Foot & Ankle Orthopaedics最新文献

Background: Weightbearing foot and ankle radiographs are essential because skeletal geometry changes under load. Radiographic measurements, which guide management decisions, have been validated using weightbearing radiographs. Simulation of weightbearing intraoperatively would be ideal and may improve the accuracy of deformity correction in foot and ankle surgery. This study aims to validate the accuracy of angular measurements on intraoperative simulated weightbearing fluoroscopic foot images.

Methods: A prospective study of 50 patients with a mean age of 51.3 years undergoing elective foot surgery at a single institution was performed. A simulation of weightbearing was performed intraoperatively and fluoroscopic anteroposterior and lateral images were obtained. Six angular measurements were performed on the standard preoperative weightbearing radiographs and compared to the intraoperative simulated weightbearing fluoroscopic images, by 4 researchers at 2 intervals.

Results: The mean differences for the hallux valgus angle (HVA), intermetatarsal angle (IMA), interphalangeal angle (IPA), 4-5 intermetatarsal angle (4-5 IMA), calcaneal pitch (CP), and talocalcaneal angle (TCA) were +0.02, -1.79, +1.13, -0.01, +4.80, and -1.41 degrees, respectively. Of the anteroposterior and lateral measurements, the HVA, IPA, 4-5 IMA, and TCA showed no statistically significant mean difference (paired t test), and inter- and intraobserver reliability was good to excellent. The IMA and CP showed a mean difference that was statistically significant; however, this mean difference was clinically negligible (IMA: -1.79 ± 1.68 degrees; CP: 4.8 ± 3.4 degrees). A good inter- and intraobserver reliability was found between researchers. Regression analyses showed strong correlations for the HVA, IMA, 4-5 IMA, and CP and fair correlations for the TCA and IPA.

Conclusion: The study suggests the technique we use for intraoperative simulated weightbearing fluoroscopic imaging correlates with standard preoperative weightbearing foot radiographs and may facilitate a more accurate, real time assessment of alignment during foot deformity correction surgery.

Level of evidence: Level II, diagnostic.

Background: Traumatic peritalar instability following talar fracture-dislocation is a complex surgical challenge with no consensus on adjunctive stabilization. Current strategies can involve extensive soft tissue dissection or external fixation. We report a retrospective case series evaluating temporary transarticular screw fixation as an adjunct to open reduction and internal fixation (ORIF).

Methods: We conducted a retrospective case series of 9 patients (10 extremities) treated at a single tertiary institution between 2015 and 2024 for traumatic peritalar instability persisting after ORIF. After primary ORIF of the talus, persistent subtalar instability was addressed with one or two 4.0-mm cortical screws placed across the subtalar joint. Screws were removed after radiographic evidence of fracture union. Primary outcomes were resolution of instability judged by intraoperative resolution of dislocation/subluxation with maintenance of joint congruity to injury resolution. Secondary outcomes were incidence of complications, including avascular necrosis (AVN) and posttraumatic arthritis (PTA).

Results: The cohort included 9 patients (mean age 37 years) with a mean follow-up of 27 months. All 10 operative extremities achieved full resolution of peritalar instability. Three extremities required subsequent arthrodesis because of PTA and/or AVN. Two extremities developed AVN, with 2 of the 3 arthrodeses following AVN development. One patient did not have the transarticular screw removed because of articular surface damage at the time of index injury. Three extremities developed infections: 2 superficial infections resolved with oral antibiotics, and 1 deep infection necessitated tibiotalar and subtalar arthrodesis using an antibiotic-coated intramedullary nail due to osteomyelitis, with infection resolution and return to activity. Nine extremities exhibited some form of PTA in the peritalar articulations. Four of 10 patients underwent Achilles tendon lengthening for contracture. Eight of 9 patients returned to unprotected weightbearing and full activity at the most recent follow-up; 6 resumed work and could perform a double-leg heel rise, and 2 required bracing.

Conclusion: Temporary transarticular screw fixation appears safe in this limited series and effective for resolving traumatic peritalar instability. The observed AVN rate (20%) is lower than many published series but should be interpreted cautiously given the small sample size. PTA rates remain high but are consistent with the expected results because of the severity of the initial injury. This technique may serve as a valuable, minimally invasive adjunct in the management of complex talar trauma.

Level of evidence: Level IV, retrospective case series.

Background: Plantar fasciitis is the most common cause of plantar heel pain and the use of custom foot orthosis is a well-supported treatment modality. Traditional custom orthoses are fabricated using foam impressions and manual techniques, but these methods are time-intensive and susceptible to variability in fit and quality. The HP Arize platform applies high-resolution 3D laser scanning with algorithm-driven modeling to streamline fabrication of custom foot orthoses. Although early reports suggest comparable comfort and durability to traditional devices, clinical data evaluating patient-reported outcomes remain limited.

Methods: This prospective pilot, randomized study assigned 34 adults diagnosed with plantar fasciitis to receive either traditionally fabricated custom orthoses (n = 18) or HP Arize 3D-printed orthoses (n = 16). Primary analyses used a modified intention‑to‑treat cohort (n = 30) comprising participants who received an insert and completed baseline assessments. Patient-Reported Outcomes Measurement Information System (PROMIS) physical function, pain interference, and mobility scores were collected at baseline, 4 weeks, and 8 weeks. Secondary measures included patient satisfaction, frequency of orthotic use, and adverse effects. Statistical comparisons were performed using Fisher exact test and Student t test or Wilcoxon signed-rank test, with significance set at P < .05.

Results: Baseline demographic and clinical characteristics did not differ between groups. At 4 weeks, satisfaction with customization, fit, and comfort was high across both groups (median 4.0-5.0). Traditional orthosis users reported greater daily use (P = .04) but also higher rates of rubbing/discomfort (P = .047). By 8 weeks, side effects were not statistically significantly different. Exploratory comparisons suggested higher mean PROMIS physical function (49.0 vs 41.9, Δ 7.1; P = .008) and mobility scores (46.9 vs 41.4, Δ 5.5; P = .02) at 8 weeks in the traditional group, whereas pain interference scores did not differ.

Conclusion: Both traditionally fabricated and HP Arize 3D-printed custom orthoses were associated with high satisfaction and functional improvement. Although traditional devices showed greater early compliance and superior 8-week functional outcomes, the HP Arize system demonstrated fewer adverse effects and offers a scalable, efficient alternative. As an exploratory pilot study, these findings are preliminary and intended to inform feasibility and effect‑size estimation for future trials.

Level of evidence: Level IV, pilot prospective comparative study.

Type of study: Quasi-experimental pre-post study.

Background: Classically, the gold standard surgical management of recalcitrant plantar fasciitis has been plantar fasciotomy. Recent research has established a correlation between posterior leg tightness and plantar fasciitis. As a result, surgeons are increasingly performing a gastrocnemius recession to manage this condition. The purpose of this report was to assess clinical outcomes in patients undergoing a combined endoscopic partial plantar fasciotomy and a gastrocnemius recession for the treatment of plantar fasciitis.

Methods: Surgery was performed on 37 feet (35 patients), of which 31 (29 patients) were retrospectively reviewed. Preoperative and follow-up measures of pain, limitations on daily activities, and maximum walking distance were assessed. Patient satisfaction, complications, and recovery time were recorded.

Results: The mean follow-up was 3.02 (range, 1-6.67) years. The mean visual analog score for pain decreased from 9.3 preoperatively to 1.5 at final follow-up. At the most recent follow-up, 21 of 31 (67.6%) patients were completely pain free, and 28 of 31 (90.3%) were very satisfied or satisfied with the surgery. Twenty-eight of 31 patients (90.3%) returned to activity without any limitations. Complications were seen in 5 patients, including 3 patients with persistent pain.

Conclusion: Our study demonstrated that endoscopic partial plantar fasciotomy combined with gastrocnemius recession was associated with improved pain and function in this case series. However these findings should be considered preliminary; prospective comparative studies are needed.

Level of evidence: Level IV, case series.

Background: Insertional Achilles tendinopathy (IAT) is a common cause of posterior heel pain and is often managed surgically when conservative treatment fails. Wound complications are common after Achilles surgery. Obesity is a known risk factor for such complications; however, evidence on morbid obesity (body mass index [BMI] ≥ 40) and outcomes after IAT repair is limited. This study evaluates the incidence of complications and pain relief in patients undergoing IAT surgery by BMI group.

Methods: This is a retrospective cohort study. All patients with an established diagnosis of IAT who underwent an Achilles central splitting, detachment, debridement, and reattachment surgery between 2015 and 2023 were included. Patient demographics, surgical outcomes, and reported pain (visual analog scale for pain [VAS] scores) were collected. Patients were categorized into 2 BMI groups: <40 and ≥40. Statistical analysis included independent t test, Fisher exact, and χ² testing.

Results: There were 123 patients in this study, of which 90 had BMI <40 and 33 had a BMI ≥40. The mean age was 53.6 ± 10.6 years. Twenty-four had documented complications: higher in the morbidly obese group (30.3%) than in non-morbidly obese patients (15.6%, P = .077), with a significantly increased rate of wound dehiscence (24.2% vs 8.9%, P = .035; relative risk 2.72, 95% CI 1.11-6.67). VAS scores were highest in patients with BMI ≥40 compared to BMI <40 both preoperatively (P = .003) and at their final follow-up appointment (P = .006). No difference was found in change in VAS scores from preoperative to final follow-up visits (P = .818).

Conclusion: Morbid obesity was associated with increased wound complications and higher levels of pain in this retrospective cohort undergoing IAT surgical repair. However, VAS reduction after surgery was comparable across BMI groups.

Level of evidence: Level III, retrospective cohort.

Background: The Zadek osteotomy, a dorsal closing-wedge procedure of the calcaneus, is commonly used in the surgical treatment of insertional Achilles tendinopathy, particularly in patients unresponsive to conservative measures. Although minimally invasive surgical (MIS) techniques offer potential benefits such as reduced soft tissue trauma and faster recovery, concerns persist regarding the risk of iatrogenic injury to the sural nerve because of limited visualization. This cadaveric study aims to provide a detailed anatomical assessment of the sural nerve and its branches in relation to the entry point of the MIS Zadek osteotomy, with the goal of quantifying their proximity and offering data that may help reduce the risk of nerve injury during the procedure.

Methods: Twenty fresh-frozen human lower limb specimens were subjected to a standardized MIS Zadek osteotomy using a 3 × 30-mm Shannon burr. The osteotomy was guided fluoroscopically and performed through a lateral percutaneous approach. Post-procedure, meticulous anatomical dissections were conducted to identify the sural nerve and measure its distance from the anterior and posterior arms of the osteotomy using digital calipers with 0.1-mm precision. Measurements were independently recorded by 2 observers to ensure accuracy.

Results: The sural nerve was successfully identified in all specimens. No instances of sural nerve transection or gross anatomical disruption were observed. The mean distance from the osteotomy to the sural nerve was 11.95 mm, with a range of 8.3 to 15.4 mm and an SD of 2.18 mm. These findings suggest that when performed within the defined anatomical parameters, the MIS Zadek osteotomy maintains a safe distance from the sural nerve.

Conclusion: In our cadaver study, we found that the MIS Zadek osteotomy maintained a mean distance of 11.95 mm from the sural nerve. These findings define anatomical proximity; clinical safety requires prospective validation.

Clinical relevance: Our study defines a reproducible anatomical margin for MIS Zadek osteotomy; clinical safety needs prospective validation.

Graphical Abstract.

Background: First metatarsophalangeal (MTP) joint fusion is a common surgical procedure to treat hallux rigidus and malalignment at the MTP joint. Nonunion after first MTP arthrodesis can cause continued pain and limitation in function. The present study aims to provide a single-site analysis of nonunion risk factors after first MTP fusion. We hypothesized that diabetes, smoking, and a body mass index (BMI) ≥30 are associated with increased risk of nonunion.

Methods: This is a retrospective cohort study. All patients who underwent first MTP fusion performed by 3 orthopaedic foot and ankle surgeons between September 20, 2013, and September 20, 2023, were included. Patient demographics, comorbidities, intraoperative medications, and postoperative complications were collected. Relationships to nonunion were evaluated using the multivariable logistic regression (a < 0.05) and both odds ratio (OR) and adjusted odds ratio (aOR) were calculated.

Results: A total of 417 patients (450 feet) were included. Average BMI was 27.94 ± 6.79. There were 25 nonunions, which did not statistically differ in sex or age. Per-patient models identified idiopathic peripheral neuropathy and bilateral surgeries as independent predictors, with BMI ≥30 showing a trend toward significance. Diagnosis of peripheral neuropathy was subdivided into diabetic and idiopathic peripheral neuropathy, with increased nonunion rates in the idiopathic group. Osteoporosis, bisphosphonate use, and smoking history showed no statistical difference in nonunion rates. BMI and diabetes showed statistical differences with univariate logistic regression but were deemed insignificant on multivariate analysis.

Conclusion: In this single-institution cohort, idiopathic peripheral neuropathy and bilateral MTP fusions were associated with higher odds of nonunion; findings for BMI ≥30 and diabetes should be interpreted prudently, given the limited events and wide CIs.

Level of evidence: Level III, retrospective cohort study.

Background: First tarsometatarsal (TMT) arthrodesis is a surgical option for moderate to severe hallux valgus, particularly in the setting of first-ray instability. The use of a supplemental intermetatarsal screw (IMS) has emerged as a technique intended to enhance transverse plane stability and may help maintain correction; however, limited clinical data exist regarding its radiographic and complication profile. This study compared radiographic correction, maintenance of alignment, and postoperative complications following TMT arthrodesis with vs without IMS fixation.

Methods: A retrospective review was performed of adult patients who underwent first TMT arthrodesis for hallux valgus from 2013 to 2023 at a tertiary academic center. Patients undergoing additional midfoot fusion or with <6-month follow-up were excluded. Patients were grouped by whether supplemental IMS fixation was used, which was determined at surgeon discretion. Demographic, operative, and clinical data were recorded. Radiographic measurements included intermetatarsal angle (IMA) and relative first metatarsal (MT) length preoperatively, immediately postoperatively, and at latest follow-up.

Results: Eighty-nine patients met criteria (51 IMS; 38 no IMS). Baseline demographics and comorbidities were similar between groups. Immediately postoperatively, the IMS cohort demonstrated a smaller IMA (5.8 vs 7.8 degrees, P = .010), which persisted at latest follow-up (7.3 vs 9.3 degrees, P = .015). The IMS group demonstrated a greater reduction in IMA from preoperative to final follow-up (6.9 vs 3.9 degrees, P = .001). Relative first MT length remained greater in the IMS cohort across all time points (P ≤ .045) but change‑score (Postop-Preop) differences in length were not statistically significant. Complication rates, including nonunion (2.0% vs 2.6%), revision surgery (9.8% vs 18.4%), and hardware-related complications (7.8% vs 2.6%), did not differ significantly between groups (P > .05).

Conclusion: Supplemental IMS fixation in first tarsometatarsal arthrodesis for hallux valgus was associated with greater maintenance of radiographic correction without observed differences in complication rates. These findings support IMS augmentation as a potential adjunct in appropriately selected patients.

Level of evidence: Level III, retrospective review.

Background: Clinical data are limited for allograft reconstruction of peroneus brevis tears, and its complication profile remains poorly defined.

Methods: Retrospective chart review was conducted for patients with peroneus brevis tears who underwent tendon reconstruction with semitendinosus allograft at a single tertiary center between March 2010 and July 2019. A total of 68 patients (69 feet), 24 men and 44 women, were identified with mean age at surgery 51.8 (range, 23-74) years and mean follow-up 20.2 (range, 3.4-71.4) months. At the time of chart review, patients were contacted by phone to assess satisfaction, brace use, and work status.

Results: Visual analog scale (VAS) pain score was significantly lower postoperatively (4.0 ± 2.7 vs 2.4 ± 2.8, P = .0018) in the 54 patients with VAS pain data. A total of 40 (58%) feet had at least 1 complication. The most common complications were sural neuralgia in 18 (26%) feet and allograft failure in 7 (10%) feet. Fifteen feet (21%) required reoperation, including 7 for graft failure. In the 30 feet with prior peroneal tendon surgery, there was no association between prior surgery and complications (P = .21). Of the 24 (35%) patients available for phone survey, 20 (83%) were employed prior to surgery and 18 (90%) of these employed patients returned to work and 14 (58%) did not use an assistive device at final follow-up. Sixteen (67%) of the 24 patients contacted reported being very satisfied or satisfied with the procedure.

Conclusion: This is the largest case series to date, demonstrating significant pain improvement and high return-to-work rates in complex cases, but also a 58% overall complication rate and 10% graft failure. Allograft reconstruction may be effective when few options exist, yet careful patient selection and awareness of technical challenges are essential.Level of Evidence: Level IV, case series.