Foot and Ankle Surgery最新文献

Background: The number of total ankle replacements (TAR) is increasing each year and with that an associated rise in the burden of revision ankle replacement (rTAR) (Ratnamsey et al.) [3]. When a TAR fails, two options emerge: Arthrodesis or rTAR (Goldberg et al.) [1]; (Egglestone et al.) [2]; (Hinterman et al.) [4]. The preferred option in our centre following network discussion, is to convert the failing TAR to a rTAR. There is uncertainty whether this is best done in a single staged approach or two stages. The aim of this review was to assess the outcomes of single-to-two-staged approaches in rTAR, and to ascertain if there was any increase in complications or impaired outcome in the single-staged approach.

Method: A review was carried out of the prospectively collected data of all rTAR performed in our centre between Nov 2016 and Jan 2023. We reviewed: preoperative micro-sampling, intra-op microbiology and histology results, infection rate, tourniquet time, length of hospital stay, wound complications and PROMS of all patients who had undergone a single-staged rTAR, compared to two stages.

Results: We identified 86 rTAR patients, with a mean age of 71.4 (38-88) with a minimum of 2-year follow-up, range 2-7 years. There were 44 Left and 42 Right failing total ankle replacements. 14 were two staged procedures and 74 were single staged. No preoperative microbiology sampling was performed in the single or in the staged group. Both groups who underwent intraoperative microbiology sampling showed no positive microbiology growth. There was a significant difference in tourniquet times but with no associated significant complication rate in the single staged group versus the staged group. There was one infection in the single-staged group that went on to have a successful DAIR. There was no difference in wound complications post-op. Both groups showed improvement in PROMS, with no difference between the groups or in increase in length of hospital stay.

Conclusion: In our series, which is the largest in the literature, we have found single-staged revision arthroplasty to be safe and effective compared to a two-stage procedure in patients where there is a low index of suspicion of infection.

Level of evidence: Level III, Retrospective Cohort.

Background: Football causes over 4 million injuries each year, making injury prevention a priority. To mitigate the risks, FIFA neuromuscular programs (FIFA 11 +, FIFA 11 + Kids, and FIFA 11) are implemented to reduce injury risk. Nevertheless, their efficacy varies across populations and implementation protocols.

Methodology: Databases such as PubMed, Web of Science, Cochrane Library, and EMBASE (2006-2025) were searched for randomized controlled trial (RCT) studies comparing FIFA programs to standard warm-ups. Risk of bias was assessed using the Cochrane RoB 2.0 tool. Pooled relative risk (RR) with 95 % CIs were calculated using random-effects models. Prespecified subgroups were analyzed according to program version, sex, sample size, and training parameters (frequency/duration).

Results: Nine RCTs (n = 11,687) found that FIFA programs, in general, reduced ankle injury risk by 38 % (RR=0.62, 95 % CI: 0.50-0.78; P < 0.001). Version-specific analyses revealed significant effects for FIFA 11 + (RR=0.57) and FIFA 11 + Kids (RR=0.56), but no effect for FIFA 11 (RR=0.94). Sex-specific analysis showed a 44 % reduction in males (RR=0.56) but no significant effect in females (RR=0.87). Exploratory subgroup analysis revealed small-study effects: smaller trials (n < 500) demonstrated greater efficacy (RR=0.33) than larger trials (n ≥ 1000; RR=0.73). Neither training frequency (1-2 vs. >2 sessions/week; P = 0.91) nor intervention duration (20-26 vs. ≥27 weeks; P = 0.09) modified efficacy. The quality of evidence was rated as moderate according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

Conclusion: FIFA programs significantly reduce ankle injury risk in football players. However, efficacy differences primarily reflect program version (FIFA 11 ineffective) rather than biological sex, with insufficient female-specific data and diminished effects in larger trials. Future large-scale trials should confirm effectiveness in female and youth athletes, addressing limitations from small-trial bias.

Background: Flexible flatfoot is a common pediatric condition characterized by a reducible loss of the medial longitudinal arch during weight-bearing. While subtalar arthroereisis is widely used for its minimally invasive correction, long-term outcomes-particularly arch stability after implant removal-remain poorly understood. This study evaluates radiological and functional changes from implant insertion to removal in adolescent flatfoot patients.

Methods: A retrospective analysis of 21 adolescents with flexible flatfoot who underwent subtalar arthroereisis followed by implant removal was conducted. Radiographic parameters (hindfoot valgus angle, talonavicular coverage angle, etc.) and functional scores (AOFAS, VAS) were assessed preoperatively, postoperatively, and at final follow-up (mean 8.2 years).

Results: Subtalar arthroereisis significantly improved deformity and function. The hindfoot valgus angle reduced from 11.6° ± 7.8° to 1.3° ± 4.3° postoperatively, AOFAS score increased from 68.3 ± 6.2-95.5 ± 3.0. The talonavicular coverage angle was 26.2 ± 11.4° preoperatively, decreased to 10.1 ± 5.9° postoperatively. The talar pitch angle was 40.9 ± 6.0° preoperatively, decreased to 29.3 ± 3.4° postoperatively. The calcaneal pitch angle was 14.2 ± 2.2° preoperatively, increased to 16.9 ± 2.9° postoperatively. The lateral Meary's angle was -24.4 ± 6.9° preoperatively, improved to -8.1 ± 3.5° postoperatively. The AOFAS score increased from 68.3 ± 6.2 preoperatively to 95.5 ± 3.0 postoperatively, meanwhile, the VAS score decreased significantly from 3.5 ± 1.2 preoperatively to 1.3 ± 1.1 postoperatively. However, mild arch recurrence occurred after implant removal (The talar pitch angle increased to 32.6 ± 3.3° at the final follow-up. The lateral Meary's angle increased to -12.9 ± 3.6° at the final follow-up after implant removal.), though values remained superior to preoperative levels.

Conclusion: Following subtalar arthroereisis implant removal, adolescents with flexible flatfoot demonstrate mild arch recurrence; nevertheless, radiological outcomes sustain substantial improvement relative to the preoperative condition.

Aim: Established guidelines recommend a pre-operative HbA1c target of 8.5 % for elective surgeries. Patients waiting for Charcot foot reconstructions often have impaired mobility and fail to achieve this target, and risk getting their surgeries delayed or cancelled. In our unit, the multidisciplinary team (MDT) recommends proceeding with surgery even if the target HbA1c levels are not achieved. Our aim is to review the patient outcomes among patients with diabetes and variable pre-operative glycaemic control undergoing Charcot foot reconstructions.

Materials and methods: We reviewed the clinical outcomes and glycaemic control of consecutive patients that had undergone elective Charcot foot reconstructions over a 22-month period with a minimum follow-up of 12 months.

Results / discussion: 18 diabetic patients were operated on between October 2020 and August 2022, including 8 midfoot, 2 hindfoot and 8 combined hindfoot and midfoot reconstructions. There were 11 males, the mean age was 56.7 years, the mean preoperative HbA1c was 7.9 %. In 7 patients, the preoperative recommended HbA1c target of 8.5 % was not achieved (non-target group). There were 4 post-operative complications, all resolved with conservative management. There were no renal or cardiac complications. After one year, 61 % (n = 11) of patients were mobilising in shoes. There was no outcome difference between the groups with or without the targeted glycaemic control.

Conclusion: Although preoperative glycaemic optimization should be aimed for, the time critical Charcot foot reconstructions can still be performed in the absence of targeted glycaemic control if delivered by MDT.

Background: Percutaneous tarsometatarsal (TMT) fusion is a novel technique with sparse reported literature. This study aims to evaluate patient reported outcomes, fusion and complication rates following percutaneous TMT fusion.

Methods: All patients who underwent percutaneous TMT fusion by a single surgeon with at least one year follow-up from February 2018 to July 2021 were retrospectively reviewed. Pre- and post-operative patient reported outcomes were assessed with Visual Analog Scale (VAS) and Foot Function Index (FFI). Fusion was assessed radiographically at each postoperative visit.

Results: 38 patients with 86 TMT joints were included. Mean age was 60.8 years (range, 46-89 years). Mean follow up was 26.2 months (range, 17-39 months). Mean VAS scores improved from 7.5 to 0.2. Mean pre-operative FFI in pain, disability, activity restriction, and total score was 21.1, 16.5, 18.3 and 56.2, respectively. Mean post-operative FFI in pain, disability, activity restriction, and total score was 4.3, 4.7, 6.5 and 15.7, respectively. All pre- and post-operative differences in FFI and VAS were statistically significant (p < 0.0001). Fusion was achieved in 81/86 TMT (94.1 %).

Conclusion: Percutaneous TMT fusion achieves a high fusion rate and significantly improved patient reported outcomes in all domains.

Level of evidence: IV.

Objective: This study aimed to evaluate the relationship between chronic ankle instability (CAI) and both the anatomical characteristics of the anterior talofibular ligament (ATFL) and the bony morphometry of its attachment sites on the fibula and talus using MRI.

Methods: A total of 94 patients were included in this retrospective study (44 with CAI, 50 controls). Morphometric parameters including ATFL length, width, thickness, and the ATFL/PTFL angle were measured, along with sagittal and coronal widths of the fibula and talus at ATFL attachment levels.

Results: The ATFL was significantly longer, thinner, and narrower in the CAI group compared to controls (p < 0.001). The ATFL/PTFL angle was also significantly greater in the CAI group (p = 0.007). However, no statistically significant differences were observed in the sagittal or coronal widths of the talus and fibula. ROC analysis revealed that ATFL length had the highest diagnostic performance (AUC = 0.881). Logistic regression identified increased ATFL/PTFL angle and decreased ATFL width and thickness as independent predictors of instability.

Conclusion: While the ligamentous characteristics of the ATFL, particularly its length and angulation, are strongly associated with CAI, the morphometric features of its bony attachment sites do not appear to contribute significantly. The ATFL/PTFL angle may be considered a reliable, indirect MRI marker in the assessment of CAI and should be considered in routine evaluations.

Background: First metatarsophalangeal joint (MTP) arthrodesis is a common operative management for end-stage hallux rigidus. The purpose of this study is to present an evidence-based literature review and evaluation of the literature regarding the efficacy of different fixation methods and postoperative weight-bearing status for first MTP Arthrodesis.

Methods: A comprehensive literature review was conducted across three databases: Medline, Embase, and Cochrane, in September 2024. Exclusion criteria included biomechanical, cadaveric, and non-human studies, review articles, letters, and technical tips. The included articles were analysed and categorised according to their level of evidence (level I-V). A grade of recommendation (A, B, C, or I) in favour of or against each modern fixation method and weight-bearing status for first MTP arthrodesis for hallux rigid was determined by collective review of the categorised articles.

Results: 86 of the 1390 identified articles were included. There is fair evidence (grade B) for fixation with screws, plates, and plate with a compression screw, as well as both immediate postoperative weight-bearing and non-weight-bearing, according to the current literature. Insufficient evidence (grade I) for staple and novel fixation methods exists.

Conclusions: The results of this comprehensive review provide the most up-to-date recommendations for fixation and postoperative protocol for surgical management of first MTP arthritis. The best available published peer-reviewed literature demonstrates that both immediate weight-bearing or non-weight bearing are viable postoperative protocols for first MTP arthrodesis, giving similar clinical outcomes. Additionally, the literature supports the use of screws, plates and plates with a compression screw as fixation methods. It is evident that additional high-quality level I and II studies are required to compare and validate these fixation methods and weight-bearing statuses to allow for stronger recommendations.

Level of evidence: Level III, Systematic review.

Background: Hallux valgus (HV) is a common foot deformity that causes pain and functional limitations. For mild-to-moderate cases, conservative treatment such as exercise therapy and external supports is preferred. Optimal protocols remain uncertain due to variation in exercise types and combinations. This study compares conservative approaches to rank their effectiveness in reducing the hallux valgus angle (HVA) and pain relief.

Methods: PubMed, Cochrane Library, EMBASE, Medline, Web of Science, CNKI, and Wanfang were searched from inception to June 15, 2025, for RCTs evaluating exercise therapy alone or with external supports in HV patients. Outcomes included HVA and pain relief. Network meta-analyses calculated the mean differences (MD) with 95 % CIs, and interventions were ranked using SUCRA.

Results: Eleven RCTs involving 401 HV patients were included. Exercise therapy (MD = -3.32, 95 % CI: -4.40 to -2.23) was significantly superior to adjusted placebo for HVA. Exercise combined with taping was the most effective intervention (MD = -6.72, 95 % CI: -9.34 to -4.11; 89.5 %), followed by exercise combined with orthoses (MD = -6.67, 95 % CI: -9.70 to -3.64; 85.6 %). For pain relief, exercise combined with taping ranked first (MD = -3.76, 95 % CI: -4.79 to -2.73; 92.7 %), followed by exercise combined with orthoses (MD = -3.43, 95 % CI: -3.98 to -2.87; 72.6 %).

Conclusion: For mild-to-moderate HV, exercise therapy was effective in reducing HVA. Exercise combined with external support provides greater benefits for HVA reduction and pain relief. Further large-scale, high-quality RCTs are needed confirm these findings and assess potential adverse events.

Introduction: Progressive collapsing flexible foot deformities are generally treated with joint-preserving techniques. Our objective was to evaluate biomechanically the effect of different calcaneal osteotomies with or without a peroneus brevis to longus transfer (PBtoPL) on a cadaveric flatfoot model.

Methods: 15 cadaveric foot and ankle specimens were used in a mid-stance phase of gait model. Evans, medial displacement, Double, Z (step cut), and IZ (inverted Z) osteotomies were compared. A Vicon positioning system was used to measure angular changes.

Results: Evans and Double osteotomies generated the highest adduction effect; Z and IZ osteotomies generated 50 % less. Evans, Double and IZ osteotomies created a significant supination effect. The PBtoPL transfer produced non-significant changes.

Conclusions: Evans and Double osteotomies were the most potent calcaneal osteotomies. Evans, Double, and IZ osteotomies had a similar supination effect. Further studies are needed to explore the role of the PBtoPL tendon transfer in greater detail.

Background: Ankle fractures are common injuries treated by trauma surgeons. Failure of fixation necessitating subsequent revisions remains a significant concern, carrying increased morbidity and healthcare cost. Mechanical failures are poorly categorised in the literature. This study aims to classify patterns of mechanical failure following primary ankle internal fixation.

Methods: A retrospective observational study was conducted at a single major trauma centre, reviewing electronic patient records (EPR) and radiographs of 897 patients who underwent internal fixation for unstable ankle fractures over five years (June 2014 to August 2018). Data on patient demographics, injury characteristics, surgical techniques, and complications were collected. Mechanical failures were categorised into three subtypes based on the direction of talar displacement and syndesmotic involvement: Type 1 (lateral talar instability with intact syndesmosis), Type 2 (lateral talar instability with disrupted syndesmosis), and Type 3 (posterior talar instability). The inter-rater reliability of this classification system was evaluated using intraclass correlation coefficient (ICC) analysis.

Results: The revision rate after primary ankle internal fixation was 6.6 % (59/897), with mechanical failures accounting for 69 % (41/59) and infective failures for 31 % (18/59). Patients in whom the primary ankle fixation failed were significantly older than the group in whom the primary ankle fixation did not fail (mean age 60 vs. 52 years, p = 0.0018). The mean ICC values for the classification system was 0.84, indicating good inter-rater reliability.

Conclusions: The revision rate for unstable ankle fractures treated with primary internal fixation was 6.6 %, with the majority of revisions attributed to mechanical failures. Lateral talar instability, particularly when associated with syndesmotic disruption, was the most common cause of mechanical failure. Our grading system demonstrated high inter-rater reliability and provides a tool for categorising these failures.