Foot and Ankle Surgery最新文献

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.

Background: Posterior malleolus (PM) fractures compromise overall ankle stability, lending to poorer long-term prognosis without adequate fixation. There remains inconsistency in the preferred surgical approach to fixation of the posterior malleolus, however arthroscopic approaches can reduce trauma to the soft tissue envelope and may improve clinical and radiographic outcomes. This study reviews the technical considerations of arthroscopic-assisted reduction and fixation of PM fractures and the associated clinical outcomes.

Methods: A systematic review of Pubmed, EMBASE, and UNE Library Services databases included studies evaluating arthroscopic assisted treatment of ankle fractures with associated posterior malleolus fragment.

Results: Seven studies evaluating 101 patients who underwent fixation of ankle fractures with posterior malleolus involvement met inclusion criteria. Twenty-seven patients underwent open reduction internal fixation (ORIF) alone and 74 patients underwent various arthroscopic-assisted reductions of PM fractures. The studies reported no significant difference in VAS and AOFAS scores in ORIF vs arthroscopic approach, and favorable VAS, AOFAS, OMAS, and FADI scores in arthroscopically treated patients. Acceptable radiographic differences were reported in each case. Complication rates in arthroscopic groups were minimal (mean 12 %). Reported benefits of arthroscopic assistance include improved visualization, debridement, and manipulation of the posterior malleolar fragment.

Conclusion: Fixation of ankle fractures involving the posterior malleolus consistently report favorable clinical outcomes in patients treated with arthroscopy, with many patients achieving desirable AOFAS, OMAS, FADI, and VAS scores with a very low complication rate.

Level of evidence: Level I, systematic review.

Background: Lateral ankle sprain (LAS) is the most common traumatic injury, yet its diagnosis and management remain suboptimal. This contributes to a high prevalence of residual symptoms, negatively impacting patient quality of life and increasing healthcare costs. We hypothesized that routine ultrasonography (US) following LAS could significantly modify the treatment strategy established by a specialist. Additionally, we hypothesized that US is an efficient tool for identifying osseous injuries and associated ligamentous injuries.

Methods: Fifty-one ankles with lateral instability diagnosed in the emergency department (ED) were retrospectively included. A second evaluation by an orthopedic surgeon was conducted within the first ten days to establish the "initial treatment". All patients underwent US and MRI within the first three weeks after the initial ED assessment and were reevaluated to establish the "post-US treatment". We determined concordance between initial and post-US treatment. Additionally, we assessed the diagnostic accuracy of US for identifying osseous and associated ligament injuries, including the anteroinferior talofibular ligament (AITFL), deltoid ligament, spring ligament, calcaneocuboid ligament (CCL), dorsal talonavicular ligament (DTNL), and bifurcate ligament, MRI serving as the reference standard for assessing ligamentous and osseous injuries.

Results: Treatment for LAS was modified for 16 ankles (31.3 %) following US examination (W=97, p < 0.05). US demonstrated excellent sensitivity (0.73) and specificity (0.95) for identifying osseous injuries. Additionally, US detected injuries to the AITFL in 6 ankles (11.8 %), deltoid ligament in 16 (31.3 %), spring ligament in 1 (2 %), CCL in 1 (2 %), DTNL in 1 (2 %), and bifurcate ligament in 2 (3.9 %).

Conclusion: US examination following LAS was significantly associated with treatment modifications. It also proved high accuracy for detecting osseous injuries missed by plain X-rays and diagnosing associated ligament injuries. Given these findings, it appears relevant to update the current diagnostic algorithm for LAS, including US.