Advances in Diagnosis and Management of Lateral Ankle Instability: A Review of Current Literature.

Lateral ankle sprains and instability are an increasingly identified pain point for patients, accounting for 20 to 25% of musculoskeletal injuries. Lateral ankle injuries are especially concerning given the propensity for patients to develop chronic lateral ankle instability and for the high risk of reinjury on an unstable ankle. With the complex articulation of the tibiofibular syndesmosis, subtalar, and talocrural joints, pinpointing ankle dysfunction remains difficult. Multiple reviews have evaluated management and diagnosis of lateral ankle instability, but with newer treatment options available, a more comprehensive assessment of the current literature was conducted. Although multiple surgical options exist, many nonsurgical functional options have also been developed for patients that may help patients prevent the development of chronic lateral ankle instability. In recent times, many new options have come up, including in-office needle arthroscopy and continual advancements in diagnosis and our understanding of this difficult topic. Multiple reviews have evaluated the management and diagnosis of lateral ankle instability, but with newer treatment options available, a more comprehensive assessment of the current literature was conducted. Given this, this review will help to highlight new diagnostic and nonsurgical therapeutic options for the management of lateral ankle instability.

Patient-Reported Outcome Measurement Information System Measures for Proximal Interphalangeal Joint Arthrodesis in Lesser Toe Deformities.

Although hammertoe (HT) is a common complaint among foot patients, there is little consensus on the best surgical approach for correction. These authors hypothesized that the use of a headless intramedullary screw across both the proximal interphalangeal joint (PIPJ) and distal interphalangeal joint (DIPJ) would decrease many post-surgical complications, such as infection, pain, and mallet toe deformity, found in traditional HT corrective surgical techniques. In this retrospective cohort study, N = 163 adult patients who had undergone DIPJ/PIPJ arthrodesis for HT correction at least 1 year prior to the study were identified. One hundred fifty-nine patients were contacted through REDCap to complete Patient-Reported Outcome Measurement Information System (PROMIS) physical function (PF) and pain interference (PI). Demographic, radiographic, and follow-up data were taken from the electronic medical record (EMR). Analysis was completed with Microsoft Excel; PROMIS PF and PI measures for the 32-person cohort were 45.65 ± 8.26 and 51.65 ± 9.01, respectively. The PF and PI measures had a statistically significant correlation (R2 = 0.71). The 163-person cohort had an overall revision rate of 6.75%, or 11 patients, and an infection rate of 1.23%. This procedure had lower rates of residual pain, infection, mallet toe deformity, and reoperation when compared with current techniques. This study supports the safety and viability of PIPJ/DIPJ arthrodesis using a headless screw for HT correction.Levels of Evidence: Level III Retrospective Cohort Study.

Use of a Novel Adhesive Suture Retention Device in Non-traumatic Diabetic Lower Extremity Amputations: A Multicenter Case Review.

Background: Amputations in the diabetic foot are commonly associated with complications, including delayed wound healing, surgical site dehiscence, and the need for additional amputations. Use of a novel adhesive suture retention device (ASRD) has been previously shown to support improved linear closure outcomes. The purpose of this retrospective case review was to determine if the adoption of the ASRD in 5 podiatric surgical practices would reduce postoperative complications in patients with diabetes undergoing foot amputations including surgical site dehiscence and the need for additional amputation. Methods: A 5-center retrospective chart review was performed to assess the difference in postoperative surgical site dehiscence and reamputation rates for patients with diabetes undergoing minor and major lower extremity amputations before and after adopting the use of the ARSD. Results: Adoption of the adhesive retention suture device was associated with an overall decrease in wound dehiscence of 81% (P < .01). Additionally, there was an 89% reduction in progression to higher level amputation in the ARSD cohort (P = .015). Conclusions: Utilization of the ARSD decreased the incidence of postoperative wound dehiscence and reamputation in this patient cohort, thus lessening patient morbidity and decreasing the overall cost of care.

Imaging of osteoarthritis from the ankle through the midfoot.

Ankle, hindfoot, and midfoot osteoarthritis (OA) is most commonly posttraumatic and tends to become symptomatic in younger patients. It often results from instability due to insufficiency of supportive soft tissue structures, such as ligaments and tendons. Diagnostic imaging can be helpful to detect and characterize the distribution of OA, and to assess the integrity of these supportive structures, which helps determine prognosis and guide treatment. However, the imaging findings associated with OA and instability may be subtle and unrecognized until the process is advanced, which may ultimately limit therapeutic options to salvage procedures. It is important to understand the abilities and limitations of various imaging modalities used to assess ankle, hindfoot, and midfoot OA, and to be familiar with the imaging findings of OA and instability patterns.

Characteristics and Trends of Highly Cited Articles in Calcaneus Fracture Research.

Background: Despite significant effort expended toward exploring fracture patterns, surgical timing, surgical approaches, and possible implants within the calcaneus fracture literature, treatment is still fraught with complications and controversy. This study aims to conduct a citation analysis of the most cited articles related to calcaneus fractures to highlight the most historically influential articles, as well as the more recent breakthrough articles that are leading change within the field. Methods: A literature search was performed via Scopus on September 20, 2021 using the terms "(calcaneus OR calcaneal OR hindfoot) AND (fracture OR injury)" to search "article title, abstract, and keywords" of all primary and review articles. Search results were rigorously reviewed to ensure appropriateness for this study. The 50 highest total cited included articles were analyzed. Title, authors, journal, country of origin, institution, year of publication, citation variables (total citation count, total citation density, citation count from the last 5 years, and 5-year citation density), and level of evidence were collected for each article. One-way analysis of variance with post hoc testing was used to identify differences in citation variables and level of evidence. Pearson correlation was used to directly compare different citation variables. Results: The total citation count average was 178±33, with a total citation density average of 9±2. The year of publication for the 50 articles ranged from 1948 to 2014, with a median year of 1999. Roy W. Sanders was the most productive author in the field, authoring 6 articles and lead authoring 3. The most frequent level of evidence was IV with 19 articles. There was a strong correlation between total citation density and 5-year citation density. The article level of evidence showed no impact on the included measures of an article's influence. Conclusion: This study successfully analyzes and presents the characteristics among the highest cited articles related to calcaneus fractures. The provided characterization of influential works and authors highlights trends, impactful findings, and future areas of focus within calcaneus fracture literature.Level of Evidence: Review Article.

Superficial Deltoid Ligament and Deep Deltoid Ligament Play Equally Important Roles in the Stability of Isolated Lateral Malleolus (OTA/AO 44-B1) Fractures: A Biomechanical Study.

OBJECTIVE: To evaluate the individual contributions to stability of the superficial and deep deltoid ligaments in the setting of SER IV ankle fractures. METHODS: Nineteen total cadaveric specimens were used. SER IV injuries were created with the rupture of either the superficial (SER IV-S) (n = 9) or deep deltoid (SER IV-D) (n = 10). These were tested by applying an external rotation force (1 Nm, 2 Nm, 3 Nm, and 4 Nm). Changes in the position of the talus were recorded with a 3D motion tracker. Injury conditions were compared with a 4-step general linear model with repeated measures. Injury condition was also compared with the intact state and to each other using 2-tailed t tests. RESULTS: The general linear model showed that increased loading had a significant effect with axial rotation (P = 0.02) and sagittal translation (P = 0.003). SER IV-S and SER IV-D showed significantly greater instability compared with the intact state in axial rotation (1 Nm, 2 Nm, and 3 Nm). SER IV-S and SER IV-D did not significantly differ from each other. CONCLUSIONS: SER IV fracture patterns can be unstable with isolated injury to either the superficial or deep deltoid. This challenges the notion that deep deltoid rupture is necessary. Further clinical studies would help quantify the consequences of this instability.

Biologic Augmentation of Tibiotalocalcaneal Arthrodesis With Allogeneic Bone Block Is Associated With High Rates of Fusion.

BACKGROUND: The orthopaedic conditions and systemic comorbidities that occur in patients who require bone block tibiotalocalcaneal (TTC) arthrodesis have made this procedure associated with a higher-than-normal risk of nonunion, graft collapse, hardware failure, and amputation. Here, we present a novel approach to bone block TTC arthrodesis using adjunctive osteoinductive agents and a prolonged course of protected weightbearing to assess if we could improve on historical outcomes. We also evaluated the efficacy of a vascularized medial femoral condyle (MFC) free flap to augment TTC arthrodesis. METHODS: Fourteen adult patients underwent bone block TTC arthrodesis biologically augmented with fresh-frozen femoral head allograft, bone marrow aspirate concentrate, and demineralized bone matrix cortical fibers. Three patients with soft tissue defects underwent vascularized reconstruction with an MFC free flap. Radiographic union, the Foot Function Index (FFI), and PROMIS pain interference (PI), and physical function (PF) scores were assessed at follow-up. RESULTS: TTC fusion was documented on plain radiograph in 13 of 14 patients (92.9%) and CT in 10 of 11 patients (90.9%). Mean time to fusion was 183.2 ± 83.2 days. One patient (7.1%) experienced nonunion and persistent infection requiring amputation. Patients who underwent vascularized bone grafting had significantly shorter time to fusion (112.3 ± 31.7 days vs 204.4 ± 82.7 days, P = .05). Patient-reported outcomes revealed mild to moderate pain and dysfunction after 1 year (mean FFI = 41.0% ± 23.1%, PROMIS PI = 58.3 ± 1.8, PROMIS PF = 39.0 ± 2.2). CONCLUSION: In this relatively small series, the biologic augmentation of bone block TTC arthrodesis with osteoinductive agents and protective weightbearing resulted in excellent rates of fusion, modest pain, and preserved function of the lower extremity in almost all those treated. Osseous healing appears to be enhanced and accelerated with application of an MFC flap. We believe that this approach offers a viable salvage option for these challenging clinical problems. LEVEL OF EVIDENCE: Level IV, case series.

Calcaneal Reconstruction With Femoral Head Allograft Vascularized by an Osteocutaneous Medial Femoral Condyle Flap: A Case Report.

CASE: A 25-year-old man presented with a closed calcaneal fracture after a 6-storey fall, complicated by osteomyelitis from fixation attempts necessitating near-complete debridement of his calcaneal tuberosity. He underwent a successful single-stage calcaneal and soft-tissue reconstruction using a femoral head structural allograft vascularized with an osteocutaneous medial femoral condyle flap. At the 18-month follow-up, his limb is largely pain-free and functional, allowing ambulation and his combined allograft-vascularized bone reconstruction shows radiographic evidence of incorporation. CONCLUSION: Calcaneal tuberosity reconstruction with a femoral head structural allograft and vascularized bone flap is a viable option for calcaneal tuberosity bone loss because of injury/infection.

Spring and Deltoid Ligament Insufficiency in the Setting of Progressive Collapsing Foot Deformity. An Update on Diagnosis and Management.

The spring ligament and deltoid ligament are important stabilizers of the medial ankle. Together, they form a complex along the medial ankle and foot that is critical to stability of both the ankle and the medial longitudinal arch. Incompetence of the spring and deltoid ligament is a component of both the early and late stages of progressive collapsing foot deformity. As the importance of this medial ligament complex has been recognized, repair and reconstruction of these ligaments have progressively evolved, initially as separate reconstructions, and more recently as combined techniques.

Mal-union of sustentaculum tali fracture with talo-calcaneal coalition leading to tarsal tunnel syndrome: A case report.

Displaced isolated fractures of sustentaculum tali are rare. Inadequate treatment of these injuries can rarely lead to non-union or mal-union and in most cases are treated non-surgically. We report a unique case of undiagnosed mal-union of sustentaculum tali in the setting of underlying tarsal coalition that resulted in symptoms of tarsal tunnel. Osteotomy and excision of the mal-united fragment and coalition along with decompression of the tarsal tunnel was performed. The patient had immediate improvement in pain and the paraesthesia recovered by the end of 6 weeks post-operatively. The Foot and Ankle disability score (FADI) score improved from 26.0 pre-operatively to 96.2 at 3 years' follow-up. This case highlights that isolated fractures of sustentaculum tali warrant advanced imaging and surgical reduction and fixation may be appropriate to avoid long-term disability where displacement compromises the tarsal tunnel or function of the subtalar joint.

Acute foot and ankle injuries and time return to sport.

Foot and ankle sports injuries encompass a wide spectrum of conditions from simple contusions or sprains that resolve within days to more severe injuries that change the trajectory of an athlete's sporting career. If missed, severe injuries could lead to prolonged absence from the sport and therefore a catastrophic impact on future performance. In this article, we discuss the presentation of the commonest foot and ankle sports injuries and share recent evidence to support an accurate diagnosis and best management practice.

Radiographic analysis of specific morphometrics and patient-reported outcomes (PROMIS) for surgical repair of zones 2 and 3 fifth metatarsal fractures.

BACKGROUND: Zones 2 and 3 fifth metatarsal fractures are often treated with intramedullary fixation due to an increased risk of nonunion. A previous 3-dimensional (3D) computerized tomography (CT) imaging study by our group determined that the screw should stop short of the bow of the metatarsal and be larger than the commonly used 4.5 millimeter (mm) screw. This study determines how these guidelines translate to operative outcomes, measured using Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) surveys. Radiographic variables measuring the height of the medial longitudinal arch and degree of metatarsus adductus were also obtained to determine if these measurements had any effect on outcomes. And lastly, this study aimed to determine if morphologic differences between males and females affected surgical outcomes. METHODS: We retrospectively identified 23 patients (14 male, 9 female) who met inclusion criteria. Eighteen patients completed PROMIS surveys. Preoperative PROMIS surveys were completed prior to surgery, rather than retroactively. Weightbearing radiographs were also obtained preoperatively to assist with surgical planning and postoperatively to assess interval healing. Correlation coefficients were calculated between PROMIS scores and repair characteristics (hardware characteristics [screw length and diameter] and radiographic measurements of specific morphometric features). T tests determined the relationship between repair characteristics, PROMIS scores, and incidence of operative complications. PROMIS scores and correlation coefficients were also stratified by gender. RESULTS: The average screw length and diameter adhered to guidelines from our previous study. Preoperatively, mean PROMIS PI = 57.26±11.03 and PROMIS PF = 42.27±15.45 after injury. Postoperatively, PROMIS PI = 44.15±7.36 and PROMIS PF = 57.22±10.93. Patients with complications had significantly worse postoperative PROMIS PF scores (p=0.0151) and PROMIS PI scores (p=0.003) compared to patients without complications. Females had non-significantly worse preoperative and postoperative PROMIS scores compared to males and had a higher complication rate (33 percent versus 21 percent, respectively). Metatarsus adductus angle was shown to exhibit a significant moderate inverse relationship with postoperative PROMIS PF scores in the overall cohort (r=-0.478; p=0.045). Metatarsus adductus angle (r=-0.606; p=0.008), lateral talo-1st metatarsal angle (r=-0.592; p=0.01), and medial cuneiform height (r=-0.529; p=0.024) demonstrated significant inverse relationships with change in PROMIS PF scores for the overall cohort. Within the male subcohort, significant relationships were found between the change in PROMIS PF and metatarsus adductus angle (r=-0.7526; p=0.005), lateral talo-1st metatarsal angle (r=-0.7539; p=0.005), and medial cuneiform height (r=-0.627; p=0.029). CONCLUSION: Patients treated according to guidelines from our prior study achieved satisfactory patient reported and radiographic outcomes. Screws larger than 4.5mm did not lead to hardware complications, including screw failure, iatrogenic fractures, or cortical blowouts. Females had non-significantly lower preoperative and postoperative PROMIS scores and were more likely to suffer complications compared to males. Patients with complications, higher arched feet, or greater metatarsus adductus angles had worse functional outcomes. Future studies should better characterize whether patients with excessive lateral column loading benefit from an off-loading cavus orthotic or plantar-lateral plating.

A qualitative assessment of return to sport following Achilles tendon repair.

Studies have demonstrated successful return to sport rates following Achilles tendon rupture and repair. The purpose of this study is to understand the subjective intrinsic and extrinsic motivational factors influencing an athlete's return to pre-injury level of sport following Achilles tendon repair. Qualitative, semi-structured interviews of 23 athletes who had undergone Achilles tendon repair were conducted and analyzed to derive codes, categories, and themes. Three major themes affecting return to sport were elucidated from the interviews: personal motivation, shift in focus, and confidence in healthcare team. These findings can direct healthcare teams on how to better guide patients post-operatively.

Patient-Reported Outcomes and Radiographic Assessment in Primary and Revision Stage II, III, and IV Progressive Collapsing Foot Deformity Surgery.

BACKGROUND: Progressive collapsing foot deformity (PCFD) is a progressive hindfoot and midfoot deformity causing pain and disability. Although operative treatment is stage dependent, few studies have looked at patient-reported and radiographic outcomes stratified by primary vs revision stage II, III, and IV reconstruction surgery. Our goal was to assess operative improvement using Patient-Reported Outcomes Measurement Information System (PROMIS) and to determine whether radiographic parameter improvement correlates with patient-reported outcomes. METHODS: PROMIS Physical Function (PF) and Pain Interference (PI) scores were prospectively obtained on 46 consecutive patients who underwent PCFD reconstruction between November 2013 and January 2019. Thirty-six patients completed pre- and postoperative PROMIS surveys, 6 patients completed only preoperative PROMIS surveys, and 4 patients completed 12-month postoperative PROMIS surveys but did not complete preoperative PROMIS surveys. Minimum follow-up was 12 (average, 23) months. Radiographic correction was measured with pre- and postoperative weightbearing radiographs and correlated with PROMIS scores. Measurements included the talonavicular uncoverage angle, talonavicular uncoverage percentage, anteroposterior talo-first metatarsal angle, Meary angle, medial cuneiform height (MCH), and medial cuneiform-fifth metatarsal height. RESULTS: For the overall cohort, PROMIS PF increased significantly from 37.5±5.6 to 42.3±7.1 (P = .0014). PROMIS PI improved significantly from 64.5±6.0 to 55.1±9.8 (P < .0001). Preoperative, postoperative, and change in PROMIS scores were not statistically different between PCFD stages. Change in PROMIS PI was significantly greater in primary (-12.3) vs revision (-3.7) surgery (P = .0157). Change in PROMIS PF was greater in primary (+6.0) vs revision surgery (+2.3) but did not reach statistical significance. All radiographic measurements improved significantly (P < .05). In primary stage II PCFD, postoperative PROMIS scores correlated with postoperative MCH (PF: r = 0.7725, P = .0020; PI: r = -0.5692, P = .0446). CONCLUSION: Patient-reported and radiographic outcomes improved significantly after PCFD reconstruction. We found no significant difference in preoperative, postoperative, or change in PROMIS scores between PCFD stages. However, stage III patients had smaller improvements in PROMIS PF, which we feel may be secondary to change in function after arthrodesis. Primary operations had better patient-reported outcomes compared to revision operations. In primary stage II PCFD, reconstructing the medial arch height correlated significantly with improvement in pain and functionality. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Impact of COVID-19 Pandemic on Patients' Perceptions of Safety and Need for Elective Foot and Ankle Surgery in the United States.

BACKGROUND: With the development of the COVID-19 pandemic, elective foot and ankle surgeries were delayed throughout the United States to divert health care resources and limit exposure. Little is known about the impact of COVID-19 on patient's willingness to proceed with elective procedures once restrictions are lifted and factors contributing to such decision. METHODS: Patients across 6 US orthopedic institutions who had their elective foot and ankle surgeries cancelled secondary to the pandemic were given a questionnaire. Specifically, patients were asked about their willingness to move forward with surgery once restrictions were lifted and if not why. Pain-level and pain medication use were also assessed. Univariate analysis was used to identify factors that contribute to patient's decisions. RESULTS: A total of 150 patients participated in this study. Twenty-one (14%) opted not to proceed with surgery once restrictions were lifted. Forty-three percent (n = 9) listed concern for COVID infection as the reason; however, 14% of them would proceed if procedures were performed in surgery center. Twenty-nine (19% of the total cohort) patients had increased pain and 11% of patients were taking more pain meds because of the delay to their procedure. Patients who decided not to proceed with surgery reported pain reduction (3% vs 14%) and lower increase in pain medication used (5% vs 12%). CONCLUSION: COVID-19 has made a significant impact on the health care system. Delay of elective foot and ankle procedures impact patient quality of life and outcomes. Access to surgery centers may provide a partial solution during the pandemic. LEVEL OF EVIDENCE: Level III.

Trends in Leadership Within Orthopedic Foot and Ankle Fellowships.

BACKGROUND: No study in the orthopedic literature has analyzed the demographic characteristics or surgical training of foot and ankle fellowship directors (FDs). Our group sought to illustrate demographic trends among foot and ankle fellowship leaders. METHODS: The American Orthopaedic Foot & Ankle Society (AOFAS) Fellowship Directory for the 2021 to 2022 program year was queried in order to identify all foot and ankle fellowship leaders at programs currently offering positions in the United States and Canada. Data points gathered included age, sex, race/ethnicity, location of surgical training, time since training completion until FD appointment, length in FD role, and individual research H-index. RESULTS: We identified 68 fellowship leaders, which consisted of 48 FDs and 19 co-FDs. Sixty-five individuals (95.6%) were male, and 3 (4.4%) were female. As regards race/ethnicity, 88.2% of the leadership was Caucasian (n = 60), 7.4% was Asian American (n = 5), 1.5% was Hispanic/Latino (n = 1), and 1.5% was African American (n = 1). The average age was 51.5 years, and the calculated mean Scopus H-index was 15.28. The mean duration from fellowship training to fellowship leader position was 11.23 years. CONCLUSION: Leaders within foot and ankle orthopedic surgery are characterized by research prowess and experience, but demographic diversity is lacking. LEVEL OF EVIDENCE: Level III.

Evaluating Prospective Patient-Reported Pain and Function Outcomes After Ankle and Hindfoot Arthrodesis.

BACKGROUND: Hindfoot and ankle fusions are mechanically limiting procedures for patients. However, patient-reported outcomes of these procedures have not been well studied. This study assessed outcomes of hindfoot and ankle fusions by using Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) Computer Adaptive Tests (CATs). METHODS: Between 2014 and 2018, 102 patients were prospectively enrolled after presenting to a tertiary care facility for ankle and hindfoot fusions, including tibiotalar, tibiotalocalcaneal, subtalar, and triple arthrodeses. Study participants completed preoperative and 12-month postoperative PF and PI CATs. The differences between mean 12-month postoperative and preoperative PROMIS PF and PI T scores were analyzed with paired t tests. The relationship between the 12-month PF and PI differences for the overall sample and patient factors was examined using multiple regression modeling. RESULTS: The sample had mean age of 57.69 years; 48% were male, and 55% were obese. Patients who underwent ankle and hindfoot arthrodesis had statistically significant improvements from preoperative to 12 months postoperative in mean PF (36.26±7.85 vs 39.38±6.46, P = .03) and PI (61.07±7.75 vs 56.62±9.81, P = .02). Triple arthrodesis saw the greatest increases in physical function (▵PF = 7.22±7.31, P = .01) and reductions in pain (▵PI = -9.17±8.31, P = .01), achieving minimal clinically important difference (MCID). Patients who underwent tibiotalar fusion had significant improvement in physical function (▵PF = 4.18±5.68, P = .04) and pain reduction that approached statistical significance (▵PI = -6.24±8.50, P = .09), achieving MCID. Older age (≥60 years ) was associated with greater improvements in PF (ß = 0.20, P = .07) and PI (ß = -0.29, P = .04). Preoperative PF and PI T scores were significantly associated with the 12-month change in PF and PI T scores, respectively (ß = -0.74, P < .01; ß = -0.61, P < .01). CONCLUSION: Hindfoot and ankle fusions are procedures with favorable patient outcomes leading to increased physical function and decreased pain at 12 months postoperation relative to preoperation. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Modern total ankle arthroplasty versus ankle arthrodesis: A systematic review and meta-analysis.

The controversy in surgical management of end-stage tibiotalar arthritis with Total Ankle Arthroplasty (TAA) versus Ankle Arthrodesis (AA) has grown in parallel with the evolution of both procedures. No randomized controlled trials exist due to the vast differences in surgical goals, patient expectations, and complication profiles between the two procedures. This makes high quality systematic reviews necessary to compare outcomes between these two treatment options. The aim of this study was to provide a systematic review with meta-analysis of publications reporting outcomes, complications, and revision data following third-generation TAA and/or modern AA published in the past decade. Thirtyfive articles met eligibility criteria, which included 4312 TAA and 1091 AA procedures. This review reports data from a mean follow-up of 4.9 years in the TAA cohort and 4.0 years in the AA cohort. There was no significant difference in overall complication rate following TAA compared to AA (23.6% and 25.7% respectively, P-value 0.31). Similarly, there was no significant difference in revision rate following TAA compared to AA (7.2% and 6.3% respectively, P-value 0.65). Successful treatment of end-stage tibiotalar arthritis requires an understanding of a patients' goals and expectations, coupled with appropriate patient selection for the chosen procedure. The decision to proceed with TAA or AA should be made on a case-by-case basis following an informed discussion with the patient regarding the different goals and complication profiles for each procedure.

Anterior Syndesmotic Augmentation Technique Using Nonabsorbable Suture-Tape for Acute and Chronic Syndesmotic Instability.

Syndesmotic instability is a source of significant pain and disability. Both subtle instability and gross diastasis, whether acute or chronic, require stabilization and may benefit from reconstruction with ligamentous augmentation. The use of nonabsorbable suture-tape has emerged as a promising operative strategy, allowing surgeons to anatomically reconstruct the syndesmosis, in particular the anterior inferior tibiofibular ligament. The current work provides a detailed description of the technique and preliminary results of a patient cohort treated using nonabsorbable suture-tape for syndesmotic augmentation.Level of Evidence: Level V, expert opinion.