Foot & Ankle Orthopaedics最新文献

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.

Background: Cuboid fractures are rare, and there is a scarcity in evidence of the long-term functional outcome of these fractures in literature. This study aimed to evaluate functional outcome, complications, quality of life, and patient satisfaction after surgical treatment of cuboid fractures.

Methods: This retrospective study was conducted at a level 1 trauma center, reviewing patients ≥16 years with cuboid fractures operated between 2014 and 2024. Functional outcome was assessed using the Foot Function Index (FFI), the American Orthopaedic Foot & Ankle Society (AOFAS) midfoot score, and EQ-5D quality of life questionnaire. Complications such as nonunion, infection, and secondary arthrodesis were recorded.

Results: The total cohort of surgically managed patients was 45 (28 females and 17 males), with a median age of 39.1 (IQR, 24.2) years and median follow-up of 67.0 (IQR, 91) months. A subset of 42 patients were treated with open reduction and internal fixation within 4 weeks after the injury. Overall, AOFAS was fair to good (median 76, range 34-100) and treatment satisfaction was high (mean 8.7/10, SD 1.1). There were no infections and no cases of nonunion. Secondary calcaneocuboid joint fusion was required in only 2 patients. In multivariate linear regression analysis, the type of fixation (cuboid plate) was significantly associated with better AOFAS (P = .03, R ² 0.11).

Conclusion: Surgical intervention aimed at restoring articular congruence and column length with cuboid plate fixation can lead to union with overall fair to good functional outcome and high patient satisfaction.

Level of evidence: Level III, retrospective cohort study.

Background: Very few studies reported outcomes of common conservative surgeries with antibiotic-impregnated cement when treating diabetic foot osteomyelitis (DFO). The aim of this descriptive study is to report the results of the association of cement with a specific type of toe-sparing resection, combining total metatarsectomy/phalangectomy (internal pedal amputation) with partial bone excision, for acute on chronic forefoot DFO.

Methods: Six patients with confirmed acute on chronic DFO were included. A probe-to-bone test was performed for open wounds. For all patients, radiographs, magnetic resonance imaging (MRI), and pathology were conducted in search of osteomyelitis signs. The level of resection was defined as 1 cm away from the contrast enhancement shown on MRI. The polymethylmethacrylate (PMMA) cement was prepared with 2 g of vancomycin before being placed in the defect. A minimum period of 6 months of clinical follow-up was set.

Results: All patients demonstrated wound healing at last follow-up with normalized C-reactive protein. There were no clinical signs of osteomyelitis recurrence. One wound infection was recorded 4 weeks postoperatively and treated successfully with debridement and lavage. None of the cement had to be removed or exchanged. Subjectively, 5 patients were extremely satisfied scoring 5/5 on Likert scale, and 1 patient was moderately satisfied (3/5). All patients were able to walk with full weight using insoles.

Conclusion: This preliminary report demonstrated that PMMA cement could be a viable option when used to locally control infection following an internal pedal amputation for acute on chronic DFO of the toes. In addition to the high rate of healing, the esthetical result was highly appreciated by the patients.

Level of evidence: Level IV, case series.

Background: Despite the safety and versatility of circular external fixators (CEFs) for many indications, there is limited information on their contemporary usage and the factors contributing to their potential underutilization. This study aims to estimate the prevalence of contemporary CEF use, characterize barriers to adoption, and identify potential solutions among American Orthopaedic Foot & Ankle Society (AOFAS) members.

Methods: A multibranched survey was designed for distribution to all active practicing members of the AOFAS to collect data on demographics, training background, CEF usage profile, provider opinions, barriers to device adoption, and factors that could encourage greater use. Data were collected through Qualtrics XM. Statistical analysis analyzing respondent differences included descriptive statistics, χ² tests for independence, and unpaired t tests.

Results: Of 169 participants, 27.81% reported not using CEFs in their practice despite 94.08% of respondents agreeing that their use is critical for certain patients. Overall, 70.21% of nonusers believed it could have a role in their practice but had hesitations. In addition, 59.76% of participants received minimal to no exposure in residency, and this was a significant predictor for current usage (P = .0119). CEFs are most commonly used for Charcot neuroarthropathy (86.07%), infection management (83.60%), and other deformity corrections (65.67%). Nonusers are more likely to believe CEFs take too long to assemble intraoperatively, express greater concern about postoperative burden, and are less confident in postoperative care compared to users (all P < .01). The most popular interventions that would facilitate usage were access to longitudinal mentorship, further technological advancement, and attending non-industry-sponsored courses.

Conclusion: Perceived lengthy operative time, postoperative burden, and lack of postoperative management confidence were predominant reasons for the lack of CEF use. This survey suggests that these barriers could be addressed by more exposure during training, attending non-industry-sponsored courses, and longitudinal mentorship.

Level of evidence: Level IV, cross-sectional study.