Category Sports; Trauma Introduction/Purpose: Turf Toe remains a diagnostic challenge for the orthopedic surgeon. A high index of suspicion is needed, in addition to adequate imaging strategies to characterize the broad spectrum of injuries involving this pathology. MRI imaging provides excellent static soft-tissue details and it has become widely used to determine the anatomical structures damaged. However, defining the stability of the 1st metatarsophalangeal (MTP) plantar plate complex is difficult without proper dynamic evaluation and this is crucial to define between conservative or operative management. Since there is no current consensus regarding the optimal imaging assessment to optimize turf toe diagnosis we present the results of an imaging protocol, including dynamic fluoroscopy and ultrasound (US), to enhance the identification of unstable Turf Toe injuries. Methods: A prospective imaging protocol consisting of bilateral comparative weightbearing x-rays, US examination, and mobilization under fluoroscopy was designed. The inclusion criterion was any patient with clinical findings consistent with plantar plate injury after forced hyperextension of the hallux. All studies were informed and performed by trained musculoskeletal radiologists. Location and symmetry of the sesamoids under the metatarsal, increased distal sesamoid-to-phalanx distance and proximal migration of one or both sesamoids were suggestive findings of unstable plantar plate rupture on weightbearing x-rays. Ultrasound examination was performed to address soft tissue injuries, characterize the magnitude of the plantar plate rupture and for dynamic/comparative stability assessment. A comparative dynamic fluoroscopic evaluation was performed to evaluate the behavior of the sesamoids under maximal dorsiflexion and plantarflexion of the hallux on the lateral view. MRI was also done in all of the patients with positive findings of instability. Results: Eighteen patients (11M/7F) were evaluated under suspicion of turf toe injury from August 2016 to November 2019. The mean age was 31 years old (range:14-50). Weightbearing X-rays were positive for sesamoid complex instability in one patient. Four patients (22,2%) had positive findings for instability in fluoroscopy and US. The agreement between US and fluoroscopy was excellent (kappa coefficient 1). Assuming fluoroscopy examination as the gold standard for instability, the US was highly effective at detecting unstable injuries (Sensitivity 100%, Specificity 100%, PPV 100%, NPV 100%). Four patients positive for instability received operative treatment. Conclusion: In our series, dynamic ultrasound and fluoroscopy allowed detection of 4/18 unstable turf toe injuries compared to Weightbearing X-rays that detected only one unstable injury. US examination is highly sensitive for instability being comparable to fluoroscopic examination. Dynamic testing, with either US or fluoroscopy, in turf toe may improve the diagnosis of severe injuries, leading to higher detection of patients requiring surgical stabilization of the plantar complex.

Category: Midfoot/Forefoot Introduction/Purpose: Modified Lapidus arthrodesis is performed in the treatment of different pathologies, including hallux valgus and osteoarthritis of the 1C-MTT joint. Complications of this procedure include delayed union and non – union. To prevent them, several rigid fixation methods have been proposed. Biomechanically, plantar plate fixation may be the best solution. Therefore, we sought to investigate our clinical results and complications in patients operated on with a modified Lapidus arthrodesis using two different plantar plate fixation systems. Methods: After IRB approval, we reviewed our prospectively collected database for patients operated on with a modified Lapidus arthrodesis. Dedicated foot and ankle orthopaedic surgeons performed all procedures. Patients were included if they were older than 18 years, had a minimum FU of 1 yr and agreed to participate in the study. Patients with neuropathy, previous surgery, concomitant midfoot/hindfoot procedures or those which fixation method was different from a plantar plate were excluded. Preoperative and postoperative IM angle was evaluated. Two independent musculoskeletal radiologists assessed consolidation under CT scan at 12 weeks postop. Triaxial 2-mm reformatted CT slices were used to calculate joint fusion percentage. Each patient was assigned to a consolidation group considering joint fusion percentage: 0-24%, 25-50%, 51-74%, 75-100%. Intra/interobserver coefficients of variability were calculated. SF-36, SMFA, FAOS and FAAM were obtained preoperatively and at one year follow up. t-test was performed to address for functional outcomes differences in-between groups. Results: Twenty-three patients (35 feet) met inclusion criteria. Mean age was 47 years (13-65), 83% female and 17% male. Eleven patients had bilateral surgery. Mean preoperative/postoperative IM angle were 16+3 and 9+2, respectively (p<0.001). Ten feet achieved <24% consolidation (33%) and 20 feet >25% (67%). With the numbers available, consolidation rate didn´t differ in patients undergoing unilateral/bilateral surgery(p=1.0) or plating system(p=0.22). One patient had an anterior tibialis tendon rupture and 1 patient presented an infected non-union, prompting revision. Mean preoperative/postoperative values for SF-36 physical and mental component were 49 and 76(p<0.001); and 43 and 68(p<0.001), respectively. FAOS-pain were 60 and 81(p<0.001);FAOS-daily-life were 59 and 96(p<0.001);FAOS-sport were 43 and 74 (p<0.001);and FAAM-Daily-life score were 67 and 87(p<0.001). No significant differences were found for SMFA. Conclusion: Despite a low consolidation rate at 12 weeks post op, patients with plantar plated Lapidus arthrodesis presented a significant increase in functional outcomes and a low revision/complication rate at 1 yr FU. Consideration should be given to delay evaluation under CT scan to 24 weeks post op.