Foot & Ankle Orthopaedics最新文献

Background: Hallux rigidus is a degenerative condition affecting the first metatarsophalangeal (MTP) joint, characterized by pain and limited dorsiflexion. In early stages (grades I and II), joint-preserving procedures such as dorsal cheilectomy and Moberg osteotomy are commonly employed. Although traditionally performed through an open approach, the Moberg osteotomy has been adapted to percutaneous techniques, which may offer advantages including reduced soft tissue trauma and faster recovery. This study compares clinical outcomes, postoperative pain, and complication rates between open and percutaneous Moberg osteotomy, both combined with dorsal cheilectomy, in patients with early-stage hallux rigidus.

Methods: A retrospective analysis was conducted on 96 patients who underwent either open (n = 43) or percutaneous (n = 53) Moberg osteotomy in combination with dorsal cheilectomy. All had failed at least 3 months of nonoperative treatment. Exclusion criteria included prior first-ray surgery and advanced hallux rigidus (grades III and IV). Outcomes included the visual analog scale (VAS), Foot Function Index (FFI), and the number of oxycodone tablets consumed during the first 2 postoperative weeks. Complications and reoperations were also documented.

Results: Both groups showed significant improvements in VAS and FFI scores at a minimum of 24-month follow-up, with no statistically significant differences between them. However, postoperative opioid consumption was significantly lower in the percutaneous group compared with the open group (3.6 ± 1.9 vs 13.3 ± 6.1 tablets over 2 weeks; P < .0001).Wound complications occurred in 4.7% of the open group and 0% of the percutaneous group (P = .20). Reoperation rates were comparable, with 2.3% in the open group and 1.9% in the percutaneous group.

Conclusion: Percutaneous Moberg osteotomy with dorsal cheilectomy is a safe and effective treatment for early-stage hallux rigidus, yielding comparable functional and pain outcomes to the open technique, with lower early postoperative opioid use in this cohort.

Level of evidence: Level III, retrospective comparative study.

Background: Progressive collapsing flatfoot deformity (PCFD) is a complex pathophysiologic condition, with many different treatment options. The complexity of the condition and variety of treatments can greatly impact patient-reported outcomes (PROs), along with individual patient characteristics. The purpose of this study was to examine PROs in patients receiving surgical treatment for PCFD and compare those outcomes with patients with ankle instability or hindfoot arthritis.

Methods: The Orthopaedic Foot and Ankle Outcomes Research (OFAR) Network database was queried to identify all patients with flexible PCFD, ankle instability, or hindfoot arthritis procedures from October 2017 to October 2019 with at least 12 months of follow-up. Patient satisfaction was also measured at both 6 months and 12 months. Changes in PROs and satisfaction were assessed over time and compared between those with PCFD and those with ankle instability or hindfoot arthritis using generalized logistic regression and estimating equations.

Results: After adjusting for age, sex, body mass index, hypertension, autoimmune conditions, and type 2 diabetes, there were significant improvements in average Global Physical Health (P < .0001), Pain Interference (P < .0001), Pain Intensity (P < .0001), and Physical Function (P < .0001) for both groups following surgery. Changes in Pain Intensity scores between the baseline and 12-month visits were significantly different between the 2 groups (P = .0286), with those receiving PCFD surgery reporting greater change. The odds of surgical satisfaction was significantly lower at 12 months compared to 6 months for both groups.

Conclusion: This study found that patients who underwent surgical management of PCFD demonstrated significant improvements in their PROs and postoperative satisfaction; however, there were lower odds of satisfaction at 12 months compared with 6 months. Additionally, PCFD patients showed greater improvement in Pain Intensity from baseline to follow-up, whereas other PROMIS domains improved similarly between groups.Level of Evidence: Level III, retrospective comparative cohort study.

Background: Orthopaedic surgical interventions are often costly, not only due to the procedures themselves, but also due to the need for frequent follow-up and imaging tests. Recent orthopaedic literature across several subspecialties has produced evidence suggesting that routine immediate postoperative radiographs do not provide any clinical advantage to justify their costs. This study aims to evaluate the economic feasibility of first postoperative radiographs after minimally invasive (MIS), fourth-generation MIS transverse double osteotomy for treatment of hallux valgus.

Methods: We retrospectively evaluated patients with hallux valgus treated with fourth-generation MIS transverse double osteotomy between January 2019 and December 2021. Medical records were reviewed to assess changes in management following initial radiographs taken on average 1.38 ± 0.83 weeks after surgery. Direct costs of radiographs at the first postoperative visit (FPOV) were estimated using 2025 Medicare Fee Schedule data (HCPCS Code 73630), United Healthcare cost estimator website (zip code 33146), and multiple locally available public self-pay resources. National costs were estimated using Medicare data for the estimated 110,000 to 220,000 annual bunion procedures performed in the United States.

Results: A total of 245 patients were included in our analysis. Four patients (1.6%, 95% CI 0.64%-4.12%) had an FPOV radiographic finding that warranted a change in management. Reasons included 1 (0.4%) loss of reduction of the first metatarsal osteotomy, 1 (0.4%) fracture through the Akin proximal phalanx osteotomy, and 2 (0.8%) subluxations of lesser toes fixated via K-wire. The cost per 3-view radiograph of the foot ranged from $31.68 to $106, depending on provider and payment type. National costs of routine radiographs for MIS bunion were estimated to be between $3.5 million to $23.3 million annually.

Conclusion: Routine radiographs after fourth-generation MIS transverse double osteotomy surgery at FPOV rarely result in a change of management. In patients without clinically visible signs or symptoms warranting intervention, radiographs in the FPOV are rarely justified for MIS bunionectomy patients. We recommend physical evaluation at FPOV but suggest that substantial health care expenses could be saved by removing unnecessary FPOV radiographic analysis.

Level of evidence: Level IV, therapeutic/economic case series.

Background: The Lapidus procedure evolved into the first tarsometatarsal (TMT) arthrodesis, primarily used for treating severe hallux valgus, particularly in TMT arthritis or instability. Although effective, early techniques have high nonunion rates. Recent developments, including locking plate (LP) and intramedullary nail (IN) use, are aimed at enhancing fixation. LPs enable early weightbearing but may cause symptomatic hardware irritation. We hypothesized that IN fixation would yield better clinical and radiologic outcomes and fewer complications than LP fixation. In this retrospective study, we aimed to compare the radiographic and clinical outcomes of IN and LP fixation.

Methods: Eighty-five patients (120 feet) underwent the modified Lapidus procedure between 2020 and 2023 and were retrospectively grouped according to the fixation type: IN and LP with a crossing screw. Three foot and ankle attending surgeons performed the procedures. Radiographic parameters (hallux valgus angle [HVA], intermetatarsal angle [IMA], and metatarsocuneiform angle [MCA]) were evaluated preoperatively, 2 months after initial weightbearing, and 1 year postoperatively. Clinical outcomes were measured using the Self-Administered Foot Evaluation Questionnaire (SAFE-Q), comprising 5 subscales scored out of 100.

Results: Among the 64 patients (94 feet) analyzed, 57 and 37 underwent IN and LP fixation, respectively. At 1 year postoperatively, the amount of IMA correction from preoperative to 1 year was similar in both groups, but the IN group showed slightly lower IMA (95% CI: -3.57 to -0.22, P = .0265). HVA correction was similar between the groups; however, there was greater variability in the IN group. MCA changes indicated a comparable degree of correction loss between groups. SAFE-Q scores were statistically similar. The IN group experienced fewer complications (8.8%) compared with the LP group (22%). The LP group revisions mostly involved hardware removal.

Conclusion: In the modified Lapidus procedure, IN fixation demonstrated a slightly lower IMA at final follow-up and less hardware irritation compared with LP fixation. IN fixation should be considered an alternative to LP fixation.

Level of evidence: Level III, retrospective case control study.

Background: Antiphospholipid syndrome (APS) is a systemic autoimmune disorder associated with a heightened risk of thromboembolic events. The purpose of this study is to evaluate the impact of APS on medical and surgical postoperative outcomes following foot and ankle surgery.

Methods: Using the TriNetX Research Network, we identified patients undergoing foot and ankle surgery between 2004 and 2024. APS patients with and without postoperative venous thromboembolism (VTE) prophylaxis were matched 1:1 with controls based on demographics and comorbidities. Outcomes within 30 and 90 days postoperatively were compared, including thromboembolic events. Preoperative laboratory test values were also assessed in a subset of APS patients not on anticoagulation.

Results: At 90 days postoperatively, APS patients receiving VTE prophylaxis (APS+VTE) (n = 524) had significantly higher rates of deep vein thrombosis (13.4% vs 9.0%, P = .024), but similar rates of stroke and pulmonary embolism compared to patients without APS receiving VTE prophylaxis (Control+VTE). Anemia was significantly less common in the APS+VTE group at 30 days (14.7% vs 22.3%, P = .001) and 90 days (16.4% vs 23.9%, P = .003). APS patients without postoperative anticoagulation (APS-VTE) (n = 932) had a higher rate of pulmonary embolism at 90 days (5.8% vs 3.3%, P = .011) compared to patients without APS and VTE prophylaxis (Control-VTE). Anticoagulation-naïve APS patients demonstrated significantly higher preoperative International Normalized Ratio (1.64 vs 1.09, P < .001), prothrombin time (17.7 vs 12.3, P < .001), activated partial thromboplastin time (38.6 vs 29.2, P < .001), serum creatinine (1.08 vs 0.94, P < .001), estimated dry weight (14.3 vs 13.7, P < .001), along with urea nitrogen (17.0 vs 15.9, P < .001), sodium (139.13 vs 139.25, P = .001), potassium (4.14 vs 4.10, P = .012), and bicarbonate (26.2 vs 25.8, P < .001) compared with matched controls.

Conclusion: APS patients undergoing foot and ankle surgery had significantly higher thromboembolic event rates than controls, even with anticoagulation, and those who received anticoagulation had lower anemia rates, suggesting differential bleeding risk.

Level of evidence: Level III, retrospective cohort study.

Background: Hallux valgus can severely limit physical function in demanding professions like military service. Traditional open surgeries have shown limited success in achieving rapid recovery and full functional return. The primary objective of this study was to assess functional outcomes of active-duty service members who have undergone minimally invasive bunion surgery.

Methods: Eighteen active-duty service members with mild to moderate hallux valgus deformities who underwent minimally invasive bunion correction between 2020 and 2022 were retrospectively reviewed.

Results: Minimally invasive bunion surgery demonstrated significant improvements in self-reported outcomes of the Foot and Ankle Outcome Scores from pre- to post-procedure (total score: 57.0 vs 95.0 respectively, P > .001) including all subscales of symptoms, pain, activities of daily living, sports and quality of life. Additionally, radiographic analyses revealed marked corrections pre- to post-procedure in intermetatarsal angle (12.0 vs 7.5 degrees, P < .001), hallux valgus angle (25.5 vs 12.0 degrees, P < .001), and tibial sesamoid position (5.0 vs 2.0 degrees, P < .001), with 12 of 13 patients achieving full bone consolidation by their 6-month follow-up. Complications were minimal, with only 1 case requiring further intervention. Approximately half of the patients (8/18) did not require any limited duty, and 13 of 18 remained on active duty at final follow-up (median of 13 months).

Conclusion: These findings underscore the potential of minimally invasive surgery in high-impact populations, although further research with larger cohorts is recommended to confirm long-term outcomes and functional durability in high-stress settings.

Level of evidence: Level III, retrospective comparative study.

Background: Medial malleolar stress fractures (MMSFs) are difficult to detect early because of subtle or absent findings on plain radiographs, which often delays diagnosis and return to play. Identifying measurable radiographic alignment patterns may assist in raising early clinical suspicion, particularly in settings where advanced imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) is not readily available.This study aimed to investigate the radiographic features of MMSFs in athletes by comparing specific ankle alignment angles on plain radiographs.

Methods: A retrospective observational study was conducted. Athletes diagnosed with MMSFs were matched 1:1 with control athletes based on age, sex, and the laterality of the affected ankle. Radiographic measurements included the tibial anterior surface (TAS), tibial medial malleolus (TMM), tibial bimalleolar (TBM), and tibial lateral surface (TLS) angles.

Results: The MMSFs group included 23 athletes (19 men, 4 women), and the control group included 23 athletes (20 men, 3 women). The TAS angle was significantly smaller in the MMSF group compared with controls (86.3 ± 2.1 degrees vs 89.3 ± 1.6 degrees, P < .01). Receiver operating characteristic curve analysis yielded an area under the curve of 0.86 (95% CI 0.75-0.96), with an optimal TAS angle cutoff value of 87.8 degrees showing 73.9% sensitivity and 91.7% specificity. No significant differences were observed for the TMM (P = .09), TBM (P = .14), or TLS angle (P = .84).

Conclusion: These findings suggest that smaller TAS angles may be a radiographic feature associated with increased susceptibility to MMSFs in athletes and could support clinical suspicion during early evaluation.

Level of evidence: Level III, case-control study.

Background: Foot type significantly impacts the development and progression of foot and ankle pathologies by influencing biomechanics and force distribution. However, it is typically assessed qualitatively and with a 2D radiographic measurement called Meary's angle. This study seeks to determine the minimum number of bones required in a statistical shape model (SSM) to accurately represent the full cavus through planus spectrum, enabling future machine learning applications in clinical practice.

Methods: Our study included weightbearing computed tomography (WBCT) data from 151 patients grouped based on clinical diagnosis or Meary's angle: 33 Charcot-Marie-Tooth (CMT), 29 cavus, 28 rectus, 27 planus, and 34 progressive collapsing foot deformity (PCFD). Ten multi-bone SSMs, with varying numbers of bones, were created from bony segmentations. Principal component analysis (PCA) assessed the modes of variation for all SSMs.

Results: PCA mode 1 demonstrated significant results (α = 0.05) for all SSMs, with the 2-bone subtalar joint (STJ) model capturing the most variance at 70.9% and the largest effect size of 0.75. The mean shape of all SSMs exhibited neutral STJ and midfoot alignment, whereas severe cavus and planus deformities were observed at 2 SDs from the mean shape. Models that included the STJ had statistical differences between all group PCA score comparisons. In contrast, models without the STJ had significant differences between all groups, except between the planus and rectus groups.

Conclusion: STJ orientation and morphology appear fundamental for determining foot type. Our study revealed that the STJ alone offers sufficient information for computational differentiation because of its high variance and effect sizes when included in SSMs, highlighting the possible clinical utility as a simplified model. Although full foot models provide additional insights, the STJ model's effectiveness makes it ideal for streamlined assessment and treatment planning.

Clinical relevance: Modeling the STJ captures the full cavus-planus foot type spectrum, suggesting its morphology may drive foot type and related pathologies. This underscores the potential of using simplified models in combination with machine learning as a rapid morphologic classifier; clinical impact remains to be determined.

Background: The medial clear space (MCS) is a radiographic proxy for the ankle mortise used to determine the need for surgical intervention for ankle fractures. Several measurement methods have been described but no consensus exists on which method is most appropriate to guide clinical care. Our objective was to assess commonly used measurement methods to determine which was most accurate and reliable for measuring the MCS on nonweightbearing and weightbearing studies.

Methods: Imaging of 34 morphologically normal, uninjured patients was reviewed. Paired radiographs and computed tomography (CT) scans, 17 nonweightbearing and 17 weightbearing, were measured by 5 observers. Three different methods were used to measure the MCS on each radiograph and 1 method on CT. CT was used as the "true" value of the MCS. Two-sided P tests were used to compare each radiographic MCS measurement to the CT MCS value. Cronbach alpha was calculated for each MCS measurement method to determine the interobserver correlation.

Results: Measuring the MCS halfway between the superior medial talar dome and the tip of the medial malleolus, perpendicular to the tibiotalar joint, was the most accurate on weightbearing imaging (no difference in radiographic method 2 vs CT, P = .09). There was a significant correlation between any nonweightbearing radiograph measurement and CT (all P < .001). Interobserver reliability was found to be good to excellent for nonweightbearing MCS measurement (ICC 0.82-0.97), whereas weightbearing imaging demonstrated good reliability (ICC 0.77-0.9).

Conclusion: Any of the 3 tested measurement methods can be used when analyzing nonweightbearing radiographs. Measuring the MCS halfway between the superior medial talar dome and the tip of the medial malleolus, perpendicular to the tibiotalar joint, should be used when examining weightbearing imaging. To support standardization, this method may be reasonable to use, particularly on weightbearing radiographs.

Level of evidence: Level III, retrospective comparative study.

Background: A controlled ankle movement (CAM) walking boot introduces an artificial leg length discrepancy (LLD), which alters gait mechanics and may increase pain. Using a contralateral shoe lift in conjunction with the CAM boot is a common strategy to address this discrepancy; however, the extent to which the shoe lift restores gait biomechanics remains understudied. This study investigates the effects of the combination of CAM boot and contralateral shoe lift on gait parameters compared to normal (shod) conditions.

Methods: Thirty healthy adults (mean age 24.6 ± 7.9 years), including 15 men and 15 women, walked overground under 3 conditions: normal shod walking, unilateral CAM boot, and CAM boot with a contralateral shoe lift. A Vicon motion capture system tracked 16 markers to calculate spatiotemporal gait parameters as well as hip and knee kinematics and kinetics using the Plug-in-Gait model. A 1-way analysis of variance followed by Tukey pairwise comparisons identified significant effects of walking condition on various gait characteristics.

Results: The CAM boot with shoe lift restored kinematic parameters, including hip flexion (P = .036), knee flexion (P = .023), and hip abduction (P = .038), as well as kinetic parameters including knee axial compression force (P = .014) and hip medial-lateral force (P = .007), to normal walking levels on the booted limb. The reported P values reflect differences observed with the CAM boot alone, which were eliminated by the shoe lift.

Conclusion: A corrective contralateral shoe lift used with a CAM boot can restore some of the knee and hip kinematic and kinetic alterations introduced by the CAM boot. However, it has limited effect on other gait parameters and does not fully replicate the mechanics of normal shod walking.

Level of evidence: Level IV, case series.