Highlights of the twentieth annual summer meeting of the American Orthopaedic Foot and Ankle Society, Seattle, Washington, July 29–31, 2004

Foot and Ankle Surgery 11 (2005) 183–191 www.elsevier.com/locate/fas

Highlights of the twentieth annual summer meeting of the American Orthopaedic Foot and Ankle Society, Seattle, Washington, July 29–31, 2004* Elly Trepman*, Lowell D. Lutter, E. Greer Richardson, Glenn B. Pfeffer, Stephen F. Conti American Orthopaedic Foot and Ankle Society, Seattle, Washington, USA Received 24 April 2005; accepted 22 June 2005

1. Introduction The Twentieth Annual Summer Meeting of the American Orthopaedic Foot and Ankle Society (AOFAS) was held 29–31 July 2004 at the Westin Hotel in Seattle, Washington. There were 459 registrants in attendance, including 66 individuals from 19 countries outside the United States.

2. Early bird symposia I. Surgical pearls: Fibular sesamoidectomy may be performed from a plantar approach, but the surgical defect should be closed [1]. Subluxing peroneal tendons may be managed with a stabilization procedure that includes superior peroneal retinaculoplasty with an anterior-based periosteal flap and fibular groove deepening [2]. Subtalar hypermobility and inversion instability may result in subtalar joint pain; management may include a split peroneus brevis tenodesis to limit subtalar excursion [3]. II. Meet the researcher: There were 80 poster presentations that covered diverse basic science and clinical studies. III. International orthopaedic perspectives: The AOFAS outreach mission to Vietnam (2002–2004) included * Publication does not constitute endorsement of content or validation of conclusions. Comparisons should be made with caution because statistical significance might not have been noted in the abstracts published in the conference program. * Corresponding author. Address: Kay Daugherty or Linda Jones, Campbell Foundation, 1211 Union Avenue, #510, Memphis, TN 38104, USA. Tel.: C1 901 759 3270; fax: C1 901 759 3278.

equipment upgrades, staff training, and direct clinical and surgical activity [4].

3. Clinical symposia I. Cavus foot: The cavus foot may or may not be neurogenic, and may include structural deformities including a plantarflexed first ray, forefoot equinus deformity, or a posteriorly positioned fibula [5]. Patients may have associated clinical problems including chronic lateral ankle sprains, fifth metatarsal stress fractures, and dorsolateral ankle sprains [5]. The deformity is defined by the talonavicular joint and the hindfoot is unstable [6]. Clinical signs of the subtle cavus foot include medial prominence of the medial heel viewed from the front or medial bulge of the first metatarsal head, and management may include a cavus foot orthosis or surgical reconstruction [7]. Surgical treatment options vary with associated deformities including heel varus (calcaneal osteotomy and plantar release), lateral column overload (midfoot osteotomy and tendon transfer), and plantarflexed first ray (dorsiflexion first metatarsal osteotomy and Jones procedure) [8]. II. Postsurgical deformity: Complex revision cases were reviewed [9]. In a patient with rheumatoid arthritis, an ankle valgus deformity after a triple arthrodesis was managed with a total ankle replacement, but this was complicated by persistent valgus ankle malalignment. Another patient with a nonunion of a lateral column lengthening was managed successfully with bone

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grafting and fixation with an H-plate. In another patient who had post-poliomyelitis deformity with a failed triple arthrodesis (varus deformity) and associated ankle osteoarthritis, treatment included revision triple arthrodesis and total ankle replacement [9]. III. Complex ankle ligament repair problems: Medial ankle instability is characterized by medial ankle pain, giving way, and pronation deformity of the foot, and may be managed with deltoid ligament repair with or without additional procedures for associated conditions [10]. Failed lateral ankle ligament reconstruction is a difficult problem, and tendon graft salvage procedures are under evaluation [11,12]. Distal tibiofibular syndesmotic injuries may occur in 5–20% of ankle sprains, and may be treated non-operatively or with syndesmosis ligament repair and screw fixation [13].

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4. Debates I. Hallux valgus deformity: The proximal crescentic osteotomy does not lengthen or shorten the first metatarsal, but is associated with a 28% risk of hallux elevatus (minimum, 1 mm elevation) [14]. The Ludloff (oblique) osteotomy enables immediate weightbearing in a postoperate shoe, but is not advised for a foot with an incongruent joint and an increased distal metatarsal articular angle or instability of the first tarsometatarsal joint [15]. The modified proximal chevron osteotomy is a medial opening wedge osteotomy, but loss of fixation may occur in people with osteopenia [16]. II. Posterior tibial tendon insufficiency: Posterior tibial tendon insufficiency with flexible deformity (stage II) may be managed with lateral column lengthening (Evans open wedge calcaneal osteotomy) and a medial slide calcaneal osteotomy; hindfoot motion is retained but the procedure is technically demanding [17]. Another option is triple arthrodesis, which may provide correction of deformity and a high patient satisfaction rate despite loss of hindfoot motion [18]. III. Nerve conditions: Treatment of seven clinical nerve problems in the foot and ankle was discussed with multiple choice questions [19]. Varied treatment approaches were noted between three panel members and between members of the audience who were surveyed with an interactive electronic response system [19].

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each, over 3 weeks) or no training [20]. Testing with a perturbation rig and electromyographic (EMG) analysis showed that the training group had a 23% increase (P! 0.05) in activation of five superficial muscles about the ankle joint, including a 25% increase in EMG activity of the peroneus longus, but the non-trained group had no increase in muscle activation [20]. Peroneal tenodesis: In eight feet (eight patients; average age, 38 years) treated with peroneal tenodesis for traumatic or attritional tendon tear, follow-up evaluation at a mean of 30 months after surgery showed that mean AOFAS Ankle-Hindfoot Score was 75 points (77% of control) and peak torque was 75% of control [21]. Flexor hallucis longus: In 81 patients (average age, 38 year) with clinically diagnosed tenosynovitis of the flexor hallucis longus, non-operative treatment (immobilization and stretching program) was successful in 37 (64%) of 58 patients treated non-operatively, and surgical treatment (decompression and synovectomy) was successful in all 23 (100%) of 23 patients treated surgically [22]. Acute Achilles tendon rupture: In 13 men (mean age, 37 years) who had surgery and early rehabilitation for an acute Achilles tendon rupture, strength testing at a mean of 39 months after surgery showed plantarflexion peak torque differences (P%0.02) and functional horizontal and vertical jump differences (P%0.03) between the injured and uninjured side [23]. In 14 physically active, uninjured men, plantarflexion peak torque differences (P%0.05) were also noted between right and left sides, and there were no significant differences between the injured patients and the control group [23]. Acute Achilles tendon rupture: In 125 patients who had an Achilles tendon rupture in which there was contact between the ruptured tendon ends demonstrated by ultrasonography, non-operative treatment (immobilization in a boot with a 3 cm hindfoot lift) was used [24]. Results at mean of 5.5 years after injury were good or excellent in 92 (74%) patients, satisfactory in 11 (9%) patients, and poor in 22 (18%) patients [24]. Chronic Achilles tendon rupture: Six patients (average age, 43 years) with a chronic Achilles tendon rupture were treated with open reconstruction using a synthetic ligament to bridge the gap between the proximal and distal tendon stumps [25]. At six months after surgery, all patients returned to full activity except running, and the average strength of the injured side was 92% that of the opposite side [25].

5. Scientific sessions 5.2. Diabetes 5.1. Sports A. Ankle stability: Fourteen healthy subjects were assigned to either wobble board training (ten sessions, 20 min

A. Quality of life: In 60 adult diabetic subjects, including 20 subjects with a diabetic foot ulcer or infection and 20 subjects who had had a lower extremity amputation,

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the Short Form-36 (SF-36) survey showed impaired health related quality of life in subjects with ulcer or infection (P!0.001) and amputees (P!0.001) [26]. The Mini Mental Exam, Clock Drawing Test, and clinical depression screening showed no evidence of cognitive impairment or depression in either group [26]. Transmetatarsal amputation: A comparison of risk factors was done between 21 diabetic patients who had a failed transmetatarsal amputation (TMA) that was revised to a below knee amputation and 21 diabetic patients who had a successful TMA [27]. Long-term control of blood glucose (hemoglobin A1c) was a predictor of successful healing of TMA, and the need for debridement was a predictor of failure of TMA [27]. Charcot arthropathy: A radiographic analysis of diabetic midfoot Charcot arthropathy in 24 feet (19 patients; mean age, 54 years) showed that the lateral talo-first metatarsal angle was significantly associated with the skin pathology (ulceration or callus formation) (P!0.001) [28]. Hallux amputation: In 35 diabetic patients who had hallux amputation, indications included chronic ulceration in 14 (40%) toes, infection in 11 (31%) toes, and ischemia in 10 (29%) toes. [29]. Healing occurred in 11 (50%) of 22 amputations that were distal to the metatarsophalangeal joint and in 3 (23%) of 13 amputations that were through or proximal to the metatarsophalangeal joint, and 10 (29%) of the 35 feet developed postoperative second toe deformities [29]. Charcot arthropathy: Surgical treatment of Charcot arthropathy in 19 patients (9 [47%] ankle and 10 [53%] hindfoot reconstructions) included 13 (68%) arthrodesis procedures [30]. All 17 (89%) patients who were available at follow-up evaluation (average, 30 months after surgery) achieved a stable, plantigrade foot, with recurrent ulceration in 2 (12%) patients [30]. Diabetic foot ulcer: In 38 diabetic patients (mean age, 51 years) with non-infected, non-ischemic plantar neuropathic foot ulcers, treatment with a total contact cast (19 patients) or a removable walker boot that was closed with a strip of fiberglass cast material (19 patients) resulted in similar median healing times (cast, 5 weeks; boot, 4 weeks; not significant) and complication rate (cast, 68%; boot, 42%; not significant) [31]. Boot application was significantly faster than cast application (median or mean [not stated] application time: cast, 13 min; boot, 8 min; P!0.0001) [31].

5.3. New procedures A. Hallux varus: Seven patients (average age, 42 years) with iatrogenic hallux varus deformity after hallux valgus surgery were treated with a split transfer of the extensor hallucis longus tendon to drill holes in

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the hallux proximal phalanx and first metatarsal [32]. Evaluation at an average of 11 months after tendon transfer surgery showed that correction of hallux varus was maintained in all feet with no recurrence (average hallux valgus angle: preoperative, K158; postoperative, 138), and there was significant improvement in AOFAS Score (average AOFAS Score: preoperative, 52 points; postoperative, 89 points; P!0.00001) [32]. Hallux rigidus: In 11 patients (mean age, 61 years) with hallux rigidus, treatment included osteophyte resection and dorsal, dome-shaped osteotomy of the first metatarsal neck [33]. Evaluation at an average of 2 years after surgery showed that all patients had relief of pain, and average AOFAS Score was improved (preoperative, 66 points; postoperative, 90 points) [33]. Flatfoot: Eleven feet with symptomatic hypermobile flatfoot in six children (age range, 9–13 years) were treated with an extra-articular cannulated screw placed lateral to the subtalar posterior facet to block hindfoot valgus, and an Achilles tendon lengthening [34]. At an average of 17 months after surgery, correction was noted in all patients [34]. Midfoot arthritis: In 10 patients (average age, 46 years) with fourth and fifth metatarsocuboid arthritis, treatment included resection of the base of the fourth and/or fifth metatarsals and ceramic ball interposition arthroplasty [35]. At an average of 17 months after surgery, 9 patients were satisfied, average AOFAS score was improved 60% over preoperative values, and average pain (rated by a visual analog scale) was improved by 45% [35]. Peroneal tendinopathy: Seven patients (average age, 38 years) with chronic rupture of the peroneus brevis and longus tendons were treated with a staged reconstructive procedure consisting of peroneal tendon resection, temporary (3 months) placement of a Hunter rod to the distal peroneus brevis stump, and flexor hallucis longus transfer [36]. Evaluation at an average of 8.5 years after surgery showed that 6 (86%) patients had complete pain relief and returned to full activity level [36]. Retrocalcaneal bursitis: In 28 patients treated with endoscopic bony and soft tissue decompression of the retrocalcaneal space, average AOFAS Score improved (preoperative, 62 points; postoperative, 97 points) and 25 (89%) patients had excellent results [37]. One (4%) patient had a postoperative Achilles tendon rupture and one (4%) patient had revision (open) surgery for residual pain and swelling [37]. Bone graft: Bone graft for foot and ankle surgery was used from the proximal tibia in 200 Italian and 6 American cases [38]. Follow-up evaluation in 50 Italian and 6 American cases showed that none of the patients recalled any major pain or complications at the graft donor site [38].

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5.4. Trauma A. Syndesmosis: Ankle syndesmotic disruptions were treated with 3.5 mm fully threaded cortical screws placed through either three cortices (59 patients) or four cortices (61 patients) [39]. Evaluation at 5 months after surgery showed that there was no difference between the two groups in loss of reduction (three cortices, 3 patients; four cortices, 0 patients), screw breakage (three cortices, 5 patients; four cortices, 4 patients), or need for hardware removal (three cortices, 1 patient; four cortices, 0 patients) [39]. B. Distal tibial fixation: Twelve fresh frozen cadaver ankles and three live ankles had magnetic resonance imaging done after pressurized ankle joint distension with gadolinium [40]. The anterolateral intrasynovial capsular region had the most proximal reflection of all tibiotalar joint regions in all specimens (proximal distance from subchondral bone at joint line: mean, 9 mm; range, 5–12 mm), and the distal tibiofibular joint had a maximum proximal extension of 21 mm from the tibiotalar joint line [40]. Distal tibial fixation wires would avoid intrasynovial capsular penetration if they were placed proximal to these regions [40]. C. Osteochondral defect: Eight patients (average age, 29 years) had cryopreserved osteochondral allograft reconstruction with titanium screw fixation for large talar (6 ankles) and navicular (2 feet) defects [41]. At an average of 15 months after surgery, 7 (88%) patients were satisfied and reported mild or no pain; one patient had failure associated with graft loosening [41]. D. Talar malunion: In 10 patients with painful talar malunion or non-union, secondary reconstruction consisted of correctional osteotomy for malunion or pseudarthrosis resection and bone grafting for nonunion [42]. Evaluation at a mean of 26 months after reconstruction showed that 9 (90%) patients were fully satisfied with the result and mean Maryland Foot Score was improved (preoperative, 41 points; postoperative, 87 points; P!0.001) [42]. E. Calcaneal fracture: In 35 patients (average age, 50 years) who had isolated intraarticular calcaneal fractures that were treated with open reduction and lateral plate fixation using a lateral extensile approach, average Musculoskeletal Functional Assessment (MFA) score was 17G14 points at an average of 3.7 years after surgery [43]. The Sanders classification of the preoperative computed tomography scan significantly correlated with functional outcome (MFA score) (PZ 0.05). Furthermore, fractures with four or more anterior process fragments had worse outcomes than those with one or two fragments (PZ0.01) [43]. F. Calcaneal fracture: A calcaneal fracture fixation model with artificial calcaneus bone models and four types of fixation plates showed that plates with locked screws provided higher stability during cyclical loading than

a plate without locked screws [44]. Failure loads and displacement during load-to-failure testing were similar for plates with or without locked screws [44]. G. Calcaneal fracture: In 18 patients with acute calcaneal fractures that were treated with delayed open reduction and internal fixation (average time from injury to surgery, 33 days) with a lateral approach, evaluation at an average of 26 months after injury showed that no patient required a subtalar arthrodesis [45]. H. Midfoot injury: In 9 competitive football players (7 professional and 2 collegiate players), injury to the first ray included the first naviculocuneiform joint [46]. Treatment included open reduction and internal screw fixation in 7 (78%) patients, and all 9 patients returned to full athletic activity [46].

5.5. Biomechanics A. Calcaneal osteotomy: In loaded (100 lb) cadaver specimens, medial calcaneal osteotomy (medial shift, 1 cm) without superior translation resulted in decreased plantar pressure under the first and second metatarsals and increased pressure under the lateral forefoot [47]. Superior translation (0.5 cm) of the osteotomy resulted in a decrease in lateral forefoot plantar pressure compared with osteotomy without superior translation [47]. This study received the Roger Mann Award. B. Lateral column lengthening: The Evans opening wedge calcaneal osteotomy and the calcaneocuboid distraction arthrodesis were done on opposite sides of 12 matched pairs of cadaver specimens [48]. Both procedures (arthrodesis moreso than osteotomy) resulted in significant increases in pressure under the lateral forefoot and decreased pressure under the medial forefoot during simulated foot-flat and early heel rise components of gait [48]. C. Subtalar arthrodesis: In 30 unilateral, intra-articular calcaneal fractures that were salvaged with subtalar arthrodesis, evaluation at an average of 58 months after surgery showed that 27 (90%) patients were satisfied with treatment and average AOFAS Ankle-Hindfoot Score was 81 points [49]. Gait analysis showed changes at midstance and terminal stance phase compared with normal control subjects [49]. D. Hallux rigidus: Preoperative (average, 9 days) and postoperative (average, 1.5 years) gait analysis was done in 23 patients (average age, 58 years) with hallux rigidus who were treated with first metatarsophalangeal joint arthrodesis [50]. There was a significant increase in maximum ankle push-off power after surgery (preoperative, 1.1G0.7 W; postoperative, 1.5G0.6 W; PZ0.007) [50]. E. Hallux valgus deformity: In 12 cadaver specimens with a hallux valgus deformity, correction of the deformity with distal soft tissue realignment and proximal first

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metatarsal crescentic osteotomy resulted in a significant decrease of mean sagittal first ray motion (preoperative, 11 mm; postoperative, 5 mm; P!0.0005) [51]. F. Lesser metatarsal osteotomy: In 12 paired cadaver specimens that were axially loaded to 100 lb, plantar pressures under the second and third metatarsals were not significantly changed by second and third distal metatarsal horizontal osteotomies but were decreased after second and third metatarsal chevron osteotomies [52]. G. Hindfoot arthrodesis: In 18 patients who had a double (talonavicular and subtalar) arthrodesis for symptomatic flatfoot, cavovarus deformity, or hindfoot arthritis, evaluation at a minimum of 18 months after surgery showed significant improvement in the average AOFAS Ankle-Hindfoot Score (preoperative, 47 points; postoperative, 78 points; P!0.01) and all patients were satisfied [53]. Radiographic parameters were also improved, including average AP talo-second metatarsal angle (preoperative, 208; postoperative, 58) and lateral talo-first metatarsal angle (preoperative, 158; postoperative, 68) [53].

5.6. Old procedures A. Tibiotalocalcaneal arthrodesis: Ankle and subtalar arthrodesis with an intramedullary nail in 26 patients (26 feet) resulted in solid union with minimal or no pain in 20 (77%) patients [54]. There were 6 (23%) patients who had a delayed union or non-union, and there were 2 (8%) amputations for non-union (1 patient) and infected non-union (1 patient) [54]. B. Flexor hallucis longus tendon transfer: In 16 patients who had flexor hallucis longus (FHL) tendon transfer for chronic Achilles tendon rupture or tendinosis, evaluation at a mean of 44 months after surgery showed that 14 (88%) patients scored maximally on the AOFAS Hallux Metatarsophalanageal-Interphalangeal Score and none of the patients noticed any functional weakness of the hallux during activities of daily living [55]. C. Flexor digitorum longus tendon transfer: Flexor digitorum longus tendon transfer of the second toe was done in conjunction with other procedures in 64 feet (59 patients) for treatment of second toe instability problems including crossover deformity in 56 (88%) feet [56]. Evaluation at an average of 45 months after surgery showed that residual second metatarsophalangeal joint dorsiflexion contracture was present in 22 (34%) feet and pain in 17 (27%) feet [56]. D. Claw toe: In 9 patients (10 feet) who had a flexor hallucis longus (FHL) tendon transfer for treatment of hallux claw toe associated with cavus foot deformity, evaluation at an average of 47 months after surgery showed that 5 (56%) patients were satisfied and 4 (44%)

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patients were somewhat satisfied with the result [57]. Average Musculoskeletal Functional Assessment score was 18 (1Zbest; 100Zworst), and hallux interphalangeal angle (lateral radiograph) was decreased by an average of 338 [57]. E. Amputation: Twelve patients with a failed below knee amputation were managed with a program including hydrotherapy, serial debridements, hyperbaric oxygen therapy, limited open tenotomies of flexion contractures, temporary knee pinning in extension, and revision of the below knee amputation [58]. With this program, 11 (92%) patients retained functional below knee amputations and avoided revision amputation to a higher level [58].

5.7. Ankle arthritis A. Total ankle replacement: An e-mail survey showed that in a general orthopaedic society, the Canadian Orthopaedic Association (COA), 83% of members devoted less than 25% of time to foot and ankle disorders, but 79% of members of the AOFAS devoted more than 50% of time to foot and ankle disorders [59]. A larger percentage of AOFAS members performed total ankle replacement than COA members (percentage of members who performed total ankle replacement: COA, 6%; AOFAS, 51%) [59]. B. Total ankle replacement: In 18 patients (mean age, 62 years) who had a Scandinavian Total Ankle Replacement for arthrosis associated with a preoperative coronal plane deformity (varus or valgus deformity greater than 108), alignment was usually improved immediately and at two years after surgery [60]. Ankles with an incongruent preoperative deformity had more loss of correction between the immediate postoperative period and 2 years after surgery than ankles with a congruent preoperative deformity (average loss of correction: incongruent, 4G38; congruent, 1G18, P! 0.05) [60]. C. Total ankle replacement: In 67 patients (69 ankles) that were treated for ankle arthritis with an Agilitye total ankle replacement, clinical evaluation at a mean of 9 years after surgery showed that over 90% of patients reported decreased pain and were satisfied with the surgery [61]. Radiography of 117 total ankle replacements at a minimum of 2 years after surgery showed that 89 (76%) ankles had peri-implant radiolucency [61]. D. Total ankle replacement: Ten cadaver ankle specimens were implanted with a Scandinavian Total Ankle Replacement prosthesis and axially loaded to 500 N [62]. Application of shear loads (100 N) showed that varus or valgus malposition of the components resulted in decreased anteroposterior calcaneotibial displacement; application of torques (250 N cm) showed that that varus or valgus malposition of the components

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resulted in decreased rotational range of calcaneotibial external-internal rotation [62]. Total ankle replacement: In patients with ankle arthritis who were treated with an Agilitye total ankle replacement, the use of autologous concentrated growth factors from platelet concentrate resulted in a lower tibiofibular syndesmosis nonunion rate than in patients in which autologous growth factors were not used (number [%] nonunions: no growth factors, 17 [15%] of 114 ankles; autologous platelet concentrate, 2 [3%] of 66 ankles) [63]. Ankle arthrodesis: Evaluation of a group of patients at an average of 15 years after ankle arthrodesis showed that 91% of patients were definitely satisfied with the fused ankle [64]. Radiographic assessment showed moderate to severe subtalar arthritis in 64% of patients and talonavicular arthritis in 18% of patients [64]. Total ankle replacement: In 10 subjects who had an Agilitye total ankle replacement, videotape fluoroscopy during gait showed that the implanted ankles had less anteroposterior motion than non-implanted ankles (average anteroposterior translation: implanted, 2.0 mm; non-implanted, 2.5 mm) [65]. Total ankle replacement: In 59 patients (average age, 60 years) with post-traumatic arthritis who were treated with total ankle replacement, outcome surveys done preoperatively and at 6, 12, and 24 months after surgery showed that the Musculoskeletal Functional Assessment had a more uniform distribution of patients, and was more sensitive, than the AOFAS Ankle-Hindfoot score [66]. The AOFAS Ankle-Hindfoot score had an early ceiling effect [66].

5.8. Potpourri A. Charcot arthropathy: Histological and immunohistochemical analysis of tissue from 20 patients with Charcot arthropathy showed a disproportionate increase in osteoclasts to osteoblasts in Charcot reactive bone [67]. The osteoclasts were immunoreactive to interleukin-1, interleukin-6, and tumor necrosis factor-a [67]. This study received the J. Leonard Goldner Award. B. Arthrodesis: In 122 fusion sites in the foot and ankle in 61 patients (mean age, 51 years) with risk factors for nonunion (smoking, diabetes, immunologic or nutritional impairment, history of impaired union, multiple failed operations, high energy trauma, or chronic steroid use), autologous platelet concentrate (APC) was applied to the fusion sites with or without bone graft [68]. The mean time to union was similar regardless of bone graft composition (all cases, 40 days; APC alone, 42 days; APC with autograft, 39 days; APC with allograft, 30 days) [68]. C. Bone graft: A survey of 8 manufacturers of demineralized bone matrix, marketed as a substitute for

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autogenous bone graft, showed that only 5 (63%) manufacturers tested the final product for osteoinductivity and 2 (25%) manufacturers declined to supply any information regarding harvesting or processing techniques [69]. Accessory ossicle: In 26 patients (mean age, 18 years) with an os submalleolare (symptomatic accessory ossicle about the medial malleolus), painful symptoms resolved by an average of 2 months after surgical excision of the ossicle [70]. Evaluation at one year after surgery showed that all patients had resumed activities of daily living without complaint [70]. Hallux valgus deformity: Three-dimensional, simulated weightbearing computed tomography scans of 30 feet (17 women; average age, 47 years) with hallux valgus deformity (mean hallux valgus angle, 388; mean 1–2 intermetatarsal angle, 168) showed that the first metatarsophalangeal joint was incongruent in 25 (83%) feet and congruent in 5 (17%) feet [71]. Compartment syndrome: In 12 athletic patients who had bilateral, exercise-induced compartment syndrome, simultaneous bilateral fasciotomies were done [72]. All patients resumed athletic training by 6 weeks after surgery, and evaluation at an average of 14 months after surgery showed that all patients were satisfied with the results [72]. Clubfoot: In 24 idiopathic clubfeet that had been treated with posterior release, evaluation at a mean of 41 years after surgery showed that 19 (79%) feet had demonstrable pronation and 5 (21%) feet had no pronation motion [73]. The feet with pronation had a significantly greater average AOFAS Ankle-Hindfoot Score than feet without pronation (pronation present, 87 points; pronation absent, 57 points; P!0.05) [73]. Morton foot: In four groups (asymptomatic control, hallux valgus, hallux rigidus, and interdigital neuroma) of 43 subjects each, weightbearing radiographs showed that there was no significant difference between the control and other groups in measured values of second metatarsal hypertrophy (cortical thickness or diaphyseal metatarsal width) [74]. There was no correlation between second metatarsal hypertrophy and first ray mobility, first metatarsal length, pes planus, or restricted ankle dorsiflexion [74]. Talar osteonecrosis: In 10 feet (10 patients; mean age, 66 years) with avascular necrosis of the talus (idiopathic, 8 patients; traumatic, 2 patients), a ceramic artificial talar prosthesis was used [75]. Evaluation at a mean of 2 years after surgery showed that mean AOFAS Ankle-Hindfoot Score was improved (preoperative, 41 points; postoperative, 91 points) and results were rated as excellent in 9 (90%) patients [75]. Residency education: A core curriculum for residents rotating on a foot and ankle service included 12 weekly learning modules, a syllabus, weekly goals and objectives, reading assignments, weekly tutorial

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sessions, and tests [76]. Residents were pleased with this format, but the biggest challenge was finding the time to complete the academic work [76].

6. Conclusion The conference included special presentations about disparities in health care in different racial and socioeconomic groups [77], outreach rehabilitation care in rural Mexican villages [78], and physician-patient communication [79]. Retiring Editor-in-Chief of Foot & Ankle International, Lowell D. ‘Hap’ Lutter, was honored with an eloquent tribute from his wife Judy and publication of a volume of his numerous thought-provoking, insightful, and soul searching editorials [80]. Outgoing president Glenn B. Pfeffer reviewed an impressively long list of AOFAS accomplishments during the past year (Table 1) [81]. Incoming president Mark S. Myerson discussed priorities for the forthcoming year, including membership participation, diversity and opportunity in AOFAS, and international relations [82]. The summer meeting was a great success, thanks to the outstanding efforts of the AOFAS staff and generous educational grants from 49 corporate sponsors. The next meeting of the AOFAS was held on Specialty Day, February 26, 2005, at the meeting of the American Academy of Orthopaedic Surgeons in Washington, DC. The next summer meeting of the AOFAS will be held July 15–17, 2005 in Boston, MA. Table 1 Partial list of AOFAS special projects and new programs during 2003–2004 Education and research Master Techniques in Foot and Ankle Trauma (a one-day trauma course) First annual AOFAS Resident and Fellow Conference AOFAS orthopaedic Resident Lecture Series Core curriculum for medical student foot and ankle education Multiple foot and ankle seminars at state primary care meetings Inaugural Outreach and Education Fund (OEF) Fellowship Increase in research grants from OEF for trauma and sports research Publication AOFAS member website (www.aofas.org) revamped New website for public education (www.footcareMD.com) Advanced Reconstruction: Foot and Ankle—textbook published with American Academy of Orthopaedic Surgeons (AAOS) Lowell ‘Hap’ Lutter, MD—A Collection of Editorials from Foot & Ankle International, March 1994–August 2004 published Workers Compensation Manual published Dissemination of pamphlet ‘10 points for a Proper Shoe Fit’ to industry Committees and networking Nomination Committee changes to broaden nominations Industrial Relations Committee AAOS-Specialty Society Summit Relationship with American Association of Retired People (AARP) Political action: lobbyist support for foot and ankle care

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