Foot & Ankle Orthopaedics最新文献

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.

Background: Ankle arthroscopy (AA) is a commonly used operative technique to diagnose and treat a variety of intraarticular pathologies of the ankle joint. In AA, 2 portals are commonly established to achieve visualization of the joint: the anteromedial (AM) and anterolateral (AL) portals. However, the superficial peroneal nerve (SPN) runs near the anterolateral portal site; thus, creation of the AL portal is associated with neuropraxic injuries to the SPN.When AA is combined with additional procedures, such as a Brostrom-Gould ligament repair or open reduction internal fixation (ORIF), the use of a direct lateral incision is required. We present a novel approach to combining AA with lateral adjunct procedures which avoids creation of the AL portal; the AM portal and lateral incision are used for instrumentation instead. The primary objective of this study is to compare complication rates, such as SPN injury, between the lateral incision (LI) approach and conventional arthroscopy plus a lateral incision approach.

Methods: Following IRB approval, a retrospective chart review was conducted spanning a time frame from January 2020 to October 2024. Patients were included if they underwent AA plus either a Brostrom-Gould repair or ORIF (AA+) or if they underwent AA plus adjunct procedures using the lateral portal instrumentation method (LI). Ninety-four patients were initially identified; 2 were excluded per criteria. Demographic information, intraoperative details, and any postoperative complications or reoperations were recorded. Descriptive statistics were used to describe demographics and operative data, and 2-tailed Student t tests were used to identify statistical differences between group metrics.

Results: Ninety-two patients were included in the study. No statistical differences were observed between cohorts in either of the intraoperative metrics considered (procedural duration and tourniquet duration; P = .44 and .89, respectively). In addition, complication and reoperation rates were not statistically different between the LI and AA+ groups (P = .94 and .40, respectively). The rate of SPN neuropathy or neurapraxia were also compared between groups, resulting in no statistical differences (P = .37).

Conclusion: In this retrospective cohort study, we observed no differences when only anteromedial and lateral portals are used for an ankle arthroscopy with adjunct procedures compared with the traditional 3-incision approach. We hypothesize that instances of infection or wound dehiscence would decrease given a large enough cohort because of the creation of 1 fewer portal. However, given the small, underpowered sample, we cannot determine whether the lateral approach alters complication risk; larger multicenter studies are needed.

Level of evidence: Level III, retrospective cohort study.

Background: Lisfranc injuries pose diagnostic challenges, particularly in evaluating joint stability. Conventional weightbearing computed tomography (WBCT)-based distance measurements of the C1-M2 interval fail to account for the second metatarsal's triplanar orientation, potentially leading to inaccuracies. This study introduces a new 3D-corrected triplanar measurement method correcting for axial, coronal, and sagittal alignment to improve diagnostic accuracy.

Methods: In this retrospective study, 31 patients with acute Lisfranc injuries underwent bilateral WBCT. Injuries were defined based on radiographic findings in the first to third tarsometatarsal joints and the C1-M2 interval. Two fellowship-trained foot and ankle surgeons independently performed manual measurements using a previously described uniplanar method and a new triplanar technique, applied proximally and distally in the C1-M2 interval. Intra- and interrater reliability were assessed via intraclass correlation coefficients (ICCs), and side-to-side differences were compared using paired statistical tests.

Results: The triplanar method demonstrated higher ICCs (intraobserver: 0.96-0.97; interobserver: 0.94-0.97) than the uniplanar method (intraobserver: 0.86-0.91; interobserver: 0.84-0.90), with distal measurements showing the highest reliability. Notably, the uniplanar method incorrectly measured the M1-M2 interval instead of the intended C1-M2 interval in 22.6% of injured feet. No such errors occurred in contralateral feet or with the triplanar method, which demonstrated 100% intra- and interobserver agreement. All 6 performed C1-M2 measurements showed significant differences between injured and contralateral feet (P < .05). The triplanar method applied distally in the coronal plane yielded the greatest absolute side-to-side difference (1.81 mm, SD 1.60).

Conclusion: This study demonstrates excellent intra- and interobserver reliability for a novel WBCT-based method that realigns the measurement planes with the second metatarsal rather than the floor. This method improves measurement precision and prevents systematic errors observed with previous techniques, particularly the misidentification of the M1-M2 interval using uniplanar methods. Clinical validation studies correlating measurements with surgical outcomes are needed to establish diagnostic thresholds and confirm clinical utility.

Level of evidence: Level III, retrospective diagnostic study.

Background: The purpose of this study was to characterize trends and public interest of Achilles tendon ruptures (ATRs) between 2013 and 2023 in the United States utilizing Google Trends data to evaluate how patients seek information on ATRs online.

Methods: Using Google Trends health category for the United States and worldwide through a 10-year period (January 1, 2013, to December 31, 2023), these search terms were queried: Achilles, Achilles tendon, Achilles tendon injury, Achilles tear, Achilles tendon rupture, Achilles repair, Achilles surgery, and Achilles rupture recovery.

Results: Several Achilles-related search terms demonstrated significant increases in interest in the United States, including Achilles, Achilles tendon, Achilles tear, Achilles repair, and Achilles surgery (all P ≤ .038). Worldwide, similar increases were seen, although aggregate global trends were not statistically significant.

Conclusion: Public interest in Achilles tendon injuries significantly increased over the past decade in the United States, with a parallel rising trend worldwide. The greatest peaks in interest were corresponded with high-profile injuries, indicating the influence of media on public awareness. These trends suggest that patients are actively seeking information online, particularly regarding treatment options and outcomes. As such, these findings highlight the importance of meeting this demand through the creation of accurate and accessible online educational content about ATRs.

Level of evidence: Level IV.