IMA (0.95) and 3D coordinates assessment (0.99). Intermethod correlation, considering bias and interactions, were respectively 0.71 and 0.51 in control and HV patients. IMA measurements were found to be similar when measured in DRR, 2D and 3D WBCT images, for both controls and HV patients. Mean values and confidence intervals (CI) were comparable to known values for all measurement modalities. CONCLUSIONS Although all three measurement modalities resulted in similar values and confidence intervals, WBCT 3D biometric measurements for hallux valgus may prove to be more reliable when the deformity is present, compared to controls.
P075 François LINTZ Hindfoot Distance mapping analysis of the Foot and Ankle complex joints using Weight Bearing CT in varus and valgus deformities. Maui Jepsen The WBCT international Study Group Sorin Siegler Background: Measuring alignment in the Foot and Ankle remains a challenge. Weight Bearing CT (WBCT) provides precise and reliable 3D data, but to date, no validated biometric tool exists to analyse the resulting datasets. Distance mapping could enable color-coding of the joint distance between two bones under load, therefore providing a useful way to interpret this complex data. Aim: To investigate the value of distance mapping as a new a 3D biometric tool based on WBCT data. Method: This is a retrospective cohort study of 30 bilateral data sets (20 normal, 20 varus, 20 valgus). The images were processed to produce 3D segmented color-coded distance maps, representing interarticular surface distances . Results: In valgus, external rotation of the talus and internal rotation of the calcaneus, are visualized, along with increased impingement in the calcaneocuboid joint. In varus, the talocalcaneal configuration is opposite, and the impingement at Chopard level is within the talonavicular joint. Conclusion: The application of distance mapping in this study was successful in characterizing the specific surface-to-surface joint interactions. These differences may help explain pathogenesis associated with hindfoot deformities Color-coded distance maps applied to WBCT provide an effective tool to assess the effect of hindfoot deformities on articular joint spaces. Future clinical applications may be to enhance diagnostics and evaluate the effectiveness of surgery in restoring normal alignment.
P076 Henryk Liszka Forefoot Percutaneuous PIP joint arthrodesis with intramedullary compression screw fixation for the treatment of rigid hammertoe deformity – is it future without open procedure? Artur Gądek BACKGROUND: Main goal of the study was to present surgical technique, preliminary clinical and radiological results and complications of the percutaneuous proximal interphalangeous (PIP) joint arthrodesis with intramedullary compression screw fixation for the treatment of rigid and semi-rigid hammertoe deformity. METHODS: We described surgical technique of percutaneous excision of cartilage and subchondral bone of PIP joint of lesser toes with correction of deformity and intramedullary fixation with full-threaded 2,5 mm compression screw inserted axially from the tip of the toe. We performed 42 percutaneous PIP fusions together with other forefoot procedures. 3 months after surgery we assessed preliminary clinical and radiological results, signs of bony union on X-ray. We noted all complications. RESULTS: We achieved good clinical results of hammertoe correction in 40 patients. Radiological signs of full bony union were observed in 22 and partial fusion in 12 patients. In 6 patients we not-ed lack of bony formation and signs of fibrous union but they were out of complaints. 1 patient had fusion with rotation deformity and was unsatisfied of the result and 1 patient had painful non-union and required revision surgery. Analysis of the cases with partial and fibrous union revealed lack of good initial compression of the site of arthrodesis. We did not observed neurovascular complications. CONCLUSIONS: Percutaneuous PIP joint arthrodesis with intramedullary compression screw fixation for the treatment of rigid hammertoe deformity is a promising technique with good preliminary results. Meticulous technique and appropriate diameter of compression screw is probably essential.
P077 Federico Maria Liuni Forefoot Role of Relative Metatarsal Length in Metatarsalgia after Percutaneous Hallux Valgus Surgery Alberto Fontanarosa Luca Berni Riccardo Cepparulo Alberto Guardoli Aldo Guardoli Background: Metatarsalgia is frequently associated with hallux valgus surgery. Role of lesser metatarsal length has been studied in depth without reaching a definitive solution on surgical treatment. Aim: To evaluate how the variation in length of first metatarsal (calculated with Relative Metatarsal Length), can influence the onset of metatarsalgia in patients treated with PBS (Percutaneous Bianchi System) technique for hallux valgus correction. Method: A clinical and radiographic retrospective analysis was performed in 85 patients with isolated hallux valgus, without clinical metatarsalgia, treated with PBS first metatarsal osteotomy, mean follow-up 26.3 months. Patients were evaluated with AOFAS score and weight bearing radiographs. The relative length of the first metatarsal compared to the second (RML - Relative Metatarsal Lenght), a prognostic index of metatarsalgia, was determined. Results: The AOFAS score increased from 31 in the preoperative to 90 at the last follow-up. RML decreased from -1.08 mm of the preoperative to -5.05 at the last follow-up. Three patients showed clinical signs of transfer metatarsalgia at the last follow-up. Conclusions: Even with significant shortening of the first metatarsus, only three cases of secondary metatarsalgia were observed with this technique. The explanation could be the dynamic correction allowed by this technique, which provides an immediate load without any fixation device. Also the plantarization given by the osteotomy may reduce the risk of secondary metatarsalgia. In case of preoperative plantar callosity associated with severe hallux valgus with consequent greater risk of shortening, it is advisable to associate a shortening osteotomy of the central metatarsals.
P078 Sheng Pin Lo Ankle The Modified Rolling Hitch Could Facilitate the Process of Split Peroneus Brevis Tendon Transfer in Lateral Ankle Stabilization Chih-Kai Hong Chen-Hao Chiang Yi-Hung Huang Wei-Ren Su Background Chronic lateral ankle instability is a common injury and various surgical procedures have been reported. In Split peroneus brevis tendon transfer procedure, suture techniques were applied for tendon graft preparation. To minimize the tendon injury, several tendon-wrapping techniques have been previously proposed, and the modified rolling hitch was one of them. Aim The use of the modified rolling hitch for tendon graft fixation could assist the process in the split peroneus brevis tendon transfer procedure. Method The patient is placed in the supine position with a bump placed under the ipsilateral hip. An incision wound is made from the level of the peroneal tendon to the base of the fifth metatarsal. The split peroneal brevis procedure is performed. The modified rolling hitch is utilized for grasping the peroneal brevis tendon. The subperiosteal-subcapsular channel is created from the base of the fifth metatarsal, exiting at the anterior margin of the fibula. A drill hole was made in the middle of the fibula. The suture-tendon construct is routed through the channels. The ankle is placed into a neutral position and the tendon is advanced into the superior aspect of calcaneus with. The wound are then closed. The operated ankle is placed in a cast for 3 to 4 weeks postoperatively. Conclusion The modified rolling hitch for tendon grasping is an attractive technique for foot and ankle surgeons since it can facilitate the process of the procedure and avoid the tendon injury caused by the needle.
P079 Camilla Maccario Ankle Clinical and radiological outcomes of transfibular total ankle arthroplasty at 2-Years follow-up: a prospective study from a non-designer surgeon Francesco Granata Claudia Di Silvestri Cristian Indino Luigi Manzi Federico G. Usuelli Introduction: End-stage ankle osteoarthritis is a painful, disabling condition, resulting in dysfunction, impaired mobility and worsening quality of life. With the evolution of prosthetic design and surgical techniques, total ankle replacement (TAR) has become a reasonable alternative to arthrodesis. Aim: The purpose of this study was to evaluate clinical and radiological findings in a transfibular TAR (tTAR) with follow-up of at least two years. Methods: This prospective study included 89 patients who underwent tTAR from May 2013 to February 2016. The mean age was 53.2 ±13.5 years. All patients were followed for at least 24 months postoperatively with an average follow-up of 42.0 ±23.5 months. Patients were assessed clinically and radiographically preoperatively and at 6, 12, and 24 months postoperatively. Results: At 24 months postoperatively, patients demonstrated statistically significant improvement in the AOFAS ankle-hindfoot score, VAS and SF-12 Physical and Mental (P<0.001). Ankle dorsiflexion and plantarflexion improved respectively (table 1). Radiographically, patients demonstrated maintained neutral alignment of the ankle at 24 months (table 2). No patient demonstrated any radiographic evidence of lucency at final follow-up. Seven patients underwent reoperation for removal of symptomatic hardware; two patients had a delayed wound healing treated with hardware removal; one patient developed a postoperative prosthetic infection requiring removal of implants. Conclusion: This study demonstrates that tTAR is a safe and effective option for patients with ankle arthritis. However, further studies are required to determine the mid/long-term performance of these implants.
P080 BRUNO MAGNAN Trauma TREATMENT OF SEVERE POST-TRAUMATIC MIDTARSAL BONE DEFECT WITH 3D PRINTED CUSTOM MADE CUBOID PROSTHESIS: A CASE REPORT Stefano Negri Roberto Valentini Bruno Magnan Background Extensive traumatic bone loss of the midfoot is an uncommon occurrence and the treatment of its sequelae are challenging for the foot and ankle surgeon. Nowadays traditional treatments (e.g. Bone grafting with plating) are not effective in terms of restoring bone defect and giving back a stability. Total body prosthesis of tarsal bones could be an interesting option for these types of lesions. In particular, young active patients with massive midtarsal bone loss could benefit from this treatment. To date, no studies have investigated this surgical approach. Aim To evaluate the practical advantages and the real possibility to implant a 3D printed custom made cuboid prosthesis in a Young and active patient. Methods We report the case of a 47 y.o. active man affected by a traumatic missing cuboid and lateral cuneiform associated with navicular fracture, Chopart open luxation and extensive soft tissue damage. This condition was primarily treated in another hospital with bridging external fixation and stabilization of the residual tarsal bones with K wires and was further complicated with the a navicolar’s pseudarthrosis. It hesitated in a midtarsal valgus deformity and retracted paiful scar on the site of exposition. This condition had an important impact on the patient’s quality of life (QoL) since he could not walk without assistance and could not get back to work. The patient comes to our attention after one year from trauma. We designed a 3D printed porous titanium custom cuboid-lateral cuneiform body prosthesis fixed on the calcaneum and medial cuneiform with flanges. The first step was to acquire high-resolution 3D CT images of the contralateral healthy midfoot that was mirroring obtaining the volume of “missing bones” to provide the optimal fit. Then the 3D printed implant was manufactured. We first treated navicolar’s pseudarthrosis and then custom made prosthesis was fixed antero-posteriorly (2 screws to heel, one to scaphoid, two for third and fifth metatarsals and one for the fourth metatarsal). Results No intraoperative and postoperative complications were recorded. Six weeks after surgery patient can walk with a post-operative orthesis and after 3 months he can walk without any assistance. After this period he return to work. We evaluated the patiens at 6 months after surgery. Conclusions The early result obtained after this midtarsal manufactured by a CAD-CAM procedure encourages consider this 3D printed custom implant as a new alternative solution for massive midtarsal bone defects in active patients.
P081 BRUNO MAGNAN Reconstructive 3D PRINTED CUSTOM MADE TALUS PROSTHESIS COUPLED WITH TOTAL ANKLE ARTROPLASTY: A CASE REPORT Roberto Valentini Stefano Negri Elena Samaila Background Total ankle replacement (TAR) is contraindicated in patients with a significant talar collapse due to AVN. Total talus body prosthesis has been proposed to restore ankle joint in young, active patients with massive AVN or traumatic missing talus. To date, five studies have reported implantation of a custom-made talar body in patients with severely damaged talus, showing the limit of short-term damage of tibial and calcaneal thalamic joint surfaces. Aims To evaluate the practical advantages and the real possibility to implant a 3D printed custom made talus prosthesis coupled with total ankle artroplasty in a young patient who refused the artrodesis. Method In november 2015 a 27 years old man,hard worker had a high energy trauma (motocross)and reported a bimalleolar fracture associated with a comminuted fracture of the body and talar neck of the talus first treated by ORIF. At 6 months after surgery presented the complication of a massive AVN of the talus. Hardware were removed and an Oxygen Hyperbaric Therapy was done but instead of that evolved in a big deformity of the talus. Patient refused arthodesis and given the high motive we propose a total tibial and talus replacement. We designed a 3D printed porous titanium custom talar body prosthesis fixed on the calcaneum and coupled with a TAR. We previously performed such an implant in other two cases in active individuals for missing talus that now present a survival follow-up of 15 years. The first step was to acquire high-resolution 3D CT images of the contralateral healthy talus that was " mirroring" obtaining the volume of fractured talus in order to provide the optimal fit. Then the 3D printed implant was manufactured. The talar body was manufactured in titanium and as trabecular metal for the calcaneus facet. The titanium device was assembled with the TAR talar crome-cobalt component to be coupled to the poly and tibial component (BOX prosthesis). Talar prosthesis was fixed on the calcaneus with 2 cannulated screws previously sized. Result Weightbearing was progressively allowed after 6 weeks. At 8 months of follow-up patient presents a good recovery in function and alignement with an AOFAS of 89 points. Conclusion This treatment requires hight demanding technical skills and experience with total ankle replancement of the ankle and trauma of foot and ankle. The 15 years survival of 2 total talar prosthesis coupled to a TAR manufactured by a CAD-CAM procedure encourages consider this 3D printed custom implant as a new alternative solution for massive AVN and traumatic missing talus in active patients.
P082 Karan Malhotra Forefoot Minimally Invasive Distal Metaphyseal Metatarsal Osteotomy (DMMO) for Symptomatic Forefoot Pathology – Short to Medium Term Outcomes from a Retrospective Case Series Nikita Joji Benjamin Rudge Background: Distal metaphyseal metatarsal osteotomy (DMMO) may be used to treat metatarsalgia. It may be performed percutaneously, but there are few large series reporting its results. Aims: We report the radiographic and clinical results of a cohort of patients treated with percutaneous DMMOs at our unit. Methods: This was a single-centre retrospective study looking at the outcome of consecutive patients undergoing percutaneous DMMOs over a 52-month period. We analysed demographics, radiological and clinical outcomes, complications and patient reported outcome measures. Results: We included DMMOs on 106 toes in 43 feet. Mean age of patients was 60.2 ±10.2 years and 41 were female (95.3%). The median duration of follow-up was 38 months. The indication was metatarsalgia in 31 patients (72.1%) and MTPJ subluxation in 12 (27.9%). Concurrent procedures were performed in 26 cases (60.5%). DMMO was performed on multiple toes in 42 cases (96.7%). Mean shortening achieved was 3.6 ±2.2mm, 4.1 ±1.6mm, and 3.6 ±1.6mm for the 2nd, 3rd and 4th toes respectively. Mean time to fusion was 11.4 ±7.8 weeks and union occurred in 105 toes (99.1%). The single non-union was asymptomatic at 12 months. Two patients (4.7%) required a subsequent additional DMMO for transfer metatarsalgia. Overall, minor complications were seen in 14 patients (31.1%). At final follow-up mean MOxFQ was 28.8 ±27.6, EQ-5D was 0.789 ±0.225, VAS-Pain was 3.1 ±2.8, and 41 patients (95.3%) were satisfied overall. Conclusions: We have demonstrated excellent radiological and clinical outcomes, with relatively few complications in the short to medium term with percutaneous DMMOs.
P083 Giuseppe Manfredini Trauma Displaced physeal fractures of the ankle. Medium and long term results after surgical treatment. Sara dr.sa Cavalera Alessandro dr. Corradini Carmen dr.ssa Marongiu Maria Teresa dr.ssa Donini Fabio dr. Catani Background: Ankle physeal injuries are the most common physeal injury in the lower limb, they frequently require surgical management. If displaced the anatomic alignment is restored with closed or open reduction followed by fixation. Salter-Harris Classification (S-H) is used to describe physeal injuries. Aim To evaluate the mid-long term results of displaced ankle physeal injuries treated with fixation considering: limb alignment, physeal anatomy, and joint congruency. Method From Jan 2006 to Dec 2016, 46 displaced ankle physeal injuries (11 % S-H 1, 63% S-H 2, 13% S-H 3, 13% S-H 4) were treated in our institution. (M/F=2,2; mean age 13 ys.) In 34 cases, the reduction was obtained with closed manoeuvres weather in 10, with an open access. All the fractures were fixed with K wires or screws. A long leg cast was maintained for 4/6 weeks. After 3 months the hardwares were removed. X-rays follow-up: 1, 3, 6 months, then annually. Clinical evaluation: AOFAS score, range of movement (ROM). Results After 56 months of follow-up (17-141) the mean AOFAS score was 91 (min 63-max 100) with full recovery of the ROM. In 3 cases the treated limb shortened (0.5 cm); in 1 case resulted an Achille’s tendon retraction. All the joint were congruent and limb alignment were mantained. Conclusion Physeal fractures need careful assessment to achieve an anatomic reduction and rigid fixation to prevent an abnormal development of the joint. The young age allow a fast recovery. Cartilage damage can be evaluated only with very long follow up.
P084 Giuseppe Manfredini Forefoot First metatarsal osteotomy to correct hallux valgus. When, how and why? Corradini dr. Alessandro Lana dr.ssa Deborah Cavalera dr.ssa Sara Catani prof. Fabio First metatarsal osteotomy to correct hallux valgus. When, how and why? Background: First metatarsal osteotomy allow the correction of intermetatarsal (IMA), metatarsophalangeal (HVA) and distal metatarsal articular angle (DMAA) together. This technique is then used to correct severe hallux valgus deformity (IMA>17- 18°, HVA> 35°-40° and DMMA> 20°-25°). Aim: To evaluate the corrective power of the osteotomy observing clinical and X-Ray results with a medium-long follow-up. Method: Twenty-nine hallux valgus underwent a osteotomy correction (28: IMA>18°, HVA> 40°, DMMA>25°; 1: IMA>18°, HVA> 40°, DMMA<25°). Nineteen underwent an open wedge base osteotomy (WBO) fixated with a low profile plate associated with Reverdeen-Green (RVG) distal osteotomy. Ten underwent a closed base osteotomy (Juvara) fixated with two 2,7 mm screws, associated with distal RVG. Clinical follow-up: AOFAS score. X-Ray follow-up: 1, 3, 6, 12 months. Result: The mean AOFAS score after 62 months of follow up was 87,7 in BWO group while 84,9 for the Juvara group (mean follow-up 109 months). In both groups the HVA, IMA e DMMA angles normalized after surgery. No recurrences were recorded. First metatarsophalangeal stiffness was present in 18% of cases. Conclusion:The first metatarsal osteotomy is a good technique to correct severe hallux valgus (IMA > di 18-19° e HVA> di 35°-40°). The more frequent complication consist in first metatarsophalangeal stiffness. The osteotomy should be avoided if it is present a cuneometatasal instability; in these cases a Lapidus procedure is necessary to prevent the recurrences.
P085 Luigi Manzi Reconstructive Trabecular Metal™ ankle spacer associated with tibio-talo-calcaneal (TTC) nail as salvage procedure in patients with sever bone defects. Claudia A. Di Silvestri Cristian Indino Camilla Maccario Federico Giuseppe Usuelli Background. The main problem when a tibio-talo-calcaneal (TTC) arthrodesis as salvage procedure is performed is the presence of a local large bone defect. Recently, Trabecular Metal™ ankle spacer cages have been introduced as spacer in ankle arthrodesis with large bone defect. Aim. Objective of this study was estimate clinical and radiological results in patients treated with TTC nail arthrodesis with a trabecular metal cage. Methods. Seven patients, one woman and 6 men, mean age 58 years (range 47-72), were treated with TTC nail and Zimmer® Trabecular Metal™ ankle spacer cage between 2014 and 2017, in two cases after an ankle replacement, in 5 cases after an ankle arthrodesis. For each patient, pre-and post-operative clinical data were recorded (Visual Analogue scale for pain-VAS; American Orthopedic Foot and Ankle Society-AOFAS score; short-form12- SF12 in both parts Mental- MCS- and Physical-PCS) and radiological parameters (TTS, LDTA, ADTA) on ankle weight-bearing x-rays and CT scan. Results. The minimum follow-up was one year for each patient. All clinical and radiological parameters improved after surgery. No malunion and non-union, no major complications were recorded. One patient reported the delayed wound healing with superficial infection, resolved with oral antibiotics. One patient referred pain on plantar calcanear side. Conclusion Based on our results, the use of Trabecular Metal™ spacer cage associated with TTC nail in salvage procedures is a valid option to fill the bone gap and restore the lower limb lengthening.
P086 Luigi Manzi Ankle Sport and physical activities in patients with Chronic Achilles tendon rupture reconstruction using flexor hallucis longus transfer Camilla Maccario Claudia Di Silvestri Riccardo D'Ambrosi Cristian Indino Federico Giuseppe Usuelli BACKGROUND: Neglected or chronic Achilles tendon ruptures can be significantly disabling to patients if the muscle-tendon unit is stretched beyond its normal passive limit. Chronic rupture of the Achilles tendon (delayed diagnosis of more than 4 weeks) can result in retraction of the tendon and inadequate healing. Direct repair may not be possible and clinical results may not be satisfactory especially if the distal stump is grossly tendinopathic and when the defect exceeds 5-6 cm. AIM: The aim of this study is to evaluate the clinical result of patients with chronic cchilles tendon rupture reconstruction using flexor hallucis longus transfer METHODS: We evaluated 9 patients (mean age 63) who underwent flexor hallucis longus transfer for treatment of chronic Achilles tendinopathy between May 2014 and January 2017 at a 12 months follow-up. Our results were measured with the SF-12 survey, AOFAS Ankle-Hindfoot Scale and VAS. Activity levels were determined using the Halasi ankle activity scale and the UCLA score obtained preoperatively and 12 months after surgery. Wound complications and tip-toe stance were also assessed. RESULTS: All patients had a significant improvement of AOFAS, VAS and SF-12 scores. The Halasi activity scale and UCLA score were 5.8 and 8.2 respectively 12 months after surgery. Patient reported outcome measures consistently demonstrated improvement in clinical putcomes at 12 months follow-up. The patients went back to full daily function, could single leg heel raise and were gradually returning to sport. No major complications were recorded. CONCLUSION: Reconstruction of chronic tears of the Achilles tendon with flexor hallucis longus transfer can achieve satisfactory improvements in clinical outcomes at 1 year follow-up.
P087 Luigi Manzi Ankle Hindfoot alignment in total ankle replacement at 2 year follow-up Camilla Maccario Claudia Di Silvestri Riccardo D'Ambori Cristian Indino Federico Giuseppe Usuelli BACKGROUND: End-stage ankle osteoarthritis frequently involves multiplanar malalignment both tibio-talar and subtalar joint. Restoration of the correct position of the tibial and the talar component and of the hindfoot is mandatory for the long-term survival of total ankle replacement. Since patients with ankle osteoarthritis often present concomitant hindfoot deformity, radiographic references are needed to describe deformities. However, the possible compensatory mechanisms of these linked joints are not well known. Aim:The aim of this study is to show if there is any difference regarding hindfoot position at 6 months, 1 year and 2 years follow-up. METHODS: The study included 68 ankles who underwent Total Ankle Replacment through a later transfibuklar approach between May 2013 and December 2015. The main indications for TAR were: post-traumatic (55 patients, 80.9%) and reumathoid arthritis (5 patients, 7.4%). In these patients the hindfoot view angle was measured 6, 12 and 24 months postoperatively. Furthermore, clinical outcomes were recorded. Patients who underwent hindfoot/midfoot fusions were excluded. RESULTS: The mean hindfoot alignment angle (HAV) was 0.4±0.0 pre-operatively and 0.1±6.2, 0.7±6.2, 1.2±7.0 at 6, 12 and 24 months postoperatively. There was no statistically significant difference in the HAV between follow-up. A statistically significant improvement in clinical scores (AOFAS, VAS and SF.12) was found at each follow-up. The main complications were: 6 hardware removal for intollerance (8,8%), 3 delayed wound healing (4,4%), 1 medial impingement (1,5%). CONCLUSIONS: Regarding the hindfoot alignment angle, TAA through a lateral approach showed a good reliability. Furthermore, hindfoot alignment remains stable over time.
P088 Luigi Manzi Ankle Periprosthetic cysts in total ankle replacement: role of metal back at 2-year follow-up. Claudia A. Di Silvestri Camilla Maccario Federico Giuseppe Usuelli Cristian Indino Background. Many studies have been conducted about total ankle replacement since their introduction into clinical practice. Thanks to growing interest and to innovations, ankle prosthesis is now considered one of the most valid therapeutic strategies for the treatment of arthrosis of the ankle, progressively surmounting the arthrodesis, once considered the gold standard. The Zimmer® Trabecular Metal ™ Total Ankle system is based on 3 components and fixed polyethylene. Aim. The aim of this study was to estimate the presence of periprosthetic cysts in patients undergoing total ankle arthroplasty with the Zimmer® Trabecular Metal ™ implant, at two years of follow-up. Methods. 89 patients, mean age 53 years (range: 22-78 years), with ankle arthritis were treated with Zimmer® Trabecular Metal ™ total ankle system between 2013 and March 2016. 54 were male (60.7%) and 35 were females. The preoperative imaging study included, for each patient, weight-bearing radiographs of the ankle and ankle CT scan. Subsequently, each patient was evaluated with post-operative ankle radiographs and at 1, 3, 6, 12, 24 months; CT of ankle at 12 and 24 months. Results. At 24 months of follow-up, periprosthetic cysts were observed in 1 of 89 patients included in the study, and were visible on both radiographs and CT. The remaining 88 patients did not develop periprosthetic cysts within 24 months of surgery. Conclusion. Based on the clinical and radiographic data reported, satisfactory results were achieved in terms of implant stability in patients undergoing total ankle replacement with Zimmer® Trabecular Metal ™ system.
P089 Domenico Mercurio Forefoot Our experience in the treatment of metatarso-phalangeal joint replacement with Primus Great Toe Silicon Implant for End-Stage Hallux Rigidus. Giuseppe Niccoli Piero Giardini Fabrizio Cortese Background First metatarsophalangeal joint (MTP-1) replacement with silicone implant is a possibility for the treatment of end-stage Hallux Rigidus. Aim The aim of this study is to show the surgical techinique of the MTP-1 replacement and to show our functional and radiographical short term results with the Primus implants. Method 41 prosthesis were implanted from 2014 to 2018. Patients were studied clinically and radiographically. American Orthopedic Foot and Ankle Society Hallus Metatarsophalangeal Interphalangeal scoring Systme (AOFAS-HMI) was used to assess clinical and function results. Weight-bearing radiographs were made at the final follow-up and analyzed for presence of mobilization, osteolysis and radiolucencies around the implants. Digitigrad weight-bearing lateral position radiographs were made pre-operatively and post-operatively to assess the angle of maximal dorsiflexion. The average follow-up period was 24 months. There were 30 women and 11 men, and the average age at the operation was 65 (min 43-max 83). Results There were non revision. The median pre-operative AOFAS-score was 44 points and the median post-operative was 89 points. No sign of radiograph failure was noted at the final follow-up. 2 patients reported mild level of satisfaction, 39 reported high level of satisfaction. Conclusion The present study reported excellent short-term clinical out-comes of Primus Great Toe Silicone implant for MTP-1 replacement. The clinical outcomes confirm the results of recent mid-term studies, that demonstrated efficacy of this type of silicone -stemmed implants, though longer-term follow-up is necessary to confirm its safety and these results.
P090 Kirill Mikhaylov Ankle Clinical and functional outcomes after arthroplasty of the ankle joint A.A. Bulatov D.G. Pliev M.S. Guatsaev E.P. Sorokin Backgroud: Current aim of our study was to evaluation early and long-term results after ankle arthroplasty using third generation ankle prosthesis. Materials and Methods: We performed an analysis of 71 patients between 22 and 82 years old, comparable by gender and osteoarthritis stages. All patients included in the research underwent total ankle arthoplasty using three types of ankle prosthesis – Mobility - 27, Hintegra - 37, STAR Waldemar Link - 7, being followed up before and 6,12,24 month after the surgery. Retrospective group control study was done 3, 5, 7 and 10 years after procedure. They also had X-ray examination, VAS and AOFAS scales questioning and gait biomechanics research. Results: The most frequent reason for unsatisfactory treatment was an aseptic instability. We found radiological signs of instability were observed 2 years after the surgery in 6 (19.4%) of 31 patients. However, the presence of a severe pain syndrome and essential decrease in functionality which necessitated carrying out a repeat operation was reported only by one (3.2%) patient. From 3 to 10 years radiological signs of instability were recorded for 16 (40%) of 40 patients. Conclusion: In our observations, the proportion of patients with radiographic signs of instability was 19.4% after 2 years and 40% after 3 to 10 years. However, severe clinical symptoms arising from this condition and requiring repeat surgery were observed much less frequently: 3.2% after 2 years and 17.5% in the later periods of observation.
P091 Shayan Moradi Trauma Review of operative treatment of subtle Lisfranc injuries: short term results Verduyckt J. Caruso G. Serwier J.-M Background: Subtle Lisfranc injuries often occur after a low energy trauma and are commonly missed on initial review. Misdiagnosed injuries can result in early osteoarthritis and chronic disability.  Aim: While surgical management of displaced injuries is well codified, the treatment of subtle injuries is not and is often treated by immobilization by default. Residual instability is a precipitating factor of tarsometatarsal(TMT) c osteoarthritis. An open reduction and internal fixation is performed for every fractures even without displacement. Material and methods: This is a retrospective cohort study evaluating short term results of the operative treatment of 27 patients with subtle and unstable TMT injuries. A CT was performed for all patients. All cases underwent ORIF, with transarticular screws, by a single surgeon. The mean follow-up period was 20 (4-38) months. Patients outcomes were assessed according to the American Orthopaedic Foot & Ankle Society (AOFAS) score and a visual analog scale (VAS) for global satisfaction. Results:  Surgery was performed an average of 14,5 days after trauma. The mean satisfaction VAS score was 8,4. The average AOFAS score after surgery was 88 points, with a return to professional and sport activities after 6 months for the majority of patients. Our serie does not contain any surgical revisions. Conclusion: Subtle injuries of Lisfranc complex leads to osteoarthritic deterioration. Surgical management of subtle Lisfranc injuries seems beneficial. The literature report a failure rate of more than 50% when treated by immobilization. An associated injury and delayed surgical management can also be sources of poorer outcomes.
P092 Hideo Noguchi Ankle Is nonoperative treatment better than operative treatment for severe injuries to the lateral ligaments of the ankle? Yoshinori Ishii Junko Sato Background: For over the past few decades, nonoperative treatment has been considered the first choice for acute ligament injury of the ankle. However, the treatment for severe ligament injury remains controversial. Aim: We have actively recommended operative treatment for patients with severe acute injuries to the lateral ligaments of the ankle. The purpose of the present study was to compare the outcomes of operative and nonoperative treatment when patients were rehabilitated in an identical manner. Method: From 2008 to 2014, 1,067 patients diagnosed with acute injuries to the lateral ligaments of the ankle underwent talar tilt angle (TTA) X-ray examination in our outpatient clinic. Severe injuries (TTAs≥15°) were evident in 211 feet (211 patients). Of the 211 patients, 103 chose operative and 108 nonoperative treatment. The post-treatment protocol featured cast immobilization for the first 3 weeks, range-of-motion and muscle recovery exercises using a short brace for the next 3 weeks, and a gradual return to sports activities after 6 weeks. After 12 weeks, final TTA examinations were performed to evaluate ligament improvement. We used exactly the same rehabilitation protocol for the operative and nonoperative groups. The time to return to previous sporting activities, the follow-up rate, and the final TTA were compared between the two groups. Results: The mean initial TTA was 23.9° in the operative and 19.1° in the nonoperative group. The final TTA after 12 weeks was 5.8° in the operative and 7.9° in the nonoperative group; the difference was significant. The average time taken to return to sporting activities was 8.5 weeks in the operative and 8.8 weeks in the nonoperative group; these times did not differ significantly. The follow-up rate (attendance at the outpatient or physiotherapy clinic for the full 12 weeks) was 82.5% in the operative but only 28.2% in the nonoperative group. Conclusion: Thus, in those with severe injuries, operative treatment afforded superior mechanical stability compared to nonoperative treatment. Patients in both groups could resume prior sporting activities. Many foot and ankle surgeons consider that operative treatment is associated with a longer recovery time than nonoperative treatment. However, we found that operative treatment was not inferior to nonoperative treatment in this context. Especially when the injury to the ankle ligament is severe, operative treatment should be the first choice.
P093 Ezequiel Palmanovich Forefoot Akin Derotation Osteotomy for medial first Toe Diabetic Ulcer Meir Nyska Omer Slevin David Segal Iftach Hetsroni Yaron S. Brin Introduction: Diabetic ulcer is a common problem in diabetic patient. Mild callus formation due to overloaded areas can lead to ulcer formation with serious sequela. We developed osteotomy which the main correction is derotation of the proximal phalange to supination- the “Akin derotation osteotomy”. Aim: The outcome of this osteotomy was assessed in diabetic patients with non-healing ulcer Materials and Methods: Eight patients were included in this study, Seven patients with Diabetes Mellitus Type 2 and one patient with Charco-Marie Tooth. The patients did not respond to conservative treatment for at least 6 months. Ulcer were classified by Wagner Classification. Under local anesthesia Akin derotation into supination osteotomy was performed in order to unload the area of pressure. The osteotomy was fixed by KW which was removed after 4 weeks Results: The ulcer resolved in all eight patients within average of 5 weeks (3-8 weeks) One patient present mild rubor at the area of KW fixation that resolve with KW removal. No surgery was required at one year follow up Conclusion: Akin derotation osteotomy is simple and easy procedure that can reduce the overload of the ulcer area on the area of the medial first toe and lead the wound healing with minimal complications
P094 Ezequiel Palmanovich Forefoot SERI TECHNIQUE VERSUS DISTAL CHEVRON OSTEOTOMY FOR THE TREATMENT OF MILD HALLUX VALGUS DEFORMITY Meir Nyska Omer Slevin David Segal Iftach Hetsroni Meir Nyska Background: Minimal invasive approach (SERI technique) is suggested as alternative for mild Hallux Valgus)HV( deformity, but the advisability of this approach has been questioned. Aim: The purpose of this study was to test outcomes of a modified SERI technique versus Chevron osteotomy for the treatment of mild HV. It was hypothesized that SERI technique with a modification of the osteotomy cut can result in comparable outcomes versus Chevron osteotomy for these cases. Methods: 38 patients undergoing mild HV correction were enrolled. Twenty-three patients underwent correction using SERI technique with plantarly angulated modification of the osteotomy cut and 15 patients underwent correction using standard Chevron osteotomy. Outcome measures included Inter-metatarsal angle (IMA), Hallux valgus angle (HVA), and Distal metaphyseal articular angle (DMAA) measured preoperatively and at 12 months postoperatively, AOFAS-forefoot score at 12 months postoperatively. Results: In both groups, reductions in IMA, HVA, and DMAA after surgery compared to before surgery were significant (p < 0.001). Mean total AOFAS-forefoot score at 12 months postoperatively was 93.4±6.1 in the SERI group versus 88.4±7.9 in the Chevron group (p = 0.04), whereas Metatarsophalangeal joint (MTPJ) motion was the only significantly improved outcome sub-score in the SERI group versus the Chevron group (9.6±1.4 versus 5.8±1.9, p < 0.01). Minor postoperative complications were observed Conclusion: Using SERI technique with plantarly angulated osteotomy cut modification for the correction of mild HV deformity can result in comparable clinical outcomes to standard Chevron osteotomy. This could be of particular importance in medically-compromised patients where minimal invasive surgery is desired.
P095 Ezequiel Palmanovich Reconstructive Novel Reconstruction Technique for an Isolated Plantar Calcaneonavicular (SPRING) Ligament Tear Prof Shay Shabat Dr Yaron S. Brin Dr Sabri Massrawe Iftach Hestroni Meir Nyska Background: It is usually accepted that acquired flatfoot deformity after injury is usually due to partial or complete tear of the posterior tibial tendon (PTT), with secondary failure of the other structures which maintain the medial longitudinal arch, such as the plantar calcaneo-navicular (SPRING) ligament. It is unusual to find an isolated Spring Ligament (SL) tear, with an intact TP tendon. Aim: evaluate the spring reconstruction after reconstruction. Methods: The medial arch reconstruction technique of an isolated SL tear in 5 patients is presented discussed in this paper. In these 5 cases the clinical presentation mimicked PTT dysfunction. The operative regimen consisted of three steps: direct repair of the ligament, primary reconstruction of the SL by using FiberWire(®) (Arthrex, Inc) and a medial calcaneal osteotomy. Results: American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score improved from 55.8 (range, 34-74) before surgery to 97.6 (range, 91-100) at more than one year follow-up. No recurrence of the flatfoot deformity was observed at 10 years follow-up. Conclusion: SL tear should be suspected in cases of clinical presentation of medial arc collapse even when PTT is intact. In such cases of isolated SL tear reconstruction of the torn ligament using the method described is recommended.
P096 Young Uk Park Anesthesia and Pain Control Complications after multiple site peripheral nerve blocks for foot and ankle surgery compared with popliteal sciatic nerve block alone Jae Ho, Cho, M.D Doo Hyung Lee, M.D Wan Sun Choi, M.D Han Dong Lee, M.D Keun Soo Kim, M.D Background: Single or combined multiple site peripheral nerve blocks (PNBs) are becoming popular for patients undergoing surgery on their feet or ankles. These procedures are known to be generally safe in surgical settings compared with other forms of anesthesia such as a spinal block. The purpose of this study was to assess the incidence of complications after the administration of multiple PNBs for foot and ankle surgery and to compare the rates of complications between patients who received a single PNB and those who received multiple blocks. Materials and Methods: Charts were reviewed retrospectively to assess peri- and postoperative complications possibly related to the PNBs. The records of 827 patients who had received PNB-sciatic nerve block, femoral nerve block, adductor canal block, or combinations of these for foot and/or ankle surgery were analyzed for complications. The collected data consisted of age, sex, body mass index, presence of diabetes mellitus, smoking history, tourniquet time, and complications both immediately postoperative and one year later. Results: Of these 827 patients, 92 (11.1%) developed neurologic symptoms after surgery; 22 (2.7%) of these likely resulted from the nerve blocks, and 7 (0.8%) of these were unresolved after the patients’ last follow-up visits. There were no differences in complication rates between combined blocks and single sciatic nerve blocks. Conclusion: There were higher complications either transient or long term after anesthetic PNBs than previous literature had reported. Combined multiple sites blocks did not increase the rates of neurologic complications.
P097 Nikke Partio Forefoot Surgical treatment of Hallux valgus – Nationwide Data From Finland in 1997–2014 Heikki Mäenpää M.D. PhD Tuomas Huttunen M.D. PhD Heidi Haapasalo M.D. PhD Heikki-Jussi Laine M.D. PhD Ville M. Mattila M.D. PhD Background: Many operation repairs have been described for hallux valgus. The evidence currently available investigating the different procedures is poor. Aim:The purpose of this study was to assess the incidence of HV surgery in Finland between 1997 and 2014 and find out whether operation techniques of HV have changed during the study period. Method: The study included all adult patients (≥ 18 years) who underwent HV operation. Patients were included into study if they had been operated with a diagnosis of HV (ICD-10 code M20.1). The data collected by the Finnish National Hospital Discharge Register (NHDR). Results: The total incidence of primary HV operations was 66.7 per 100.000 person-years in and 41.4 per 100.000 person-years in 2014. The incidence of arthroplasty operations of the MTP-1 joint decreased while at the same time incidence of the MTP-1 joint arthrodesis and TMT-1 arthrodesis increased. The gender difference (13% men, 87% women) is consistent with previous studies. Conclusion: This study shows the significant decreasing trend of HV operations in Finland between 1997- 2014. During the study period the incidence of the MTP I joint arthroplasty has decreased and the incidence of the MT-1-osteotomies has almost halved since 2005. At the same time the incidence of the MTP-1 joint arthrodesis increased over 1000% and TMT-1 joint arthrodesis nearly 2000%.
P098 Ngwe Phyo Infection More than 50% of heel ulcers can heal at 6 months with a multi-disciplinary management Dr Nina Petrova Ms Wegin Tang Miss Ines Reichert Mr Raju Singh Ahluwalia Mr Venu Kavarthapu Aim: Diabetic heel ulcers are difficult to treat, often requiring surgical debridement when complicated by osteomyelitis. This cohort-series explores the outcomes of those infected heel ulcers treated with surgical debridement. Our primary outcomes included ulcer healing rates at 6-months, and long-term outcomes of functional-weight-bearing, recurrence rates, amputation and mortality at 12-months. Method: A total of 30-patients (31 heel ulcers) who had undergone surgical debridement were identified from electronic theatre records from 2010-17. Post-surgery, all patients were monitored within our multi-disciplinary diabetic foot clinic and managed with appropriate sharp debridement when required, wound dressings, offloading and control of infection. Outcomes at 6 and 12-months were independently assessed from the patients’ medical notes. Results: Of the 31 heel ulcers, 26 (84%) were complicated by calcaneal osteomyelitis. 17 ulcers (55%) healed by 6-months; 4-patients (13%) had re-ulcerated by 12 months, 4-patients had died (13%); the one patient with bilateral heel ulcers with osteomyelitis had failed ulcer healing in one foot and underwent a below knee amputation for the contralateral heel ulcer. Functional analysis was found to be recorded for 16 patients at 12-months; and 11 returned to independent weight-bearing in protective orthosis . Conclusion: This study showed more than 50% of heel ulcers heal at 6-months, following prompt surgical debridement and multi-disciplinary-management. Aggressive treatment of infection and intensive podiatric therapy results in a very low amputation and acceptable mortality rate. Therefore heel ulcers are best managed within a multidisciplinary-team, where early referral to diabetic foot-surgeon is essential to avoid adverse outcomes.
P099 Ville Ponkilainen Trauma Incidence and Characteristics of Midfoot Injuries Heikki-Jussi Laine Heikki Mäenpää Ville Mattila Heidi Haapasalo Background: The epidemiology of midfoot injuries is poorly known. It has been estimated that the incidence of Lisfranc injuries is 1/55 000 person-years and the incidence of Chopart injuries 4/100 000 person-years. Aim: The purpose of our study is to assess the computed tomography (CT) imaging-based incidence (per 100,000 person-years) and trauma mechanisms of midfoot injuries. Method: All CT studies performed due to the acute injury of the foot and ankle region between 1.1.2012 and 31.12.2016 at Tampere University Hospital were reviewed. Patients presenting an injury in the midfoot region in the CT scan were included in this study, and their patient records were retrospectively evaluated to assess patient characteristics. Result: During the five-year study period, 953 foot and ankle CT scans were obtained due to an acute injury of the foot and ankle. Altogether, 464 foot injuries were found. Of these, 307 affected the midfoot area: 233 (75.9%) the Lisfranc joint area, 56 (18.2%) the Chopart joint area and 18 (5.9%) were combined injuries or miscellaneous injuries in the midfoot. The incidence of all midfoot injuries was 12.1/100 000 person-years. The incidence of Lisfranc injuries was 9.2/100 000 person-years. The incidence of Chopart injuries was 2.2/100 000 person-years. Conclusion: The incidence of Lisfranc injuries seems to be significantly higher than reported in the previous literature. Over two-thirds of the midfoot injuries in this study were non-displaced (<2 mm displacement in fracture or joint) and were caused by low energy-trauma.
P100 Martinus Richter Forefoot Comparison total joint replacement (Roto-Glide) with arthrodesis of the 1st metatarsophalangeal joint – clinical follow-up study including pedography Stefan Zech Stefan Andreas Meissner Background Total joint replacement (TJR) and arthrodesis (A) are treatment options for severe osteoarthritis of the 1st metatarsophalangeal joint (MTP1). Aim The aim of this study was to compare outcome (clinical and pedographic) of JTR (Roto-Glide) and A of MTP1. Methods All patients that completed follow-up of at least 24 months after TJR and A of MTP1 before November 5, 2017 were included. Radiographs and/or weight-bearing CT were obtained. Degenerative changes were classified in four degrees. Visual-Analogue-Scale Foot and Ankle (VAS FA) and range of motion (ROM) were registered. All parameters were compared between TJR and A and between preoperatively and follow-up. Results From November 24, 2011 until October 31, 2015, 19 TJR and 38 A were performed that completed follow-up. Parameters for TJR/A were preoperatively: mean age 59/60 years; 5(26%)/10(26%) male; height 167/166 cm; weight 73/74 kg; degree degenerative changes 3.3/3.1; ROM 10.3/0/18.8°//10.8/0/19.2°; VAS FA 45.5/44.9. Follow-up time on average 37.4/32.6. VAS FA at follow-up was 71.7/69.4; ROM 35.4/0/20.5°//10.2/0/0. Parameters did not differ between TJR and A (each p>.05) except lower ROM for A at follow-up (each p
P101 Martinus Richter Ankle Comparison total joint replacement (STAR) with arthrodesis of the ankle – clinical follow-up study including pedography Stefan Zech Stefan Andreas Meissner Background Total joint replacement (TJR) and arthrodesis (A) are treatment options for severe osteoarthritis of the ankle. Aim The aim of this study was to compare outcome of JTR (STAR) and A of the ankle. Methods All patients that completed follow-up of at least 24 months after TJR and A of the ankle before November 5, 2017 were included. Preoperatively and at follow-up, radiographs and/or weight-bearing CT were obtained. Degenerative changes were classified in four degrees. Visual-Analogue-Scale Foot and Ankle (VAS FA) and ankle range of motion (ROM) were registered. Results From October 11, 2011 until October 31, 2015, 36 TJR and 28 A were performed that completed follow-up. Parameters for TJR/A were preoperatively mean age 61/52 years; 20(56%)/14(50%) male; height 171/175 cm; weight 83/87 kg; degree degenerative changes 3.5/3.6; ROM 5.6/0/22.8°//4.8/0/22.1°; VAS FA 43.8/40.3. Follow-up time on average was 35.8/33.1 months. VAS FA was 68.6/61.3; ROM 15.4/0/33.6°//0/0/0. Parameters did not differ between TJR and A (each p>.05) except lower age for A, higher VAS FA and ROM for TJR at follow-up (each p
P102 Christian Rodemund Hindfoot Minimal invasive Treatment of intra-articular calcaneus fractures Ronny Krenn Werner Litzlbauer Georg Mattiassich Backgrund Approximately 2% of all fractures account for calcaneal fractures. Eighty to 90% intra-articular, many of them multifragmentary- and comminuted fractures. The optimal type of treatment is still controversial. Modalities vary between conservative, open reduction with plate fixation and many different minimal invasive concepts. Aim MIOP concept with early surgery time, standardized positioning, X-ray viewing, reduction method and screw fixation and functional mobilization, reducing soft-tissue complication and improve outcome. Method 212 patients with calcaneal fractures were treated at Traumacenter Linz from 2007 to 2015, most of them using a 2-point distractor. Patient records were reviewed focused on the treatment modality, time of surgery, infection rate, implant removal and subtalar arthrodesis rate. Results Deep infection occurred in 2.7%. Implant removal was necessary in 4.2% and elective removal was performed in 34.9%. We see no massive swelling and no secondary blistering. Hospital discharge was possible earlier. Secondary arthrodesis (4,7% of our patients) are much easier to perform because of good soft-tissue conditions, easy implant removal and small incisions. Conclusion Minimal invasive treatment of intra-articular calcaneus fractures in a standardized way in terms of reduction technique and stable screw fixation shows low infection rates, is soft-tissue saving, provides good anatomical results, early functional treatment is possible and shortens hospital stay. A main advantage is that we can treat all kind of fractures, especially comminuted fractures as well as open injuries. Contraindications are rare. Due to the decreased surgical risks, we have no limitations for older patients, smokers, and patients with co-morbidities.
P103 Evita Rumba Trauma Late results of calcaneus fractures surgical treatment Laura Andersone Introduction: the surgical treatment of calcaneal fractures is difficult and is associated with a high rate of complications and poor functional outcomes, that restrict the daily activities of the patients.Aim, materials and methods. Collect and analyze late outcomes of calcaneal fractures treated surgically during the period from 2010 to 2014 in Hospital of Traumatology and Orthopaedics (HTO), Riga, Latvia. Medical records of 129 patients (139 fractures) were retrospectively reviewed. A follow-up of 32 patients was done 4-6 years after surgical treatment, evaluating the late outcomes using the AOFAS Ankle-Hindfoot Scale. Results: Pain. None 38%, mild, occasional 34%, moderate, daily 22%, severe 6%. Activity limitations, support requirement. No limitations 63%, limited daily and recreational activities 28%, severe limitation of daily and recreational activities 9%. Walking surfaces. No difficulty 40%, some difficulty 47%, severe difficulty 13%. Sagittal motion. Normal or mild restriction (30° or more) 53%, moderate restriction (15°-29°) 31%, severe restriction (less than 150) 16%. Hindfoot motion (inversion plus eversion) normal or mild restriction 31%, moderate restriction 28%, marked restriction 41%. Conclusion. Most of the patients after surgical treatment of calcaneal fracture had no or mild everyday activity limitations and marked loss of range of motion was not common. Most of the patients however have some pain with weight bearing. More objective instrumental evaluations should be conducted to recieve credible data to associate functional outcomes with the choice of treatment of calcaneal fractures.
P104 Chamnanni Rungprai Trauma Outcomes and complications following repair Achilles tendon sleeve avulsion injury using a -row SutureBride technique Yantharat Sripanich, MD Background: A sleeve avulsion Achilles tendon rupture is a rare condition and there is a little evidence reported the surgical repair technique and outcomes as well as complications after the surgery. Aim: The purpose of this study was to report outcomes and complications after repair Achilles tendon sleeve avulsion injury using a -row SutureBride technique Material and Methods: A prospective case series of Achilles tendon sleeve avulsion and underwent open gastrocnemius lengthening, calcaneal exostectomy, debridement of Achilles tendon, and reattachment of Achilles tendon to calcaneus. The patient self-reporting questionnaires and outcomes including general health measure (Short Form-36 (SF-36), region-specific outcomes measure (Foot and Ankle Ability Measure (FAAM), and pain measure (Visual Analogue Scale (VAS)) were recorded at pre- and final post-operative visit. Results: Seven patients (all men) with mean age of 46 years old who had sleeve avulsion Achilles tendon rupture were enrolled in the study. The average time to follow-up was 15 months (range, 12-18 months). There was significant improvement of SF-36 (25.4, 28.5, 24.1, and 28.7 which were improved to 50.5, 55.2, 51.7, and 52.8 for PCS and 42.4, 48.8, 45.2, and 46.2 which were improved to 55.9, 56.7, 54.3, and 59.8 for MAS), FAAM (60, 67, 65, and 68 which were decrease to 21, 30, 30, and 33 for ADL and 0, 0, 0, and 0 which was improved to 72, 70, 69, and 66 for sports) and VAS score (5, 7, 6, and 8 and decreased to 0, 0, 0, and 0) for the first, second, third, and fourth patients respectively. All patients returned to daily activities and released to work at 6 weeks and return to sport approximately 6 months post-operatively. There was no complication in this study. Conclusion: A -row SutureBridge technique seems to be an effective technique and demonstrated promising results with minimal complications.
P105 Chamnanni Rungprai Ankle An Accuracy of Syndesmotic Reduction using Direct Visualization Technique: Evaluated by Bilateral Computed Tomography Yantharat Sripanich, MD Background: Syndesmotic injury is commonly seen associated with acute ankle fracture. Syndesmotic malreduction was proven be a poor prognostic factor. Many methods have been purposed to assess the quality of reduction such as direct visualization, comparing radiographic parameters to contralateral ankle fluoroscopy, and intra-operative computed tomography. Aim In this study, we demonstrated syndesmotic malreduction rate using bilateral CT after using direct visualization technique for syndesmotic fixation. Method: A prospective case series of 49 patients (20 left and 29 right sides) with an average age of 39 years who had rotational ankle fractures with syndesmotic injury confirmed by arthroscopic examination. All patients were treated with an open reduction and internal fixation of distal fibula using either 1/3 tubular plate or distal anatomical locking plate. Syndesmosis was fixed by one or two of 3.5-mm cortical screw with three or four cortices. Before syndesmotic fixation, syndesmotic reduction is made by using a large point reduction clamp and quality of the reduction was checked by direct visualization at anterior tibiofibular line. The accuracy of syndesmotic reduction is then evaluated by post-operative bilateral CT. A widening of distance between anterior tibia and fibula at 1-cm above the ankle joint more than 2 mm compared to uninjured sides considered a malreduction of syndesmosis. Results: The accuracy of syndesmotic reduction was 93.9 percent (46/49) compare to contralateral ankle. An average of BMI was 27.2 and an average of operative time was 78.2 minutes. Three malreduction were diagnosed on the criteria of a 2 mm difference from the contralateral side occurred due to a small fragment interposition at the syndesmosis. These patients underwent revision surgery to remove the fragment and/or then fixation of syndesmosis with same manner to achieve anatomical reduction. In all cases, the screws are removed at 12 weeks. Neither breakage nor migration of screws is observed and no wound or nerve complications following this technique. Conclusion: A syndesmotic fixation using direct visualization technique demonstrate lower rate of malreduction as demonstrated by poster-operative bilateral CT scan and no complications. This technique is effective, safe, and should be considered for treatment of syndesmotic injury associated ankle fracture.
P106 Chamnanni Rungprai Gastrocnemious contracture Single Versus Multi-Level Gastrosoleus/Achilles Tendon Lengthening: A Comparative Study Grace Kunas Annunziato Amendola, MD Phinit Phisitkul, MD Background: Single level gastrocnemius or Achilles tendon lengthening including open, percutaneous, and endoscopic techniques are considered standard techniques for the treatment of equinus contracture. However, patients with severe equinus contracture require multi-level of lengthening using combined procedures to achieve adequate ankle dorsiflexion. However, there is no comparative study between single versus multiple levels Achilles tendon lengthening. Aim Compare outcomes and complications between single versus multiple level gastrosoleus/Achilles tendon lengthening for patient with moderate to severe equinus contracture. Methods: Retrospective chart review of 646 consecutive patients (676 feet) with prospective outcomes measurement and diagnosed with ankle equinus contracture (> - 5 degrees equinus) and underwent single level Achilles tendon lengthening (310 patients/340 feet) including open Valpius or Strayer(VSO) 100 patients/106 feet, Baumann 38patients/38 feet, percutaneous triple hemisections (Hoke) 52patients/52 feet, endoscopic gastrocnemius recession (EGR) (120 patients/144feet), and multi-level using combined techniques 36 patients/36 feet between January 2006 and June 2017 were conducted. The minimum follow-up was 12 months (mean, 23.9 months for open VSO; mean, 24.0 months for Baumann procedure mean, 27.5 months for Hoke procedure, mean, 17.6 months for endoscopic technique, and mean 38.9 months for combined techniques). Primary outcomes included Foot Function Index; Short Form-36, Visual Analogue Scale, ankle dorsiflexion. Secondary outcomes included operative time and complications. Results: All techniques demonstrated significant improvement in FFI, SF-36, VAS, and ankle dorsiflexion (all p-value < 0.001). Multi-level of lengthening demonstrated significantly longer operative time than Hoke technique (p-value = 0.001) but the means improvement of ankle dorsiflexion intraoperatively and at final post-operative visit were significantly greater than all single level techniques (p-value = 0.001). The ankle dorsiflexion of multi-level at final post-operative visit was significantly lesser than endoscopic technique(p-value = 0.002) but was comparable with other single level lengthening. Weakness of plantarflexion and calf muscle atrophy was significantly higher in multi-level than all single level techniques(p-value < 0.05) while Achilles tendon rupture was significant higher in Hoke technique(p-value = 0.03). Sural nerve dysesthesia was higher in multi-level but this did not reach statistical significance while other complications were similar between groups. Conclusion: Both single and multi-level techniques demonstrated significant improvement in outcomes as measured with the FFI, SF-36, VAS, and ankle dorsiflexion for treatment of tightness of gastrocnemius and gastrosoleus muscle. Hoke is fastest procedure but significant Achiles rupture rate. Multi-level lengthening resulted in significant improvement of ankle dorsiflexion intraoperatively and at final post-operative visit with significant decrease Achilles tendon rupture rate but leaded to higher sural nerve dysesthesia, significant weakness of plantarflexion, and calf muscle atrophy.
P107 Tatsuya Sakai Hindfoot The Effect of Arthroscopic Ankle Arthrodesis on the Joints in the Hindfoot Hirofumi Tanaka Background Ankle arthrodesis has been used to relieve ankle pain in patients with severe osteoarthritis. After the operation, the adjacent joints generally compensate for the limited range of motion of the fused ankle. Aim We evaluated the compensation of the hindfoot after ankle arthrodesis. Method Thirteen patients who had undergone arthroscopic ankle arthrodesis, with ankle joints fused osteogenically, were recruited. The arc of the hindfoot, tibia-metatarsal (TM) angle, defined as the angle between the long axis of the tibia and long axis of the fifth metatarsal, was measured by lateral radiography between the active maximal dorsiflexion and plantarflexion. The arcs of TM immediately after surgery and at the last follow-up were compared. Results The mean arc of TM significantly increased from 19.7º (range; 8º–37º) to 23.8º (range; 14º–38º) (p=0.0261). During follow-up, new osteophytes were observed in 4 subtalar joints and 7 talonavicular joints. Conclusion The range of motion of the hindfoot maybe increased due to compensation for the fused ankle joint, which could result in overload on the joints of hindfoot. Further studies are needed to clarify the effect of ankle arthrodesis on the joints of the hindfoot.
P108 ELENA SAMAILA Paediatric deformity THE PONSETI METHOD IN OUR HANDS:EARLY AND MID-TERM FOLLOW-UP RESULTS Roberto Valentini Alessandro Barbieri Bruno Magnan Background Congenital clubfoot is one of the most common musculoskeletal deformities presenting at birth. Worldwide, a nonoperative approach in the treatment of idiopathic clubfoot has been taken in an attempt to reduce the incidence of surgical outcomes. The Ponseti method has become the gold standard for the treatment of idiopathic clubfoot. Its safety and efficacy has been demonstrated extensively in the literature, leading to increased use around the world over the last two decades. The aim of the study was to evaluate the results and theirs reproducibility of the Ponseti methods in an University non paediatric hospital with residents that gave the treatment. Method Between May 2008 and June 2015, 71 patients were treated for idiopathic clubfoot, of which 5 patients (9 feet) were treated with Codivilla-Turco surgycal approach and were excluded from the study. There were 3 drop out. We reviewed 63 patients (110 feet), 42 male (66.6) and 21 female (33.4). Dimeglio/Bensahel scores was used for the clinical assessment. Other factors that were evaluated: number of the Ponseti's castings, number of the percutaneous Achilles tenotomy and numeber of the tibialis anterior tendon transfer (TATT). Statistical analysis were calculated using Rho of Spearman’s test. Results The average follow-up was 39.8 months (4-85 months). 538 castings were performed, a mean 5.3 for each foot to correct the clubfoot deformity. In 29 feet (32.2%) a percutaneous Achilles tenotomy were performed. Fourteen feet (15.5%) developed recurrence for brace noncompliance, ten were treated nonoperatively with re-casting and the rest (four feet) required surgical procedure with TATT. The severy of clubfoot did have statistically significant correlation with number of the castings and number of Achilles tenotomies (p value <0.01) Conclusion The Ponseti method is safe, efficient in the conservative treatment of clubfoot and decreases the number of surgical interventions and yielded good clinical results with high functional scores. We performed a very low number (32.2%) of Achille's percutaneous tenotomy comparing to the literature, because we strictly followed the Ponseti protocol. We think that most of the author now propose Achille's tenotomy in almost all the cases because of the risk of relapse, but we continue to perform it just in cases with low dorsiflession of the ankle as Ponseti stated.
P109 ELENA SAMAILA Benign tumor Ledderhose Disease (Plantar Fibromatosis): Minimaly Invasive Surgery Is Not Indicated. Stefano Negri Roberto Valentini Bruno Magnan Background Plantar fibromatosis (Ledderhose’s disease) is a rare disorder, affecting both men and women typically in the fifth and sixth decades, characterized by thickening of the plantar aponeurosis with formation of fusiform nodules, due to the proliferation of fibroblasts and myofibroblasts, which cause principally plantar pain and difficulties in walking.The etiopathogenesis is unknown, although various predisposing factors are known. It is often associated with similar disease of other districts, such as Dupuytren's and La Peyronie’s disease.Differential diagnosis is with plantar fasciitis, plantar fascia’s rupture and various soft tissues sarcomas. Diagnosis is clinic, however, ultrasound or MRI is required.The treatment may be conservative (use of special soles or footwear, corticosteroids, NSAIDs, physiotherapy, antirheumatic drugs, radiotherapy) or surgery (local or enlarged plantar fasciectomy). The aim of the study was to evaluate the surgical treatment of aggressive plantar fibromatosis through enlarged plantar fasciectomy and to evaluate its mid- and long-term results. Method We review 23 patients for 28 operations (5 were bilateral) that underwent a enlarged plantar fasciectomy including the nodule and 1cm of free margin. There were 13 male and 10 female. The mean age at surgery was 52,71 ± 8,15 (ranging 35 to 74 years). 7 of monolateral patients were treated at the right side and 11 at the left side. In the bilateral patientssurgery was performed in two different moments. All patients presented clinically one or more nodules on the plantar aspect of the foot that was painful during walking. The nodule were diagnose too by US and/or MRI.For the clinical assessment and quality of general health were used SEFAS and SF-36. Results The mean follow-up was 5,48 ± 4,34 years (min 6 months, max 16 years).The resected fascia underwent an histological examination and diagnose was confirmed in all the cases. The number of nodule was as follows: 1 nodule in 21 feet (75% of the cases), 2 nodules in 2 feet (7%) and 3 nodules in 5 feet ( 18%).The dimension of the nodule was: <1 cm in 12 feet (30%); between 1 and 2 cm in 14 feet(35%);2-3 cm in 8 feet (20%) and > 3cm in 6 (15%). We observed an association with Dupuytren disease in 8 patients and 2 patients presented La Peyronie disease.The mean SEFAS score ranged from 25,07 ± 17,18 in pre-op to 17,18 ± 5,74 at FU. Complications: suffering of the surgical wound that required local medications,in 3 feet, one reccurent nodule (3%). Conclusions The clinical results showed by that SEFAS improved in 92.9% of patients and that presented an overall state of health at follow-up.This suggests that enlarged plantar fasciectomy leads reduction of pain, improvement in function and lowest risk of recurrence. We recommends using this technique as an alternative to conservative treatment and mini-invasive surgery that present in Ledderhose disease a high rate of reccurence.
P110 ELENA SAMAILA Forefoot Correction Of Bunionette By A MIS Procedure: Is It Reliable? Stefano Negri Roberto Valentini Bruno Magnan Background Distal osteotomy of the fifth metatarsal is indicated in the surgical treatment of bunionette and varus deformities of the fifth toe in patients with a valgus deviation of the fifth metatarsal. The aim of this study was to evaluate the results of a subcapital percutaneous osteotomy of the fifth metatarsal in the treatment of this disorder using a percutaneous technique Method From 1996 to 2006, 30 consecutive percutaneous distal osteotomies (P.D.O.) of the fifth metatarsal were performed in 21 patients for the treatment of a painful prominence of the fifth metatarsal head. Associated surgical procedures as a P.D.O. of the first metatarsal (18 patients) for hallux valgus or procedures on the lateral rays (8 patients) were performed. We reviewed 18 patients for 25 procedures with a minimum follow-up of 30 months (mean 8 years). Patients were assessed radiographically and clinically using the AOFAS scale. Results The mean AOFAS score was 98.4 ± 2.6. In 72% of cases AOFAS score was 100 points with complete resolution of pain at MTP5J. In 20% of cases we obtained 95 points with decreasing of function and need to use comfortable shoes. In 8% of cases the AOFAS score was 93 points for a mild asymptomatic malalignment. No recurrence of the deformity was observed. Conclusion The percutaneous procedure proved to be a reliable technique for a correct execution of a distal linear osteotomy of the 5th metatarsal. The clinical results appear to be comparable to those obtainable with traditional open techniques, with the additional advantages of a minimally invasive procedure, substantially shorter operating times and a reduced risk of complications related to surgical exposure.
P111 Elizabeth Sanders Reconstructive The Opening Cuboid Osteotomy for Pes Plano Valgus Mark J. Mendeszoon, DPM, FACFAS, FACFAOM Elizabeth A. Sanders, DPM, AACFAS, FACFAOM Alan Kidon, DPM, AACFAS Jonathan LeSar, MD/DPM Background/Aim Evans first described his calcaneal osteotomy in 1975 for surgical correction of a flexible pes plano valgus deformity in the transverse plane by restoring the length of a short lateral column. Little has been written regarding lengthening the lateral column through an opening cuboid osteotomy. Methods A retrospective chart review was performed of 79 feet (54 patients) that were corrected of a flexible pes plano valgus deformity with a cuboid osteotomy with bone graft by one primary surgeon between April 2000 and December 2016. There were 31 males, 23 females with an average age of 25 (12-78). 25 of the 54 were bilateral (46.3%). Five cases included an isolated cuboid osteotomy, the remainder 29 included adjunctive complex flat foot reconstructive procedures. The operative technique is described. The various adjunctive procedures are noted. Pre and post-operative management is described. Patient satisfaction scores with minimum 12 month follow-up are reviewed. Results Our study demonstrated radiographic improvement similar to other studies with radiographic improvement through Evans calcaneal osteotomy. Surveyed patients demonstrated overall good satisfaction with the procedure. Discussion Little has been written regarding opening cuboid osteotomies. The primary author has been performing opening cuboid osteotomies for several years with measurable success. Risks of the cuboid opening osteotomy are similar to that of the Evan’s osteotomy. However, given the shape and location of the cuboid, the midline cuboid osteotomy allows for smaller incision, is easier, more accurate, and a more reproducible technique with measurable results.
P112 Angela Seidel Pediatric Health-related quality of life and foot-function after clubfeet treatment using Ponseti casting followed by z-lengthening of the Achilles tendon and limited posterior release Séverine Tinembart PD. Dr. med. Thoralf Liebs PD Dr. med. Fabian Krause Dr. med. Nadine Kaiser Dr. med. Kai Ziebarth Background The Ponseti method has become the state of the art for clubfeet treatment. We modified the Ponseti method to decrease the splinting duration compared to Ponseti`s original method. Aim Our objective was to analyse our clinical and functional outcome and the recurrence rate. Methods First six padded long leg Soft Cast TM3 were applied. Our modification included an open z-lengthening of the Achilles tendon followed by capsulotomy of the ankle and subtalar joint to release the soft tissue structures. A Ponseti Brace or a unilateral brace was applied for 2 years. We assessed the health-related quality of life using the PedsQL questionnaire and the functional outcome with the Disease Specific Instrument (DSI). Results Sufficient data of 107 patients (156 clubfeet) with idiopathic clubfoot from 1994 to 2015 could be obtained. The affected side was 49 bilateral, 33 right, 25 left clubfeet, respectively. The initial treatment started at a mean age of 10.1 days. At a mean follow-up of 9.6 years, 81% of patients answered our questionnaires. The mean DSI was 74.3 +-18.2, the mean overall PedsQL was 87.3 +-13.0 (PedsQL function: mean: 88.7+- 16.3; PedsQL social: mean 88.3+- 13.1). The relapse rate was 22.7%, and 20.5% necessitated surgery. Conclusion This is one of the few studies analyzing the health-related quality of life after treatment in idiopathic clubfeet. Our results were superior compared to the literature in terms of the PedsQL, and relapse rate, the DSI was slightly worse. With the modified Ponseti treatment, we decrease the splinting time significantly, which comforts the therapy.
P113 Dishan Singh Consent Obtained informed consent across Europe Marino Delmi Martinus Richter Marco Guelfi Thanos Badekas Members of EFAS Council and Committees Background Elements of an informed consent process include 1) competency and capacity 2) discussion with the patient 3) disclosure of information on treatments and alternatives 4) information on common and rare serious risks 5) autonomous authorization and 6) documentation. Method A survey of current practice to obtain informed consent was sent to senior foot and ankle surgeons across some of the largest 11 European countries. Findings Young people aged 16 are entitled to provide consent at the age of 16 years in Poland, Portugal and UK, but at the age of 18 in Belgium, France, Germany, Greece, Italy, Netherlands, Spain and Switzerland. 3 surgeons provide patient information with a multiimedia presentation, 4 surgeons provide written information and 4 only provide oral information 6 routinely obtain consent when the patient is listed for surgery in the outpatient clinic, 3 see patients in a dedicated preadmission clinic and 2 usually obtain a signature at the time of admission for surgery. 4 leave the final consenting procees to an assistant but the other 7 do so in person. For hallux valgus correction, a form stating an operation on the right foot is deemed satisfactory by 1, a consent for correction of right hallux valgus is obtained by 3 and 7 surgeons specify more specific details of the operation. Discussion The replies reflect the practice of specific consultant orthopaedic foot and ankle surgeons rather than all surgeons in Europe. However, our survey gives a clear indication of the variety of practice across different areas.
P114 Dishan Singh Unusual pain Case report of red, painful, burning feet: Erythromelalgia Mosaab Aljalahma Orthopaedic surgeons will occasionally be referred patients presenting with episodic erythema, warmth and intense burning feet should be aware of the condition labelled as erythromelalgia. Case Report A 40 year old male presented with a 4 year history of episodic bilateral burning pain associated with warmth and redness affecting the extremities. These episodes were triggered by physical exercise and alcohol. He was taking gabapentin and antidepressants for a presumed diagnosis of chronic regional pain syndrome. He had had to give up all sporting activities and his occupation as a health worker. He presented to us using crutches; there was no abnormality on vascular examination but he had localised sensory loss which had occurred after a previous ankle arthroscopy and lateral ligament stabilisation. He provided pictures of his hands and feet during the acute flares lasting hours to days. A clinical diagnosis of erythromelalgia was made after consultation with a specialist in the field. Discussion Erythromelalgia with an estimated incidence of 0.25 per 100000 per year is described as being primary (can be familial and due to sodium channel defects) or secondary to myeloproliferative and rheumatological conditions. No definitive is available for erythromelalgia but the disease usually remits if the primary cause is treated. Symptoms are managed by patient education, support groups, avoidance of triggering factors, limb cooling etc. Most concerning is the functional and mental impairment reported by victims when doctors who see them fail to recognise the classic triad of symptoms.
P115 Rie Tanabe Forefoot Gait analysis in terminal stance of the patients with bilateral hallux valgus. Hiroyuki Seki Yasunori Suda Aiko Sakurai Yuina Nitta Ken Ishii Background: Hallux valgus (HV), which is one of the most common foot pathologies, affects the kinematics and kinetics of lower limb joints. Aim The purpose of this study was to investigate the kinematic and kinetic changes in the lower limb joints in patients with bilateral HV in the terminal stance of gait. Method: Nine female patients (17 feet) with bilateral HV and 10 healthy female controls (20 feet) (CT) were involved. Three-dimensional kinematic and kinetic data were measured during walking and the differences in the terminal stance of gait between two groups were compared using Mann-Whitney U test (p<0.05). Results: No significant differences were found in the temporal parameters between groups. Patients with HV showed significantly reduced anterior (CT: -0.06±0.02N, HV: -0.05±0.01N, p<0.01) and vertical (CT: 1.03±0.03N, HV: 0.96±0.09N, p=0.017) ground reaction force at the terminal stance. Patients with HV showed significantly increased ankle dorsiflexion angles (CT: 7.7±4.1゚, HV: 10.5±4.0゚, p=0.036) and reduced ankle supination angles (CT: 9.1±4.8゚, HV: 5.5±3.8゚, p=0.022), ankle abduction angles (CT: -4.0±5.8゚, HV: -0.3±3.0゚, p=0.014), and knee extension moments (CT: 0.14±0.15Nm/Kg, HV: 0.04±0.11 Nm/Kg, p=0.026) at the terminal stance. Conclusion: In the feet with HV, the propulsive force was lower and the sinking of ankle was deeper in the terminal stance of gait compared to the feet without HV.
P116 Wong Kah Wai Thomas Aloysius Neoplasm PLANTAR FOOT LUMPS ARISING VIA THE GLABROUS SKIN REQUIRE GREATER EVALUATION PRIOR TO SURGICAL EXCISION T. JEGATHESAN Muhd Farhan Bin Mohd Fadil INTRODUCTION & OBJECTIVE The orthopaedic surgeon has a wide choice of diagnoses to consider when patients present with a lump of the foot. We study our experience of foot lumps treated surgically and hypothesize that lumps arising from the plantar aspect of the foot via the glabrous skin are often more complex, requiring advanced imaging and greater consideration with regards to preoperative planning for surgical excision. METHODOLOGY All patients who underwent excision or biopsy of a foot lump in Tan Tock Seng Hospital between 1st January 2014 and 1st July 2017 were included in the study. Patients were identified from theatre records and all lumps excised were sent for histology. Case records and the histology results were retrospectively reviewed. The data assessed included patient demographics, location of the lump and the confirmed histological diagnosis. Location of the lumps was broadly divided into foot dorsum or via the glabrous skin on the plantar surface. Lumps were also dichotomized into simple or complex lumps based on histological diagnosis which would dictate the nature of surgical excision performed. RESULTS There were 49 females and 23 male patients included in this study, with the average mean age of the patients being 50.5 years. Of the total of 72 foot lumps, 49 (68%) lumps were excised from the foot dorsum while 23 (32%) lumps arise through the glabrous skin on the plantar aspect of the foot. Based on histology following excision, 17 of the 23 plantar lumps (74%) were complex in origin while only 8 of the 49 dorsal lumps (16%) were similarly complex in origin. This finding was statistically significant (p < 0.05). CONCLUSION Our study continues to establish that there are a wide range of diagnoses associated with lumps in the foot. Based on histological diagnosis, lumps arising through the glabrous skin on the plantar aspect of the foot are complex in nature as opposed to lumps arising from the foot dorsum which are largely simple with straightforward excision. Plantar lumps would hence benefit from advanced imaging and also require detailed pre-surgical planning and considerations with contribute to successful excision of the lump.
P117 Federico Usuelli Ankle Transfibular Total Ankle Replacement outcome at 2 years follow up: a multicenter study from non-designer surgeons Alastair Younger Kent Ellington Tiusanen Hannu Eric Giza Christopher Kreulen Background: Trabecular Metal Total Ankle is a fix-bearing, transfibular total ankle replacement (tTAR). It requires an alignment external frame and milling device for accurate insertion. The alignment stand is a rigid coordinate system to base the bony resections and it enables correction of sagittal and coronal deformities, improving the reliability of the implants position. Aim: The purpose of this study is to show the preliminary results of 113 patients treated with tTAR. Methods: This prospective study included 113 patients who underwent tTAR from 2014 to 2016. Ten centers were involved enrolling subjects. The mean age was 60.0 +/- 13.2 years. Patients were assessed clinically preoperatively and at 6 weeks, 6 months, 1 and 2 years postoperatively. Clinical evaluation was performed using EQ5D, AOFAS, VAS scores. Radiographic examination included weight bearing ankle x-rays (AP, LL). Of 113 cases, 113 were followed at 6 weeks, 97 at 6 months, 84 at 1 year, and 31 at 2 years. Results: Out of 113 patients, 48.7% 
(55/113) were females and 51.3%
 (58/113) were males.We reported statistically significant improvement in EQ5D, AOFAS ankle-hindfoot score, and AOS VAS pain scale (P<0.001), (Table1). Any revision case was performed during 2 years follow up. Conclusion: This study demonstrates that tTAR is a safe and effective option at short-term follow-up. The significant increase in clinical outcome and ROM, lead us to hypothesize that the fix-bearing with a lateral approach can be an advantage.
P118 Markus Walther Forefoot Percutaneous management of hallux valgus deformity: Learning curve analysis of the Minimal Invasive Chevron- and Akin osteotomy compared to the Scarf- and Akin osteotomy Sebastian Altenberger Stefanie Kriegelstein Hubert Hörterer Alexander Mehlhorn Anke Röser Background Minimally invasive surgeries have gained increasing popularity due to less soft tissue trauma and better wound healing. Aim The study was performed to compare learning curve and complication rates between open Scarf and Akin osteotomy (OS) and minimal invasive Chevron and Akin (MIS). Method 93 consecutive patients have been treated with MIS. The control group included 42 patients with OS. The preoperative intermetatarsal angle averaged 14° (+/-4°) in the MIS versus 15° (+/-2°) in the OS group. The hallux valgus angle was 32° (+/-9°) in the MIS and 35° (+/-8°) in the OS. Results Intermetatarsal angle improved by 10° (+/-4°) in MIS and by 10° (+/-4°) in the OS group. Hallux valgus angle improved by 22° (+/-10°) in the MIS and 21° (+/-7°) in the OS group. We did not find a difference in shortening of the 1st metatarsal. For MIS a significant decrease of time could be demonstrated from 62,17 (+/-12) minutes in the first quartile to 39 (+/-5) minutes in the last quartile. The exposure to radiation decrease significantly in the MIS group. AOFAS score was 89,2 in the MIS and 88,4 in the OS group at final follow up. In the OS group 2% developed superficial, 3% deep wound healing problems. 1 patient showed a fracture at the basis of the Scarf osteotomy 1 patient a delayed union after MIS. Conclusion: MIS demonstrated good results and a similar potential of correction with lower wound complication rates compared to OS. The initial increased use of image intensifier was reduced with increasing routine.
P119 Markus Walther Forefoot Minimal invasive proximal metatarsal osteotomy for the correction of hallux valgus Sebastian Altenberger Oliver Gottschalk Hubert Hörterer Anke Röser Background: The purpose of this prospective cohort study was to evaluate the clinical and radiological results of hallux valgus surgery using a minimal invasive proximal closing wedge osteotomy. Methods: A proximal closing wedge osteotomy with plantarization, combined with distal soft tissue release, minimal invasive resection of the exostosis and a minimal invasive Akin osteotomy was performed in 26 adult patients (32 feet) with hallux valgus (figure). Both osteotomies were stabilized with headless compression screws. The median age was 63.2 years and the minimum follow-up period was 12 months (range 12-18 months). Results: The mean AOFAS forefoot score improved significantly from 62.7 points preoperatively to 95.9 points postoperatively. The mean intermetatarsal angle and hallux valgus angle decreased from 17.1° and 28.8° preoperatively to 4.2° and 11.9° postoperatively. We did not see any wound healing problems. There was 1 delayed union in a patient treated at both sides which was managed conservative. The relative shortening of the 1st metatarsal was 2.1 mm. Preoperative metatarsalgia was present in 14 feet preoperatively and persisted in 3 feet at the last FU. Removal of hardware was needed in 1 feet (3.1%). Conclusion: Minimal invasive proximal closing wedge osteotomy is an effective and save method for relief of pain and improvement of function in correction of hallux valgus deformity, resulting in at least similar results as published for open proximal metatarsal osteotomy.
P120 Markus Walther Ankle MR imaging after cartilage reconstruction with autologous matrix induced chondrogenesis (AMIC). Ulrike Szeimies Oliver Gottschalk Background: MRI after cartilage reconstruction of the talus often leads to controversies interpreting the findings. Aim: This prospective cohort study was performed to correlate MRI findings to clinical outcome in patients having a 3-5-year FU after autologous matrix induced chondrogenesis (AMIC). Methods: 36 consecutive patients with cartilage defects (Grad III/IV ICRS, size>1.5cm²) were treated with AMIC. Follow up included clinical examination, Foot Function Index (FFI), AOFAS score and Visual Analogue Scale (VAS). MRI was analyzed using the MOCART score. Figure: MRI preoperative and 12 months after surgical therapy with grafting of the cyst with autologous bone and coverage with a collagen membrane. Results: FFI improved in the category pain from 55.0±19.6 to 26.2±15.1, in the category function from 60.1±13.7 to 23.7±21.4. The AOFAS Score increased from 50.8±17.9 to 82.4±14.1. The VAS improved from 7.7±2.4 to 3.1±2.5. The MOCART Score averaged 54.1±17.2. During the first year after surgery, bone edema was visible in all patients, 80% had irregularities of the subchondral bone plate without any correlation to clinical symptoms. After 18 months, the bone edema decreased. 21 patients had moderate effusion. Partial detachment of the collagen membrane (2 patients), new cyst formation and synovitis had a significant correlation with clinical symptoms (Spearman Rho 0,73). Conclusion: The area of the reconstructed cartilage was visible at the last follow up MRI. Minor irregularities in the signal of the subchondral bone was not related to symptoms. A partial detachment of the membrane, cysts and synovitis showed a high correlation with pain.
P121 Jonas Weidow Hindfoot Total subtalar instability. Reconstruction with semitendinosus graft. Total subtalar instability. Reconstruction with semitendinosus graft. Abstract Background: When an ankle sprain is severe it can include a tear of the lateral ligaments as well as the medial ligaments, leading to a subtalar instability with a feeling of insecure and subtalar pain. Aim: Our purpose is to describe the condition total subtalar instability and present a new surgery method using an autologous hamstring graft. Method: A consecutive series of 8 young women (15-44 year; median 23 year) with subtalar pain together with a lateral and medial instability of the hindfoot were included in this study. A semitendinosus tendon graft was positioned through calcaneus from sustentaculum tali to the calcaneofibular ligament insertion on the calcaneus, and in an anatomical position to the medial malleolous as for the tibio calcaneo ligament (TCL), and to the lateral malleolous as for the calcaneo fibular ligament (CFL). Results: The movement of the ankle were not restricted at follow up and the AOFAS hind foot score were improved from 55 to 88 (mean) after 6-24 months (3 have passed 24 months (85), 4 patients 12 months (92) and 1 patient 6 month). No failures at midterm follow up. Conclusion: An autologous semitendinosus graft through calcaneus including both malleolus for reconstruction of TCL and CFL in an anatomic position, shows a promising result for total subtalar instability repair, after 6-24 months. Level of evidence: Level IIa, prospective controlled series Keywords: Subtalar instability, tendon autograft, medial instability, lateral instability, semitendinosus, hamstring
P122 Seung Hun Woo Trauma Short Term Results of a Ruptured Deltoid Ligament Repair During an Acute Ankle Fracture Fixation Su-Young Bae Hyung-Jin Chung Background: There is no consensus on the optimal treatment or preferred method of operation for the management of acute deltoid ligament injuries during an ankle fracture fixation. This study aims to analyze the outcomes of repairing the deltoid ligament during the fixation of an ankle fracture compared to conservative management. Methods: We retrospectively evaluated 78 consecutive cases of a ruptured deltoid ligament with an associated ankle fracture between 2001 and 2016. All of the ankle fractures were treated with a plate and screw fixation. Patients in the conservative treatment for ruptured deltoid ligament underwent management from 2001 to 2008 (37 fractures, group 1), while the operative treatment for ruptured deltoid ligament was included from 2009 to 2016 (41 fractures, group 2). The outcome measures included radiographic findings, the American Orthopaedic Foot and Ankle Society ankle-hindfoot scores, visual analog scale scores, and the Foot Function Index. Results: All patients were followed for an average of 17 months. Radiologic findings in both groups were comparable, but the final follow-up of the medial clear space (MCS) was significantly smaller in the group 2 (P < .01). Clinical outcomes were similar between the two groups (P > .05). Comparing those who underwent syndesmotic fixation between both groups, group 2 showed a significantly smaller final follow-up MCS and all clinical outcomes were better in group 2 (P < .05). Linear regression analysis showed that the final follow-up MCS had a significant influence on clinical outcomes (P < .05). Conclusion: Although the clinical outcomes were not significantly different between the two groups, we obtained a more favorable final follow-up MCS in the deltoid repair group. Particularly when accompanied by a syndesmotic injury, the final follow-up MCS and the clinical outcomes were better in the deltoid repair group. In the case of high-grade unstable fractures of the ankle with syndesmotic instability, a direct repair of the deltoid ligament is adequate for restoring medial stability. Level of Evidence: Level IV, retrospective comparative case series
P123 Seung Hun Woo Trauma Short Term Results of a Ruptured Deltoid Ligament Repair During an Acute Ankle Fracture Fixation Jin Soo Suh Hyung-Jin chung Background: This study aims to analyze the outcomes of repairing the deltoid ligament during the fixation of an ankle fracture compared to conservative management. Methods: We retrospectively evaluated 78 cases of a ruptured deltoid ligament with an associated ankle fracture. All of the ankle fractures were treated with a plate and screw fixation. Patients in the conservative treatment group underwent management from 2001 to 2008 (37 fractures, group 1), while the operative treatment group was included from 2009 to 2016 (41 fractures, group 2). The outcome measures included radiographic findings, the American Orthopaedic Foot and Ankle Society ankle-hindfoot scores, visual analog scale scores, and the Foot Function Index. Results: Radiologic findings in both groups were comparable, but the final follow-up of the medial clear space (MCS) was significantly smaller in the group 2 (P < .01). Clinical outcomes were similar between the two groups. Comparing those who underwent syndesmotic fixation between both groups, group 2 showed a significantly smaller final follow-up MCS and all clinical outcomes were better in group 2 (P < .05). Conclusion: Although the clinical outcomes were not significantly different between the two groups, we obtained a more favorable final follow-up MCS in the deltoid repair group. Particularly when accompanied by a syndesmotic injury, the final follow-up MCS and the clinical outcomes were better in the deltoid repair group. In the case of high-grade unstable fractures of the ankle with syndesmotic instability, a direct repair of the deltoid ligament is adequate for restoring medi
P124 Francisco Guerra-Pinto Ankle The talar tilt is significantly better to identify ATFL and CFL ruptures when it’s performed with an internal rotation pre-positioning – experimental model in 12 cadavers Nuno Côrte Real João Cunha Miguel Duarte Silva José Guimarães Consciência Xavier Martin Oliva Background The low sensitivity of the varus talar tilt test limits its utility in the diagnosis of ankle lateral ligaments’ insufficiency. We believe that the correct maneuver to diagnose an ATFL and CFL rupture should be similar to the supination trauma that caused it. Aim Our hypothesis is that the correct way to perform a varus talar tilt is with an internal rotation starting point. Methods: Our experimental model was applied in 12 cadavers. The tibio-talar movements were analyzed with a new arthrometer, which includes an Arduino Mega 2560 board as the microcontroller with the help of Mpu6050, an inertial measurement unit (IMU) with three-axis gyroscope and a three-axis accelerometer. The tibio-talar motion was analysed during the varus talar tilt in (a)the intact ankles, (b)after ATFL section and (c)after ATFL and CFL section. Results: After ATFL section the varus tibio-talar angle increased 13,01±4,98 degrees when the varus tilt was performed in a normal starting point. When an internal rotation was applied before the varus tilt it showed a tibio-talar angle of 21,2±7,44 degrees. This difference was significant (p=0,002). After ATFL and CFL section the varus tibio-talar angle increased 23,85±6,30 degrees when the varus tilt was performed in a normal starting point. When an internal rotation was applied before the varus tilt it showed a tibio-talar angle of 29,52±7,91 degrees. This difference was significant (p=0,006). Conclusion: In our experimental model the talar tilt is significantly better to identify ATFL and CFL ruptures when it’s performed with an internal rotation pre-positioning.
P125 Don Koh Hindfoot Flexor Hallucis Longus Transfer versus Turndown Flaps Augmented with Flexor Hallucis Longus Transfer in the Repair of Chronic Achilles Tendon Rupture Jeremy Lim Jerry Y Chen Inderjeet R Singh Kevin Koo Background: Repairs of chronic Achilles tendon ruptures are technically challenging due to large defects after scar excision. Multiple techniques for repair have been proposed but little consensus on best practice established. Aim: This study aims to compare Flexor Hallucis Longus (FHL) transfers versus turndown flaps augmented by FHL transfers. Methods: Between 2005 and 2015, 49 unilateral repairs of chronic Achilles tendon ruptures were performed. We retrospectively compared the outcomes of 20 patients who underwent FHL transfer with 19 patients who underwent turndown flaps augmented with FHL transfer before surgery and at three time points after surgery (three, six and twelve months). Visual Analogue Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and the 36-Item Short Form Health Survey (SF-36) were used to evaluate outcome. Results: Both techniques demonstrated significant improvement in their outcome scores and were comparable to one another. At one year, the mean VAS score was 0 for both groups. The mean AOFAS Ankle-Hindfoot score was 90 ± 11 (FHL) and 95 ± 10 (FHL with turndown flaps); and SF-36 scores showed significant improvements in physical, role and social function scores. Turndown flaps augmented with FHL transfer however required significantly longer operative time (100 ± 21 min) compared to FHL transfer alone (73 ± 23 min).
P126 Jae Hee Lee Gait Change of in-shoe plantar pressure according to different types of shoes Dong Yeon Lee Hyuck Soo Shin Yoon Bin Hwang Hyo Jeong Yoo Pressure has been used as an efficient method to evaluate a burden the foot is tolerating during the gait. Many authors have utilized the pressure in pathologic conditions such as cerebral palsy, diabetes mellitus with peripheral neuropathy. Recently, some authors suggest that plantar pressure can be measured more accurately inside the shoe using in-sole type sensors. However, most studies have been done in the field of sports. And there are few studies on the change of foot pressure according to various shoe types. So the objective of this study was to investigate the difference of plantar pressure between three types of shoes which are flat shoes, running shoes and high-heel in healthy young women. 27 feet of 27 healthy women with 18-25 years old who had normal function of the foot and ankle and no deformity on radiographic evidence were included. And we used gait data of 50 healthy young women with 20-35 years old previously obtained to confirm whether the gait of the experimental group is included in the normal range. Radiologic features on plain radiographs and clinical scores of FAOS and AOFAS were obtained. Measurements of plantar pressure of foot including pressure, force, area, force-time integral (FTI), and pressure-time integral (PTI) were done through insole type sensor (Pedar-X system), while walking on a non-inclined floor. Only measurements of right steps were used to exclude the effect of the dominant foot. Also, the sole has been masked dividing the region into hallux, lesser toes, metatarsal head (MTH) 1, MTH2, MTH3-5, midfoot and heel. 27 out of 32 participants’ data were finally used, which showed normal in radiologic features and gait analysis. There were significant differences in the plantar pressure between flat shoes and running shoes in all regions. Between flat shoes and high heel, there were some significant differences in plantar pressure except MTH3-5, midfoot. And except the toe region including hallux, there was no significant difference in plantar pressure between running shoes and high heel. Upon 7 regions of the foot, flat shoes showed meaningful higher pressure than running shoes in hallux and lesser toes. Also, flat shoes had the highest pressure in MTH3-5 and hindfoot. In contrast, on the MTH1 and MTH2 region, high heel was measured as the highest pressure, followed by flat shoes. In midfoot, running shoes showed the highest plantar pressure than other shoes (Table 1). Lastly, acceptable pressures higher than any other shoes were not measured in running shoes for the whole region. Considering the overall results, we suggest that high heel showed high pressure on MTH1. On the other hand, flat shoes showed high pressure on hindfoot, because flat shoes have no cushion compared to other two shoe types. In addition, running shoes showed a lesser pressure on all of the region while walking, which indicate wearing running shoes gives less burden on the foot. Exception can be found in MTH3-5 where flat shoes showed the highest pressure. In conclusion, we demonstrate that flat shoes and high heel can give a great burden to specific part of the foot.
P127 Dong Yeon Lee Gait Analyzing the difference of plantar pressure in the shod foot in relation to the bare foot- in female young adults Min Chung Suh Hyo Jeong Yoo Hyuck Soo Shin One of the preventive measures of the diabetic foot is utilizing protective footwear. Diabetic ulcers and infections typically form along the bottom of the foot. Relieving plantar pressures in these regions is a step towards preventing diabetic foot complications and ensuring the quality of life for many diabetics. But there is few study about plantar pressure by analyzing the differences in the shod foot. So the objective of this study was to find out how the off-the-shelf running shoes can affect the plantar pressure by analyzing the differences in the shod foot (when wearing running shoes) in relation to the bare foot. The focus of this research was the hallux, forefoot, and the heel. 27 feet of 27 healthy women with 18-25 years old who had normal function of the foot and ankle and no deformity on radiographic evidence were included. And we used gait data of 50 healthy young women with 20-35 years old previously obtained to confirm whether the gait of the experimental group is included in the normal range. Radiologic features on plain radiographs and clinical scores of FAOS and AOFAS were obtained. Measurements of plantar pressure of foot including pressure, force, area, force-time integral (FTI), and pressure-time integral (PTI) were done through insole type sensor (Pedar-X system), while walking on a non-inclined floor. Only measurements of right steps were used to exclude the effect of the dominant foot. Also, the sole has been masked dividing the region into hallux, lesser toes, metatarsal head (MTH) 1, MTH2, MTH3-5, midfoot and heel. The HR mat (TEKSCAN) and Pedar (novel) were used to compare barefoot and shod foot plantar pressures, respectively. The mean CMC which was 0.937556 (±0.080977) demonstrates high correlation. Both MMP and PTI decrease in the hallux when wearing running shoes compared to going barefoot. MMP, PTI and the FTI decrease in the lesser toes when wearing running shoes. MMP and PTI decreased in medial forefoot. PP decreases in central forefoot. PP and the PTI decrease in the lateral forefoot. PP, MMP, PTI, FTI all decrease in the midfoot (Figure 1). MMP, PTI, FTI decrease in the heel when wearing running shoes. When wearing running shoes, participants display significant decreases in pressure parameters at the hallux, forefoot, and the heel compared to going barefoot. Midfoot results were interesting but was expected. When one walks barefoot, only a portion of the midfoot touch the ground due to the arch. But when participants walk in running shoes, the arch support in the shoe allows in-sole sensor to measure the entirety of the midfoot plantar pressure. This observation can be deduced from the different peak pressures gathered from the midfoot section.
P128 Jae Hee Lee Gait Foot Gait Analysis In Old Female Patients with Acquired Adult Flatfoot Dong Yeon Lee Jae Hee Lee Doo Jae Lee Hyo Jung Yoo Hyuck Soo Shin Acquired adult flatfoot is thought to be caused by a loss of the dynamic and static supportive structure of the medial longitudinal arch. Current evaluation systems mostly rely on static measurements such as standing x-ray, CT and MRI. Recently, the gait analysis has been suggested to be a good tool for assessment of functional impairment. Although there are some previous investigations about gait of flatfoot, there was a limitation in control groups in terms of matching age and gender. The objective of this study was to find the effect of the acquired adult flatfoot on the segmental motion of the foot during gait by comparisons with age and gender controlled healthy adults. 20 symptomatic flatfeet (twelve female patients, 51–80 years old) and 50 symptom-free normal feet (fifty female participants, 60-69 years old) were included in this study. For radiographic examinations, meary angle, calcaneal pitch, talo-calcaneal angle, tibio-calcaneal angle was measured using standing lateral radiograph of the foot. And talonavicular coverage angle was measured using standing anteroposterior radiograph of the foot. For foot gait analysis, the temporal gait parameters such as the cadence, speed, stride length, step width, step time were calculated. Segmental foot kinematics evaluated using a 3D MFM of a 15-marker set (Foot3D model). Inter-segmental angles (ISA) (hindfoot relative to tibia, forefoot to hindfoot, and hallux to forefoot) were calculated at each time points (100 time points for whole gait cycle). The ISAs (position) at specific phases of gait cycle, the change of ISA (motion) between phases and range of ISAs during the whole gait cycle were calculated and compared between groups. Range of motion (ROM) of sagittal and transverse plane of hindfoot, and transverse plane of forefoot was lower in flatfoot group. ROM of coronal plane of hallux and sagittal plane of forefoot was higher in flatfoot group. There also are significantly different findings in flatfoot group such as more dorsiflexed position of forefoot segment, reduced forefoot abduction motion during terminal stance and loss of push off during preswing phase. In addition, the time of push off phase in flatfoot group occurred later than the control group. In other words, lag of stance phase occurred in flatfoot group (Figure 1). This tendency became even worse when the moderate group and the severe group were compared based on the -20 ° of meary angle As shown in the gait analysis, the overall reduction in hindfoot ROM and the increase in forefoot ROM in the flatfoot group suggest a midfoot breakage, which shows a decrease in push off power and a lag in the stance phase. So, the results of this study suggest that altered segmental motion of the foot in acquired adult flatfoot patients with PTTD, which shows progressive deterioration according to severity. And we think that gait analysis can be used as an objective functional measurement system for evaluation of acquired adult flatfoot patients.

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