Foot and Ankle Surgery最新文献

Background: Insertional Achilles tendinopathy (IAT) often necessitates surgery when conservative measures fail. In recent years, minimally invasive (MIS) Zadek osteotomy has emerged as a favourable alternative to open surgeries such as calcaneoplasty and tendon reattachment. This study evaluates our experience with MIS Zadek osteotomy and compares its clinical outcomes with those of open calcaneoplasty and Achilles tendon reattachment in the treatment of recalcitrant IAT.

Methods: A retrospective comparative study was conducted on thirty patients treated surgically for IAT between January 2023 and December 2024. Patients were divided into two groups: Open calcaneoplasty with Achilles tendon reattachment (n = 15), and MIS Zadek osteotomy (n = 15). Inclusion criteria comprised of patients with symptomatic IAT refractory to nonoperative treatment while patients with concomitant foot deformity or inflammatory conditions, and those who have undergone prior surgery to the same ankle were excluded. All patients had a minimum follow-up of twelve months. Primary clinical outcomes analysed include time taken to unrestricted independent ambulation, Visual Analogue Scale (VAS) scores, European Foot and Ankle Society (EFAS) scores, ability to perform unassisted single-legged heel raise (SLHR), satisfaction, and post-operative complications.

Results: Time to unrestricted independent ambulation and ability was significantly shorter in the MIS group (mean=7.1 weeks) versus the open group (mean=13.2 weeks; p < 0.001). More patients who underwent MIS Zadek were able to perform unassisted SLHR at 3 months (46.67 % in the open group vs 86.7 % in the MIS group; p = 0.019). Both groups had significant pain reduction at 12 months (VAS 0.67 vs. 0.20; p = 0.176). EFAS scores improved in both groups, with no significant intergroup differences at six or twelve months. Wound complications occurred in 26.7 % (n = 4) of patients in the open group, including one deep infection requiring readmission and multiple debridement. No wound-related complications were reported in the MIS group (p = 0.032).

Conclusion: MIS Zadek osteotomy is a viable surgical alternative for IAT, offering comparable pain relief and functional improvement while significantly shortening the time to independent ambulation and risk of wound complications. Comparative studies with larger sample sizes and longer term follow-up are warranted to validate these findings.

Level of evidence: III.

Purpose: Tarsal tunnel neurovascular vulnerability lacks robust anatomical classification. We established an MRI-based retromalleolar canal classification to assess its clinical utility for surgical approach guidance and pathology diagnosis.

Methods: This retrospective study analyzed normal ankle 3 T MRIs from 250 consecutive patients (2018-2023). Three musculoskeletal radiologists independently classified retromalleolar canal morphology using axial T2-weighted turbo spin-echo sequences (Siemens Skyra 3 T) acquired at a standardized plane 4 mm superior to the talar dome.

Results: Three radiologists demonstrated excellent interobserver reliability in all measurements (ICC >0.85, P < 0.001). Based on morphological parameters including shape, dimensions, and angular relationships, we classified retromalleolar canals into four distinct types: R (predominant, 60.4 %), V (18 %), K (16.8 %), and L (4.8 %). Morphometric analysis revealed significant differences across all classification groups (P < 0.001), particularly in groove depth and medial malleolar angle measurements.

Conclusions: The novel morphological classification may complement existing methods, potentially improving posterior ankle arthroscopy safety and aiding in the understanding of pathologies such as posterior tibial tendon dislocation and tarsal tunnel syndrome.

Background: The Ponseti method is the gold standard for managing congenital idiopathic clubfoot. Recent modifications, such as the accelerated Ponseti protocol, aim to shorten treatment duration without compromising outcomes. However, evidence comparing its efficacy and safety to the standard protocol remains inconclusive.

Objective: To compare the efficacy and safety of the accelerated versus standard Ponseti method in the treatment of congenital idiopathic clubfoot.

Methods: Eligible studies included randomized controlled trials and prospective comparative studies involving patients with idiopathic clubfoot treated with either accelerated or standard Ponseti methods.

Results: Sixteen studies involving 957 patients were included. There was no significant difference between groups in post-treatment Pirani score [MD = -0.03, 95 % CI (-0.24-0.17), p = 0.75], tenotomy rate [RR = 1.04, 95 % CI (0.99-1.09), p = 0.14], or relapse rate [RR = 1.11, 95 % CI (0.80-1.55), p = 0.54]. However, the accelerated group required slightly more casts [MD = 0.38, p = 0.032] but achieved significantly shorter treatment duration [MD = -20.43 days, p < 0.001]. Subgroup and sensitivity analyses confirmed the robustness of the findings. No major methodological flaws were detected, though blinding was generally lacking.

Conclusion: The accelerated Ponseti method is as effective and safe as the standard protocol, with the advantage of significantly shorter treatment duration. It may be a preferable alternative in appropriate clinical settings, though standardized implementation and long-term follow-up are recommended.

Background: Ankle fractures are highly prevalent orthopaedic injuries frequently involving the posterior malleolus, affecting ankle stability and function.

Methods: This study evaluated functional outcomes and return to sport following operative fixation of posterior malleolus fractures. The study included all consecutive patients with posterior malleolus fracture, who underwent operative fixation in a single institution in the UK. Patient demographics, fracture pattern based on Mason classification, operative details, postoperative radiographs and complications were extracted and analysed. Primary outcome was functional outcome assessed using the Olerud and Molander (OM) score and secondary outcomes were return to sport, union rates, complications and Visual Analogue Pain Score (VAS).

Results: Between May 2019 and May 2021, n = 52 patients were eligible for inclusion. Mean age was 45.2 ± 14.5 with mean follow up of 14.2 ± 4.3 months. The mean OM score was 79.3 ± 16.9 and mean VAS score was 1.2 ± 1.7. Residual symptoms were frequent: 55 % reported some level of ongoing pain, 35 % stiffness, 23 % swelling. Out of 43 patients doing sports pre-injury, 28 (65 %) returned to the same sport level, 11 (26 %) to a lower level, and 4 (9 %) were unable to return. No significant differences in outcome were observed between Mason fracture types.

Conclusions: Functional recovery was achieved in the majority of patients, with 42 % excellent and 52 % fair outcomes, though residual symptoms remained common. Residual symptoms and functional limitations must be emphasised to patients to manage postoperative expectations.

Background: The Lapidus bunionectomy has evolved with advanced fixation constructs since its first description. These new techniques have aimed to reduce complications such as non-union or hardware related symptoms. The IOFix™ system, an intramedullary device that has been designed to enhance stability and compression, may offer outcomes that are comparable to traditional medial locking plate with lag screw constructs.

Purpose: To compare outcomes of the Lapidus bunionectomy using the IOFix™ and plate construct versus a traditional medial locking plate with a plantar lag screw.

Methods: This IRB-approved retrospective case-control study reviewed 46 patients (23 per cohort) treated by a single surgeon between 2014 and 2022, with minimum 24-month follow-up. Patients underwent Lapidus bunionectomy using either an IOFix™ and dorsal plate (intervention) or a locking plate with plantar lag screw (control). Outcome measures included incidence of non-union, hardware removal, loss of correction (1st IMA >8° or HAA >20°), and AOFAS Hallux scores. Statistical analysis used two-tailed t-tests and Fisher's exact test with significance set at P < 0.05.

Results: All cases in both IOFix™ and locking plate groups achieved a union rate of 100 %. There were no reported infections, non-unions, or revision surgeries in either cohort. Hardware removal rates were not significantly different between IOFix™ (26 %) and control (13 %) groups (P = 0.46), and only the dorsal plates were removed. There were no reported cases of removal of the IOFix™ device. AOFAS scores improved significantly in both groups post-operatively (P < 0.0001), with no significant difference between groups pre- or post-operatively. There were no significant differences in demographic data, loss of correction, or complication rates between groups.

Conclusion: The IOFix™ and dorsal plate construct offers comparable outcomes to traditional locking plate with lag screw fixation in the Lapidus bunionectomy, with similar union rates, clinical outcomes, and hardware-related complications. These findings suggest that IOFix™ is an effective alternative fixation method. Further studies with larger sample sizes and long-term follow-up are warranted.

The talus is a critical bone in the foot, located between the tibia and calcaneus, playing a key role in weight-bearing and force transmission. It forms a stable structure with the tibia and fibula via the ankle joint and helps maintain foot flexibility with the calcaneus and navicular through the subtalar joint. Due to its cartilage-covered surface and lack of direct muscle attachment, its blood supply mainly depends on surrounding soft tissue. As a result, traumatic injuries can disrupt blood flow, leading to ischemic bone necrosis and significant impairment of foot function. Traumatic talus defects are typically caused by high-energy trauma, such as car accidents or sports injuries, and often involve talar dislocation, comminuted fractures, or open wounds. These injuries can also damage soft tissues and increase the risk of infection. Symptoms include pain, deformity, ankle instability, and loss of weight-bearing ability. Given the complexity of talus defects and the challenges of treatment, no universal guideline exists. Surgical treatment faces difficulties in reconstructing bone structure, restoring blood supply, controlling infection, and ensuring long-term functional recovery. Recent advancements in surgical treatment for traumatic talus defects include talus reimplantation, ankle arthrodesis, Ilizarov technique, Masquelet technique, and 3D Printing Prosthesis Technology. This article reviews the latest progress, compares the advantages and disadvantages of different techniques, and discusses their indications. It also highlights limitations and future developments to provide clinical insights and guide future research.

Introduction: Augmented repair is recommended in severe cases of ankle instability, but the technique remains debated. This study compared ankle and subtalar joint stability after Broström-Gould (BG) and Broström with inferior extensor retinaculum (IER) augmentation using a 3D opto-electronic protocol.

Methods: Eighteen cadaveric feet were tested in four conditions: intact, unstable (lateral ankle and subtalar ligaments disinserted), BG, and IER. Three manual tests were applied: anterior drawer (ADT), varus tilt in neutral (VTTN), and in dorsiflexion (VTTF). Ankle and subtalar rotations and ATFL/CFL elongation were recorded.

Results: Both techniques improved ankle and subtalar varus stability as well as ankle rotational stability (p < 0.05). Compared with BG, IER further reduced talus-calcaneus and tibia-calcaneus varus rotation during VTTN and VTTF (p < 0.05), and decreased tibia-talus flexion-extension during ADT (p < 0.05) CONCLUSION: IER provided greater ankle and subtalar varus stability than BG, though both limited motions compared with intact joints.

Objective: Diabetes-related foot complications could lead to amputation and death. Major amputations are known to yield higher mortality rate compared to minor amputations. In patients who already had a minor diabetic amputation, knowing the risk factors contributing to a major re-amputation is of great importance. This study aims to quantify the risk of major amputation following minor diabetic amputation and to investigate the systemic and local risk factors of the re-amputation event.

Methods: This is a retrospective comparative study among patients who had a minor amputation as a diabetic complication where one group had no subsequent amputation (Group 1) versus another group with subsequent major amputation (Group 2). The minimum follow-up period was of 24 months. The main outcomes were set as the frequency of major re-amputation and the independent systemic and the local risk factors such as wound healing complications, stump issues and the impact of using MRI-guided level for index amputation.

Results: Out of the 107 index amputations (97 patients), 70 cases (65 patients) did not present with subsequent amputations (Group 1) and 18 patients/cases (16.8 %) required a major amputation at the last follow-up (Group 2). The logistic regression analysis showed peripheral artery disease (PAD) and non MRI-guided index minor amputation as independent factors for higher subsequent major amputations (p = 0.04 and p = 0.02, respectively).

Conclusion: The risk of a major amputation following a diabetic minor amputation is not infrequent, almost 17 %. PAD was found to be the only independent systematic factor to positively correlate with the risk of major re-amputation. MRI-guided level of index amputation, at least 1 cm proximal to MRI bone infection sign, was significantly negatively correlated with re-amputation.

Background: Treatment of foot and ankle critical-sized defects (CSDs) remains a surgical challenge. Custom 3D-printed metallic implants have emerged as a promising solution, however current literature is limited. This study evaluated the incidence and associated factors of deep postoperative infection following custom cage implantation.

Methods: A retrospective cohort study was conducted on 62 patients who underwent custom cage implant arthrodesis. Pre-, peri-, and postoperative variables were collected, with deep postoperative infection as the primary outcome.

Results: Of 62 patients, 13 (21 %) developed deep postoperative infections at a median 957 days. Superficial wound breakdown was significantly associated with infection. History of ipsilateral foot and ankle infection, diabetes, smoking, and neuropathy were not significantly associated with infection.

Conclusion: Infection rates after custom cage implantation were comparable to those of traditional CSD management methods. These findings support continued evaluation of custom cage implants and emphasize the importance of reducing postoperative infection risk.

Level of evidence: III.