Foot & Ankle Orthopaedics最新文献

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.

Background: Rotational malalignment of the first metatarsal is increasingly recognized as a key feature of hallux valgus deformity, but the reliability of radiographic rotation markers remains uncertain. This study assessed the inter- and intraobserver reliability of 4 commonly used radiographic parameters: metatarsal pronation angle (MPA), tibial sesamoid position (TSP), lateral head shape (LHS), and round head sign (RH).

Methods: In this prospective reliability study, 3 senior clinicians independently evaluated weightbearing anteroposterior and axial sesamoid radiographs of 75 hallux valgus cases on 2 occasions. Metatarsal pronation angle (MPA) was measured as a continuous variable and analyzed using intraclass correlation coefficients (ICCs). Tibial sesamoid position (TSP), lateral head shape (LHS), and round head sign (RH) were graded using ordinal scales and assessed with weighted kappa statistics (κ). Subgroup analyses evaluated whether reliability varied by deformity severity (hallux valgus angle) or increased distal metatarsal articular angle (DMAA > 10 degrees).

Results: MPA showed excellent agreement (ICC = 0.81-0.94). TSP also demonstrated high reliability (κ = 0.88-0.98), although its value as a rotation marker is limited. LHS showed moderate to substantial agreement (κ = 0.59-0.85), whereas RH had fair to moderate reliability (κ = 0.35-0.66). RH was least reliable in mild deformities, whereas other parameters remained stable across subgroups, with slightly lower values in cases with elevated DMAA.

Conclusions: Conventional radiographs offer reliable assessment of MPA and TSP. LHS provides acceptable reproducibility, whereas RH is less consistent. These findings support the use of selected radiographic markers and suggest that further validation against 3-dimensional imaging and standardized grading frameworks may improve consistency and clinical applicability.

Level of evidence: Level IV, case series.

Background: The Achilles tendon is prone to rupture, particularly in middle-aged men, and chronic injuries are often due to missed diagnoses or inadequate treatment. While acute ruptures can be managed with primary repair, chronic cases with tendon gaps >3 cm require reconstruction. A minimally invasive technique using autologous semitendinosus and gracilis tendon grafts has previously shown favorable short-term outcomes. This study evaluates longer-term outcomes with a minimum 5-year follow-up.

Methods: This study analyzed 21 patients undergoing minimally invasive Achilles tendon reconstruction with autologous hamstring grafts, compared with 21 healthy controls. magnetic resonance imaging confirmed diagnoses, and surgeries (2016-2019) used the EndoButton system for graft stabilization. Assessments included Achilles tendon Total Rupture Score (ATRS) for patient-reported outcomes, EuroQoL-5 Dimensions, 5 Levels (EQ-5D-5L) for overall health, and visual analog scale (VAS) for pain and satisfaction. Functional tests measured dorsiflexion (lunge test), calf endurance (heel rise test), and muscle strength (single-leg hop test), comparing operated vs unoperated legs.

Results: ATRS and EQ-5D-5L Index improved from 2 to 5 years (P = .0136, P = .0396), although significance was lost after Bonferroni correction. Functional test results remained stable. The operated limb achieved >90% of the nonoperated side across tests. Compared with controls, patients reported lower EQ-5D-5L scores and greater pain (P < .05), but satisfaction remained high (VAS score 9/10). One retear occurred due to infection.

Conclusion: Minimally invasive Achilles tendon reconstruction using hamstring autografts results in sustained functional and subjective improvements at a minimum of 5 years postoperatively. Despite modest residual deficits compared with uninjured controls, high satisfaction and strong limb symmetry support the long-term efficacy of this approach. This study demonstrates that the functional and subjective results of patients after Achilles tendon reconstruction with hamstring graft remain stable and satisfactory at a minimum of 5 years postoperatively.

Level of evidence: Level III, retrospective cohort study.

Graphical Abstract.

Background: An accessory navicular is a supernumerary ossicle located medial to the navicular bone, typically within the substance or insertion of the posterior tibial tendon, and can be a source of pain and dysfunction in active individuals.

Methods: This was a retrospective comparative study evaluating the outcomes of the modified Kidner procedure in athletes (ballet, basketball, volleyball, running, football, soccer, etc) and nonathletes. Our study included 42 consecutive feet that were operatively managed with the modified Kidner procedure for a symptomatic accessory navicular between the years 2014 and 2023. Patients who underwent any other procedure in addition to the modified Kidner procedure were excluded from the study. The objective of this study is to determine the outcomes of the modified Kidner procedure for an accessory navicular in the athletic population compared to the nonathletic or general population.

Results: Athletes had no difference in postoperative Foot and Ankle Ability Measure (FAAM) activities of daily living (ADL) and visual analog scale (VAS) scores compared with nonathletes. Interestingly, comparison of single-sport to multisport athletes revealed that single-sport athletes presented with worse preoperative VAS and FAAM scores. However, there was no significant difference in postoperative patient-reported outcomes between single-sport and multisport athletes.

Conclusion: Our results suggest that although single-sport athletes may present with more severe preoperative symptoms, they experience comparable improvement following operative management relative to nonathletes or multisport athletes.

Level of evidence: Level III, retrospective comparative study.

Background: The Hintermann osteotomy (HOT) is one type of calcaneal lengthening osteotomy during progressive collapsing foot deformity surgery. The entry point on the lateral wall of the calcaneus is critical because it affects the direction and depth of the osteotomy. Accurate osteotomy placement can be technically demanding, and joint facets can sustain damage in up to 50% of the cases. We hypothesize that the further posterior the osteotomy is performed, the greater the risk of facet injury.

Methods: Twenty-two computed tomography-based 3-D models underwent simulated HOT at 5, 10, 15, 20 mm posterior to the calcaneocuboid joint. Primary outcomes were facet penetration rate and "safe-zone" angle; secondary outcomes were distance to the flexor hallucis longus (FHL) and anterior-facet translation.

Results: Facet penetration increased from 0% (0/22) with entry points 5 to 15 mm posterior to the calcaneocuboid joint to 23% (5/22) at 20 mm. The safe-zone angle narrowed from 11 ± 2.6 degrees at 5 mm to 3.0 ± 6.5 degrees at 20 mm (P < .01). Mean FHL clearance decreased from 44 ± 6 mm to 35 ± 6 mm (-20%, P < .05), and anterior-facet translation increased by 32% between the 5- and 20-mm cuts.

Conclusion: The choice of the entry point is crucial. If an entry point is chosen 20 mm behind the calcaneocuboid joint, facet penetration is anatomically inevitable in 23% of cases. A more anterior entry point results in a longer distance between the lateral wall and the sensitive medial structures.

Level of evidence: Level IV, case series.

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Background: Total ankle replacement (TAR) is a surgical option for patients with ankle arthritis who have failed conservative measures. Newer implants have markedly improved; however, osteolysis causing aseptic loosening continues to be a main cause of TAR failure. The objective of this study was to review the HINTEGRA TAR experience at a single institution specifically evaluating the presence and outcomes of osteolysis.

Methods: Retrospective study including all HINTEGRA TARs completed by 1 experienced foot and ankle surgeon from 2006 to 2014. Radiographs were reviewed, assessing for implant positioning, presence, location, and progression of cysts as well as relationship between osteolysis with reoperations and revisions.

Results: Fifty-one TARs were identified with radiographic follow-up of 5.8 ± 3.5 years. Eighty-four cysts were detected in 37 patients, with increasing number and size of cysts being correlated to length of time from surgery. The most common location was the posterior tibia. Thirteen patients had enlarging cysts identified over time, with the lateral malleolus being the most common location. Seven patients met criteria for malaligned prosthesis, 12 patients required a reoperation, and 2 patients experienced implant failure.

Conclusion: Osteolysis is a very common finding after TAR using the HINTEGRA prosthesis, specifically on long-term radiographic follow-up. Progressive cysts and prosthesis coronal malalignment appear to be risk factors for developing osteolysis, prosthesis loosening, and reoperation. Most cysts did not result in clinical failure, but progressive lesions identified beyond 1 year warrant closer monitoring. This study also shows excellent and reliable outcomes of the HINTEGRA TAR compared with designer surgeons with acceptable complication and revision rates.

Level of evidence: Level IV, Case series.

Background: Distraction arthroplasty aims to treat ankle osteoarthritis while preserving the native ankle joint, often to prevent or delay ankle arthrodesis or total ankle replacement (TAR). No study to date has explored TAR outcomes in patients who have had prior distraction arthroplasty. Thus, this study described the clinical, radiographic, and patient-reported outcomes for TAR at minimum 2-year follow-up in patients who had undergone prior ankle distraction arthroplasty.

Methods: This retrospective review included 19 ankles in 17 patients who underwent TAR at a single institution subsequent to ipsilateral distraction arthroplasty. The primary aims were to evaluate complication rate and patient satisfaction following TAR. PROMIS scores were obtained preoperatively and at minimum 2 years postoperatively. The proportion of patients who achieved the patient acceptable symptom state (PASS) threshold for each Patient-Reported Outcomes Measurement Information System (PROMIS) domain at final follow-up was used to assess patient satisfaction following TAR.

Results: TAR was performed a mean of 5.3 ± 3.5 years following distraction arthroplasty. At mean 4.4-year follow-up after TAR, 18/19 (94.7%) ankles remained implanted. One ankle was revised because of failure of the talar component, and there were 4 additional reoperations. Radiographic complications were observed in 37% of patients at 2 years postoperatively. Patients experienced significant improvement at 2-year follow-up for PROMIS domains of Physical Function (P = .002), Pain Interference (P = .007), and Pain Intensity (P = .010). At final follow-up, PASS was achieved by 65% and 71% of patients in the Physical Function and Pain Interference domains, respectively, but only 35% in the Pain Intensity domain.

Conclusion: TAR is a viable option to treat ankle osteoarthritis symptoms that persist after distraction arthroplasty. However, many of these patients present with a complex surgical history and, therefore, may be at a greater risk for reoperation. Thus, patients should be counseled appropriately before electing to proceed with distraction arthroplasty before more definitive surgical treatment options.

Level of evidence: Level IV, case series.