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: Other; Basic Sciences/Biologics Introduction/Purpose: Large Language Models (LLMs) like ChatGPT and Bard have emerged as potential but not risk-less tools in science, offering specialized answers to queries based on elements of context. In Foot and Ankle (FA) surgery, efficient triage is crucial due to the variety of conditions and limited surgical time. This study evaluates LLMs' ability to guide patients towards appropriate medical or surgical management compared to a panel of board certified FA surgeons. Methods: Forty-four fictitious clinical scenarios were created, incorporating chronicity, onset, and anatomic localization. Outcomes were assessed on a Likert scale (1-5) for the likelihood of needing surgical management, alongside the 3 most probable diagnoses and 2 indicated imaging modalities. Two FA surgeons and the LLMs ChatGPT and Bard were evaluated, with agreement analyzed using Fleiss' and Cohen's Kappas. Results: Initial Likert scale agreement (Fleiss' Kappa) was 0.233, indicating low concordance. Recategorizing outcomes into binary (surgical vs. medical orientation of patients) improved agreement to fair (0.423). Pairwise comparison using Cohen's Kappa showed slight to moderate agreement among LLMs and surgeons, with Bard aligning more closely with surgeons (77.27% agreement) than ChatGPT. Conclusion: LLMs show promise in FA triage but require refinement for clinical reliability. Bard's higher surgeon agreement suggests some models may better capture clinical judgment nuances. Future research should enhance LLM interpretive algorithms and explore their supportive role in medical decision-making.
Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Progressive Collapsing Foot Deformity (PCFD) is a symptomatic, complex, three-dimensional foot deformity that can occur in feet that were previously neutrally aligned or in those with congenital/pediatric flat feet. Once collapsed, it becomes challenging to differentiate the initial foot shape. This study aims to evaluate differences in Weight-Bearing CT (WBCT) parameters among a cohort of symptomatic PCFD patients with a history of pediatric flat foot (= pediatric PCFD), without such a history (= non-pediatric PCFD), and a control group without PCFD. We hypothesized that pediatric PCFD would display distinct WBCT parameters compared to non-pediatric PCFD, particularly with less forefoot abduction and middle facet subluxation. Furthermore, we sought to identify which parameters are the most predictive of pediatric PCFD. Methods: This retrospective comparative study included adult patients with symptomatic PCFD. Pediatric PCFD was defined as patients with flat feet since childhood, and non-pediatric PCFD was defined as patients with no history of childhood flat foot. A total of 37 symptomatic pediatric PCFD patients were compared to 52 symptomatic non-pediatric PCFD patients and 11 control patients. All patients underwent foot/ankle WBCT scans. Using dedicated software, both manual and semi-automated 3D measurements were carried out for the various PCFD deformity categories (A-Hindfoot Valgus, B-Abduction, C-Arch Collapse, and D-Peritalar Subluxation). The data underwent normality testing with the Shapiro-Wilk method, and comparisons were made via Paired T-tests or Paired-Wilcoxon tests. A p-value threshold of 0.05 or below was deemed significant. To determine which factors affect the presence of rigidity in PCFD, a multivariate nominal regression analysis was conducted. A partition prediction model was employed to identify threshold values that most accurately determine “pediatric PCFD”. Results: All parameters showed significant differences compared to control, except for BMI. Compared to non-pediatric PCFD, the pediatric PCFD group showed significantly less deformity in classes A, B, C, and D (all p< 0.002) and became symptomatic at a younger age (p< 0.001). Compared to controls, pediatric PCFD measurements for HMA (p=0.053) and SF (p=0.07) were not statistically significant. Multivariate analysis indicated that axial TFM (p=0.005), MFS (p=0.013), and ST (p=0.03) were the best predictors of pediatric PCFD (R2: 0.27). The partition prediction model showed that an ST distance >0.24 mm, axial TFM >24.28, and MFS >43.7% can rule out pediatric PCFD with 95% confidence. Conclusion: This study showed that symptomatic pediatric PCFD presents with distinct WBCT parameters compared to symptomatic non-pediatric PCFD, notably exhibiting less forefoot abduction, less middle facet subluxation, and less hindfoot malalignment and seems to become symptomatic at a younger age. ST distance >0.24 mm, axial TFM >24.28, and MFS >43.7% could rule out a PCFD with “pediatric origin.” These results suggest that a different threshold should be set to assess PCFD in patients with flat feet since childhood.
Category: Midfoot/Forefoot; Hindfoot Introduction/Purpose: Midfoot arthritis (MA) and progressive collapsing foot deformity (PCFD) are both entities characterized by biomechanical changes of the foot leading to collapse of the medial arch. The effect of PCFD on peritalar dislocation/subluxation has been described extensively and is a critical consideration in preoperative planning of deformity correction. While midfoot arthritis has been previously associated with subluxation of the midfoot joints such as the naviculocuneiform and tarsometatarsal joints, no studies have evaluated the effect of midfoot arthritis medial column collapse on peritalar parameters. The primary objective of this study was to compare the extent of medial arch collapse in MA and PCFD and correlate these parameters with peritalar changes. Methods: This is a retrospective comparative study identifying patients with PCFD and MA. PCFD was defined as a known history of flatfoot deformity and symptomatic progression of medial arch collapse. Midfoot arthritis was identified through radiological findings along with patient-reported symptomatic medial arch collapse. Patients with both flat foot deformity and radiological findings of midfoot arthritis were excluded. All patients underwent foot/ankle Weightbearing computed tomography (WBCT). Manual and semi-automated 3D measurements of the middle facet subluxation percentage, middle facet incongruence angle, foot & ankle offset, forefoot arch angle, and transverse arch plantar angle were performed. Measurements were done independently by two fellowship-trained readers. Variables were assessed for normality (Shapiro-Wilk) and compared using Paired T-tests or Wilcoxon signed rank test. P-values of 0.05 or less were considered significant. Results: A total of 28 feet were analyzed (14 extremities with PCFD and 14 extremities with MA). The difference in middle facet subluxation percentage and middle facet incongruence angle were statistically significant between the 2 groups favoring more peritalar subluxation in the PCFD group as compared to the MA group (38 vs 14.1 p-value < 0.001 and 12.5 vs 4.1 p-value < 0.001, respectively). The forefoot arch angle was significantly lower in the PCFD group (2.8 vs 6.6, p-value < 0.005) No significant difference was identified in the transverse arch plantar angle between the groups (125.5 vs 121.6, P-value: 0.2). Conclusion: In this retrospective comparative study, midfoot arthritis was found to have a limited effect on peritalar parameters in the setting of medial arch collapse. This study demonstrated that the deformity associated with midfoot arthritis is confined to the medial column and does not affect peritalar subluxation, unlike PCFD. These data demonstrate for the first time that midfoot arthritis and PCFD require distinct approaches in order to address medial column stability in order to achieve the required restoration in foot alignment.
Category: Other Introduction/Purpose: The increasing prevalence of foot and ankle procedures in the United States has coincided with rising costs of care, exposing socioeconomic disparities within this area of orthopedics. Insurance payor status is one such factor that can affect the quality and accessibility of medical care and has been implicated in orthopedic patient outcomes. While previous studies in other fields of orthopedics have demonstrated an association between insurance status and access to treatment, length of hospital stay, postoperative outcomes and complication rates, no comprehensive review has explores this relationship in foot and ankle surgery. Thus, the goal of this study is to examine the association between insurance payor status and outcomes in foot and ankle procedures. Methods: A systematic review of five databases was conducted, focusing on the interplay between insurance coverage and foot/ankle procedures. Included studies reported on insurance payor status and patient outcomes following foot and ankle surgery. Extracted outcomes included time to be seen by a provider, complication and revision rates, post-operative Emergency Department (ED)/Urgent Care utilization, readmission rates, hospital length of stay, pain, functional scores, discharge destinations, return to work/activity, and follow-up. Meta-analyses were performed using the Revman 5.3 software. Studies that did not qualify for meta-analyses were described qualitatively. Results: Of 1401 studies identified, 24 texts met inclusion and exclusion criteria. Across the 24 studies, there were a total of 20,950 patients. Noninsured patients had a 59% higher risk of ED/urgent care utilization within 30 days of surgery compared to insured patients [Risk Ratio (RR) = 1.59, 95% Confidence Interval (CI) = 1.18 to 2.12, p < 0.05]. Privately insured patients were seen 3.65 days earlier than patients with government insurance [95% CI = 2.02 to 5.27, p < 0.0001]. Worker’s Compensation patients tended to have poorer outcomes, higher pain scores, and lower functional scores. Similarly, Medicaid patients also fared worse on functional scores and had delayed access to appointments and treatments. Conclusion: Patients without private insurance have worser pain and functional outcomes, delayed access to care, and increased utilization of emergency resources following foot and ankle procedures. It is crucial for providers to be cognizant of these discrepancies when caring for patients. Further research is needed to better understand the nuances of these insurance-related disparities within foot and ankle subspecialties.
Category: Ankle; Ankle Arthritis Introduction/Purpose: Infection is a serious complication of primary total ankle arthroplasty (TAA) and can lead to implant failure and revision surgery. While various patient demographics, comorbidities, and surgical factors have been associated with an increased risk of infection, evidence is limited, and further research is required to better understand infection in TAA. This study aims to analyze risk factors of infection and explore outcomes following infected TAA. Methods: A retrospective cohort study was conducted using data from a single institution from 2002 to 2022. Patients who underwent primary TAA and had subsequent infection were identified and matched using propensity-score matching (PSM) based on various demographic, comorbidity, and surgical factors. Demographics were compared between the matched groups using Mann-Whitney U test and Fisher's exact test. The outcomes following infection were identified and summarized using descriptive statistics. Results: A total of 1,863 patients who underwent primary TAA were identified, and 19 (1%) were diagnosed with an infection. After PSM, there were no significant differences in age, gender, BMI, and smoking status between the cohorts. There was a statistically significant increase in the rate of diabetes in the infected cohort (26.3 vs. 15.3; p =0.01). Subsequent surgical intervention resulted in limb salvage in 18 (94.7%) cases. Two-stage revision to total ankle replacement was performed in 7 cases (36.8%), while revision to arthrodesis and isolated polyethylene exchange were each carried out in 4 cases (21.1%). One patient had to undergo amputation, however, at the time of the most recent follow-up (5.3%). All patients were found to be free of infection. Conclusion: This study demonstrated significantly increased rates of smoking and diabetes in the infected TAA cohort. Two-stage revision to TAR and revision to arthrodesis with isolated polyethylene exchange were successful in eradicating infection. Overall, a high rate of limb salvage was reported.
Category: Ankle; Sports Introduction/Purpose: Osteochondral Defects (OCD) can be a painful condition that frequently affect the ankle joint, with talar OCD being more frequent than the tibia ones. Changes in bone density (BD) have been described around the lesion, particularly with sclerosis at the subchondral and cancellous bone of the talus. However, there is a paucity of data describing what happens with the distal tibia bone adjacent to a talar OCD. Weightbearing computed tomography (WBCT) offers a method for quantifying BD via calculation of tomographic Hounsfield units (HU), a quantitative scale for describing radiodensity. The aim of this study was to assess WBCT HU around talar OCD, investigating the pattern of BD distribution in the talus and adjacent tibia secondary to locally altered mechanics and stress concentration. Methods: In this retrospective comparative study, we included patients with talar OCD, either as primary diagnosis or as incidental finding, that underwent WBCT imaging of the foot and ankle. The Volume of Interest (VOI) represented a cube positioned around the talar OCD (width/depth) and length expanding 5mm below the OCD, the OCD, the joint space, and 5mm above the tibial plafond. The HU distribution was obtained along three parallel lines (anterior, central, and posterior aspects of the OCD) positioned inside the VOI, and aligned perpendicular to the joint surface. The same VOI and exact same process was then repeated on the opposite non-lesion side of the talus, that served as a control for normal HU distribution of talus, joint space and tibia. Graphical plots for HU distributions were generated for each line, separating the HU values and distributions in 3 control or 4 segments: talus, osteochondral lesion, joint space and tibia. Results: Thirty-two talar OCD patients (10 males, 22 females) were included. The mean age was 54 years old (range: 22-82 years). Fifty-two percent were symptomatic, and 48% had an incidental OCD finding. There was not significant difference in mean HU along the three lines (anterior, central, and posterior) in any segment (talus, OCL, joint space and tibia) when comparing the symptomatic and incidental OCD patients. However, when comparing talar OCD patients and controls, the mean HU followed a different distribution pattern. In controls, the talus had higher HU average than the tibia, but in OCD patients the tibia demonstrated higher HU than the talus. When comparing the HU in the tibia between OCD and controls, the OCD patients demonstrated significantly increased BD (p<.0001). Conclusion: Our study provides a novel understanding about BD changes in the subchondral bone of the distal tibia in talar OCD patients, with significantly increased bone density when compared to controls, even among asymptomatic cases. The observed increase in bone density in the distal tibia of OCD patients probably demonstrates the local mechanical derangement secondary to the talar OCD, and the tibial response to this derangement, what could potentially explain the pain symptoms in talar OCD patients, as well as the subsequent occurrence of concomitant mirror OCD in the tibia (kissing lesion). Future studies are necessary to further elucidate this issue.
Category: Hindfoot; Other Introduction/Purpose: Middle facet subluxation (MFS) and middle facet incongruence angle (MFIA) are established indicators of peritalar subluxation (PTS) in evaluating Progressive Collapsing Foot Deformity (PCFD) using Weight-Bearing CT (WBCT). Traditionally, MFS and MFIA are assessed in the coronal plane, which is not perpendicular to the plane of the middle facet (MF). However, the angle between the plane of the medial facet and the plane of measurement changes with plantar flexion of the talus. This approach may lead over- or underestimating the MFS and MFIA as well as a over-dysplastic appearance of the middle facet. We hypothesized that measuring these parameters in a plane perpendicular to the MF would result in changes in MFS, MFIA, and the incidence of diagnosed dysplastic joints. Methods: In this retrospective case-control study, 89 patients with PCFD and 11 controls without PCFD who underwent WBCT were evaluated. Measurements of MFS, MFIA, and middle facet dysplasia were conducted using both the classical method and the new method. The classical method consisted of identifying the center point of the middle facet on sagittal view and taking measurements in the coronal plane as described in the literature. The new method comprised of taking measurements after rotation of the coronal plane around the axis defined by the center of the middle facet on sagittal view until the coronal plane was perpendicular on sagittal view. The inclination of the MF in the sagittal plane was also recorded. Additional WBCT parameters (Foot and Ankle Offset (FAO), Talo-navicular coverage angle (TNCA), Talus-first metatarsal angle axial) were also measured. The Shapiro-Wilk test assessed data normality. A p-value of < 0.05 was considered statistically significant. Results: Significant differences were observed between the two methods across all parameters for PCFD. For controls, only the MFIA was significantly different (p:0.0045) between the two methods. Regarding the PCFD the new method demonstrated lower MFS (25.4% vs. 40.3%, p< 0.0001), lower MFIA (4.7 degrees vs. 13.1 degrees, p< 0.0001), and fewer dysplastic joints (1% vs. 37%, p< 0.0001) when compared to the classical method. However, multivariate analysis did not show inclination angle as predictive of MFS. TNCA (p < 0.05) talus-first metatarsal angle axial (p < 0.05) and FAO (p < 0.05) were stronger predictors of MFS than the inclination of the talus. Conclusion: This study confirms that MFS is a complex deformity influenced by multiple parameters but not talar inclination. The new method showed lower MFS, MFIA, and dysplasia measurements compared to current classical method. Future research should compare these two measuring techniques to more comprehensive modalities (coverage mapping). When assessing MFS, surgeons should be mindful that the plane of measurement relative to the structure is critical, and any change in the inclination of the talus may influence the appearance of MFS. We suggest using a plane of measurement perpendicular to the plane of the middle facet when assessing its subluxation.
Category: Sports; Ankle Introduction/Purpose: A symptomatic os trigonum is a common cause of posterior ankle pain that has been traditionally managed with open excision. Minimally invasive surgery (MIS) has been proposed as an alternative to open excision for improved outcomes and decreased complication rates; however, no systematic review to date has examined the utilization of MIS for a symptomatic os trigonum. The purpose of this study was to examine patient outcomes, return to sport, and complications associated with MIS for a symptomatic os trigonum. Methods: A systematic review was performed on February 22, 2023, using the PubMed, CINAHL, MEDLINE, and Web of Science databases from database inception until February 22, 2023, on the topic of MIS for a symptomatic os trigonum. Results: From initial search, 17 articles (N = 435 patients) met inclusion criteria. Mean age of the cohort was 26.01 ± 4.68 years, with a mean follow-up time of 34.63 ± 18.20 months. For MIS patients, the mean preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score was 55.85 ± 12.75, the mean final postoperative AOFAS score was 94.88 ± 4.04, the mean preoperative visual analog scale pain score was 7.20 ± 0.43, and the mean final postoperative visual analog scale score was 0.71 ± 0.48. The mean time to return to sport for patients undergoing MIS was 7.76 ± 1.42 weeks. MIS had an overall complication rate of 5.0%, the majority of which consisted of transient neurapraxia of the sural or superficial peroneal nerve. Conclusion: Minimally invasive management of a symptomatic os trigonum appears to be a viable alternative to open surgery in terms of outcomes, return to sport, and complication rates. More high-quality evidence will be required to definitely recommend minimally invasive approaches as the standard of care over open surgery.
Category: Sports; Ankle Introduction/Purpose: Ankle sprains are one of the most common acute injuries amongst ballet dancers and may lead to chronic ankle instability. Certain ballet positions, if performed incorrectly or with inadequate technique, can further increase the risk of bone and soft tissue injuries. Dancing en pointe, which forces the foot and ankle into extreme plantar flexion, has been reported as the most common mechanism of injury. While these injuries occur frequently, little research has been done to understand the biomechanics of the foot and ankle in ballet. The aim of this study was to use weightbearing computed tomography (WBCT) and distance mapping to describe ankle joint mechanics in various ballet positions. Methods: This was an institutional review board approved case study analyzing five healthy professional ballerinas. WBCT scans were taken bilaterally in five different positions: a control/neutral position, first position, fifth position, plié, and relevé (en pointe). A semi-automatic software was used to segment models of all bones proximal to the first distal phalanx. Talar dome and gutter articulations were selected manually, and distances along the entire tibiofibular interface and gutter articulations were calculated using a previously published protocol. The mean syndesmosis width was calculated at 1 cm, 3 cm, and 5 cm from the tibiotalar joint. Results: Syndesmotic widening was greatest in first position at 5 cm above the tibiotalar joint (Mean: 9.39 mm). The relevé position consistently had the greatest syndesmotic narrowing at all heights along the syndesmosis. The anteromedial gutter had the largest range in regard to distance mapping, with greatest joint space width in fifth position (Mean: 4.99 mm) and narrowest joint space in plié (Mean: 2.68 mm). More specifically, in fifth position the anteromedial gutter space was 71% wider than the control position. Conclusion: This study is the first of its kind to mechanistically describe the ankle as it relates to ballet dancing. Interestingly, syndesmotic and tibiotalar joint space widening was greatest in first and fifth position, which may suggest that external rotation plays a greater contributing role in ankle instability compared to plantarflexion in ballet. Future research with larger cohorts and more WBCT stress positions is needed to comprehensively understand the foot and ankle joint mechanics in this demanding sport.
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