Category: Ankle; Ankle Arthritis Introduction/Purpose: Complications such as nonunion and infection following ankle arthrodesis can lead to increased patient morbidity and financial burden from repeat operations. Improved knowledge on complication likelihood and associated risk factors can improve patient selection and inform post-ankle arthrodesis surveillance protocols. Methods: This is a large retrospective, database study with structured query of a national insurance claims database (PearlDiver Technologies) for patients treated with ankle arthrodesis from 2015 through 2019 as identified by ICD-10 codes. Patients with any operation one year prior to or following ankle arthrodesis were excluded from analysis to prevent attributing complications to another operation. Likelihoods of nonunion and infection within one-year and three-years following ankle arthrodesis were analyzed using Kaplan-Meier estimations. Patient characteristics associated with the identified complications following ankle arthrodesis were analyzed using multivariable logistic regression analyses; data included age at time of operation, sex, obesity, smoking record, diabetes, and the Elixhauser Comorbidity Index score. Results: Our query yielded 2,463 patients in the five-year period who underwent ankle arthrodesis. Nonunion occurred in 11% (95% CI, 10-12) of patients within one-year of ankle arthrodesis and 16% (95% CI, 14-17) of patients within three-years. Infection occurred in 3.9% (95% CI, 3.1-4.7) of patients within one-year of ankle arthrodesis and in 6.2% (95% CI, 5.1-7.2) of patients within three-years. Obese patients increased odds of nonunion on multivariable analysis (OR 1.6 [95% CI, 1.3-2.0]; P<0.001). On multivariable analysis, diabetes (OR 1.7 [95% CI, 1.2-2.6]; P=0.010) and each one-unit increase in Elixhauser Comorbidity Index scores (OR 1.1 [95% CI, 1.1-1.2]; P<0.001) contributed to increased odds of infection after ankle arthrodesis. Conclusion: Nonunion and infection are common complications following ankle arthrodesis with a three-year probability of 16% and 6%, respectively. Over one-quarter of patients with nonunion post-ankle arthrodesis experience a delay in diagnosis past one- year. The risk of post-ankle arthrodesis nonunion is highest in patients with obesity; the risk of infection is highest in patients with diabetes or an elevated Elixhauser Comorbidity Index score. Although diabetes and its associated 'poor biology' is often viewed as the culprit in an obese diabetic who fails to heal, our research suggests that we should pay more attention to the mechanical and biologic consequences of obesity.
Category: Ankle Introduction/Purpose: Injury to the syndesmotic ligaments can lead to prolonged functional limitations and thus, long-term ankle mobility dysfunction if not diagnosed and treated appropriately. Obesity has been studied in relation to syndesmotic instability but there is a paucity of literature investigating syndesmotic risk associated with other bone fragility characteristics. Additionally, ankle injury complexity associated with risk of Charcot in patients with a syndesmotic injury remains unstudied. Methods: This is a large retrospective, database study with structured query of a national insurance claims database (PearlDiver Technologies) for patients treated with ankle fixation from 2015 through 2020 as identified by ICD-10 codes. Patient characteristics associated with obtaining a syndesmotic injury with ankle fracture were analyzed using multivariable logistic regression analysis. In addition to corroborating the increased risk seen with elevated BMI, data included age at time of operation, sex, smoking record, diabetes, and osteoporosis. Likelihood of developing Charcot in patients with an ankle fracture and unstable syndesmosis was also analyzed using univariable logistic regression. Results: Our query yielded 168,359 patients who underwent ankle fixation; 32,502 (23.9%) were treated for syndesmotic injury. On multivariable analysis, obese and male patients had a higher probability of syndesmotic injury (OR 1.39 [95% CI, 1.36-1.43] and OR 1.55 [95% CI, 1.52-1.59], respectively; P<0.001); osteoporotic patients had lower probability of syndesmotic injury (OR 0.64 [95% CI, 0.62-0.67]; P<0.001). Of 13,275 diabetic patients, 2,822 (21.3%) were treated for syndesmotic injury. Diabetic patients had increased probability of developing Charcot (OR 1.54 [95% CI, 1.19-2.00]; P=0.001). A total of 36,883 patients were treated with ankle fixation and unstable syndesmosis. While statistically insignificant, compared to patients with syndesmotic injury treated with bimalleolar ORIF, patients undergoing isolated fibular ORIF had lower probability of developing Charcot (OR 0.71 [95% CI, 0.50-0.99]) versus undergoing trimalleolar ORIF had higher probability (OR 1.24 [95% 0.91-1.69]). Conclusion: Among this population derived from a large all-claims database using ICD-10 coding, higher probability of syndesmotic injury was associated with male or obese patients; lower syndesmotic injury probability was associated with osteoporotic patients. This suggests that injuries obtained with a greater force or patients with stronger bone strength are more likely to sustain a syndesmotic disruption while weaker bones are more susceptible to fracture, leaving the syndesmotic structures intact. These findings suggest purposeful evaluation for syndesmotic disruption in patients with these higher risk characteristics. Increasing ankle injury complexity demonstrates a gradient in Charcot risk in patients with syndesmotic instability.
Background: Hallux rigidus is a common arthritic condition that has been addressed surgically with a range of techniques, from an isolated cheilectomy to first metatarsophalangeal (MTP) joint fusion. Recently, hemiarthroplasty with polyvinyl alcohol (PVA) hydrogel implant has been used as an alternative treatment to relieve pain while preserving motion of the first MTP joint. We retrospectively reviewed patient-reported outcome scores and clinical outcomes for patients treated for hallux rigidus with PVA hydrogel implant at an academic, multisurgeon center. Methods: A total of 103 patients who underwent first MTP hemiarthroplasty with PVA hydrogel implant between January 2017 and October 2018 were retrospectively reviewed (average, 26.2 months). Eight surgeons were represented. Baseline Patient-Reported Outcomes Measurement Information System (PROMIS) scores for the Physical Function, Pain Interference, Pain Intensity, Global Physical Health, Global Mental Health, and Depression domains were collected prospectively and compared with PROMIS scores collected at a minimum of 1 year postoperatively (average, 13.9 months). Seventy-three patients had both preoperative and postoperative scores. Ten of these patients had undergone a prior procedure of the first MTP, and 52 underwent concurrent Moberg osteotomy at the time of PVA hydrogel implantation. Results: For patients with baseline and postoperative PROMIS scores, significant pre- to postoperative improvement was detected for the Physical Function, Pain Interference, Pain Intensity, and Global Physical Health domains ( P < .05). Patients who had undergone a prior procedure of the first MTP had significantly higher postoperative Pain Intensity scores compared with those who did not undergo a prior procedure. Patients undergoing concurrent Moberg osteotomy had significantly lower postoperative Pain Interference and Pain Intensity scores compared with those who did not undergo a Moberg. Two patients underwent revision procedures in the first 2 years postoperatively, one with revision hemiarthroplasty and one with conversion to arthrodesis. Conclusion: On average across our entire cohort, physical function and pain scores improved significantly pre- to postoperatively; however, postoperative pain scores were significantly higher for patients who had undergone a prior procedure of the first MTP and significantly lower for patients who underwent concurrent Moberg osteotomy. The implant displayed excellent survivorship in the first 2 years postoperatively, with only 2 revision procedures. Level of Evidence: Level III, comparative series.
Category: Ankle Arthritis; Hindfoot Introduction/Purpose: To properly treat osteoarthritis-(OA) patients, a grading-system is used to diagnose the stage-of-the- disease. The current gold-standard system, which relies on plain-2D-radiographs, is subjective, categorical, and lacks reliability. Using WBCT-images, 3D-Hounsfield-Unit-(HU) algorithms have been developed to measure the intensity of each image voxel across the joint-space, highlighting transitions between cancellous/subchondral bone and joint-space. The purpose of this study was to analyze and define normal standard values of joint-space-width (JSW) in the four essential joints of the foot-and-ankle (tibiotalar (ankle), subtalar (ST), talonavicular (TN), and first-metatarsophalangeal- (MTP) -joints) using an objective computational WBCT-HU algorithm in healthy non-arthritic feet. We hypothesized that the measurements of JSW and HU distributions across each of the four-essential-joints of the foot-and-ankle would be significantly different from each other, respecting local anatomy and unique functional characteristics of each joint. Methods: Retrospective-comparative-study, we evaluated WBCT-scans of 30 healthy ankle-joints, 28 ST-joints, 26-TN joints, and 30 1st-MTP-joints of control volunteers with no radiographic signs of foot-and-ankle OA. For each-joint, we used dedicated software to define a volume-of-interest (VOI) cube centered on the joint space. Five HU linear search arrays were then defined within this 3D VOI perpendicular to the articular-surface of each-joint, including four projections in each quadrant, and one in the center of the VOI (Figure 1). Image intensity profiles were generated for each search array crossing the transition from cancellous- to-subchondral bone, across the joint-space, back to subchondral-and-cancellous-bone (Figure 2). This profile was used to calculate JSW and to measure HU contrast in the region. Comparisons between the JSW of each joint and within each-joint were accordingly performed using paired t-tests or paired Wilcoxon. Significance was considered for p-values < 0.05. Results: The median-value and 95%-Confidence-Intervals-(CI) for JSW were 4.07mm [CI:3.73–4.20] for the ankle-joint; 4.07mm [3.95–4.44] for the ST-joint; 3.24mm [3.19–3.46] for the TN-joint; and 3.70mm [3.64–4.12] for the 1st-MTP-joint. The TN JSW was significantly narrower than the JSW in the ankle (p=0.0007), ST (p < 0.0002), and 1st-MTP-joints (p=0.0034) (Figure-3). JSW- values were similar across the entire ankle, ST and 1st-MTP-joints. In the TN-joint, the dorsal aspect of the joint was found to be slightly but significantly wider-than the plantar-aspect (p < 0.001). Regarding HU-contrast, we found a progressive increase in the overall contrast from proximal-to-distal (p < 0.001), with a mean HU contrast-value and 95%-CI of respectively 71.8[67.3–76.3] for ankle, 92.4[87.8–97.1] for ST, 84.1[79.2–88.9] for TN, and 101.3[96.9 – 106.8] for 1st-MTP-joints. The only joints with similar HU-contrast were ST and TN. Conclusion: We utilized a novel WBCT-3D-HU measurement algorithm to assess the normal JSW and HU contrast of the four- essential mobile joints of the foot-and-ankle. We found the JSW to be similar (~4mm) in the ankle, ST, and 1st-MTP joints. The TN-joint however, demonstrated a significantly narrower JSW when compared to the other 3 joints. HU-contrast increased progressively from proximal-to-distal, being less prominent in the ankle, similarly increased in TN and ST, and maximum at the 1st-MTP joint. This study's joint characteristic normality data provide a foundation for future-work developing an objective WBCT-based 3D HU-algorithm staging-system for OA-disease-progression in the foot-and-ankle joints.
St. John's wort (Hypericum perforatum) is a medicinal plant that has been used throughout history to treat depression. Its active constituent, hyperforin, inhibits neuronal uptake of monoamines and has been shown to be effective in the treatment of mild to moderate depression. However, hyperforin is highly unstable, sensitive to the effects of heat, light, oxygen, and lipophilic solvents. Despite this extensive degradation potential, this laboratory experiment has been optimized to allow upper-level undergraduate students studying nature's medicines to isolate purified hyperforin from a standardized preparation by employing a number of techniques, such as purging mobile phases with nitrogen gas to remove oxygen and using amber sample tubes to protect purified fractions from light. Using these conditions, hyperforin is stable in a methanolic solution, and students take advantage of this factor during the isolation. Students acquire skills in the isolation and stabilization of a highly unstable molecule through use of flash column chromatography and carry out structure elucidation using a variety of spectroscopic methods. The experiment can be conducted over one three-hour laboratory period. A crossword puzzle to assess student learning following the experiment enables a comprehensive and engaging education, allowing appreciation of the journey of medicinal plant from bench to bedside.
Introduction/Purpose: Evidence in the literature suggests the negative effects of using High Heels (HH), becoming a challenge for clinicians and researchers since they are welcomed by women worldwide, mainly due to the subjective power of attractiveness given to them. Although some people blame HH as one of the causes of Hallux Valgus (HV), until now, there are no studies in the literature that effectively prove a cause-effect relationship between HH and HV. The objectives of this study are: (1) to analyze whether the increase in heel height can lead to HV and (2) to evaluate whether HV can increase in severity with increasing heels. We hypothesized that an increase in heel height could cause and increase the severity of HV deformity. Methods: Comparative cross-sectional study. Forty-one feet from twenty-one participants (11 males and 10 females, aged 30.8 ± 8.9 years, and with Body Mass Index 25.5 ± 2.0 m kg2) were recruited. HH shoes were designed for this study with three heights for each participant: 3, 6, and 9 cm. The inclusion criteria were: no regular wearing of heels. The exclusion criteria were: Hallux Valgus diagnosis and/or any orthopedic conditions that affect the Foot and Ankle joints. Hallux Valgus Angle (HVA), Intermetatarsal Angle (IMA), First-Metatarsal Phalangeal Angle, 1st-to-5th Intermetatarsal Angle, First Tarsometatarsal Angle (axial), Second tarsometatarsal angle (axial), Hindfoot Moment Arm (HMA) (mm), Saltzman 45 angle and, Foot Ankle Offset (FAO) were measurement using semiautomated software analysis. Multiple comparisons were performed (Bonferroni's for normal distributions and Wilcoxon test for no normal distributions) when there was a main effect on an outcome (p < 0.05). Results: With the increase in HH, we noticed a progressive increase in HVA (p < 0.001), IMA (p < 0.001), First-Metatarsal Phalangeal Angle (p < 0.001), First Tarsometatarsal Angle (axial) (p < 0.001), and the Second tarsometatarsal angle (axial) (p < 0.001). The Hindfoot Moment Arm (HMA) (mm), Saltzman 45 angle, and Foot Ankle Offset (FAO) had hindfoot varization behavior. When we stratified the groups and compared them, we noticed that an increase of 3 cm in heels slightly increased HVA and IMA (p > 0.05). However, heel increases above 6 cm significantly increased HVA and IMA (p > 0.001). Based on Coughlin's classification, a 3 cm heel increase promoted a mild HV and increases above 6 cm caused a moderate HV. Conclusion: Based on data from our study with patients without Hallux Valgus through analysis with WBCT versus high heels, we conclude that increasing heel height can lead to Hallux Valgus and can progressively increase the severity with increasing high heels. High heels above 6 cm can lead to moderate Hallux Valgus. These findings may be an essential step toward a better understanding of the effects of increasing high heels on Hallux Valgus pathology.
Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Lapidus procedure and Scarf osteotomy are indicated for treatment of mild to moderate hallux valgus. Advantages of modified Lapidus procedure include ability to address severe deformity, first tarsometatarsal arthritis, and first ray hypermobility. Advantages of Scarf osteotomy include greater correction of the distal metatarsal articular angle (DMAA) and greater fixation stability than other techniques. Both procedures have shown good radiographic and clinical outcomes; however, no prior studies have compared these outcomes between the procedures. The aim of this study was to compare clinical and radiographic outcomes between patients with hallux valgus treated with the modified Lapidus procedure or Scarf osteotomy. Methods: This retrospective cohort study included patients treated by one of seven fellowship-trained foot and ankle surgeons were identified. Inclusion criteria were age greater than 18 years, primary modified Lapidus procedure or Scarf osteotomy for hallux valgus, minimum 1-year postoperative PROMIS scores, and minimum 3-month postoperative radiographs. Revision cases were excluded. Clinical outcomes were assessed using six PROMIS domains: Pain Interference, Pain Intensity, Physical Function, Global Mental Health, Global Physical Health, and Depression. Pre- and postoperative radiographic parameters were measured on AP (HVA, IMA, DMAA, tibial sesamoid position), and lateral (talo-1st-metatarsal angle (Meary’s), Horton index, Seiberg index, sagittal IMA) x-rays. Statistical analysis utilized targeted maximum likelihood estimation controls for confounding of bunion severity by including covariates for baseline HVA and IMA. Statistics were also analyzed in a restricted cohort of mild to moderate severity bunions (HVA<40 and IMA<16; n=57 each). Complications including repeat surgeries, recurrence of deformity, and malunion/nonunion were recorded. Results: 136 patients (73 Lapidus, 63 Scarf) with average 17.8 month follow-up constituted our study. Both groups demonstrated significant improvement in Global Physical Health, Global Mental Health, and Physical Function, with patients in the Lapidus group showing a significantly greater improvement of 3.6 points (p=0.01) compared to Scarf. After controlling for bunion severity, the probability of having normal postoperative IMA (<10 ) was 17% lower (p<0.001) with Scarf compared to Lapidus. This finding was consistent in the restricted cohort of mild to moderate severity bunions. Lapidus group demonstrated significantly greater correction in Meary’s angle, Seiberg index, and sagittal IMA. Complications in the Lapidus group included one nonunion, three symptomatic implants, two hallux varus. The Scarf group had one reoperative cheilectomy and one second metatarsal stress fracture. Conclusion: This is the first study to compare both radiographic and patient-reported outcomes between Lapidus procedure and Scarf osteotomy for correction of hallux valgus deformity. While both procedures yielded improvements in outcomes, results suggest that the probability of having a normal postoperative IMA is greater with Lapidus procedure, even when adjusted for severity of deformity. In addition, greater correction reflected in sagittal measurements may further support the role of rotational correction in the Lapidus procedure. [Table: see text]
Category: Ankle Arthritis; Ankle Introduction/Purpose: Multimodal therapies are critical for limiting use of opioids for postoperative pain control after orthopaedic procedures. Though NSAIDs and COX-2 inhibitors are effective non-opioid adjuncts for postoperative pain, animal models have demonstrated increased rates of nonunion or delayed union in the presence of NSAIDs. Nonunion or delayed union results in a protracted postoperative course that may warrant longer duration of surveillance or revision procedures. Retrospective studies and meta-analyses investigating NSAID use and bone healing have conflicting findings. Additionally, there are few studies investigating NSAID use and other adverse events such as postoperative infection. Improved understanding of the impact of NSAID use on union rates and infection after ankle arthrodesis will allow practitioners to optimize safe, effective pain control while limiting risk of nonunion. Methods: This large retrospective database study queried a national insurance claims database (PearlDiver Technologies) for patients undergoing ankle arthrodesis from 2015 through 2019 as identified by ICD-10 codes. Patients prescribed NSAIDs or COX-2 inhibitors within six weeks following ankle arthrodesis were identified. Patients with any operation one year prior to or following ankle arthrodesis were excluded from analysis to prevent attributing complications to another operation. Association between NSAID or COX-2 inhibitor use and infection or nonunion following ankle arthrodesis were analyzed using multivariable logistic regression analyses. To adjust for comorbid conditions, multivariable models included age at time of operation, sex, obesity, tobacco use, and diabetes. Results: Our query yielded 2,355 patients in the five-year period who underwent ankle arthrodesis. 257 (11%) patients were prescribed NSAIDs following surgery and 56 (2.4%) patients were prescribed COX-2 inhibitors. Infection risk was similar between patients not prescribed either medication (n=92, 4.5%) and those treated with NSAIDs (n=14, 5.4%; P=0.60) or COX-2 inhibitors (n=2, 3.5%; P=0.99). The nonunion rate between patients not prescribed either medication (n=232, 11%) was similar to those treated with COX-2 inhibitors (n=8, 14%; P=0.64), but increased in patients treated with NSAIDs (n=45, 18%; P=0.006). On multivariable analysis, tobacco use (OR, 1.46; 95% CI, 1.09-1.94), obesity (OR, 2.08; 95% CI, 1.57-2.76), and NSAID use (OR, 1.53; 95% CI, 1.06-2.17) were associated with increased odds of nonunion after ankle arthrodesis (all P<0.02) (Table). Conclusion: Analysis of the PearlDiver database, the largest available administrative claims database, for 2,355 patients undergoing ankle arthrodesis demonstrated an 11% risk of nonunion and 4.5% risk of infection. The risk of nonunion is increased in patients prescribed NSAIDs within six weeks postoperatively (18%). After adjusting for comorbid conditions associated with nonunion, such as tobacco use and obesity, NSAID use increased risk of nonunion whereas COX-2 inhibitor use did not. Prospective investigation is necessary to better understand these relationships, however, our analysis suggests practitioners should judiciously utilize NSAIDs and consider use of COX-2 inhibitors for pain control after ankle arthrodesis surgery.
Complications such as nonunion and infection following ankle arthrodesis can lead to increased patient morbidity and financial burden from repeat operations. Improved knowledge of risk factors can improve patient selection and inform post-ankle arthrodesis surveillance protocols.This is a large retrospective, database study with structured query of a national insurance claims database (PearlDiver Technologies) for patients treated with ankle arthrodesis from 2015 to 2019 as identified by International Classification of Diseases, Tenth Revision (ICD-10), codes. Patients with any operation 1 year prior to or following ankle arthrodesis were excluded from analysis to prevent attributing complications to another operation. Likelihoods of nonunion and infection within 1 year and 3 years following ankle arthrodesis were analyzed using Kaplan-Meier estimations. Patient characteristics associated with the identified complications following ankle arthrodesis were analyzed using multivariable logistic regression analyses.Our query yielded 2463 patients in the 5-year period who underwent ankle arthrodesis. Nonunion occurred in 11% (95% CI 10-12) of patients within 1 year of ankle arthrodesis and 16% (95% CI 14-17) of patients within 3 years. Infection occurred in 3.9% (95% CI 3.1-4.7) of patients within 1 year of ankle arthrodesis and in 6.2% (95% CI 5.1-7.2) of patients within 3 years. Obese patients increased odds of nonunion on multivariable analysis (OR 1.6, 95% CI 1.3-2.0; P < .001). On multivariable analysis, diabetes (OR 1.7, 95% CI 1.2-2.6; P = .010) and each 1-unit increase in Elixhauser Comorbidity Index scores (OR 1.1, 95% CI 1.1-1.2; P < .001) contributed to increased odds of infection after ankle arthrodesis.Nonunion and infection following ankle arthrodesis have a 3-year probability of 16% and 6%, respectively. More than one-quarter of patients with nonunion following ankle arthrodesis experience a delay in diagnosis beyond 1 year. The risk of post-ankle arthrodesis nonunion is highest in patients with obesity; the risk of post-ankle arthrodesis infection is highest in patients with diabetes or an elevated Elixhauser Comorbidity Index score.Level III, prognostic study.
Category: Midfoot/Forefoot; Other Introduction/Purpose: In 2016, the US Food and Drug Administration (FDA) approved the use of a polvinvyl alcohol (PVA) hydrogel implant (Cartiva, Elmsford, NY) for surgical treatment of hallux rigidus, or degenerative arthritis of the first metatarsophalangeal (1st MTP) joint. While studies have demonstrated the safety and usability of PVA implant, clinical outcomes following hemiarthroplasty with the PVA have not yet been compared to that of traditional joint-preserving procedures such as cheilectomy with Moberg osteotomy in the treatment of hallux rigidus. The purpose of this study is to compare patient-reported outcomes and postoperative complications between PVA hemiarthroplasty and cheilectomy with Moberg osteotomy, with the hypothesis that the addition of PVA would result in superior clinical outcomes. Methods: Patients were retrospectively identified who underwent hallux rigidus correction by one of seven Foot and Ankle fellowship-trained orthopaedic surgeons between March 2016 and November 2018. Out of 162 patients, a total of 133 patients constituted our study cohort after excluding patients with insufficient follow-up. Of the 133, 60 patients (mean age 57.2 years) were treated with combination PVA, cheilectomy, and Moberg osteotomy (PCM) and 73 patients (mean age 54.1) were treated with cheilectomy and Moberg (CM) alone. Both preoperative as well as minimum 1-year postoperative patient-reported outcome scores (PROMIS) were compared between the two cohorts. Chart review was performed to compare rates of revision and complications. Results: Average time to follow-up was 14.5 months for PCM and 15.6 for CM groups. Both PCM and CM cohorts demonstrated significant improvement in PROMIS scores, with the CM group demonstrating significantly greater increase in Physical Function (7.14 +- 8.48 vs 3.58 +- 6.24, p=0.01). While preoperative scores were comparable, postoperatively the CM group had a significantly higher average Physical Function (51.8 +- 8.7 vs 48.8 +- 8.0, p=0.04) and lower Pain Intensity (39.9 +- 8.3 vs 43.4 +- 8.7, p=0.02). There were 2 cases of revision with re-implantation and 1 case of conversion to arthrodesis in the PCM group. There was 1 case of conversion to PVA in the CM group. Three patients who underwent PCM had a documented postoperative infection requiring antibiotics. Conclusion: Our data suggests that the addition of polyvinyl alcohol implant in the treatment of hallux rigidus results in significant improvement in patient-reported outcomes. However, patient-reported physical function may not be up to par at minimum 1-year follow-up compared to cheilectomy and Moberg osteotomy alone. In addition, while incidence was low in our cohort, revision of the implant as well as conversion to arthrodesis remain possible complications of PVA. Therefore, we believe that proper patient selection is recommended when considering surgical treatment options for hallux rigidus. [Table: see text]
