Foot & Ankle Orthopaedics最新文献

Background: Accurate hindfoot alignment (HA) assessment is essential for surgical planning of foot and ankle procedures, as measurement errors may lead to inappropriate indication. Weight-bearing computed tomography (WBCT) enables HA assessment through coronal images, typically aligned perpendicular to the second ray. However, this forefoot-based reference may not be appropriate in all clinical scenarios, particularly when isolated hindfoot evaluation is required. This exploratory study sought to evaluate how 3 anatomical reference axes affect HA measurements in patients with different foot deformities.

Methods: This retrospective cohort study examined 136 WBCT and standard foot radiographs of patients older than 18 years. HA was measured as hindfoot alignment angle (HAA) in coronal images perpendicular to (1) second ray, (2) ankle mortise (bisection of medial and lateral malleoli), and (3) forefoot midpoint (bisection of first and fifth metatarsal heads). Meary, Sgarlato, hallux valgus, and intermetatarsal I-II and I-V angles assessed foot morphology. Spearman correlation analysis was performed to assess relationships between 2-dimensional (2D) parameters and HAA measurements.

Results: Median age was 50.3 years and 64% were female. HAA showed significant variations across different reference systems (second ray: 10.0 degrees, ankle mortise: 15.2 degrees, forefoot midpoint: 12.7 degrees; P < .01), with 20.6% of feet showing a discrepancy exceeding 10 degrees between the second ray and ankle mortise. Spearman correlation analysis showed correlation between HAA and Meary angle across all reference axes (ρ = -0.58 to -0.49, P < .01), and between HAA and Sgarlato angle with second ray referencing (ρ = -0.41, P < .01).

Conclusions: Reference axis selection substantially influences 2D HA measurements on WBCT. The ankle mortise reference could provide isolated measurement of HA regardless of concurrent forefoot deformities. When using 2D measurement methods, reference system selection could be tailored to whether surgical planning requires comprehensive foot alignment assessment or isolated hindfoot evaluation.

Level of evidence: Level III, retrospective cohort study.

Background: Hallux valgus (HV) is a common forefoot deformity treated surgically. Vitamin D is essential for bone and soft tissue health, but its role in postoperative outcomes after HV is unclear. This study evaluated whether low preoperative vitamin D is associated with increased complications.

Methods: Adults undergoing HV correction were analyzed retrospectively using the TriNetX Research Network. Patients were categorized as vitamin D deficient (≤20 ng/mL), subsufficient (≤30 ng/mL), or sufficient (≥30 ng/mL). Secondary analyses examined outcomes by surgical setting (inpatient vs ambulatory) and procedure type among subsufficient patients. Propensity score matching controlled for demographics and comorbidities. Ninety-day outcomes included wound complications, health care visits, opioid use, and thromboembolic events. Significance was set at P <.05.

Results: After matching, 7041 deficient and 8150 subsufficient patients were compared with equal numbers of sufficient controls. Vitamin D deficiency and subsufficiency were associated with higher rates of wound dehiscence, postoperative infection, inpatient consultation/admission, emergency department (ED) visits, and opioid use (all P < .05). In secondary analyses, 1286 inpatient and 6346 ambulatory subsufficient and sufficient patients were matched. Vitamin D subsufficiency was associated with higher ED visits in inpatients and increased wound dehiscence, inpatient encounters, ED visits, and opioid use in ambulatory patients (all P < .05). Among 3600 vitamin D-subsufficient patients per cohort, metatarsophalangeal (MTP) fusion had higher wound dehiscence than HV correction (P = .033).

Conclusion: Low preoperative vitamin D is associated with increased postoperative complications after HV, including wound dehiscence, infection, health care utilization, and opioid use. Subsufficient vitamin D was linked to higher ED visits in inpatients and increased wound dehiscence, inpatient encounters, ED visits, and opioid use in ambulatory patients. Among subsufficient patients, MTP fusion had higher wound dehiscence than HV correction, likely due to greater soft tissue disruption. These findings highlight that both vitamin D status and procedure type are associated with postoperative complications; however, given the modest absolute risk differences, preoperative vitamin D screening should be viewed as a possible risk-stratification tool.

Level of evidence: Level III, cohort study.

Background: Ankle fractures occurring in the setting of underlying neuropathy pose a significant risk for complications. Poor clinical outcomes such as primary failure of an operative surgical construct, wound infection, ulceration, and osteomyelitis are increased in neuropathic diabetic patients. Operative management includes open reduction internal fixation (ORIF) vs a fusion of the ankle using a tibiotalocalcaneal (TTC) nail. This study aims to compare clinical outcomes and complication profiles following operative fixation of neuropathic ankle fractures between patients undergoing ORIF and those undergoing TTC fusion.

Methods: Institutional review board approval was obtained to create a retrospective database of patients over a 17-year period. Included patients had a diagnosis of neuropathy of the lower extremity and an ankle fracture requiring either ORIF or TTC fusion. Demographic and clinical data were collected for the study sample. Descriptive statistics were conducted, and Kruskal-Wallis and χ² tests were used for analysis.

Results: Forty-five patients were included in the study, of which 26 underwent ORIF and 19 had a TTC fusion. There was a significant difference in weightbearing status at 2 weeks postoperatively between the 2 groups (P < 0.01), with 80.8% of ORIF patients and 36.8% of TTC fusion patients being nonweightbearing (NWB). However, there was no significant difference in the weightbearing status between ORIF and TTC fusion patients (P > .05) at later time points. Postoperative complications (P > .99) and use of opioid medications (P > .99) were not statistically significant when comparing ORIF to TTC fusion with no clear difference detected.

Conclusion: In patients with neuropathic fractures, TTC fusions were associated with earlier enhanced weightbearing capabilities compared to ORIF. This suggests that electing for a TTC fusion instead of an ORIF may provide the patient with improved function earlier in their recovery process, but we detected no clear difference in long-term postoperative outcomes when comparing TTC fusion and ORIF procedures.

Level of evidence: Level III, retrospective cohort study.

Background: Fluoroscopy is a vital imaging technique in orthopaedic surgery, particularly with the growing adoption of minimally invasive surgery (MIS). Because of their increased reliance on intraoperative imaging, MIS techniques may necessitate greater use of fluoroscopy and radiation compared with open procedures; therefore, the use of modern mini C-arm systems is recommended to mitigate radiation exposure. Although MIS offers significant benefits, its use also raises concerns regarding radiation exposure for both patients and surgical staff. This study evaluated radiation dose and fluoroscopy time comparing 2 common procedures used to treat insertional Achilles tendinitis: the percutaneous Zadek osteotomy (ZO) and the open midline Achilles tendon splitting Haglund resection (HR). We hypothesized that the percutaneous ZO would be associated with increased radiation dose and fluoroscopy time in comparison to the open HR but would be below the recommended occupational exposure limits.

Methods: A retrospective review was conducted of all patients who underwent a percutaneous ZO or an open HR between January 2021 and July 2025. All procedures were performed by one of 2 fellowship-trained foot and ankle surgeons at a single academic institution. Radiation exposure was assessed using total radiation dose (mGy) and total fluoroscopy time (minutes).

Results: A total of 139 patients met inclusion criteria. Sixty patients underwent a percutaneous ZO, whereas 79 underwent an open HR. The percutaneous ZO cohort demonstrated a mean fluoroscopy time of 2.83 ± 1.64 (range, 0.70-7.17) minutes and an average radiation dose of 3.25 ± 2.06 (range, 0.55-8.07) mGy. Meanwhile an average fluoroscopy time of 0.42 ± 0.19 (range, 0.03-0.90) minutes was observed in the open HR cohort, which had a mean radiation dose of 0.38 ± 0.20 (range, 0.02-1.17) mGy. The percutaneous ZO cohort demonstrated a significantly higher radiation dose (P < .001) and fluoroscopy time (P < .001).

Conclusion: The percutaneous ZO was associated with a significantly higher radiation dose than the open HR; however, despite being statistically significant, this may not be clinically relevant. As surgeons receive only 0.50% of the dose, approximately 1225 percutaneous ZO procedures would be required to exceed annual safety limits. These findings suggest that radiation exposure during the percutaneous ZO technique remains well below the International Commission on Radiological Protection's annual occupational limit of 20.00 mSv. Consistent with the ALARA principle, low-dose mini C-arm settings and protective equipment help minimize radiation exposure to patients and surgical staff.

Level of evidence: Level III, retrospective comparative study.

Background: Total ankle replacement (TAR) is a surgical option for end-stage ankle arthritis, offering pain relief while preserving joint mobility. Although TAR utilization has increased globally, limited data exist regarding demographic and regional trends in Sweden in the last decade. This study aims to analyze national trends in TAR between 2008 and 2023, with a focus on age, sex, and geographic disparities.

Methods: This retrospective cohort study used data from the Swedish National Patient Register (NPR) to identify all patients aged ≥15 years who underwent primary cementless TAR between January 1, 2008, and December 31, 2023. Exploratory analyses used descriptive statistics to examine trends in procedure volume, incidence, and demographic distribution. Regional incidence rates were calculated using population data.

Results: A total of 1255 primary TAR procedures were identified during the study period. The volume of surgical cases increased by 205%, from 63 cases in 2008 to 129 cases in 2023. The incidence doubled from 0.6 to 1.2 per 100 000 inhabitants, despite a 14% increase in population size between 2008 and 2023. Female patients constituted 55% of overall cases, though male patients became the majority by 2023. Nearly half of all TARs were performed in individuals aged ≥65 years, with the 70-79-year age group showing the greatest relative increase (350%). Regional disparities were noted, with high variability in incidence between regions. Projections indicate that future incidence will rise for men and decrease for women.

Conclusion: The utilization of TAR in Sweden has increased substantially over the past 16 years, with notable demographic shifts toward older and male patients. Geographic disparities persist but have narrowed slightly. These findings highlight the importance of ongoing evaluation of access to TAR and the variability of surgical practices. Further studies are necessary to evaluate the continued development of TAR.

Level of evidence: Level III, retrospective cohort study.

Background: It remains unclear whether insurance as a proxy for socioeconomic status and social determinants of health is associated with functional outcomes after ankle fracture surgery. This study assesses the association between insurance and Patient-Reported Outcomes Measurement Information System (PROMIS) measures of physical function (PF) and pain interference (PI) after ankle fracture surgery.

Methods: All patients who underwent ankle fracture surgery (2016-2021) were reviewed retrospectively. Multiple injuries, open fractures, pilon variants, and nonanatomically reduced fractures were excluded. Final analysis included 190 patients at minimum 1-year follow-up who completed postoperative surveys querying PROMIS and fear of reinjury. Insurance was categorized as "private," "Medicaid," "Medicare," or "worker's compensation."

Results: Twenty-one of 190 had Medicaid, 21 of 190 had Medicare, 141 of 190 had private, and 7 of 190 had worker's compensation. Mean clinical follow-up was 32.1 months for Medicaid, 39.2 Medicare, 45.0 private, and 56.3 worker's compensation. Mean PF (P < .01) and PI scores (P < .01), respectively, were 47.7 ± 9.1 and 53.9 ± 8.1 for Medicaid, 47.6 ± 10.6 and 48.9 ± 10.9 Medicare, 53.9 ± 9.3 and 47.1 ± 7.8 private, and 51.3 ± 10.5 and 51.5 ± 10.5 worker's compensation. In adjusted models, compared with private, Medicaid was associated with 6.41 points lower PF (95% CI: -10.69, -2.13; P < .01) and 6.95 points higher PI (95% CI: 3.11, 10.79; P < .001). Worker's compensation and Medicare were not associated with significant differences in PROMIS compared with private (P > .05). Differences in proportion of patients with fear of reinjury were significant (P < .01): fear was highest in Medicaid (52.4%, 11 of 21) and lowest in Medicare (9.5%, 2 of 21). Fear was associated with significantly worse PF (8.45 points lower, 95% CI: -11.62, -5.28; P < .001).

Conclusion: Medicaid patients report significantly worse PROMIS scores than those with other insurances following ankle fracture surgery. Fear may be a primary driver of worse PF, as a significantly higher proportion of Medicaid patients experience fear, and fear is associated with significantly worse PF. To improve outcomes, fear and worse functional outcomes in Medicaid patients should be addressed.

Level of evidence: Level III, retrospective comparative study.

Background: Suprasyndesmotic ankle fractures, commonly resulting from pronation-external rotation (PER) mechanisms, are traditionally associated with disruption of the syndesmotic ligaments, a medial malleolus fracture or complete deltoid ligament rupture. However, recent imaging and clinical studies suggest that key stabilizing ligaments may remain intact in certain cases, potentially affecting talocrural stability. This pilot study aims to evaluate modelled ligament tension patterns in PER injuries using a validated musculoskeletal computer simulation model.

Methods: A musculoskeletal model of the ankle joint was developed using the AnyBody Modeling System (version 7.4), incorporating detailed anatomical structures and ligament biomechanics. The PER mechanism was simulated by applying external rotation (0-50 degrees) with the foot fixed, and ligament tensional forces was recorded for the deltoid and syndesmotic complexes. Because of limitations in the computer model, a fibular fracture was not simulated. Strain patterns were analysed across simulation steps to assess the sequence and magnitude of ligament loading.

Results: The anterior and superficial deltoid ligaments (tibionavicular, deep anterior tibiotalar, tibiospring, and tibiocalcaneal) and the anterior inferior tibiofibular ligament (AITFL) demonstrated early and substantial increases in tension. Conversely, the deep posterior tibiotalar ligament (dPTTL) and posterior inferior tibiofibular ligament (PITFL) showed minimal strain during the majority of the simulation, suggesting they may remain intact in a subset of PER injuries.

Conclusion: In a computer-simulated pronation-external rotation injury mechanism, the observed tensional force acting on the posterior inferior tibiofibular ligament and the deep posterior tibiotalar ligament is substantially lower compared to the remaining ligaments of the syndesmotic and deltoid complex. The study highlights the potential of a of a novel computer-based ankle/foot model as an alternative to traditional in vitro biomechanical studies.

Clinical relevance: This study finds that in a simulated pronation-external rotation injury to the ankle, key stabilizing ligaments show low tensional forces, suggesting they might be spared from complete rupture. These findings challenge traditional views of complete ligament disruption in PER injuries, and may question the injury cascade originally described by Lauge-Hansen. Additionally, it highlights the use of computer simulation as an alternative to traditional biomechanical research and offers new opportunities for hypothesis generation, improving diagnosis, and injury classification.

Background: There has been increasing interest in the use of percutaneous osteotomy techniques for bunionette (tailor's bunion) correction. This study evaluated clinical and radiographic outcomes following an unfixed, percutaneous oblique distal metaphyseal-diaphyseal osteotomy and compared outcomes between complete and incomplete osteotomy groups.

Methods: A total of 43 feet (mean age 54.2 ± 17.1) underwent percutaneous oblique distal osteotomy by a single surgeon over a 4-year period. The primary outcome was the presence of significant postoperative hypertrophic callus at the osteotomy site (>150% of the width of the fifth metatarsal shaft), which decreases over time due to normal bone remodeling. Secondary exploratory outcomes included the radiographic parameters fourth-fifth intermetatarsal angle (IMA) and metatarsophalangeal angle (MPA), and patient-reported outcome measures (PROMs) of Manchester-Oxford Foot Questionnaire (MOXFQ), EuroQol 5-Dimension, 5-Level (EQ-5D-5L), and visual analogue scale (VAS) Pain (minimum 12 months' follow-up).

Results: Thirty feet had a complete osteotomy, and 13 feet had an incomplete osteotomy with the lateral cortex remaining intact. In the complete osteotomy group, 60% of patients (P = .001) had callus equivalent to >150% of the metatarsal width at 6-week follow up; this reduced to 19% (P = .31) at 6 months and 0% (P = 1) at 12 months. No significant hypertrophic callus was observed in the incomplete osteotomy group. All PROMs, except EQ-5D-5L VAS, showed significant improvements (P < .05). The IMA and MPA significantly decreased postoperatively across both groups (P < .001). There were no significant differences between the incomplete and complete osteotomy groups at follow-up radiographically and clinically, except for the MOXFQ Walking/Standing Domain (P = .014), where patients in the incomplete osteotomy group demonstrated greater improvement.

Conclusion: Unfixed, minimally invasive oblique distal osteotomy for bunionette deformity is a safe and effective procedure that is associated with significant improvement in radiographic and clinical outcomes. Whether or not the osteotomy is complete does influence hypertrophic callus formation but does not significantly affect the radiographic or clinical outcomes.

Level of evidence: Level III, retrospective comparative study.

Background: Surgical management of failed ankle fusion is challenging. The objective of this study is to present the clinical and radiographic results of tibiotalar fusion takedown via a lateral approach with conversion to transfibular, trabecular metal (TM) total ankle arthroplasty (TAA).

Methods: Sixteen patients underwent an ankle fusion takedown with conversion to transfibular TAA: 9 patients had prior tibiotalar fusions, and 7 had tibiotalocalcaneal fusion. Patient demographics, complication profiles, and radiographic parameters were collected. Pre- and postoperative patient-reported outcome measures (PROMs) were analyzed with 12-Item Short Form Health Survey (SF-12), visual analog scale (VAS), and the Ankle Osteoarthritis Scale (AOS). Radiographic outcomes included coronal and sagittal alignment, tibiotalar plantarflexion (PF) and dorsiflexion (DF) range of motion, and incidence of periprosthetic radiolucency and/or implant subsidence.

Results: Average age was 56.8 (range, 25-75) years with 4.7 (2-11) years' follow-up. There was significant improvement in VAS, AOS pain and disability, and SF-12 physical and mental component summary scores (all P < .05). There was 1 (6.3%) case of implant revision for periprosthetic fracture about the tibial component. There were 8 (50%) reoperations at an average of 20.9 ± 10.8 months following fusion takedown, 4 (25%) cases of fibular hardware removal, and 4 (25%) cases of medial gutter debridement. Average radiographic DF and PF postoperatively was 12.5 ± 5.6 degrees and 13.5 ± 9.1 degrees. There was no presence of periprosthetic cysts at final follow-up.

Conclusion: Ankle fusion takedown with conversion to a TM ankle through a transfibular approach yielded significant improvement in PROMs and radiographic ROM, with a modest complication rate at average 4.7 years' follow-up. Although technically challenging, transfibular TAA following ankle fusion takedown is a reasonable treatment option for symptomatic tibiotalar or pantalar fusion.

Level of evidence: Level IV, case series.

Background: First metatarsophalangeal (MTP1) joint arthrodesis is considered the gold standard for the treatment of advanced hallux rigidus and severe arthritic hallux valgus. Although open techniques are widely used, they are associated with a risk of postoperative complications, including delayed union, nonunion (pseudarthrosis), and discomfort related to hardware. Percutaneous arthrodesis could be an interesting alternative and could offer reduced soft tissue trauma, faster recovery, and similar consolidation rates. This study presents a retrospective evaluation of the clinical and radiologic outcomes of percutaneous MTP1 arthrodesis using a single 4.5-mm cannulated screw fixation.

Methods: Between December 2019 and December 2023, 31 feet (27 patients) underwent a standardized percutaneous technique, performed by a single surgeon. Operative indications were based on persistent pain resistant to conservative treatments for >6 months. The postoperative evaluation included pre- and postoperative weight-bearing radiographs (at 6 and 24 weeks, and at the final follow-up at an average of 24 months) and analysis of functional scores: visual analogue scale (VAS) for pain, European Foot & Ankle Society (EFAS), and Foot Function Index (FFI). The fixation angles were also measured and postoperative complications analyzed.

Results: The fusion rate was 93.5% (29/31 feet). Postoperative pain significantly decreased, with a mean VAS score reduction of 4.8 points. Functional scores showed notable improvement with EFAS, from 7.3/24 to 15.7/24 (P < .0001), and FFI, from 46/100 to 11.7/100 (P < .0001). Complications included 2 asymptomatic nonunions and 4 hardware removals. No infection or nerve injury was observed.

Conclusion: Percutaneous MTP1 arthrodesis with single screw fixation was found in this study to be an effective and reproducible technique, offering a high radiographic bone fusion rate while minimizing soft tissue damage. Our results demonstrate a significant improvement in functional scores, a notable reduction in pain, and high patient satisfaction. This percutaneous approach may represent a promising alternative to open surgery in select patients.

Level of evidence: Level IV, therapeutic case series.