Ankle Fellowship Research Articles

Foot and ankle fellowship-trained osteopathic orthopaedic surgeons: a review, analysis, and understanding of current trends.

Over the past several decades, orthopedic surgery has seen a substantial increase in the number of surgeons completing fellowship training. Doctors of Osteopathic Medicine (DOs) continue to advance their orthopedic education through subspecialty fellowship training. DOs have represented between approximately 6 % and 15 % of American Orthopaedic Foot and Ankle Society (AOFAS) fellows. Although historical representation has been considered strong, the fellowship match years 2020 and 2021 have seen a decline in osteopathic orthopedic surgeons participating in foot and ankle fellowships. This deviates from the recent trends of increasing participation across orthopedic subspecialities. To investigate and review the trends of orthopedic foot and ankle fellowship training. Data was reviewed from the AOFAS regarding number of fellows matched and degree obtained. Data from the Federation of State Medical Boards (FSMB), American Orthopaedic Foot and Ankle Society (AOFAS) and Association of American Medical Colleges (AAMC) were reviewed for physician trends and match statistics. Fellowship match years 2020 and 2021 have seen a decline in osteopathic orthopedic surgeons participating in foot and ankle fellowships, with only roughly 3% of AOFAS fellows being osteopathic trained. Orthopedic surgery has the highest rate of subspecialty training of all surgical specialties. Although there is hope for an increasing osteopathic presence in orthopedic surgery, recent literature has pointed to potential for continued bias in opportunities for osteopathic students. We hope that increased participation of osteopathic graduates in orthopedic surgery training programs will result in the continued expansion of osteopathic orthopedic surgeons completing fellowship training, including in foot and ankle surgery.

Variability in Surgical Case Volume Performed During ACGME-Accredited Orthopaedic Foot and Ankle Fellowship Training.

Previous studies have demonstrated a positive correlation between case volume and outcomes in foot and ankle surgery. This study elucidates surgical case volume benchmarks for Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic foot and ankle fellowship training in the United States. The ACGME provided case logs for orthopaedic residents and foot and ankle fellows (2018-2021). Variabilities in reported fellowship case volumes were defined as the fold-difference between 90th and 10th percentiles. Reported case volumes were compared between training cohorts with parametric tests. Case logs from 65 orthopaedic foot and ankle fellows and 3146 orthopaedic residents were included. Fellows reported 1.3- to 1.5-fold more foot and ankle cases during fellowship training than during residency training (P < .001). On average, orthopaedic foot and ankle fellows reported 405.4 cases and most were arthrodesis (17%), forefoot reconstruction (17%), mid/hindfoot reconstruction (13%), tendon repair/transfer (12%), and trauma ankle hindfoot (11%). Case categories with the highest variabilities were amputation (14.8-fold difference), infection/tumor (11.6-fold difference), arthroscopy (9.2-fold difference), and calcaneus (8.7-fold difference). Case volume benchmarks can assist trainees and faculty during orthopaedic foot and ankle training. More research is needed to determine case minimum requirements needed for autonomous practice in foot and ankle surgery. Level III.

Academic productivity correlates with industry earnings in foot and ankle fellowship programs in the United States: A retrospective analysis.

The study investigates the connection between academic productivity and industry earnings in foot and ankle orthopedic surgery fellowships. Utilizing metrics like the H-index and Open Payments Database (OPD) data, it addresses a gap in understanding the relationship between scholarly achievements and financial outcomes, providing a basis for further exploration in this specialized medical field. To elucidate the trends between academic productivity and industry earnings across foot and ankle orthopedic surgery fellowship programs in the United States. This study is a retrospective analysis of the relationship between academic productivity and industry earnings of foot and ankle orthopedic surgery fellowships at an individual faculty and fellowship level. Academic productivity was defined via H-index and recorded from the Scopus website. Industry earnings were recorded from the OPD. Forty-eight foot and ankle orthopedic surgery fellowships (100% of fellowships) in the United States with a combined total of 165 physicians (95.9% of physicians) were included. Mean individual physician (n = 165) total life-time earnings reported on the OPD website was United States Dollar (USD) 451430.30 ± 1851084.89 (range: USD 25.16-21269249.85; median: USD 27839.80). Mean physician (n = 165) H-index as reported on Scopus is 14.24 ± 12.39 (range: 0-63; median: 11). There was a significant but weak correlation between individual physician H-index and individual physician total life-time earnings (P < 0.001; Spearman's rho = 0.334) and a significant and moderate positive correlation between combined fellowship H-index and total life-time earnings per fellowship (P = 0.004, Spearman's rho = 0.409). There is a significant and positive correlation between academic productivity and industry earnings at foot and ankle orthopedic surgery fellowships in the United States. This observation is true on an individual physician level as well as on a fellowship level.

Analysis of Gender Diversity Within Foot and Ankle Surgery Fellowship Programs.

Women continue to be underrepresented in orthopaedic surgery. This study seeks to evaluate gender diversity of faculty and trainees at foot and ankle surgery fellowship programs. In this cross-sectional analysis of 49 US foot and ankle fellowship programs, all publicly available data on program faculty (as of July 2023) were collected, as well as data on current and past fellows between 2018 and 2024. Of 49 programs with 195 foot and ankle surgery faculty, 26.5% (n = 13) had at least 1 female on faculty, with only 8.2% (n = 4) having female fellowship directors. Female faculty made up 9.7% (n = 19) of foot and ankle surgery faculty overall. Of 307 total fellows identified within the 6-year period, 19.5% (n = 60) were female. Geographic distribution of programs was as follows: 29% (n = 14) Northeast, 31% (n = 15) South, 19% (n = 9) Midwest, and 21% (n = 10) West. Northeast programs made up 62% of all programs with female faculty, whereas Midwest programs made up the least at 8% (P = .048). Programs with female faculty had more female fellows from 2018 to 2024 than programs without female faculty (33.7% vs 14%, P < .001). Our findings suggest that females remain underrepresented in foot and ankle surgery fellowship director positions, despite an increasing proportion of females entering orthopaedic surgery. Foot and ankle surgery fellowship programs with female faculty had a higher number of female trainees; as such, diversification of foot and ankle fellowship departments may be an important factor in ongoing efforts to promote gender diversity within the specialty. Level IV, observational cross-sectional analysis.

Comparison of Intraoperative Radiation Exposure Between Minimally Invasive Chevron Akin (MICA) and Open Procedures for Hallux Valgus Correction

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The minimally-invasive Chevron-Akin (MICA) procedure for hallux valgus correction is an increasingly popular technique that has yielded comparable radiographic and clinical outcomes to open procedures3–5. Intraoperative radiation dosages for certain foot and ankle surgeries have been reported relative to the international occupational radioprotection thresholds6. In particular, the mean intraoperative radiation exposure during the MIS Scarf osteotomy has been reported to be 14-times greater than open osteotomy7. However, no study to date has reported on the intraoperative radiation exposure during MICA procedures in relation to that of open procedures. Methods: This is a retrospective comparative study from a single institution. Patients underwent a MICA (n=25) or open (n=40) hallux valgus correction by a single foot and ankle fellowship trained surgeon. To account for the learning curve8, the number of intraoperative fluoroscopy shots for the first 50 consecutive MICA procedures were analyzed, and the first 25 procedures were excluded. Four data points were retrieved from the mini C-arm, including 1) number of fluoroscopy shots taken; 2) total fluoroscopy time (s); 3) total radiation dose (mGy); and 4) total dose area product (DAP; mGy*cm2). Preoperative and postoperative radiographs were referenced to measure the hallux valgus (HVA) and intermetatarsal angles (IMA) as previously described.9 Categorical variables were compared using the chi-square test, and continuous variables were compared using Student’s t-test or the Mann-Whitney U test. Analysis of variance was used to determine the statistical significance of differences in the fluoroscopy data between groups. Results: The average total dose absorbed (4.00 vs. 1.34 mGy, p&lt; 0.001), total fluoroscopy time (226 vs. 48.5 s, p&lt; 0.001), and number of fluoroscopy shots (125 vs. 22.3, p&lt; 0.001) were 2.9, 4.6, and 5.6 times greater in the MICA versus the open group, respectively. The total DAP (4.22 vs. 2.56 mGy*cm2, p=0.175) was 1.6 times greater in the MICA group but the difference was not statistically significant. The mean preoperative and postoperative HVA and IMA were greater in the MICA cohort compared to the open cohort. However, there was no statistical difference in change in HVA (MICA -17.43 vs. Open -20.05, p=0.125) or IMA (MICA -8.08 vs. open -9.31, p=0.11) between the two cohorts, with each resulting in normal postoperative angles. Conclusion: In this single surgeon series, the MICA procedure demonstrated significantly greater dose absorbed, total fluoroscopy time, and number of fluoroscopy shots compared to the open procedure. The extent of radiation exposure to the surgeon and the patient in relation to the radioprotection thresholds must be closely monitored to specify the health risks involved with this procedure.

Ballooning Periprosthetic Osteolysis Related to Crystalline Arthropathies Following Total Ankle Arthroplasty: A Case Series

Category: Ankle Arthritis; Basic Sciences/Biologics Introduction/Purpose: From 2009-2019, there has been a 120% increase in the incidence of total ankle arthroplasty (TAA) in the United States. With the rise in primary TAA, future increases in revision TAA cases is anticipated. Aseptic loosening with periprosthetic osteolysis continues to account for a significant number of revisions. While several factors may contribute to the pathophysiology of osteolysis, an underlying inflammatory response surrounding TAA implants may play a primary role. It is well known that monosodium urate (gout) and calcium-pyrophosphate (pseudo-gout) crystals evoke a highly inflammatory response and may involve the foot and ankle joints. However, the effect of these conditions following TAA has not yet been reported. We present a small case series of patients with ballooning osteolysis following TAA with confirmed crystalline arthropathy. Methods: This is a retrospective study from a single academic institution looking at patients who underwent TAA revision surgery for periprosthetic osteolysis and concern for aseptic loosening. Revision surgeries were performed by three orthopedic foot and ankle fellowship trained surgeons. Case characteristics, including pre-operative imaging, clinical presentations, intra-operative findings and surgical treatments performed were analyzed and presented in this small case series. Results: We report 5 patients whom underwent revision surgery for ballooning periprosthetic osteolysis following TAA. Intra- operative pathology samples from periprosthetic cysts returned positive for monosodium urate (MSU) or calcium pyrophosphate (CPP) crystalline deposition (1 MSU and 4 CPP) in all 5 patients. Final intra-operative cultures were all negative for infection. Upon gross intra-operative inspection, all polyethylene liners were considered to be normal without abnormal wear characteristics. Periprosthetic cysts were isolated to the tibial component in 2 patients and involved both the tibial and talar components in 3 patients. Staged TAA revision was performed in 2 patients. Bone cyst curettage, bone grafting and polyethylene liner exchange was performed in 3 patients. Conclusion: Periprosthetic osteolysis is a known complication following TAA and often leads to implant loosening, functional disability and subsequent revision surgery. An objective strategy for management of this condition has not been agreed upon amongst orthopedic foot and ankle surgeons, as uncertainty remains surrounding the pathophysiology of osteolysis in TAA. To our knowledge, we are the first to describe a small case series of patients with crystalline arthropathy as a potential cause for periprosthetic osteolysis following TAA. Future prospective studies are warranted to better elucidate this potential cause of TAA failure.

Evaluating the Correlation Between Various Orthopaedic Foot and Ankle Fellowship Characteristics and Total Industry Payments Through the Open Payments Database.

Since the Physician Payments Sunshine Act in 2010, a substantial body of work has explored the supplemental income received by physicians to understand trends in industry payments and investigate sources of bias. To date, no study has examined how various fellowship characteristics impact industry earning levels at foot and ankle orthopaedic surgery fellowships. The purpose of this study is to examine the various fellowship and faculty-specific variables in correlation with industry earnings in foot and ankle orthopaedic surgery fellowships. This study is a retrospective analysis of foot and ankle orthopaedic surgery fellowships and respective faculty along with various fellowship characteristics in correlation to industry lifetime earning levels as of March 2023. Industry total lifetime earnings represent income directly paid to physicians, is not part of the physician's salary, and does not include any research grants or funding. Lifetime earnings represent all years recorded on the Open Payments Database website (2015-2021). There are 165 faculty physicians and 48 programs with complete data out of all foot and ankle orthopaedic surgery fellowship programs in the United States. The mean fellowship H-Index per fellowship was 48.94 ± 38.92, and the mean fellowship lifetime earning was $1 551 791.66 ± $4 136 091.64. There was no significant association between fellowship lifetime earnings and Newsweek ranking of fellowship-affiliated hospitals (P = .906), Doximity ranking of fellowship-affiliated residencies (P = .703), and region of the United States (P = .126). There was a statistically significant increase in total lifetime earnings in programs with 4 fellows as compared to 1 fellow (P = .035). There was no statistically significant correlation between a variety of foot and ankle fellowship-specific factors and lifetime industry earnings, aside from increased earnings in programs having 4 fellows. Prestige factors, such as Doximity and Ranked Hospital Newsweek List rank, as well as region of the United States is not associated with industry earnings. Level III, retrospective cohort study.

Leadership Characteristics of Orthopaedic Surgery Foot and Ankle Fellowship Directors

Category: Other Introduction/Purpose: As both fellowship training and opportunities for leadership's popularity increase, understanding a Foot and Ankle Fellowship Directors' (FD's) necessary components is crucial for evaluating Orthopaedic improvement methods and providing a template for the field's aspiring leaders. However, despite a FD's significance in trainee's development, future success, and careers in Foot and Ankle via Orthopaedic Surgery, no literature analyzing Foot and Ankle FD's demographics, surgical training, nor experience currently exists. This article aims to illustrate the trends in the characteristics and qualifications needed for leadership as an Orthopaedic Surgery Foot and Ankle FD. Methods: The American Orthopaedic Foot and Ankle Society (AOFAS) identified the FDs for all 2021 participating Orthopaedic Foot and Ankle fellowship programs in the United States. The characteristics, demographics, and educational background data for each fellowship director was gathered and consolidated by author review of available curricula vitae (CV's). Information that could not be obtained from the CV's were then further gathered from resources such as Scopus web of science, institutional biographies, and emailed questionnaires. To ensure adequate response and data points, with absence of email response, information not readily available was obtained through telecommunications. These data points were then consolidated into 1 database. The information gathered to be used as data points were: Age, sex, race/ethnicity, residency/fellowship training location and graduation year, name of current institution, length of time at current institution, time since training completion until being appointed fellowship director, length in fellowship director role, and personal research H-index. Results: 51 Foot and Ankle FDs were appraised. The mean age of Current FD's was 51.27 years old with a mean H-Index of 14.69. 94.1% of these FD's were male and 5.9% were female; 90.2% were Caucasian, 5.9% were Asian American, and 3.9% were African American. The mean residency graduation year was 2001.31; and the most attended Residency program was the Harvard Combined Orthopaedic Residency Program. The mean fellowship graduation year was 2002.30; and the most attended fellowship program was the MedStar Union Memorial Foot and Ankle Fellowship. The time from completion of fellowship until FD appointment was 11.42 years; the mean number of years spent as a FD is 4.37. 19.61% of FD's work at the same institution where they completed residency; 9.8 % of FD's currently work at the same institution where they completed fellowship. The FD with the highest research impact displayed a Scopus H-index of 48. Conclusion: This study serves as an objective summary and analysis of the current leadership within Foot and Ankle Fellowship Programs in the US. Orthopaedics sees a large disparity in diversity in percentage of women and minorities within the field as compared to several different specialties; however, that same disparity is further pronounced amongst leadership as lower percentages of women and minorities hold leadership positions within orthopaedics compared to other specialties. This study provides data to be used as a template for candidates aspiring for leadership while displaying trends that establish a more comprehensive sense of diversity and equality.

Clinical and Radiographic Outcomes after Total Ankle Arthroplasty and Suture Tape Augmentation for Ankle Arthritis Combined with Ankle Instability

Category: Ankle Arthritis; Ankle; Sports Introduction/Purpose: End-stage ankle arthritis is commonly seen in combination with various forms of ligamentous instability. Correction of the ankle arthritis and meticulous ligament balancing is key to a successful outcome after a total ankle replacement. In particular, with varus or multidirectional instability, ligament repair or reconstruction can be performed with a combination of suture and/or suture anchors if there is adequate biologic tissue remaining for repair. To date there has been no study to report on the isolated use of suture tape to correct residual intraoperative lateral ankle instability and talar tilt after total ankle replacement. The purpose of this study is to evaluate the clinical and radiographic outcomes after this combined surgical procedure. Methods: This was a single institution, retrospective study involving 36 patients that underwent a primary total ankle arthroplasty surgery in combination with a lateral ankle ligament reconstruction using a suture tape construct (InternalBraceTM, Arthrex, Naples, FL). Retrospective review of prospectively collected information from patient charts of three foot and ankle fellowship trained surgeons were evaluated at preoperative, 6-months, 1-year and 2-years postoperative for various demographics as well as VAS pain and FAAM scores. Postoperative complications including revision surgery, hardware failure, or persistent instability were also recorded. In addition, preoperative radiographs were compared to 1-year and final follow up (mean, 26 months; range, 13-90 months) radiographs for correction of the coronal deformity. Analysis involved a 1-way repeated Friedman test with post hoc Wilcoxon signed-rank tests. P values are adjusted using the Bonferroni multiple testing correction method. Assumptions for normality were checked through normal quantile-quantile (QQ) plots. Results: At two years postoperative, VAS pain (p&lt;0.001) and FAAM functional scores (p&lt;0.001) were significantly improved from preoperative. Additionally, both VAS pain (p=0.026, p-0.043) and FAAM scores (p=0.00142, p&lt;0.001) significantly improved at each time point (6-months, 1-year) compared to preoperative. On weight bearing mortise view radiographs, the mean preoperative talar tilt angle was 11.9 (range, 1.4-25.7) degrees of varus. At 1-year and 2-years postoperative the mean talar tilt angles were significantly improved from preoperative at 1.1 and 0.7 degrees, respectively (p&lt;0.001, p&lt;0.001)). The correction was significantly improved and maintained at final follow up of at least 2 years. There were no significant differences between 1-year and 2-year talar tilt measurements (p=1.00). There were three complications requiring revision surgery. Two were for component loosening and the third was for a deep infection. Conclusion: Combined ankle arthritis and instability can be a challenging problem for foot and ankle surgeons. This study demonstrated that the use of suture tape to reconstruct the lateral ankle ligament complex after total ankle replacement provides and maintains adequate correction of any residual coronal deformity at a final follow up of at least two years.

Indications and Limitations of Synthetic Ligament Augmentation Among Foot and Ankle Surgeons and Other Orthopedic Subspecialties

Category: Sports; Ankle; Trauma; Other Introduction/Purpose: Ligament augmentation repair (LAR) entails supplementing a ligament repair with synthetic material anchored to bone. Purported advantages include increased stability and a more aggressive rehabilitation. In recent years, the literature supporting LAR has grown rapidly, with published techniques and outcomes for many ligament and tendon repairs, including anterior talofibular ligament (ATFL), Achilles tendon, and the spring ligament complex. Despite the increased use of synthetic ligaments reported in literature, there remains a lack of clarity and consensus on the indications and postoperative rehabilitation protocols. The purpose of this study was to survey an international group of orthopedic specialists regarding their current use of LAR techniques and decision-making. Methods: We invited members of several international orthopaedic and sports medicine societies to participate in this survey between January and June 2021. Responding surgeons represented all six continents, and included 319 sports medicine specialists, 179 foot and ankle specialists, and 96 trauma specialists (some reported more than one fellowship). Survey questions fell into three general categories: 1) Surgeon demographics and training, 2) Current LAR use decision-making within respondents' subspecialty, and 3) Outcomes, complications, frequency, and benefits associated with LAR. Chi-square tests of independence were used to assess the likelihood of any dependent relationships between respondent demographics and LAR use our outcome. A p value of less than 0.05 was considered significant. Results: We collected 515 responses total with a 97% completion rate. 75% of all survey respondents report using LAR for some indication. The most frequent use was ATFL repair (69%, Figure 1). LAR is most commonly implemented for additional stability (72%), poor tissue quality (54%), and more rapid return-to-sport/work (47%). LAR users state the greatest limitation is cost (62%), while non-LAR users state their greatest deterrent to LAR is that it is unnecessary for a good outcome (46%). Foot and ankle fellowship trained surgeons are significantly more likely to use LAR (87% use LAR) compared to sports-trained surgeons (67%, p = 0.002) and surgeons without a fellowship (66% use LAR, p = 0.01). Surgeons treating professional/Olympic athletes are significantly more likely to use LAR. Conclusion: While synthetic ligaments are commonly used to supplement ligament repairs, the application, outcomes, and perceived benefit differ for each subspecialty. The reported limitations of LAR differ between LAR users and non-LAR users. For those who do not use LAR, the greatest limitation is perceived benefit, while for those that do, the greatest limitation is cost. Prospective studies of indications, outcomes and accelerated rehabilitation protocols are needed to further elucidate the value and cost-effectiveness of these implants.

Polyvinyl Alcohol Hydrogel Hemiarthroplasty of First Metatarsophalangeal Joint Hallux Rigidus: Single Surgeon Five-Year Experience

Category: Midfoot/Forefoot Introduction/Purpose: Hallux rigidus (HR) is the most common arthritic condition of a foot with a prevalence of up to 45% in people aged &gt;75 years-old. First metatarsophalangeal joint (MTPJ) arthrodesis has been the historical gold standard treatment for late-stage HR. Polyvinyl alcohol (PVA) hydrogel implants have similar biomechanical properties as native cartilage, and thus have gained popularity as a joint-sparing technique that provides preservation of MTPJ motion. Initial literature demonstrated pain relief and functional outcomes equivalent to first MTPJ arthrodesis and excellent five-year survivorship. However, recent studies report variable failure rates on PVA hydrogel implants for HR. The purpose of this study was to report the five-year experience and outcomes of PVA hydrogel implants for the treatment of HR performed by a single surgeon. Methods: Electronic health records were queried from August 2016 to August 2021 for patients who underwent primary PVA hydrogel implant hemiarthroplasty (Cartiva Synthetic Cartilage Implant; Cartiva Inc, Alpharetta, GA) for symptomatic late-stage HR. All patients were treated by a single foot and ankle fellowship trained orthopaedic surgeon. A minimum of six months follow- up was required. Patient demographics and perioperative data were collected. Preoperative and postoperative range of motion, visual analog scale (VAS) pain scores, and radiographs were evaluated. Complications and the overall implant survivorship were reported. A Kaplan-Meier analysis was used to evaluate implant survival. Descriptive and univariate statistics were used to analyze data. A total of 196 primary PVA hydrogel implant procedures were performed of which 146 had a minimum six-month follow-up and were included. The mean follow-up was 14.5 (+- 11.9) months. Results: The majority of patients were female (n=103, 70.5%) with a mean age of 58.1 (+-10.1) years-old, BMI of 27.3 (+-5.2) Kg/m2, and an ASA score &lt; 3 (n=131, 89.7%). The majority of patients had stage II or III disease (n=115, 78.8%). Patients experienced significant improvement in VAS (p&lt;0.0001) and hallux dorsiflexion (p=0.0005) postoperatively. There was a total of 22 (15.1%) complications including implant subsidence (n=15, 10.3%), deep infection (n=6, 4.1%), and hypertrophic ossification (n=1, 0.7%). Revision surgeries were required in 12.3% (n=18) of patients at an average of 9.4 (+- 9.2) months postoperatively. This included 9 (6.2%) revision PVA hydrogel implant procedures and 9 (6.2%) first MTJP arthrodesis. The one-and two-year survival to any revision surgery (n=18) were 89.1% and 80.5%, respectively. The one- and two-year survival to MTPJ arthrodesis (n=9) were 95.9% and 86.3%, respectively (Table 1). Conclusion: In the largest single-surgeon series reported, first MTPJ hemiarthroplasty with a PVA hydrogel implant resulted in significantly improved pain and hallux dorsiflexion at an average of 15 months postoperatively. There was a high two-year survivorship of 86.3% until failure with required first MTPJ arthrodesis. Future prospective studies should be performed to refine the indications for PVA hydrogel implants and identification of risk factors for failure.

Orthopaedic Foot and Ankle Surgery Leadership Trends: A Cross-Sectional Study of Fellowship Directors and Division Chiefs.

Background: In orthopaedic surgery departments, foot and ankle fellowship directors are tasked to create a robust clinical curriculum for trainees, while division chiefs manage the division's delivery of patient care. The primary aim of this study was to describe characteristics of foot and ankle surgery fellowship directors and division chiefs in an effort to recognize trends or disparities in leadership traits. Methods: The American Orthopaedic Foot and Ankle Society (AOFAS) fellowship directory for 2021 to 2022 was reviewed for AOFAS-recognized fellowship programs in the United States. Between March 2021 and June 2021, 48 fellowship directors and 23 publicly recognized division chiefs were administered an electronic survey to collect demographic, educational, and professional data. Univariate and bivariate statistical analyses were performed. Results: A total of 42 of the 48 (87.5%) fellowship directors and 18 of the 23 (78.3%) division chiefs responded to the questionnaire. Of the 48 fellowship directors, 45 (93.8%) were male, 43 (89.6%) identified as Caucasian, their average age at leadership appointment was 42.6 ± 7.5 (range, 32-70) years, and the average time between fellowship graduation and leadership appointment was 9.9 ± 7.8 (range, 0-36) years. Of the 23 chiefs, 22 (95.7%) were male, 20 (87.0%) identified as Caucasians, their average age at leadership appointment was 41.7 ± 7.8 (range, 32-53) years, and the average time between fellowship graduation and leadership appointment was 9.8 ± 6.8 (range, 2-21) years. The average H-index for the chiefs was greater than that of the fellowship directors (18.4 vs 13.4, P = .0373) when controlling for years of training>. Conclusion: The majority of current leaders identify as middle-age Caucasian males, demonstrate high research productivity, and have attended a select number of the same residency and fellowship training programs. By demonstrating the lack of diversity within foot and ankle surgery leadership, this study serves as a call to action for making inclusivity a priority.Levels of Evidence: Level IV: Cross-sectional study.

The Lateral Drawer Test: A New Clinical Test to Assess Mortise Instability in Weber B Fibula Fractures.

Background:Assessment of mortise stability is paramount in determining appropriate management of ankle fractures. Although instability is readily apparent in bimalleolar or trimalleolar ankle fractures, determination of instability in the isolated Weber B fibula fracture often requires further investigation. Prior authors have demonstrated poor predictive value of physical examination findings such as tenderness, ecchymosis, and swelling with instability. The goal of this study is to test the validity of a new clinical examination maneuver, the lateral drawer test, against the gravity stress view (GSV) in a cohort of patients with Weber B fibula fractures. Secondary goals included assessing pain tolerability of the lateral drawer test, as well as testing interobserver reliability.Methods:Sixty-two patients presenting with isolated fibula fractures were prospectively identified by an orthopaedic nurse practitioner or resident. Three nonweightbearing radiographic views of the ankle as well as a GSV were obtained. Radiographs were not visualized before conducting the lateral drawer test. Two foot and ankle fellowship–trained orthopaedic surgeons performed and graded the lateral drawer test. Radiographs were then examined and medial clear space (MCS) was measured. Visual analog scale (VAS) pain scores were obtained before and after testing. The results of the lateral drawer test were compared with radiographic measurements of MCS on GSV. A cadaveric experiment was devised to assess interobserver reliability of the lateral drawer test.Results:Thirty (48%) of 62 consecutively enrolled patients demonstrated radiographic instability with widening of the MCS ≥5 mm on GSV. When correlated with MCS measurement, the lateral drawer test demonstrated a sensitivity of 83%, specificity of 97%, positive predictive value (PPV) of 96%, and negative predictive value (NPV) of 86%. There was a strong correlation between the lateral drawer test grade and amount of MCS widening (Spearman correlation ρ = 0.82, P < .005). Patients tolerated the maneuver well with an average increase of 0.7 on the VAS pain scale. Testing of 2 observers utilizing the cadaveric model demonstrated a Cohen’s Kappa coefficient of 0.7 indicating moderate interobserver agreement.Conclusion:The lateral drawer test demonstrates high sensitivity, specificity, PPV, and NPV with moderate interobserver reliability compared with the MCS on GSV in patients presenting with Weber B fibula fractures. Although further external validation is required, the lateral drawer test may offer an adjunct tool via physical examination to help determine mortise stability.Level of Evidence:Level II, Prospective Cohort Study.

Triceps Surae Lengthening in Foot and Ankle Trauma: A Survey of OTA and AOFAS Members.

Background:The prevalence, indications, and preferred methods for gastrocnemius recession and tendo-Achilles lengthening—grouped as triceps surae lengthening (TSL) procedures—in foot and ankle trauma are supported by a scarcity of clinical evidence. We hypothesize that injury, practice environment, and training heritage are significantly associated with probability of performing adjunctive TSL in the operative management of foot and ankle trauma.Methods:A survey was distributed to members of the American Orthopaedic Foot & Ankle Society and the Orthopaedic Trauma Association. Participants rated how likely they would be to perform TSL at initial management, definitive fixation, and after weightbearing in the presence and absence of a positive Silfverskiöld test in 10 clinical scenarios of closed foot and ankle trauma.Results:A total of 258 surgeons with median 14 years’ experience responded. Eighty-five percent reported foot and ankle fellowship training, 24% reported traumatology fellowship training, 13% both, and 4% no fellowship. Ninety-nine percent reported performing TSL with a median 25 TSL procedures per year, 72% open gastrocnemius recession, and 17% percutaneous tendo-Achilles lengthening). Across all scenarios, we observed low overall 8% probability with fair agreement (κ = 0.246) of performing TSL (range, 1% at initial management of an unstable Weber B bimalleolar ankle fracture with negative contralateral Silfverskiöld test to 29% at definitive fixation of tongue-type calcaneus fracture with positive contralateral Silfverskiöld test). Silfverskiöld testing significantly influenced TSL probability at all time points. University of Washington training (β = 1.5, P = .007) but not trauma vs foot fellowship training, years in practice, academic practice, urban setting, or facility trauma designation were significantly associated with likelihood of performing TSL.Conclusion:Orthopaedic traumatology and foot and ankle surgeons report similar indications, methods, and low perceived propensity to use TSL in the management of foot and ankle trauma. We found that graduates of 1 fellowship training site were more likely to perform TSL in the setting of acute trauma potentially indicating the need for better scientific data to support this practice.Level of Evidence:Level V, therapeutic.

Diagnostic Accuracy of the Progressive Collapsing Foot Deformity (PCFD) Classification.

A consensus group recently proposed the term progressive collapsing foot deformity (PCFD) and a new classification with 2 stages plus 5 classes to describe the complex array of flatfoot deformities. This study aimed to validate different diagnostic accuracy rates of the PCFD classification. This was a survey-based study distributed among 13 foot and ankle fellowship programs for 3 groups of participants with varied experience in practice (group 1: fellows in training, group 2: surgeons in practice for 1-4 years, and group 3: surgeons in practice for ≥5 years). Each participant was asked to assign 20 different cases of flatfoot deformity to the appropriate classes and stages using the PCFD classification. The overall diagnostic accuracy, class, and stage diagnostic accuracy rates for the 20 cases were calculated first for the entire cohort and then compared among the 3 groups. The misdiagnosis rate for each class of deformity (the sum of overdiagnosis and underdiagnosis rates) of the entire cohort was calculated and compared with the other classes. Mean and standard evidence were used to describe numerical data. One-way analysis of variance was used to compare values among the 3 groups and the 5 classes. P <.05 was considered statistically significant. For the whole cohort, the overall diagnostic accuracy, class diagnostic accuracy, and stage diagnostic accuracy rates were 71.0%, 78.3%, and 81.7%, respectively There was a statistically significant difference between group 1 and 2, and group 1 and 3, in overall diagnostic accuracy and class diagnostic accuracy, with no significant difference among the 3 groups regarding stage diagnostic accuracy. Class B had a significantly higher overdiagnosis rate than the rest of the classes, whereas class D was significantly underdiagnosed than others. The misdiagnosis rates for classes A to E were 3.3%, 17.5%, 11.1%, 26.0%, and 3.7%, respectively. The PCFD classification showed overall fair diagnostic accuracy rates. The highest diagnostic accuracy was for "hindfoot valgus deformity" and "ankle instability." Further content validation of the PCFD classification is needed to examine the terminology and interpretation of those classes with low diagnostic accuracy including "midfoot/forefoot abduction deformity," "forefoot varus deformity/medial column instability," and "peritalar subluxation/dislocation."Level of Evidence: Level II, prospective comparative study.

Utilization of Arthroscopy During Ankle Fracture Fixation among Early Career Surgeons: An Evaluation of the American Board of Orthopedic Surgery Part II Database

Category:Ankle; Arthroscopy; TraumaIntroduction/Purpose:Rotational ankle fractures are common injuries associated with high rates of intra-articular injury. Traditional ankle fracture open reduction and internal fixation (ORIF) techniques provide limited capacity for evaluation of intra- articular pathology. Ankle arthroscopy represents a minimally invasive technique to directly visualize the articular cartilage and syndesmosis while aiding with reduction and allowing joint debridement, loose body removal, and treatment of chondral injuries. The purpose of this study was to evaluate temporal trends in concomitant ankle arthroscopy during ankle fracture ORIF surgery amongst early-career orthopaedic surgeons while examining the influence of subspecialty fellowship training on utilization.Methods:The American Board of Orthopedic Surgery (ABOS) Part II database was queried to identify all candidates performing at least one ankle fracture ORIF (Current Procedural Terminology [CPT] codes 27766, 27769. 27784, 27792, 27814, 27822, 27823, 27829, 27846, 27848) from examination years 2010 to 2019. All ORIF cases were examined to identify those that carried a concomitant CPT code for ankle arthroscopy (CPT codes 29891, 29892, 29894, 29895, 29897, 29898, 29899). Concomitant ankle arthroscopy cases were categorized by candidates self-reported fellowship training status and examination year. Descriptive statistics were performed to report relevant data and linear regression analyses were utilized to assess temporal trends in concomitant ankle arthroscopy with ORIF for ankle fractures. Statistical significance was defined as p<0.05.Results:There were 36,113 cases of ankle fracture ORIF performed of which 388 cases (1.1%) were performed with concomitant ankle arthroscopy. Ankle fracture ORIF was most frequently performed by trauma fellowship trained Part II candidates (n=8,888; 24.6%), followed by sports medicine (n=7,493; 20.8%) and foot and ankle (n=6,563; 18.2%). Arthroscopy was most frequently utilized by foot and ankle fellowship trained surgeon (293/ 6,270 cases; 4.5%) followed by sports medicine (29/7,464 cases; 0.4%) and trauma (4/8,884 cases; 0.1%). With respect to total arthroscopic cases, 75.5% were performed by foot and ankle fellowship trained surgeons while only 1.0% was performed by trauma trained candidates. Ankle arthroscopy utilization significantly increased from 3.65 cases per 1,000 ankle fractures in 2010 to 13.91 cases per 1,000 ankle fractures in 2019 (p=0.010). Specifically, foot and ankle fellowship trained surgeons demonstrated a significant increase in arthroscopy utilization during ankle fracture ORIF over time (p<0.001; OR: 1.101; CI: 1.054-1.151).Conclusion:Ankle arthroscopy utilization during ankle fracture ORIF has increased ten-fold over the past decade. Foot and ankle fellowship trained surgeons contribute most significantly to this trend.

Opioid Usage after Hallux Valgus Correction Surgery

Category:Bunion; OtherIntroduction/Purpose:More than 200,000 surgeries for hallux valgus correction occur annually in the United States. Due to the post-operative pain associated with the procedure, opioids are often prescribed to help manage pain. Given the lack of objective data on opioid use and the difficulty of addressing a patient's post-operative pain, we sought to quantify, through a prospective analysis, patient's narcotic use after hallux valgus surgery. The purpose of our study was to determine the average quantity and type of post-operative opioids consumed after hallux valgus surgery and to assess potential predictive factors for increased opioid consumption.Methods:Adult patients undergoing primary hallux valgus surgery were recruited from two foot and ankle fellowship trained orthopedic surgeons at a single institution. At the pre-operative visit, patients were consented and completed a demographical questionnaire. Data was collected from the operative and PACU record, as well as the 2, 6, and 12-week post-operative visits. A statistical analysis was performed to determine the average quantity of opioid and non-opioid pain medication consumed post- operatively, as well as any statistically significant correlations.Results:For the 58 subjects who completed treatment and data collection in the PACU, 53 consumed opioids. Initial prescriptions for these patients included Hydrocodone, 39 (73.58%) Oxycodone, 13 (24.52%) and Meperidine, 1 (1.89%). The average number of opioid pills collectively consumed at the two-week and 12-week post-operative visit was 19.99 and 22.52, respectively. At the two-week postoperative visit, only patient BMI showed a statistically significant association with increased opioid use.Conclusion:On average, patients consumed 22-24 narcotic pain pills after hallux valgus reconstruction surgery. If a physician prescribed 24 narcotics pills after surgery to patients that are not currently utilizing narcotic pain medication, there is a 95% chance they will not need additional pain medication during the two-week postoperative period.

A cost analysis of ankle fractures treated by orthopedic surgeons with or without foot and ankle fellowship training at ambulatory surgery centers and hospitals.

Introduction:Ankle fractures are commonly treated by orthopedic surgeons. Fellowship versus non-fellowship training often adds a different perspective, use of specialty-specific implants, comfort with outpatient procedures, and may contribute to cost differences between surgeons. To assess the impact of fellowship training on the value of care provided, the difference in cost of ankle fracture open reduction internal fixation procedures between foot and ankle trained orthopedic surgeons and non-foot and ankle trained orthopedic surgeons over the past 10 years was retrospectively evaluated. We additionally evaluated the cost differences of ankle fracture open reduction internal fixations between hospitals, hospital-owned ambulatory surgery centers, and physician-owned ambulatory surgery centers. The study also assessed the costs effects of inpatient versus outpatient procedures and ankle open reduction internal fixation procedure volume of the surgeon observed within the timeframe of the study.Methods:Patient data was collected from electronic medical records and billing documents for patients who underwent an ankle open reduction internal fixation procedure performed by an orthopedic surgeon in our hospital system and local hospital-owned ambulatory surgery centers between the years 2010 and 2020. Data were also collected from a physician-owned ambulatory surgery center for patients who underwent an ankle open reduction internal fixation procedure performed by an orthopedic surgeon between the years 2015 and 2020. Statistical analyses were performed to observe potential cost differences among all variables.Results:Procedures performed by fellowship-trained orthopedic surgeons were significantly less costly than those performed by non-foot and ankle trained orthopedic surgeons when performed at ambulatory surgery centers but not at hospitals. Procedures performed at ambulatory surgery centers were found to be significantly less costly than those performed at hospitals. In addition, it was noted that procedures performed at hospital-owned ambulatory surgery centers were less costly than physician-owned ambulatory surgery centers. It was also found that procedure cost decreased with an increase in surgeon volume.Conclusion:An ankle fracture open reduction internal fixation performed by a foot and ankle trained orthopedic surgeon in a hospital-owned ambulatory surgery center is the lowest cost option available, and an increase in volume of open reduction internal fixations is associated with a further decrease in cost when within our hospital system between the years 2010 and 2020.

Orthopaedic Foot and Ankle Surgery Fellowship Directors Are Typically White Men in Their Early 50s With Strong Achievements in Research

PurposeTo determine the objective characteristics of orthopaedic foot and ankle fellowship directors (FDs) by concentrating on the demographic characteristics, academic background, institutional history, research experience, and professional affiliations of these leaders.MethodsData for each FD were collected by searching institutional biographies, personal websites, or publicly available curricula vitae. Data collection included the following variables: age, sex, race/ethnicity, previous training institutions, residency and fellowship graduation years, advanced degrees, military affiliation, institutional loyalty, year hired, FD career timeline, total number of publications, total number of citations, and h-index.ResultsOf the 47 FDs, 44 (93.6%) were men and 3 (6.4%) were women. The mean age was 50.8 ± 9.4 years. Most orthopaedic foot and ankle FDs were white (n = 42, 89.4%), followed by Asian (n = 4, 8.5%) and black or African American (n = 1, 2.1%). The mean Scopus h-index, total number of publications, and total number of citations for all foot and ankle FDs were 13.3 ± 9.5, 47.5 ± 45.8, and 898.1 ± 1,040.3, respectively. Among all foot and ankle FDs, the mean tenure in the FD position was 5.8 ± 4.6 years.ConclusionsOrthopaedic foot and ankle FDs are primarily white men in their 50s, with minimal female and minority representations. These FDs are distinguished by their high level of research productivity. Additionally, orthopaedic foot and ankle training backgrounds seem to play an important role, given that most of the appointed FDs trained in only a few select programs.Clinical RelevanceThis study outlines some of the most important characteristics among foot and ankle FDs and identifies important disparities within this population of leaders that may have detrimental effects on the field.

Factors used in Applicant Ranking of Orthopedic Foot and Ankle Fellowships and the Availability of Online Information.

Background:The Internet is often the first resource used by applicants to evaluate fellowship programs. However, information on these websites can be often incomplete, inaccessible, and/or inaccurate. The primary objective of this study was to examine key factors that orthopedic foot and ankle fellowship applicants use to rank programs. The secondary objective was to assess both the accessibility and availability of the information on orthopedic foot and ankle fellowship program websites.Methods:A Qualtrics survey was distributed via e-mail to those who matched into an orthopedic foot and ankle fellowship position from years 2008-2020. A comprehensive list of orthopedic foot and ankle fellowship programs was created. Program websites were evaluated for accessibility as well as the quality of recruitment and educational content.Results:There were a total of 114 survey responses out of 644 invites (17.7%). The most important factors for establishing a rank list were operative experience, current faculty, and program reputation. Eighty-five percent (41/48) of orthopedic foot and ankle fellowship websites were directly accessible using Google. On average, accessible orthopedic foot and ankle fellowship websites contained only 57% (11.5/20) of the content deemed desirable.Conclusion:Orthopedic foot and ankle websites are widely accessible and have higher recruitment and educational quality content scores compared with previously published data. The most important factors for establishing a rank list are consistent with previous literature. Those who ranked operative experience as one of the most important factors when establishing a rank list did not complete more operative cases than those who did not.Level of Evidence:Level IV.