Foot & Ankle Orthopaedics最新文献

Visual abstract.

Background: Ankle arthrodesis (AA) is a common treatment for end-stage ankle arthritis, chronic instability, and degenerative deformity. Although minimally invasive arthroscopic techniques may reduce soft tissue disruption, postoperative pain, and related morbidity, open techniques may be beneficial for treatment of patients with aberrant anatomy, insufficient bone stock, or complex deformity. This study aimed to determine whether arthroscopic AA is associated with lower rates of adverse events, pseudarthrosis, and health care use compared with open AA techniques at short-term and long-term intervals.

Methods: We conducted a retrospective analysis using the TriNetX research network. Patients undergoing AA were identified using Current Procedural Terminology (CPT) codes for arthroscopic (CPT 29899, n = 879) and open (CPT 27870, n = 10 604) procedures. Two cohorts were defined and propensity score-matched on age, sex, race, body mass index, nicotine dependence, chronic kidney disease, and type 2 diabetes mellitus (n = 873 each). Outcomes were evaluated within 30 days, 90 days, and 2 years.

Results: The arthroscopic AA cohort experienced significantly lower rates of any adverse event, infection, and hospital admission within the 30-day and 90-day outcome windows. Arthroscopic AA was associated with fewer emergency department visits and wound dehiscence within 90 days of surgery. A diagnosed pseudarthrosis within 2 years was more common in the open arthrodesis cohort. Rates of short-term myocardial infarction, cerebral infarct, transfusion, pulmonary embolism, and hematoma did not differ.

Conclusion: Arthroscopic AA was associated with significantly lower rates of medical complications at the short-term intervals, in addition to lower rates of nonunion within 2 years. Although observational, propensity-matched data are consistent with fewer short-term medical complications and lower 2-year nonunion after arthroscopic AA, the results should be interpreted with caution because of the inability to assess the degree of coronal or sagittal plane deformity in the included cases.

Level of evidence: Level III, retrospective cohort study.

Background: Achieving interfragmentary compression and stability is critical for successful bone healing in fracture fixation and arthrodesis procedures. Modern orthopaedic plating systems incorporating variable-angle screw designs offer greater versatility; however, the impact of screw trajectory on interfragmentary compression and contact area has not been adequately explored. We questioned if the resultant forces applied by screw orientation would follow the basic principles of vector geometry.

Methods: Interfragmentary compression and contact area were quantified in foam bone surrogate osteotomy models using plates allowing maximum screw angulation of either 15 or 30 degrees, with screws inserted at various angles. Cadaveric second-tarsometatarsal (TMT) arthrodesis constructs were subsequently used to validate the mechanical findings from surrogate testing.

Results: Compression and contact area increased from 0 degrees to 15 degrees to 30 degrees in surrogate models (overall analysis of variance P < .001). Angling screws in the second bone fragment after securing the plate to the first fragment produced the largest compression gains. In cadaveric second-TMT constructs, 30-degree divergence increased compression (~15-fold; 49.4 ± 35.1 N vs 3.4 ± 3.8 N; P < .001) and contact area (~4-fold; 47.8 ± 28.9 mm^² vs 12.8 ± 7.3 mm^²; P < .001) compared with 0-degree divergence.

Conclusion: With plate fixation, screw divergence from the arthrodesis/fracture line improved interfragmentary compression and contact area, particularly when divergent screws were inserted into the second bone fragment after the plate was secured to the first fragment. As hypothesized, the findings followed basic vector geometry.

Clinical relevance: Surgeons can optimize plate fixation quality and enhance stability in midfoot arthrodesis (and other procedures) by strategically angling locking screws in the second bone fragment after securing the plate to the first fragment. These biomechanical insights offer practical guidance for achieving superior interfragmentary compression and potentially reducing the risk of nonunion in clinical practice.

Background: Modified oblique Keller capsular interposition arthroplasty (MOKCIA) is a treatment for hallux rigidus that has been shown to have similar long-term outcomes compared with metatarsophalangeal (MTP) arthrodesis. The purpose of this study was to evaluate differences in the level of sport and other activity following MOKCIA or first MTP arthrodesis.

Methods: From 2005 to 2020, 58 MOKCIA and 112 arthrodesis patients were identified. Patients completed a sports-specific questionnaire (SSQ) along with the visual analog scale (VAS) pain/satisfaction, Foot and Ankle Ability Measure (FAAM), and Patient-Reported Outcomes Measurement Information System (PROMIS) instruments, which yielded 14 MOKCIA and 15 arthrodesis subjects.

Results: At an average 13 years' follow-up, the MOKCIA group participated in a mean of 3.4 ± 1.7 sport activities preoperatively and 3.4 ± 1.9 postoperatively, whereas arthrodesis patients participated in 3.5 ± 1.7 activities preoperatively and 2.9 ± 1.4 postoperatively (P = .22). Compared with preoperative, the MOKCIA group rated sporting activities as less difficult (10/12) and same difficulty (2/12). Hundred percent of patients in the MOKCIA group were satisfied with their overall level of activity following surgery, whereas 87% patients (13/15) in the arthrodesis group were satisfied. Patients in the MOKCIA group were able to participate in similar numbers of activities postoperatively, but arthrodesis patients had decreased activities. PROMIS, VAS pain/satisfaction, and FAAM Sports scores were similar between the groups.

Conclusion: We found that MOKCIA compared similarly with MTP arthrodesis in sports physical function at long-term follow-up. These results must be interpreted in light of the very low follow-up and retrospective recall of preoperative activities.

Level of evidence: Level III, retrospective cohort study.

Graphical Abstract.

Background: Diabetic forefoot ulcers often result from increased pressure on bony prominences, neuropathy, and poor limb perfusion. The management of these ulcers, particularly when infected, is challenging and can often lead to minor or even major amputation. This study aims to evaluate the efficacy and safety of minimally invasive surgical offloading of recurrent diabetic ulcers of the fifth metatarsal by minimally invasive fifth metatarsal osteotomy and bunionette removal.

Methods: A retrospective case series study was conducted of patients who underwent surgical treatment for diabetic foot ulcers on the lateral or plantar side of the fifth metatarsal head between January 2020 and May 2025. Outcomes included time to healing of the primary ulcer and surgical wound, ulcer recurrence, postoperative complications, and reoperation rates. Clinical and radiologic parameters of the feet were assessed, and patient satisfaction Coughlin scores were collected.

Results: Ten feet from 9 patients who did not respond successfully to conservative offloading were included. The mean age of the patients was 69.5 years. Five feet were classified as Wagner grade 3 wounds, and 4 as Wagner grade 2 wounds. The ulcers healed completely in a mean time of 9.8 weeks postoperatively. Two patients required 6 weeks of antibiotic treatment because of preexisting osteomyelitis. One postoperative infection occurred. There were no corrective failures, and all patients returned to wearing orthopaedic shoes postoperatively. The overall patient satisfaction using the Coughlin satisfaction score was "good" to "excellent."

Conclusion: Minimally invasive fifth metatarsal osteotomy with bunionette removal appears safe and effective for treating refractory diabetic ulcers of the fifth metatarsal head, including cases with active infection. However, larger studies with functional outcomes are needed to establish definitive treatment guidelines.

Level of evidence: Level IV, case series.

Background: Ankle fracture incidence is increasing in the elderly. There is a growing trend toward early weightbearing. We investigated the effects of early weightbearing after ankle open reduction and internal fixation (ORIF) in the geriatric population.

Methods: A retrospective cohort study was performed of patients aged ≥65 years who underwent ankle ORIF at 3 neighboring community hospitals from 2015 to 2024. A total of 97 were included, with 52 undergoing syndesmotic fixation. Postoperatively, patients were 50% partial weightbearing for 2-3 weeks. Afterward, patients were permitted to bear as much weight as tolerable. Recorded outcomes included fracture union, radiographic maintenance of alignment, hardware failures, wound complications, hardware removals, and the need for repeat surgery.

Results: Weightbearing as tolerated was initiated at an average of 16.6 days. All patients achieved fracture union without hardware failure, catastrophic loss of reduction (>2 mm displacement), accelerated posttraumatic arthritis, or need for revision surgery. Fourteen patients (14.4%) experienced minor complications not requiring return to surgery: 3 had delayed wound healing managed with protected weightbearing, 4 had surgical site infections treated with oral antibiotics, and 7 underwent elective hardware removal for symptomatic hardware at an average of 8.6 months postoperatively.

Conclusion: This is the largest study to date reporting on the effects of early weightbearing in the geriatric ankle ORIF population. We report no major complications and a limited number of soft tissue-related complications. In a patient population with a known morbidity from prolonged immobility, and with advances in recent fracture fixation, we hope our data help build confidence in early postoperative weightbearing.

Level of evidence: Level IV, retrospective cohort study.

Background: Trimalleolar ankle fractures pose a challenge for surgical management, especially in high-risk populations such as the elderly and patients with comorbidities. Surgeons traditionally employ open reduction internal fixation (ORIF) to manage these injuries; however, some recent studies advocate for tibiotalocalcaneal arthrodesis (TTCA) as an alternative that minimizes soft tissue disruption and facilitates earlier weightbearing. This study compares complication and readmission rates associated with ORIF and TTCA in managing trimalleolar fractures, providing insight on complication risks throughout this patient population.

Methods: A retrospective analysis was performed using the 2016-2021 Nationwide Readmissions Database. Adult patients (≥18 years) diagnosed with trimalleolar ankle fractures who underwent either ORIF or TTCA were identified. To balance the cohorts, propensity score matching based on key comorbidities (defined as diabetes, hypertension, chronic kidney disease, osteoporosis, obesity, morbid obesity, or heart failure), age, and sex was performed. Primary outcomes included 30- and 90-day readmissions and complication rates; secondary outcomes were specific complications, including infection, nonunion, and malunion, assessed only in patients with ≥90 days' follow-up.

Results: A total of 602 patients were analyzed after propensity score matching (307 ORIF, 295 TTCA). TTCA patients experienced significantly higher overall complication rates compared to ORIF patients (35% [95% CI: 30.67%-41.56%] vs 13% [95% CI: 9.15%-16.53%], P < .001). Specifically, TTCA was associated with increased nonunion (10% [95% CI: 8.37%-15.67%] vs 2% [95% CI: 1.11%-4.63%], P < .001) and malunion rates (13% [95% CI: 9.53%-17.19%] vs 1% [95% CI: 0.06%-1.82%], P < .001). TTCA patients also demonstrated higher 30-day readmission rates (25% [95% CI: 21.42%-31.40%] vs 13% [95% CI: 10%-17.62%], P < .001) and 90-day readmission rates (20% [95% CI: 15.83%-24.94%] vs 10% [95% CI: 7.21%-13.98%], P < .001). In multivariable analysis, TTCA remained independently associated with higher complication risk (adjusted odds ratio: 4.10, 95% CI: 2.29-7.33, P < .001). Complication rate differences persisted across both high- and low-risk patient subgroups.

Conclusion: In this national database analysis, ORIF was associated with significantly lower complication and readmission rates compared with TTCA for trimalleolar ankle fractures. Despite theoretical advantages of TTCA in high-risk populations, these findings suggest ORIF may be preferable for most patients, with TTCA reserved for carefully selected cases where conventional fixation is unlikely to succeed. Given the limitations of administrative data, prospective randomized trials with longer follow-up are needed to definitively establish optimal treatment algorithms for this challenging pat

Background: Haglund syndrome is characterized by heel pain associated with posterosuperior calcaneal exostosis, insertional Achilles tendinopathy, and retrocalcaneal bursitis. When conservative treatments fail, surgical intervention is required. This study aims to evaluate the effectiveness of a combined surgical approach, integrating percutaneous resection of the calcaneal exostosis and proximal medial gastrocnemius release (PMGR) using the Barouk technique in treating Haglund syndrome. The goal is to assess whether this approach offers superior clinical outcomes compared to percutaneous resection alone.

Methods: We prospectively enrolled 224 patients undergoing combined percutaneous resection and PMGR, divided into group A (n = 106; with Achilles-plantar complex contracture) and group B (n = 118; without contracture) based on passive dorsiflexion testing. Outcomes were compared to 2 historical retrospective control groups treated with resection only: group 1 (n = 124; with contracture) and group 2 (n = 135; without contracture). All prospective patients received the combined treatment regardless of contracture status. Patients with body mass index >30 were excluded. The Foot Function Index (FFI) and Victorian Institute of Sport Assessment-Achilles (VISA-A) Questionnaire scores were collected at baseline and 3, 6, and 12 months.

Results: Groups A and B improved a mean 30 ± 5 FFI points and 40 ± 7 VISA-A points at 12 months (both P < .001). When compared to historical controls who underwent resection alone, the combined treatment groups showed statistically superior outcomes at all follow-up intervals (P < .05). However, these comparisons are limited by the nonconcurrent, unmatched study design.

Conclusion: This mixed prospective-retrospective study suggests potential benefits of adding Achilles-plantar complex lengthening to percutaneous calcaneal resection. However, the nonrandomized design, historical controls, and lack of patient/outcome assessor masking significantly limit causal inference. Although the combined approach showed statistically superior outcomes compared with historical controls, these findings should be considered hypothesis-generating pending validation in randomized controlled trials.

Level of evidence: Level III, retrospective-comparative cohort.